The Frontal Cortex

Medical Salaries

Posted by Jonah Lehrer on March 26, 2007
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Here’s your medical factoid of the day:

As of 2003, the average income of a French physician was estimated at $55,000; in the U.S. the comparable number was $194,000.

Personally, I’m a little frightened by the idea of my doctor not being highly paid. I don’t want my surgeon to be a member of the middle class. I hope that anybody who’s holding my heart in his hands is a highly trained professional, worthy of a ridiculously high salary. Medicine is labor intensive and high doctor salaries are inseparable from high health insurance premiums. But I’d rather invest in a better doctor than some fancy new diagnostic technology or unproven medical device.

That said, I think high doctor salaries do come with a burden. I wish more time and money was spent trying to improve the performance of medical professionals. I’ve recently read two excellent new books on this subject: Better, by Atul Gawande, and How Doctors Think, by Jerome Groopman. Both make the persuasive case that doctors don’t expend nearly enough effort trying to prevent cognitive and medical mistakes. And so emergency room doctors fall victim to false heuristics and surgeons forget to wash their hands. Radiologists display the confirmation bias and oncologists are swayed (unconsciously) by the gifts of drug companies. All of these errors are entirely preventable. If I’m going to invest in a highly paid doctor, I at least want that doctor to have seriously endeavored to improve his or her performance. As I’ve argued before, we need a new science of medical performance.

Update: I think it’s worth exploring a potential negative side effect of high medical salaries: over-confidence. A 1978 study found that the vast majority of surgeons believed the mortality rate of their own patients was significantly lower than the statistical average. (Another example of the “Lake Wobegon effect”.) A 1993 study that investigated the connection between the accuracy and confidence of a doctor’s judgment found zero correlation between the two variables. I’d be curious to see if French doctors, due to their reduced salaries, were less prone to over-confidence. I’m inclined to believe that over-confidence is one of the big obstacles that need to be overcome before we get a science of medical performance. After all, why should a surgeon try to improve their performance if they are already performing above average?

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Comments

  1. #1 Grouch
    March 26, 2007

    When somebody starts making a ton of money, he starts to feel special, and he gets treated like he is special. Soon enough, he’s a demigod, and we know the next step from there. He’ll soon forget his mistakes, having buried them, and will gloat over his successes.

    At the same time, well-trained doctors in other countries (Argentina for one) have to give up their practices to support their families — or move to the US and cash in on the craze.

  2. #2 Larry Moran
    March 26, 2007

    Your comments carry the unstated implication that American physicians are better than French physicians because the Americans are paid more. Do you have any evidence to support that implied claim?

    If not, then don’t you have to admit that poorly paid French doctors could be just as good–and just as dedicated–as American physicians? And if that’s the case then your entire argument for putting American doctors into the wealthy class falls apart.

    Physicians are supposed to be interested in saving lives. Personally, I find it scary that my doctor might only be interested in saving my life provided he gets a lot of money for it. You may be comfortable with that thought but I’m not.

  3. #3 ed kupfer
    March 26, 2007

    With Larry Moran, I would prefer to live in a culture where money is not the primary motivation for excellence among medical professionals. Call me naive, but I believe this is already the case among most doctors, perhaps even those in the USA.

  4. #4 Ted
    March 26, 2007

    Personally, I’m a little frightened by the idea of my doctor not being highly paid. I don’t want my surgeon to be a member of the middle class. I hope that anybody who’s holding my heart in his hands is a highly trained professional, worthy of a ridiculously high salary.

    See, there’s a significant difference right there.

    The life of a US citizen is worth more — similar to the way a human’s life is worth more than a monkey’s — therefore, it makes sense that the doctor handling the correspondingly expensive heart should be paid accordingly.

    I keep hearing about this runaway costs of US health care and that the runaway nature of healthcare costs seems to be under control in many of these European countries. What’s all that about I wonder.

  5. #5 Mike
    March 27, 2007

    Surgeons forget to wash their hands? Hopefully not before a case – that would be clear grounds for malpractice!

    Re: money being a primary motivation. I think most medical students and physicians are motivated by the desire to contribute positively to society. But anyone who feels they’re getting screwed will be unhappy with their work. US Doctors do make a lot of money but they also invest a ton in their education, both in money and years spent in training compared to our European counterparts. (Perhaps some reform is in order concerning the length of training, but this topic is not without its own controversy.) Personally, I have about $130,000 in debt from medical school alone, and my job will pay in the neighborhood of $40,000 for the next 5 years. If there is no carrot at the end of this stick, compassion and humanitarianism will only get me so far. That’s reality folks. By the way, adjusted for inflation, physician salaries have been in constant decline for the past 20 or so years, whereas administrative costs (i.e. coming up with reasons to deny your health insurance coverage) have been steadily increasing for the past 40 years.

    I would also be wary of comparing French physicians to US physicians, since job dissatisfaction among French physicians are disturbingly high. That is, unless you actually prefer disgruntled physicians.

  6. #6 Michael Poole
    March 27, 2007

    On top of the high costs of learning, most specialist doctors (at least judging from physician acquaintances of my father who I have met; he’s an ENT specialist) also put in a lot of hours and are regularly on call overnight, so they pay an ongoing price.

    I might be biased against the plaintiff’s-lawyering industry, but it seems to me that the current US legal system would strongly penalize doctors who engage in continuing education. If a patient were dissatisfied or injured due to a mistake in area X, and the physician took a lecture or refresher course in area X or a related area, a plaintiff’s lawyer would have a field day in front of a jury by turning that into a practical admission of malpractice — even if the course had been scheduled well before the physician first saw the patient.

    This could be mitigated by that “new science of medical performance”, but court systems have been loathe to permit any impediments to individuals having their day in court. For example, many states have passed statutory requirements that a malpractice plaintiff must get a certificate of merit from some physician stating that the claims are medically plausible. Last year, Oklahoma’s Supreme Court threw out Oklahoma’s law to that effect (Zeier v. Zimmer and Nichols); more recently, Arkansas’s Supreme Court did the same thing in Summerville v. Thrower. If any state’s courts have ultimately upheld their equivalent laws, I have not heard of it.

  7. #7 Jonah
    March 27, 2007

    I agree with Mike. It’s also about incentives: I want the best and brightest going to med school, not law school or business school. It seems to me that the only way to ensure a high quality of incoming doctors is for the field to be competitive in salary with other professional positions, especially since doctors are forced to endure an extended apprenticeship period. While I certainly hope that many doctors go to med school for humanitarian reasons, I don’t expect the entire medical field to be motivated by altruism. (I also assume that altruism would wear thin when doctors are performing some of the less rewarding aspects of their profession, like dealing with insurance companies.)

  8. #8 Larry Moran
    March 27, 2007

    Jonah says,

    I agree with Mike. It’s also about incentives: I want the best and brightest going to med school, not law school or business school.

    Why? The typical medical school graduate sets up shop in a surburban strip mall where she spends most of her day treating minor aliments and injuries. The complicated stuff is referred to specialists. Why do we need “the best and the brightest” to do that job? Isn’t that a horrible waste of resources? (Not that becoming lawyers or business tycoons is any less wasteful.)

    I teach at a medical school. There’s nothing in the medical school curriculum that requires extraordinary brain power. In fact, most of the basic science courses are watered down versions of what we teach to science students.

    It seems to me that the only way to ensure a high quality of incoming doctors is for the field to be competitive in salary with other professional positions, especially since doctors are forced to endure an extended apprenticeship period.

    There are lots of different professions. In America, physicians do far better than most. This isn’t the only way for a society to operates successfully. It it were, then all Western industialized societies would pay physicians far more than the other professions. It’s the American way. The question we need to ask is why is it different in America?

    While I certainly hope that many doctors go to med school for humanitarian reasons, I don’t expect the entire medical field to be motivated by altruism.

    Why not? What’s wrong with expecting doctors to be motivated by something other than money? We’re quite comfortable with the concept of paying teachers, nurses, and social workers low wages and they have just as much impact on society as doctors.

  9. #9 Curious
    March 28, 2007

    There are differences in the systems. In Europe the university education system is paid through taxes. That means that a European doctor will not have the same debts and therefore do not need the same salary.
    Another reason for low salaries is that hospitals are frequently run by the state, which then can use its monopsoni power and keep down overall salaries. At least in Sweden the hospital workers’ trade union wants at least some of the hospitals to be privatized to break the state’s power over salaries and to improve work conditions.

    There are some big problems with the European system, one of them is that doctors are not paid by the hour and work extremely long hours in many cases. This is true in most of the world, but there is a crucial difference: nurses are frequently paid by the hour and the nurses’ wages are not very different from the doctors’. By not very different I mean, that doctors maybe earn 1.5 to 2.5 times of the nurses’ salaries The end result is that the doctors frequently have lower salaries per hour than nurses. This may perhaps not be bad per se, but it leads to a lot of unqualified work being handled by the doctors. This work would not have been carried out by the doctors if they had been paid hourly salaries.

    The end result is that a lot of doctors leave Europe for other countries.

  10. #10 ian stevens
    March 29, 2007

    I am not a Dr but work in the Health Service (in Primary Care) . I get paid about the same as a basic classroom teacher and am at the top of my salary scale with about 12 years experience with BS and MA degrees . I am able to support a family fine and adjust my lifestyle to suit . I am not driven by the financial treadmill . The UK appears to have the highest paid Family Dr’s in Europe and have relinquished out of hours work . It seems a good deal and yet there is constant demands that they are poorly paid . The ‘statistics’ on ‘health’ suggest that the countries with the most wealth inequality are the ones with the poorest health problems -Wilkinson mind the gap .Nortin Hadler reveals the gross issues of medicalisation of many of lifes problems by the American medical machine, which I am led to believe is the most expensive and inequitable system in the developed world .
    Sure ,highly specialist staff need to be rewarded well but much of medical intervention in our technological cultures is mundane and related to lifestlyle issues covered by David Morris in the Culture of Pain . Perhaps the highly paid medical community needs to step back a little sometimes to see the problems in society which are often increasingly unlikely to be helped by the types of intervention available ?