How "Doing Right" can help you decide if you should become a doctor in America (Part II)

How much should doctors be paid? A controversial question that has made it to the headlines with recent strikes across the NHS amongst junior doctors. In discussing these strikes and doctor’s salaries with my friends, I have found the topic of “moving to America,” coming up quite frequently. I would be lying if I said I haven’t considered moving myself, I know many other people going to medical schools in the UK who have expressed similar sentiments. I have found that so many questions arise from discussions around this topic and that the information available can often be overwhelming and unclear. The beauty of the section “Better” explored this week is the clarity with which the author handles this complex subject. Thus, rather than ramble on in this section, I think it is best to allow the book to speak for itself…  

Figure 1- Newspaper headlines around the strikes in the NHS

Book of the week: Better: A Surgeon's Notes on Performance by Atul Gawande

This week’s theme of doing right is the topic covered by Gawande in the second section of his book “Better.” The author draws upon 4 key stories, 1 of which will be covered this week:

• “Piecework.” Gawande (a physician in America) opens with an awkward conversation during his first job after residency, where he is asked “How much should we pay you?” With his future employer’s refusal to tell him what surgeons usually make; the author was left to ponder what he should be paid as a surgeon. In trying to decide what salary he should ask for, he asked some of the surgeons at the hospital what they were paid but they were squeamish on hearing this and didn’t want to say. This anecdote is utilised by Gawande to raise the controversial question about what doctors should be paid. 

  The first argument presented by Gawande on this matter is the most ubiquitous: doctors are not supposed to be in it for the money. The more concerned a doctor is about making money, the more suspicious people tend to become about the care being provided. Even if this is the case, that still does not answer the question about what doctors should be paid.

  To answer this question, Gawande examines how the pay for doctors has been determined in the past and in the present. He found that doctors used to be paid per procedure, with the doctors deciding what they wanted to be paid per procedure, as you can imagine this was very biased and led to inflated procedure costs. This problem continued in the 20th century, for example cataract surgery in 1985 cost around $6,000 as it took 2-3 hours but when new technology was introduced that meant it took only 30 minutes, prices shockingly remained the same. Another problem that arose from this system is that payments for doing procedures tended to far outstrip payments for doing diagnosis. In the mid 1980s, doctors making complex and life-saving diagnosis for an hour were paid $40, whereas for doing a colonoscopy for an hour received over $600. This discouraged good quality care. 

  This archaic system had to change. Eventually, a new system was put into place so that doctors were compensated for the work involved. To facilitate this new system, in 1985 a Harvard economist (William Hsiao) was commissioned to measure the exact amount of work involved in each task the doctors perform. Using an equation, eventually, Hsiao and his team reached a relative value for everything doctors do. In 1992, Medicare paid doctors accordingly. Despite its widespread use, Gawande argues that there is a certain arbitrariness to the results. Who can say which procedure is more labor-intensive than another? However, this system is where the standardised fee schedule arose from. This schedule is a list of procedures, and the pay doctors receive for them. 

  Using this system, Gawande reports on finding out from the number of procedures he would be expected to do that he would be paid $500,000 a year but also would have to consider malpractice insurance, renting office space and clinical space, buying office equipement, hiriring staff, patients who don’t have insurance and therefore can’t pay. Then there is the issue of factoring in what kind of insurance patients have; some insurance companies pay more than others and some insurance companies may not even recognise you as a physician! 

  Trying to find answers, Gawande recounts speaking with an advisor who claims how much doctors make doesn’t necessarily link to how good they are, but instead largely depends how they deal with the business side of their practice. To be successful, doctors in the US must take on many of the insurance troubles themselves, an extremely time-consuming process. On top of that, many American doctors also must act as financial councilors, having to turn patients away and saying, “you can’t come in unless you have cash, cheque or credit card.” With all these factors considered, it is very possible for a group of surgeons to lose money in a year if they do not manage their insurance and payments properly. Gawande aptly sums this up, saying: 

  “(in order for) doctors to make money, it is a war against insurance companies every step of the way.”

  So, although doctors do get paid high amounts of money in the US, surveys revealed in some areas more than 50% of doctors think they do not get paid enough compared to the amount of work that they do. Studies back this up, by them finding that working hours for physicians are longer than for other professions on average. Adding to this point, Gawande uses statistics to compare different professions. Viewing the cost of education and training for different professions as an investment, Gawande calculated the annual rate of return for different professions as follows: 16% in primary care medicine, 18% in surgery, 23% in law and 26% in business. Although lawyers and businessmen can get higher salaries than medics, most biochemists, and scientists earn much less than medics. This then raises the question: In the end, are we working for the patients or for the profits? Most decide not to definitively make that choice. 

  However, Gawande argues that those who do decide to make that choice can earn considerably more than most. The author recounts talking to one such surgeon, with a special interest and skill in laparoscopy. This surgeon had office hours from 9:30 am to 3:30 pm one day a week, had only 6 hours of operations a week but still managed to earn $1.2 million a year for the past decade. How? He charges a lot more than insurance companies, lives in a big city (where people can afford his prices) and he is somewhat of a star in his field. Gawande confronted the surgeon on hearing this: 

  “Would you only want to be a doctor to those who can afford you?”

  The surgeon argued against this, saying:

  “For doctors to think we must be altruistic is sticking our heads in the sand. Everyone is squeezing us to make money, in 2005 the CEO of some insurance companies was 10 million dollars, these are for profit companies. In fact, insurance companies make money by withholding reimbursement to physicians or for not paying for a service doctors have provided.” 

  In this surgeon’s view, doctors need to understand that they are businessmen and the sooner they understand this the better. Gawande argues against this:

  “Yet if this is purely a service for money business, why choose to endure 12 years of medical training than say as little as 2 years of business school? Doctors are partly motivated by doing meaningful and respected work for people in society. Thus, there is responsibility most people feel to take care of patients even if insurance companies exacerbate us, as otherwise the notion that we do something special is gone.” 

  There is a struggle between “doing right” and doing well in medicine. To illustrate this point, Gawande draws upon his experiences with the heart surgery that saved his son's life. Originally, the total cost of his son’s treatment was a quarter million dollars, but he only paid 5. Despite being in no position to pay the original cost of his son’s surgery, insurance meant all he had to consider was his son’s needs. With other people being charged, he did not care what expense was paid to save his son. To him, all the members of the team deserved $1,000,000 for saving his son. Thus, the adversarial relationship patients and doctors have with insurance companies is revealed. Physicians are better compensated in America than anywhere else in the world (compared to average salaries in countries), allowing the US healthcare system to attract amazing talent from around the world and keeping doctors willing to work harder than any other profession. But there is a major problem. The USA as a country has little concern over those who are not insured, these are too poor or aren’t old enough to qualify for government profiles but whose jobs aren't good enough to provide benefits either. 

  To end this section, Gawande recounts returns to the office, after much deliberation, and gives his employer his desired salary figure. Now he was the one too embarrassed to disclose his pay.

Thanks for reading,

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