As politicians dither over Medicare cuts, Medscape readers are angry that society expects them to not be concerned about the bottom line.
A couple of consumer surveys had shown that some people wondered why doctors were not universally delighted with the healthcare reform plan. Respondents felt that doctors should be so pleased at the expanded coverage that they'd ignore their own income concerns.
When this question ("Why aren't doctors allowed to care about money?") was posted on The Kane Scrutiny blog on March 25, I suggested 3 possible answers to the question: (1) Consumers feel that doctors still make enough money; (2) people in helping professions aren't supposed to care about money; and (3) patients have an emotional need to believe that their physicians care only about patient well-being, not about money.
Medscape reader response was impassioned. Tens of thousands of physicians and healthcare professionals read the article, and over 380 physicians wrote in to express anger, sadness, and frustration. Many Medscape readers bemoaned the fact that society has lost its belief in the value of physicians' services and expertise. Some doctors chastised their own profession for allowing this situation to develop. Others said that the general public simply has no inkling of what it takes to become a physician and the level of responsibility carried on a daily basis.
Many responses provided keen insights and some useful venting. Several themes emerged:
The Medical Profession Is Different From All Other Professions
No doubt about it: Medicine has always been infused with an aura of altruism, and people expect doctors to be fulfilled by the knowledge that they're helping others. However, that doesn't allow for reaping financial rewards from their work. An anesthesiologist commented, "My plumber with no student loans, no education, and accepting only cash payments has an easier and more profitable career. Yes, medicine is a very altruistic career, but altruism doesn't pay for college, graduate schools, mortgages, food, etc. The CEO of United Healthcare with $23,000,000 in earnings last year couldn't give a hoot about the altruism in medicine."
Another anesthesiologist said, "Doctors are allowed to care about money, as long as no one's life depends on the service they provide. No one is proposing that plastic surgeons be required to provide a certain level of free care. That's the paradox -- the more life critical one's specialty is, the less they are afforded the opportunity to care about what they make."
"What really concerns me amongst people who are critics of physician salaries is the notion that physicians shouldn't care about their incomes," said a general surgeon. "This is a disrespectful and ignorant point of view that serves only to dissuade capable individuals from choosing a career as a physician in the first place."
People Resent Doctors' Success...
Both the material rewards and the general status accorded to doctors probably rankle many consumers. An emergency medicine physician said, "The two bases of human emotions are envy and greed. Joe Average is envious of physicians' status and earning ability, although he knows he was not smart enough to get the required training or disciplined enough to complete it. The latter emotion, greed, is simpler: He wants everything for free...We can't overcome these basic instincts. We have to watch out for ourselves. Ricky Nelson once sang, 'It's all right now, I've learned my lesson well, I can't please everyone, got to please myself. '"
An endocrinologist asked, "For all these patients who think that doctors make too much money, I would like some answers. Why is it okay for the entertainment world (athletes, movie stars, television personalities) to be millionaires? Is it not okay that your doctor who had to endure twelve or more years in medical school and residency be compensated for this? Should your doctor who works overtime every week be compensated for this? I believe every person has a right to be compensated for their achievements and success. I don't believe in redistribution of wealth. If people are constantly given everything for free, where is the motivation to excel in life?"
Another reader posted this comment: "It's not the doctors who make 90k or the ones who make even 200k that have most people thinking that costs could come down. It's the doctors who make 500k per year while someone with a 50k salary and a family of four might not be able to afford health insurance."
One family physician summarizes the irony of actually being an altruistic doctor: "It seems I help treat the needy and we see patients milking the system. We are in danger of being sued by the 'cannot make happy group.'"
....But Physicians Deserve Their Salaries
The years of medical school, the long hours, debts, and sacrifice seem to be irrelevant to many outside the medical profession. One preventive medicine physician noted, "At present, before expenses, the roofer gets $8 an hour more than my professional fee BEFORE EXPENSES; the electrician $12 an hour more, the mechanic, $13 an hour more and the plumber $30 an hour more." Added a psychiatrist, "My plumber, my TV repairman, the guy who mows the lawn, all demand immediate payment. Don't we all at least deserve as much respect as them?"
Said a cardiologist: "Our salaries are because we work our butts off, give up time with our families to take calls and work weekends, deal with stress most business people could never imagine (telling someone their mom has died or is dying, etc.), studied hard AND LONG (anyone get a chance to really enjoy their 20s or even early 30s? Didn't think so), and we should never have to apologize for being successful through diligence and sacrifice."
Are Doctors Partly to Blame?
A number of readers felt that doctors have abetted the decline in reimbursements.
"Doctors have allowed the insurance companies and other payers to substitute for their own collection efforts," said an emergency medicine physician. "Because of this, they have become even more uncomfortable with receiving payment in any other way. We have suckered in for 'the only ethical way to receive money is if others just GIVE it to us.' We didn't take responsibility for our own incomes and that is why we are here. It was just easier to let 'the big daddy' do it -- albeit with huge pressure from 'the big daddy.'"
A urologist added, "We have failed to take control of our collective destiny for years. When you participate in a cents-on-the-dollar agreement with an insurance company or accept crummy reimbursement from Medicare/Medicaid, you are giving up your autonomy. We gave it up years ago, and now it will haunt us. "
The Herculean effort required for doctors to get paid is also unseen by patients. One reader's suggested solution is to change the current procedure so that patients -- instead of doctors -- submit claims to insurers. Suggested an anesthesiologist, "It's time that physicians make patients deal with the insurance companies and get their medical care paid for. If large numbers of physicians stopped taking the responsibility of holding the patient's hand through the insurance process and instead let the patient deal with the hassle, a lot would change. Patients would see how dysfunctional the system is and begin to demand change."
The Public Has a Misguided View of Physicians
Some readers noted that patients have a negative view of doctors based on some notorious physician offenders. Said an emergency medicine physician, "The problem is that the public's impression of our profession is colored by the worst 10% of doctors (as they say, it is a profession in a fish bowl). The fact is there are doctors who let money come before the lives and health of others. In the ER I've seen specialists ask for a wallet biopsy before they would see a patient."
Another reader, in an overall sympathetic posting, noted the occurrence of medical errors and fraud, "showing hospital coding violations, deaths due to poor physician handwriting, unneeded surgeries (not related to defensive medicine), and some bad doctors." The reader asked, "If you were a legislator throat-latch deep in an HC Reform debate, how much confidence would you have that medicine ought to continue policing itself?"
Some postings suggested that doctors have been too quiet about expressing the situation to the public, and that speaking up might make a difference. A cardiothoracic surgeon suggested, "Every opinion expressed above reflects the genuine frustration of a profession committed to doing good for their public. For some reason, all these honest observations have never been presented to the public in ways that will gain their attention and support for needed fair change. The conversation seems to begin and end in doctors' lounges and at conferences.
"Maybe someday in the not too distant future," he added, "a critical mass of physicians will stick their heads out of windows and express their undeserved frustrations to their public. Perhaps only then will the public wake up to the fact that their 'doc' is working under hostile conditions which need to be alleviated."
Yet a general cardiologist felt that even that won't make a difference. "Unfortunately, I am convinced that the only 'yells out of the window' that the public will hear is the locking of our office doors as we quit."
Time to Take Action?
A couple of readers suggested a more activist stance. A family physician recommended: "Just say no. Let the doctors, except for a skeleton crew of ER docs, go on strike one day a month. Go to Washington, NY, LA with white coats on. Nothing medical happens in this country without physicians; not prescriptions, procedures, examinations, or even home care orders. There are fewer than 800k of us, way too few for a population of 300 million. Doctors have been far too passive, perhaps because we are afraid of being accused of "being in it only for the money."
Yet Doctors Still Express Positive Notes
While frustration was clearly the emotion of the day, there were still positive feelings for the profession. One internist said, "I enjoy my job and love my patients. And I make above average money for an internist, 240k or so. I own my own practice and work pretty hard. When I compare what I make to what the local public teachers make on an hours worked basis and figure in their benefits, it's about the same pay. I guess I have nothing to apologize for, in terms of income."
A psychiatrist summed up what may be the gut-level issue that plagues everyone who charges for services. He quoted an old Russian proverb: "The doctor is an angel when he tenders his cure and a devil when he tenders his bill."
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Cite this: Leslie Kane. Why Aren't Doctors Allowed to Care About Money? (Part 2) - Medscape - May 13, 2010.