Friday, April 25, 2014

Yes, times are tough. But don’t compare doctors to janitors.

“Given that primary care doctors do the work that no one else is willing to do, being a primary care physician is more like being a janitor—but without the social status or union protections” writes internist Daniela Drake.  She asserts that being a doctor “has become a miserable and humiliating undertaking” and that many believe that, “America has declared war on physicians.”  And this: “It’s hard for anyone outside the profession to understand just how rotten the job has become.”

Some of her complaints (rants) may have some merit—physicians, especially primary care physicians—are undervalued, relative to other specialists, and they are drowning in paperwork that saps their professional satisfaction and takes time away from their patients.  But let’s get real: doctors are still among the most highly respected and highly paid occupations in the United States.   By comparing primary care to being a janitor, Dr. Drake demeans both her own chosen field and the hard-working people who work nights mopping her practice’s floors and cleaning its toilets.

Here are the facts. According to a new Medscape salary survey, internists who specialize in primary care earned an average of $188,000, and family physicians, $176,000 in 2013.  Yes, that’s near the bottom of all specialties’ earnings, but still more than 90% of Americans earned.  And if you are a primary care physician in a household with an income of $232,000 or more, which is the case for many whose spouses also work, you are in the top 5 percent!  To put this in perspective, “If you're in a family of four, and your family's income surpasses $66,000 a year, you're doing better than the typical American family. If you're making six figures, then you're doing much better than the typical American family. If you're making $200,000 or more, you're in truly rarified territory” reports the Washington Post.   The Bureau of Labor Statistics reports that the mean annual wage for janitors was $25,140.   The Census Bureau reports  that median household income, all occupations, was $51,000 (2012 data).

And, perhaps surprisingly, primary care physicians overall aren’t that much more dissatisfied with their pay than other physician specialists, a new study finds. “Primary care physicians were only slightly more negative [about their compensation] with 52% saying they did not feel fairly compensated while 48% did  with their pay,”  reports Medscape. “Considering the ongoing income disparities between primary care physicians and specialists, their having the same perception is somewhat interesting. There has been very little change in the responses to this question over the past 3 years.”

Lack of social status?  Actually, physicians rank third, behind members of the military and teachers, as the most respected professions.  “Roughly six-in-ten or more adults also say that medical doctors (66%), scientists (65%) and engineers (63%) contribute a lot to society. As with the military and teachers, negative perceptions of these occupations are comparatively rare.”  Lawyers are at the bottom of the public’s respect ranking, say the researchers at Pew.  The Gallup organization finds that 69% of the public rank physicians highly on ethics and honesty; nurses score the highest at 82%, followed by pharmacists (70%), grade school teachers (70%), and then physicians.  Lawyers, again, were near the bottom, with only 20% of the public saying they were honest and ethical.

So, Dr. Drake may not respect her own profession, but the public clearly does.  And by any standard, physicians—even primary care physicians—are in the top ranks of compensation.

This is not to say that there isn’t real heartache on the front lines of medicine.   According to Medscape, Internal medicine physicians are the most likely (68%) to say they would choose medicine as a career if they had to do it all over again, but internists are last  (27%) in saying they would choose the same specialty.  One likely reason is the amount of time that internists and other primary care physicians have to spend on paperwork.  “According to this year's compensation survey, 35% of employed physicians spend at least 10 hours a week on paperwork compared with 26% of the self-employed” reports Medscape.

Yet most physicians still like being physicians.  “Despite the frustrations, most physicians find their careers deeply rewarding” says Medscape. “Being good at their jobs (34%) and relationships with patients (33%) were cited most among those who responded. Twelve percent chose "making the world a better place." Simply being proud to be a doctor (6%) and making good money (10%) were less compelling factors.”

So no, Dr. Drake, most of your colleagues aren’t miserable.  Most are not leaving the field.  Only 3 percent are in concierge practices, Medscape found.

Fortunately, there are physicians who are willing to directly rebut Dr. Drake’s views. Dr. Aaron Carroll, a professor of pediatrics, penned this:

“Monday night, at the Seder we were attending, we all discussed things for which we were thankful. I acknowledged my thanks for my family and friends, and then said that I was very, very grateful to have a job which I found so utterly rewarding and fulfilling. Evidently, Daniela Drake disagrees with me . . .

I’ve written about this again and again, and I don’t want to repeat myself more than I have to. I think physicians complain far more, and far more publicly, than their situations warrant. For all their complaints, they still do incredibly well financially. They have more professional freedom than most working people. And they’re beloved.

Moreover, tons and tons of people want to be them. Applications remain at an all time high for medical school.

. . .  I’ve been around physicians for all my life, and for the entirety of it, I can remember many of them complaining. I can remember many of them complaining even while they made fortunes, lived fantastic lives, and had fulfilling careers. I remember many of them threatening to quit. None did.

I imagine that a fairly large number of Americans work just to get a paycheck. They find their jobs to be dull and unfulfilling, should they be lucky enough to have them. Being a doctor is a great gig, and I don’t really know any who would give it up to punch a clock or go do something else. I know some who’d threaten to do so, and some who wish things were better, but the number of them who follow through and abandon the field is near zero. At some point, people are going to ignore the cries of ‘wolf’. Other than bankers, is there any profession doing so well overall that complains so much in the media?”

Like Dr. Carroll, I also have been around physicians almost all of my life, although I am not one. I have spent my entire career, over 35 years now, advocating for the medical profession, and specifically, for internists, first with the American Society of Internal Medicine and since 1998, with ACP.  Every day, my colleagues and I on the ACP staff work to address the aspects of their jobs that are professionally unrewarding, especially excessive administrative burdens and a payment system that undervalues them compared to others.  So I sympathize with some of Dr. Drake’s complaints.

But I also know that engaging in public expressions of self-pity isn’t going to help physicians, nor is hyperbole.  Comparing a highly compensated and respected profession, doctors, with one of America’s most marginalized and least respected, janitors, isn’t going to make any friends for physicians.

Today’s questions? What do you think of Dr. Drake’s comparing being a primary care physician to a janitor “without the social status?”  And Dr. Carroll’s rejoinder that being a doctor is still a great gig?


Suresh Gupta said...

Yes I enjoy being an Internist someone who knows his/her patient, is able to guide the patient thru the labyrinth of procedures and tests most which they do not need. Unlike PAs or NPs I am nit triaging the patients to su specialists, and keeping the patient and family apprised of the status esp in an acute hospital.

Suresh Gupta, MD, CMD

Harrison Robinson said...

Who doesn't see the past as better than the present?
Isn't that what the sentiment is all about? Nostalgia, but really pining over something that never was.

I encourage young people to pursue careers in medicine. What could offer as many choices and as much career fulfillment?

I know primary care doctors who work like crazy -- apparently with goals of retiring young, I guess. But they make $30,000 to $40,000 per month.
They sometimes complain. But it is a choice.
They could choose to work much less and still make a lot of money. But they don't.
I know others who do work much less and yet complain.

But I live in San Diego, and I used to live in Wisconsin.
You would think that people in Wisconsin would complain more about the weather.
You would think that, right?
That's not what I see.
It's too cold. It's rainy. It's cloudy. I'm gonna go to the desert for the next month because it is warm and sunny there.
I hear it all the time.

The thing is, San Diego's weather is just about the best that Earth has to offer.

So, maybe listening to doctors complain is just....well, human.


Unknown said...

Please read "Physician Suicide Letters."

Now trending on KevinMD top story of the week:

I get these nearly every day. No amount of money or social status can heal the wounds doctors receive during their training.

This is not about money. Dr. Drake writes about the inhumane working conditions for doctors, people who went into a career to help people and they are now miserable. Many of them. Far too many.

I lost both male docs I dated in med school to suicide. And we lost 3 physicians in town to suicide in just over a year. And this is a smallish town - great place to live and work as a doc. One MD in town lost 7 colleagues to suicide in her career. What other profession allows this kind of loss?

Pamela Wible MD

Unknown said...

Please read "Physician Suicide Letters."

Now trending on KevinMD top story of the week:

I get these nearly every day. No amount of money or social status can heal the wounds doctors receive during their training.

This is not about money. Dr. Drake writes about the inhumane working conditions for doctors, people who went into a career to help people and they are now miserable. Many of them. Far too many.

I lost both male docs I dated in med school to suicide. And we lost 3 physicians in town to suicide in just over a year. And this is a smallish town - great place to live and work as a doc. One MD in town lost 7 colleagues to suicide in her career. What other profession allows this kind of loss?

Pamela Wible MD

PCP said...


A little light on the elitist "I'll tell you how it really is".
There are a few ground level facts. Internists do great work and i would personally not select any other provider to do the primary care for an aging population. My parents are both under the care of a wonderful general internist well into his 50s and i pray every day he is on the job into his 70s. I know they are fortunate to be under his care and would wish that upon a majority of american seniors.
Yet when I see the non sense transformation of american medicine endorsed by organized medicine and liberal elites, i see a path towards care fragmentation, corporatization, use of sub par practitioners with increased autonomy etc . I sense that care it is getting ever more remote for tomorrows seniors. I sense tomorrows Internists feel marginalized and less valued by the system, they feel less control over their work environment, they then sense the changes foisted upon them and can only do what they can within a broken system that systematically. Decision makers ie CMS, Large Hospitals and Insurance Corporations, Big Pharma etc, really set the rules that we just follow. We are heavily regulated and marginalized as a profession, and persistently under attack. We have the weakest representation amongst all stakeholders and the results speak for themselves.
When one looks at every so called assistance rendered to the solo private practice generalist. One can't help but yell out to you all in DC to please just quit helping us!
The unfunded mandates, the onerous paperwork and reporting requirements, the semi annual threat of massively business model disruptive SGR cuts, the price fixing monopolistic bureaucracy that is medicare, the whole host of issues we have discussed ad nauseum with no apparently desired cure, clearly suggest that the days of the majority of internists thriving in private practice are numbered. They are numbered mainly because the customer was not really given a choice. CMS/Federal gov't through its policies and with its overwhelming market power has decided for them. Just the way liberals would have it. Mind you the mainstream Republican solution of turn it over to the mega insurers is just as non sensical. The sensible solution that can bring quality primary care back from the death is tax advantaged/subsidized HSAs for all for primary care, coupled with deregulation of simpler OP services, with catastrophic insurance reserved for coverage for major illness.
PCPs are not stupid, they remember very well their work environment 20yrs ago. As a lobbyist for all these years one wonders how well you regard the work environment today for physicians in comparison?

PCP said...

When you say we are still respected and well paid, one wonders if your strategy is to wait until we are much less so?
When you speak of the "the top 5% income!" I must remind you of a few simple facts. At that level of income, one faces discriminatory or as you would perhaps call it progressive taxes, retirement benefits will no doubt be means tested, your children's college education will be fully paid, ie all social rebalance mechanisms work against you. Next you don't get to that point without incurring about 300k in debt, basically a second mortgage, and you won't get there until well into your 30s. Adjusting for those factors, the income differential is not quite what you make it out to be. As you can see all of these things are real and present issues faced by new graduates every year. And lets face it they are fairly unique to medicine which has the most deferred gratification quotient of any profession I can think of.

I think that delivering quality whole patient oriented longitudinal primary care is a most gratifying profession, especially if it can be structured to be doctor-patient centric. It is what I cherish that my parents still have and what I would wish for anyone else at their age.
We need for the system to treat it as such. When we trample on that foundation and replace it with a much inferior one, why should we be surprised at the results.

JW said...

As a geriatrician in the community I make $120,000 dollars a year and it has steadily gone down for the last 4 years as my hours have gone up (with non-compensated paperwork, travelling to multiple nursing homes, phone calls, emails and care coordination). The system is not geared toward intensive primary care that is required by geriatrics. I cannot do it all alone. I have resigned.

Walter Bond said...

What strikes me as interesting here, is that the data cited is a recent survey done by Medscape. Does not the ACP have any data? I would assume that the ACP would be interested in data that reflects actual behavior, such as: changes in average retirement age, what sort of practice internists are participating in, what % of IM residents are choosing to practice primary care general medicine, changes in rates for disability insurance (an indirect marker of job satisfaction taken in the aggregate), what % of internists recommend it as a career for their children (particularly if they themselves are children of internists). There are many other relevant questions, I am sure, that get at actual behavior rather than survey satisfaction percentages done by an outside group. What does the ACP data suggest about actual physician behavior regarding primary care, rather than answers on surveys?

Harrison Robinson said...

I'm guessing that you see only self pay and straight Medicare, or perhaps you are in a state where you can see Medicaid patients and survive too.
Coding is everything in that setting. And even with that it may not be good enough.
You probably see 12 patients per day, or around 50 per week.
Most of them pay you about $100 per visit. So about $5000 or maybe $6000 per week, or about $240,000 up to about $300,000 per year -- with rent going for about $5000 per month and staff costs of about $60,000.
That leaves about $120,000 for you.

There may be ways to create efficiencies, or to bill higher.
Coding can help.
Taking capitation contracts can stabilize income streams. And potentially pay you for cost savings to the carrier.
In office labs might pay something.
Nursing Homes need you to take Medicaid patients. You can ask them for stipends for services as a medical director or associate medical director.

I don't know anyone's individual circumstances, but I know the current environment can be frustrating.


james gaulte said...

Who would know better the professional conditions and psychic state of practicing physicians than someone who has "been around" a small subset of physicians involved in medical politics for many years and who works as a paid lobbyist for one such organization? Oh,I don't know maybe a real physician such as Dr. Drake.

BDoherty said...

You think I've been around only a "small number of physicians", Dr. Gaulte? In the past twelve months, I have attended, mingled with,listened to and spoken to thousands of practicing internists attending ACP clinical chapter meetings, grand rounds, and others in VA,DE, MD, KS, UT, NE, PA, FL,DC, IL, MA, AK, NV, NY, SD . . . and many many more. (And over the years, I have visited with internists in every state of the country). One of the parts of my job I like most is getting out of DC to hear from the rank and file in all parts of the country. The "small" number of internists involved in ACP leadership and policy development actually are hundreds on our councils, Board of Regents, and Board of Governors. So with respect, I think I have probably spoken to more doctors, in more parts of the country, than just about anyone. While many have frustrations with practice, most of them also love what they are doing, and would find Dr. Drake's comparison of their proud profession to be ludicrous and offensive.

There is much that can and must be done to improve the environment for practicing physicians, but public expressions of self-pity,hyperbole, and tunnel vision on how physicians compare in income and status to the rest of society will not help physicians.

Mark Mayer said...

In the Medscape survey of physicians released last week, in answer to the question "If you had it to do over, would you go into Medicine again?" the specialty answering yes most often was Internal Medicine!

Mark Mayer said...

In a recent Mescape survery, when asked "If you had it to do over, would you go into Medicine?" the specialty saying yes most often was Internal Medicine!

james gaulte said...

Mr Doherty,

If you quote me please get it right. I did not say small number , I said small subset.Of the practicing physicians in the country you have talked to and been around a small subset.Further it is likely a biased sample as you have talked to mainly members of ACP who attend ACP functions and for the most part agree with ACP policies while there are many physicians who do not.

Shivam Joshi said...

The post by Daniela Drake wasn't about remuneration or social status. Her post focused on the struggle to provide quality care to their patients while remaining sane - and in some cases, literally. As a leader of a prominent physician organization, it is unfortunate that these issues are being dismissed instead of being addressed. We plea not for us, but for our patients.

Shivam Joshi, MD