A Difficult Time
My Journey in Medicine	by Jerry Sobieraj, MD © 2001
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Chapter 11: Do we earn too much?

I tend to think that as a profession, we physicians are overpaid. Of course, if you ask any particular physician, he or she will tend to feel they are undervalued. My final income as a physician just topped $100,000 a year. I recognized this placed me in the top few percent of Americans, and I found this more than acceptable. In fact, I have made it clear to my boss in the past, and to the medical community at large in a letter I had published in the New England Journal of Medicine in 1998, that I was willing to make less money if it permitted me to practice Medicine in a way more conducive to my needs.

I was willing to earn less if it permitted me more time to talk to my patients. When I had ample time to explore the issues brought forth with each visit, I not only could do a better job, but I enjoyed it much more. In fact, on days when I was able to practice this way (due to cancellations and no shows), I actually left satisfied and refreshed. Thus I asked myself, why couldn't everyday (or at least most days) be like this? I was willing to make the sacrifice financially. After all, I was trained to practice Medicine, not to make a lot of money or to document in order to maximize billing. However, I have faced nothing but barriers when I tried to develop such a practice.

When I was in solo private practice, I was able to control the time aspect of my practice. However, concerns over capitation led me to a group and the corporate medical model. In the seven years since I left private practice, the corporate model has become even more the norm. A physician's ability to negotiate a style to meet his or her individual needs has become nearly impossible. When I discussed the time I needed to see patients with my boss, he felt that if he let me have longer appointments with patients, then others in my group would demand it. In addition, he felt they wouldn't be willing to take a commensurate cut in pay, as I was willing to do. I have found this rationale shallow and conservative to say the least. I didn't see how such a simple quid pro quo could be a problem for my colleagues, who were pretty good at complex reasoning.

Physician compensation wasn't just an issue of being willing to work for less money so one could improve one's work environment. If you looked at the average doctor salary, you would find it had grown close to $200,000 per year. So why was my salary so low in the first place, relative to the average? Who was making all the money? Simply stated, specialists have been driving much of the cost of health care. However, a critical analysis of this income disparity didn't make sense. A couple of examples would demonstrate the point.

A colleague of mine told me about a radiologist in the Boston area who was a contemporary of ours (i.e. early 40s). He had three years of post-graduate training (the time after med school), like the average general internist or family practitioner. Yet he earned $350,000 a year, and had 10 weeks of vacation. So what did this person do to deserve such an income? The answer was simple: he went into a field of Medicine that was over-reimbursed. Radiologists are paid for each x-ray they read. They often will bill for two tests related to a single procedure (e.g. a CAT scan of the abdomen may be billed as one of the abdomen and one of the pelvis if cuts (slices of an x-ray) are taken low enough down in the body). Their reimbursement isn't based on how many films you would expect the average radiologist to read in a day, but just on the actual readings. This is consistent with the philosophy that those who work harder will get ahead. However, if the average number of films a radiologist can read leads to a $200,000 annual salary, have they earned it? How dose their effort and training compare to a primary care practitioner who may earn half that amount?

Why does a person who has no more training in their specialty than a family practitioner (who, like an internist, has three years of post-graduate training) earn so much more money? They have different training, but that is expected. After all, they learn how to read x-rays, and we learn how to take care of people. Yet this difference in training should not distort the value placed on one type of physician over another! Unfortunately, this type of disparity has remained typical in Medicine, and not at all an exception. In fact, it is one of the main reasons that medical students are shying away from primary care once again (as in the late 1980s).

Five years ago I was visiting a friend of mine who was an anesthesiologist practicing in Georgia. As an anesthesiologist, his job was to give medications to people so that they could have surgery or other procedures, without undue pain or discomfort. Surely, this was important. However, he also had the typical three years of training after med school. Yet he felt that he would never accept less than $150,000 a year as starting compensation for work in his field. At the time of our discussion I wasn't even earning $100,000. I had double the post-graduate training (6 years) and had been out practicing for five years (he was just out of training).

This kind of thinking has not only inflated our perceived value of ourselves, but also has led to business school like decisions amongst trainees. In June of 2001, I saw a fourth year Boston University medical student for whom I had provided primary care. Her course in med school was slowed by a couple medical problems, which prolonged her stay. Partly as a result of that, she became interested in primary care. When we last talked in the winter of 2001, before the Residency Match, she was talking about a career in women's health. When I saw her in June, she was going to be starting at a local community hospital as medical intern. However, instead of a career in women's health, she had changed to anesthesiology. I asked her the current starting salaries (i.e. for someone right out of anesthesiology training, 3-4 years total), and she told me they were $200-300,000 a year (at least my friend in Georgia would have had his needs met). In this case, the income disparity between anesthesiology and primary care had unequivocally affected her decision not to enter primary care, yet her empathy and understanding would have been valuable assets for patients. Her concern was med school debt (which would remain deferred in terms of payments until she completed her anesthesia training), which would have been nearly impossible to pay back over the 10 years they were due if she went into primary care.

Her need for a high salary to compensate for substantial med school debt could be argued effectively. However, some of the ways physicians have earned income has been downright bothersome. Early in my private practice days (the early 1990s), I was having a discussion with a med school classmate of mine who had completed an oncology (the treatment of cancer) fellowship after his internal medicine training. He was making enormous amounts of money (at that time over $300,000 a year). Since he didn't have much to speak of in terms of procedures (he could occasionally bill for a bone marrow biopsy, but this didn't generate a lot of income), I was perplexed by his earning power. I then learned that he had adopted a common practice amongst oncologists when he went into private practice. He would purchase the chemotherapy drugs to be given to his patients in an outpatient setting, and when they came in for a treatment, his nurse would administer them. Nothing unusual there. What was remarkable was the ability to mark up the chemotherapy drugs they were purchasing on behalf of their patients. In addition, they could have a nurse give the drugs, and bill another $30-40 for each patient to whom they administered the medications. When a single nurse gave therapy to 30-40 patients a day, it would really add up.

I would wager the oncologist might argue that these drugs needed great care when administered (indeed some did), and that the nurse needed to monitor patients after giving the drugs for side infects (as he or she indeed did need to do). But this amounted to a nurse generating over $1000 per day in revenue, with the nurse seeing little of it. The oncologists got the lion's share, and for what reason? That they were supervising the use of poisons in a controlled fashion (my overall view of oncology, the treatment of cancer)? This is not to argue that they were not due some compensation for this type of supervision, but as with the other examples above, compensation should be in proportion to the level of expertise required.

Attempts had been made in the past to try and equalize the playing field. In the early 1990s, a relative based valuation (RBRV, relative base relative value) system was proposed, and partially implemented. The problem was that some professions (e.g. radiology, ophthalmology and anesthesia) had created over billed profiles in the past, so that a 50% cut still amounted to maintaining notable disparities in the system. In the final chapter, I discuss some strategies that I think may be helpful in trying to remedy this situation. If we don't try to level the playing field, it will surely continue to affect the pool of new entrants into primary care medicine.

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