Appendix 55 - Money

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]


"A doctor shouldn't have to worry about money. That's one disease he's not trained to fight. It either corrupts him or destroys him." - Sidney Kingsley

Betrayal

Annals of Internal Medicine: "Physicians should heed the sobering message the [Healthcare Fraud and Abuse] laws send - Americans have lost faith in their physician's ability to restrain themselves when tempted by money."[632] One survey found that two thirds of Americans believe that physicians are, "too interested in making money."[633] A few doctors agree. "I get $700 from medical insurance companies to do a D&C," one doctor writes. "If I go slow, it takes forty-five seconds, maybe a minute. I mean, I ought to be wearing a holster and a mask. That's absurd."[634] From Women and Doctors: "What can you call it but greed when an ophthalmologist charges $3,000 to perform a cataract procedure that takes twenty minutes?"[635]

From Pharos: "Medical fees have risen much more than the rate of inflation. During the period from 1970 to 1990, medical charges rose about three times the rate of inflation, yet the service provided diminished."[636] Reported in Women and Doctors, "The ratio of physician income in America relative to the average compensation of all workers in 1986 was 5.1 to 1."[637] And this meteoric rise in physician incomes, one doctor notes, occurred at the very time when increasing numbers of American citizens, particularly children, moved into poverty.[638] From an article called "Doctors and Dollars":

At a very simple level, the fact that physicians are so well paid augments the sense of them up there, of them being God, of them not making any mistakes. And when someone is paid $100,000 a year, and a patient makes $15 or $20,000 a year, that just exacerbates that sense of separation... not to mention the resentment people feel over physician's salaries. Other doctors - caring, sensitive doctors - literally look at me like I'm crazy when I say this. They think I'm dead wrong.

We have no special talents; we're just ordinary folk who have sworn to serve the ordinary folk we came from. When we exploit our service role to gain power to achieve financial gain while our neighbors cannot, we are deliberately choosing upward mobility at the price of alienation from those who we need most.... Is there any wonder they call it greed? Maybe betrayal would be a better word.[639]

The love of money is the root of all evil - I Timothy 6:10

A doctor describes speaking before a group of conservative Christian doctors:

Most of them were very wealthy - millionaires. I told them that accumulated wealth was wrong, that they ought to be using their wealth for other people, that the only purpose of wealth is to create justice, and that we have enormous injustices in this country.... They asked me if I was sure I was saved and basically got into questioning the validity of my own conversion. I am fairly sure that the reason they needed to do that was because I had presented them with something that didn't jibe with their interpretation of Scripture. So they needed to disqualify me as a person who had authority to talk about these issues.[640]

Leona Helmsley: "We don't pay taxes. Only the little people pay taxes."

Medical school promised to steal one's youth and breed some kind of greed for reparations - Fitzhugh Mullen

Phyllis Chesler talks about doctors in her book About Men:

'I'll make them pay,' they mutter, long-distance runners, biding their time. And the patients do 'pay': in money, in respect, independence. But even the money is not enough... most doctors withdraw, turn cold and contemptuous; a child's most frightening tantrum.[641]

She envisions a room filled with physicians:

They talk of paintings, real estate, art, and good years for wine.... After dinner, thick green Havana cigars, brandy, coffee poured from a silver service. The wives are all young, but already know how to manage servants, are already in touch with the best private schools, already know where the best vacations can be had.

Less than ten blocks away, the poor are propped up in several hospital emergency rooms; a patient rings for a nurse who doesn't answer; an ambulance arrives too late; a young intern, without sleep for two days, doesn't know what to do.[642]

How could doctors get this way? One second year resident from an article in Social Science and Medicine:

'Internship is a rough experience.... And people have no concept of the sacrifices you're already making and you reach the limit in internship to the amount you can give and you want something in return.... God damn it - wait a minute. What's in it for me! You can carry the altruism of a third year medical student just so far.... You aren't willing to make any more sacrifices....'[643]

From M. D. Doctors Talk about Themselves:

I understand why physicians come to feel this way. The hard work and concentration camp-like environment in the third and fourth years of medical school and residency give you the feeling that you are abused and that you are owed something.... And when I got home at three or four in the morning, I said to myself, Goddamn it! I deserve all I can get! It was a visceral feeling, and I could see that if you ran with it there would be no bounds to how much you thought you deserved.[644]

From Mother Jones:

Medical students and residents... crave to compensate for the loss of 'the best years of their lives' with outlandish incomes.... Perhaps each student should simply be given a Porsche on finishing residency - it would be a lot cheaper than 30 years of six-figure incomes.[645]

"Most surgeons are well paid," one doctor writes, "and I think they ought to be. I've paid a personal price to become a surgeon. I've paid a family price. My family hardly ever sees me.... I tell you, the surgeons making $800,000 a year are earning it."[646] Says one doc in Forbes, "Medicine is still a noble profession... but we also want basic things for ourselves."[647]

Cui bono? (Who profits?) - Cicero

From a book by Thomas Szasz, The Theology of Medicine:

In general, we should regard the medical man, whether as investigator or practitioner, as the agent of the party that pays him and thus controls him; whether he helps or harms the so-called patient thus depends not so much on whether he is a good or bad man as on whether the function of the institution whose agent he is, is to help or harm the so-called patient.[648]

From Our Bodies, Ourselves:

The image and myth of the doctor as humanitarian, which has been so assiduously sold to the American public for the last fifty years, is out of date. If there ever were such doctors, they are mostly all gone now.... Most men in practice today most closely resemble the American businessman: repressed, compulsive, and more interested in money (and the disease process) than in people.[649]

Quoting from Academic Medicine: "Medicine faces no greater threat to its very survival as a calling than the alarming erosion of trust between doctor and patient that we are witnessing."[650] Pharos: "If doctors view their practices as businesses, they should not be surprised to find that their patients view them as businessmen and women."[651]

Greed for Dummies

Greed in medicine is nothing new. From the premiere issue of the business journal Medical Economics, an article entitled "Injecting the Prompt-Pay Germ to Prevent Slow Pay Disease." One collection letter from the article read, "The doctor is your best friend in time of trouble and just as in emergencies he strives to help you and yours, you should strive to help him by promptly paying your bills." Commentators suspect the veiled message is, "Pay up, or the doctor might not show up at your next emergency."[652]

Advice and instruction from books at the turn of the century:

How to Obtain the Best Financial Results in the Practice of Medicine

Never allow sentiment to interfere with business. The 'Thank-you' is best emphasized by the silvery accent of clinking coins.

Large Fees and How to Get Them

No doctor who is wise will receive a caller immediately upon arrival. It creates a good impression to keep the caller waiting for a few moments even if there is nobody ahead of him.

[The doctor's] earnest talk will be on the prospect of obtaining... a cure for the ailment. So far as the patient can judge from the doctor's attitude and conversation the professional features of the case have a much stronger hold upon his mind as the financial.... [The author admits to his readers, however,] this is pure bunk. The doctor doesn't mean a word of it.

Building a Profitable Practice

Always seem serious and busy when patients come into your office; have medical books strewn about, showing that you are studying. Never let a patient see you reading novels....[653]

 


 

[632] Bloche, MG. "Cutting Waste and Keeping Faith." Annals of Internal Medicine 128(1998):688-689.

[633] Nelson, AR. "Humanism and the Art of Medicine." JAMA 262(1989):1228-1230.

[634] Pekkanen, J. MD: Doctors Talk about Themselves New York: Delacorte Press, 1988:145.

[635] Smith, JM. Women and Doctors New York: Atlantic Monthly Press, 1992.

[636] Massell, TB. Letter. The Pharos 1994(Summer):44.

[637] Smith, JM. Women and Doctors New York: Atlantic Monthly Press, 1992.

[638] Rogers, DE. "On Trust." The Pharos 1994(Spring):2-6.

[639] Owen, JA. "Doctors and Dollars." The Pharos 1994(Winter):2-5.

[640] Szasz, TS. The Theology of Medicine New York: Syracuse University Press, 1977.

[641] Chesler, P. About Men New York: Simon and Schuster, 1978:180.

[642] Ibid.

[643] Mizrahi, T. "Managing Medical Mistakes." Social Science and Medicine 19(1984):135-146.

[644] Pekkanen, J. MD: Doctors Talk about Themselves New York: Delacorte Press, 1988:150.

[645] Osborne, D. "My Wife, the Doctor." Mother Jones 1983(January):21-25, 42-44.

[646] Pekkanen, J. MD: Doctors Talk about Themselves New York: Delacorte Press, 1988:152.

[647] Lau, G and TW Ferguson. "Doc's Just an Employee Now." Forbes 18 May 1998:162.

[648] Szasz, TS. The Theology of Medicine New York: Syracuse University Press, 1977.

[649] Boston Women's Health Book Collective. Our Bodies, Ourselves New York: Simon and Schuster, 1973:252.

[650] Cohen, JJ. "Leadership for Medicine's Promising Future." Academic Medicine 73(1998):132.

[651] Landsberg, L. "Altruism in Medicine: Prescription for the Nineties." The Pharos 1993(Winter):9-10.

[652] "Collection Letters from the '20s." Medical Economics 19 October 1998:29.

[653] Holt, N. The Business of Medicine." The Pharos 1998(Winter):32-37.

 


 

Reader's Comments

No one is debating that physicians compared to the median population make a decent salary. My question is why does the debate about over-paid professions seem to encompass only physicians? The ophthalmologist that charges $3,000 for the cataract surgery does not pocket that $3,000. There is the cost of equipment (which in that type of office can be quite an initial capital outlay). There is the operational cost of the office (leasing or mortagage payments, salaries for supporting staff, computers, copiers, paper etc., the cost of billing and collections and malpractice insurance. This does not include the cost of maintaining credentials (licensing fees, contined medical education, fees for hospital priveleges). This does not even take into account educational debts which may encumber the physician early in his/her career. Indeed, to succeed in becoming a physician, there are years of delayed gratification. When many of our colleagues in college have long since graduated and have been making sizeable salaries, we still languish in training, with long arduous hours, immersed in one of the most stressful learning environments that one can imagine and with little or no income (and most likely, additional and more profound educational debt). During this time, we sacrifice precious, youthful years. A time when others can choose to be adventurous, or date, marry and begin their families. When we finish, we can look forward to taking on the additional debt of starting a practice, inevitable law suits and on-call schedules. For most of our working lives we can continue to count on missing holidays with our families, birthdays with our children and anniversaries with our wives. We have the honor of being in a group with a high rate of burnout, break-downs, addictions and divorce. And, no wonder. It is one of the few professions were work is not just a job to provide for our needs. Our work is our life. It defines us and who we are. You're not just a doctor in the office or hospital, you're that doctor every minute of every day in your community. At home with family and friends, at church, even in the grocery store, we are approached, and are expected to live up to the role of "physician". Most of us place nothing above the job we do. We take pride and honor in our profession. We will neglect our health (rarely does a doctor call off sick), our families (can't make the family reunion, I'm on call), or spirituality (got paged in church, gotta go!). Often, we feel we feel no higher calling than the patients we care for. In my humble opinion, to ask our physicians to commit to this degree of life-long dedication and sacrifice, then begrude them and their families of a decent salary is unfair. Do we hail a similar outcry to CEOs of major corporations who spend less time in training and commit to less personal sacrifice when they make 10, 20, 30 times the amount of the average physician? Are we as aghast at athletes who, even if they don't finish college, make over 100 times the salary of a physician? Never mind the opthalmologist who charges $3,000 for a cataract surgery. When we find out that Tom Cruise commands 20 million dollars per movie (not including residuals), will we in outrage stop paying $15 dollars for a movie ticket? I'm sure no one would ever dream of supporting their local sports team by building a new stadium/arena with tax payer dollars, even though the majority of revenue generated by such ventures end up in the pockets of sports team owners and private venture capitalists! Surely, Bill Gates, worth billions of dollars, should be required to give away the computers (or at least the software) that we as a society cannot live without! Fast forward to reality. Health care is costly. In terms capital outlay for building, maintaining and enlarging health care facilities, recruiting and paying for health care professionals, research, developing and implementing new technologies and in creating avenues of access to health care for all of our citizens, the cost of having arguably the best health care system in the world costs real money. Even so,in general, as health care professionals, we provide more free services (not really free, but at our own personal cost) than perhaps any other industry. Hospitals and Emergency Physicians are mandated by federal EMTALA laws to see every patient that presents to the emergency department, regardless of their ability to pay. Each of those patients represent a real cost that must be bourne by someone (and not the federal government). I realize that healthcare is important and should be accessible to all of our citizens. Yet, a starving man could not demand free food from a supermarket or restaraunt (certainly, food is at least as important as health care)! A homeless family cannot demand shelter at a local hotel (yet, we recognize shelter as an important component of a decent quality of life). Even an elderly patient, who cannot afford necessary prescription medicines nor air conditioning during a sweltering summer, could demand goods from the pharmacist or utilities from the local electric company. So when we decide what our priorities should be, we should consider our choices. Would we rather pay 50 bucks for an office visit or 100 bucks for those playoff tickets. Will it be $100 to the radiologist or $120 buck for a new pair of Nikes? Should grandma get the $3000 cataract surgery or grandson get the $20,000 bass boat? 100 grand for the coronary bypass, or 120 grand for the mercedes? PAP smear vs HBO television, PSA vs more minutes on the cell phone? Every other year colonoscopy vs one pack per day cigarettes? Before we start to round up all the rich and greedy physicians and burn them at the stake, understand that the best and brightest of all children will migrate towards the professions that reward them the most. That will be the direction of our greatest and finest industrial and technological advances. Ask yourself, "where do I place my real priorities?". And when the rubber meets the road, like that funny and popular credit card commercial, ask yourself, "what's in your wallet?"!

-- kelvin spears, October 10, 2003
I do not have a problem with people who have worked hard to enter a certain profession making more money, but the disparity has gotten completely out of hand. I know a good, caring daycare worker who makes minimum wage. It costs her $89 to go to the doctor or take her children to the doctor, often for a 5 minute appointment. It takes her about 23 hrs. of work to pay for that 5 minute doctor's appointment.

As a teacher and daycare worker (while home with my own kids), I can attest to the backbreaking and often thankless work of raising and teaching other people's kids for very little pay. I think all teachers and daycare workers should refuse to come near doctors' children for anything less than $100/hr. per child. Afterall, how much is the education of little Dr. junior worth?

-- Kristine Soedal, January 29, 2004

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