Respectful Insolence

Et tu, Radagast?

I sort of expected some attacks when I posted yesterday yesterday about how physicians’ incomes have been steadily falling. After all, whenever Kevin, M.D. does similar posts, people with–shall we say?–issues regarding physicians often come out in droves to post nasty comments, just as they tend to do whenever he posts about how out of control the malpractice system in this country is. In fact, I was pleasantly surprised when there were so few such comments.

But et tu, Radagast?

Actually, I never really asked anyone to have a lot of sympathy for us doctors. As I’ve said many times, I make a more than comfortable income, although it took me until I was almost 38 to start making it. As I joked before, if you want to make a lot of money, don’t go into medicine. (The correllary to this is if you want to make money, definitely don’t go into academic medicine.) I don’t expect Radagast to feel a lot of pain for those of us in the upper percentiles of income, regardless if our income has been declining adjusted for inflation, but I do have one quibble with what he said:

Orac, of course, plays the “rare is the newly minted doctor who doesn’t finish with a six-figure debt” card. This article reports that in 2001 the average debt for medical school students was just around $100,000. Yes, that is indeed a large number. However, even assuming that number has risen to $125,000, that’s still less than one year’s salary for the average physician.

Radagast neglects two things here. (I won’t go into my perception that comparing incomes of everyone over 15 years of age is appropriate for these purposes. Given that few doctors actually start working “real jobs” until they are 30 or even older, I would think that a more appropriate comparison would be the population aged 30-70. But that’s a relatively minor quibble that would probably not affect the comparison all that much.) First is the effect of residency and compound interest. The interest for most student loans interest is generally only deferable for at most three years. The shortest residencies there are (internal medicine or pediatrics) take three years or usually four, and then most doctors go on to subspecialty training. Let’s look at the training of a surgical oncologist (it’s what I know well), shall we? After medical school, there’s still surgery residency. That’s a minimum of five years, although if you want to get into a good fellowship, you will probably do at least one (and usually two) additional years in the laboratory doing research. That’s seven years. Then, your typical surgical oncology fellowship is three more years. Consequently, you’re looking at 8 to 10 additional years of training after medical school before you can make anything more than starvation wages, and your interest on your student loans starts accruing around three years out of medical school. (And this interest is usually compounded.) Because residency pay doesn’t allow you to make serious payments on it, the only real choice a resident has is to let the interest start compounding until he finishes. My personal (and exceptionally masochistic) story led me to 11 additional years of training after getting out of medical school, during which time I also got a Ph.D., by which time my original medical school debt had doubled because of compound interest. The second thing Radagast neglected is that $100,000 is only the mean debt. The distribution is such that there are quite a few medical students finishing with debt loads of $200,000 or more. I’m continually amazed when talking to medical students at how much debt some of them will be carrying upon graduation.

So, no, Radagast, don’t cry for me or my colleagues, but do remember this: When faced with the prospect of taking anywhere from 4 to 12 years to finish training in a specialty so that they can actually practice, during which time they make a pittance in salary and work ridiculously long hours, even with the 80-hour work-week restrictions, more and more of the best and brightest are deciding it’s just not worth it. It’s a problem that we in general surgery have seen for years, as fewer and fewer medical students opt for surgery leading to unfilled spots in the match in good programs for the first time in decades. Things have improved somewhat since a few years ago, but it’s still enough to worry us surgeons. Alternatively, rather than going into primary care specialties, where the most new doctors are needed (and which, unfortunately, remain among the poorest-paid specialties), in order to pay off their student loans in a reasonable period of time they’re opting to become specialists.

You can speculate for yourself what all this means for the quality of American medicine when you and I are reaching the age when we start to need lots more medical care and decide if the present situation concerns you or not.

Comments

  1. #1 Tara C. Smith
    June 30, 2006

    I’m continually amazed when talking to medical students at how much debt some of them will be carrying upon graduation.

    And even worse when they marry each other. Two of my friends are doctors, and between them, they have almost $500K in loans from undergrad and med school.

  2. #2 Robert
    June 30, 2006

    Do physicians who take out large loans to pay for their education charge a different amount than physicians who get scholarships?

  3. #3 Robert
    June 30, 2006

    Tara wrote:

    Two of my friends are doctors, and between them, they have almost $500K in loans

    But presumably, between them, they have two incomes.

  4. #4 Tara C. Smith
    June 30, 2006

    Sure. But right now they’re residents living in a very expensive city. They’re making barely more than I made as a postdoc. This has also affected their speciality choice. One wanted to go into primary care and work in a more rural area (where docs are lacking), but that simply won’t pay the bills.

  5. #5 Patrick Ford
    June 30, 2006

    Robert,

    A throw away line that I use when presented with questions like this regarding fee is “I can charge what ever I want, what I get paid is entirely different.” Except for a select few who have opted out of Medicare etc., the reimbursement is “negotiated” with insurance companies, usually based on a percentage of the Medicare rate in the geographic area. In an area where the insurance company (IS) has an advantage (pretty much everywhere), the conversation goes like this:

    IS: We will pay you 105% of Medicare.

    Doctor: That doesn’t even cover my office expenses!

    IS: So?

    Doctor: I can’t survive on that.

    IS: That’s not our problem.

    Doctors cannot just get together and negotiate as a group and set a price (price fixing) in an area since that would violate antitrust laws. The ability to negotiate is severely restricted.

    Then there is the delay in payment by having multiple different forms needed that increases the propensity for errors, the arbitrary denial of payments and non-payment by patients. (As a patient myself, the billing system is so Byzantine as to be practically incomprehensible, so it is hard to know just what you are paying for.) The IS get to collect interest on funds that have not been dispersed, while the doctor’s office pays interest on its overhead, contributing to a cash flow problems.

    So in a nutshell, no they can’t just raise their fees and charge a different price.

  6. #6 Dr. Free-Ride
    June 30, 2006

    Orac, do you have any feeling for whether the pool of people pursuing medicine would change substantially if the education was essentially free (like a Ph.D. program) but the pay once one was fully trained was correspondingly lower (like, what philosophy professors get paid)? The big investment of time would undoubtedly still scare some people away, but would the reduction of debt millstone make medicine a more attractive career for some who are passing on it now? Would it help people to choose the specialties and locations they prefer in their heart of hearts (and opposed to the ones that seem smarter financially)?

  7. #7 Sid Schwab
    June 30, 2006

    And, once again: it’s not entirely about income per se. It’s that there is no ability effectively to negotiate it, nor is there any recognition of value of the “product.” You get what the payer says it’ll pay, and what they pay makes no mind of whether one doctor does a better job than another. It in effect disincentivizes hard work to acheive superior results.So it’s a perverse system, and getting perverser; which means it is turning away good people and causing early exit of docs at their prime. How much should a doctor make? To what extent does the extra training required justify high income? Can’t say. But as a matter of public policy, the facts are there to be addressed. Of course, using facts while making public policy hasn’t exactly been center stage of late.

  8. #8 Robert
    June 30, 2006

    Tara and Patrick:

    So debt level has nothing to do with compensation level. So why do physicians always bring it up as if it should? When you hire a teacher, or an engineer, or a historian, or an epidemiologist, do you ask how much their debt-load is during salary negotiations and offer the candidate with a larger debt load a higher salary?

    Janet:
    You mean, like in France, where medical school is free? AFAICT, the pool of applicants is ballpark similar.

  9. #9 Frumious B
    June 30, 2006

    Dr Free-Ride:

    PhD’s are essentially free? Damn, I wish I had known that before writing all those tuition checks.

  10. #10 jepalmer
    June 30, 2006

    “When faced with the prospect of taking anywhere from 4 to 12 years to finish training in a specialty so that they can actually practice, during which time they make a pittance in salary and work ridiculously long hours, even with the 80-hour work-week restrictions, more and more of the best and brightest are deciding it’s just not worth it.”

    Ooh, sounds like teaching college!

    Sadly, I wish I had done something other than the PhD. I’m essentially debt-free, but I wasted my twenties working frantically in lab to earn my “free” PhD, I have a sub-postdoc salary as a state college professor, and I get no respect from my students, who can’t believe anyone would CHOOSE a PhD over an MD. I’m starting to see their point. Somehow, I don’t find the prospect of gigantic, but temporary, debt scary when compared with perpetual penury and disrespect.

  11. #11 Dr. Free-Ride
    June 30, 2006

    Frumious B, my understanding is that, at least in the U.S., Ph.D. students are almost always given tuition remission and a stipend. There are rare cases where this is covered by someone other than the university (e.g., by an external funder like NSF, or the company of the parent of an international student), but the common wisdom was that a program that didn’t offer funding didn’t really want you as a student.

    This is not to say that every Ph.D. program offered enough years of funding to reasonably complete a degree (especially given the teaching load that came along with being a grad student). And, the stipends hardly ever paid for much beyond rent and food; one big health or automotive emergency and you’d end up with big-time credit card debt. But it was a totally different set of expectations (tuition-wise) than professional schools.

    Have things changed substantially in the last n years?

  12. #12 Jackdog
    June 30, 2006

    It is more difficult, but a committed individual can still practice primary care in a rural setting and do pretty well. I completed my training 10 years ago. At the time I entered med school, yearly tuition and fees were already over 2OK for a private school, so even though I was accepted, I avoided this and entered a state school for less than 10K. I ended up with only 35K in debt. After a 3 year residency, I went to an underserved area and qualified for loan repayment. One year out of residency and I was debt free. I work pretty hard, but I am adequately compensated and my cost of living is low.

    I am far more concerned about our academic colleagues. I have former teachers who are scraping by living in an urban area and probably don’t even qualify for living in the upper middle class. I know of at least one excellent researcher under whom I trained who moved to private practice for this reason.

    I sympathize with our public school teachers and feel that they should be paid more. But see Orac’s previous post. Do we want people that have the power to hold our lives in their hands being trained by less than the very best?

  13. #13 Kitty City
    June 30, 2006

    What’s especially unfortunate is that the debt load and lengthy training are becoming more and more of a barrier to bright young people from minority communities or disadvantaged families. I’ve seen kids who have the desire and the motivation, but the practical barriers are just huge. It seems like medicine is increasingly becoming the province of the upper middle class, and I don’t view this as a good development.

    Then again, we are a society that chooses to put multimillion-dollar values on individuals who can slam-dunk a basketball or play loud, pointless music… so there you go.

  14. #14 Nick
    June 30, 2006

    Frumious B and Dr. Free Ride,

    It might be more accurate to say that in the U.S. a Ph.D. in science is “essentially free.” My first hand experience is with the biological sciences, where Ph.D. students usually earn a small stipend and tuition is covered by the department. In many cases, Ph.D. students in large medical centers don’t even need to work as teaching assistants. They can just concentrate on classes and research.

    Conditions for students in the liberal arts may be significantly different.

  15. #15 tgibbs
    June 30, 2006

    I think the medical profession has pretty much painted itself into its current corner. When I was first entering college, the medical profession had become an American aristocracy. Most doctors earned more–generally several times more–than their patients, and one of the primary activities of the American Medical Association was lobbying against any kind of regulation of the medical profession, with frequent appeals to the glories of the free market. The problem is that while Americans generally believe in the free market to the extent that they believe that anybody has the right to charge the maximum the market will bear, they don’t particularly like anybody who fully takes advantage of that right, particularly when what they are selling is a necessity of life. So when the insurance companies and the lawyers came looking for a share of that income stream, the doctors found that they had few friends among the public. The national image of the doctor had changed from the kindly neighbor who lives down the street, who visits your home to ease your pain and save your life when you are most in need, to the wealthy stranger in the mansion on the hill who makes you wait in his office, groaning in pain for hours, before he will see you, and while he may save your life, he leaves you (or sometimes your widow) a pauper. So a lot of people found a certain poetic justice in seeing the medical profession hoist on the petard of the free market.

    That being said, the modern medical student takes on a 6-figure debt, having only the vaguest notion of what he will be able to make when he finally finishes medical school–and pity the guy who flunks out or decides that med school is not for him in the 3rd year, that debt will not be forgiven. I remember when there were people in medical school who were obviously in it for the money, but I haven’t seen a med student like that for years. The vast majority of people in medical school today are there because they have a calling, and simply can’t imagine doing anything else with their lives. The guys who want to get rich are going into business school or law. And while it is sometimes possible to get some of that debt forgiven, the burden of debt often discourages doctors from serving the communities most in need, or offering the kind of informal charity that doctors once offered to people in need.

  16. #16 Hyperion
    June 30, 2006

    [quote=sid]How much should a doctor make? To what extent does the extra training required justify high income? Can’t say. But as a matter of public policy, the facts are there to be addressed. Of course, using facts while making public policy hasn’t exactly been center stage of late.[/quote]

    Finally, something I’m actually qualified to address:

    The problem isn’t the policy analysts, we’re not idiots and we’re not ignoring the facts (certain politicians, on the other hand, are a different matter entirely). The problem is that healthcare policy in general involves a number of market failures. I’m not going to go into this in depth, partly because it’s not my blog, and partly because I’m not getting paid for it, however:

    The main problem is that a free-market in general is not going to efficiently allocate healthcare resources. If we had a pure free-market system, many individuals would simply not be able to afford healthcare at all, especially the elderly. So we set up a number of public (Medicare, Medicaid) and private (health insurance) methods of spreading the cost of healthcare across the general population. This ensures not only that people can afford somewhat expensive necessary treatments, but also that they gain access to preventative treatment that they might otherwise avoid to save money. This is important because preventative treatments save money in the long run.

    However, this relates directly to physicians’ salaries because it has unintended side-effects. When move the cost burden from the patient to a third-party payer, you create a situation in which the recipient of the service (the patient) is not the consumer (which is the health insurance or CMS, depending). This means that you’re not looking at a typical market-set price like you would with most goods and services. A physician is therefore not compensated based on the value of his service to the patient, but by the value of his service to the insurance company or state agency that is paying for the service.

    On the one hand, this sometimes causes patients to request tests or procedures that are unnecessary or which offer little benefit compared to cost, because they’re not paying for it, and this is one thing that drives up healthcare costs. The more common effect, though, is that an insurance company (or CMS) compensates the doctor based on issues unrelated to his services. The insurance company is mostly concerned with the effect that his services will increase the productivity of the patient, which affects the patient or his employer’s ability to pay money to the insurance company. Medicare and Medicaid, being entitlements, must cover everyone who is eligible without creating huge budget overruns (this is extremely oversimplified, of course).

    You’ll notice that the cost to the doc doesn’t really carry much weight there at all. This isn’t a market situation where the parties involved agree on a price that meets everyone’s satisfaction. There are many flaws with the system, but it is important to note why these flaws exist, as well as understanding that any proposed policy change would have to take a lot of these issues into consideration. Moving to a more free market model would result in a lot of people being denied healthcare access, especially the elderly. Moving to a more Canadian-style system would still leave you with the problem of having a third-party payer, so many of the above problems would still exist, although there might be other benefits to employers and to those currently lacking healthcare coverage.

    So there really isn’t an easy policy choice here (which is a good thing, ecause it keep policy analysts employed :) ), because trust me, if there was a realistic answer, someone would try to implement it.

  17. #17 nevins
    June 30, 2006

    It is interesting to hear comparisons of the cost of something (in this case educational debt) with a yearly income. One must remember that there is that little thing called the progressive income tax. The physician will see only 60% of his income go home. The incentive for further effort is even worse, as the marginal tax rate, the rate on each additional dollar earned, is substantially higher. Many will take home less than 50% for each dollar of extra effort. Compare this with the tax rates of the average family where 85% of pay is take home. So the physician cannot just pay his debt down with just one year’s salary. Because of taxation, it will be two years. But then he has to have something to live on, and is probably acquiring new debt; I bought a small home and had to buy into my practice. So that educational debt becomes a 5 and probably 10 year prospect. So now the doc, who is finishing his education in his/her 30s is having children. Time to start saving for their college; better save fast because by the time your own debt is paid those kids will be in moving toward high-school.

    I make a comfortable income, but it is by no means lavish compared to my college peers who obtained careers right out of school, and had 12-15 years of income and investment before I started my first real job. One also should not compare physician income to averages or to that of their patients. It should be compared to that of other people who invest similar amounts of time toward academic success and education. It makes little sense to compare my income to the hospital groundskeeper who did not finish high-school. If you don’t grant that a meritocracy should work by rewarding effort then we will have to settle for doctors having the abilities of the guy asking you if you want fries with your meal.

  18. #18 Renee
    June 30, 2006

    Speaking of comparisons to other fields that require a commitment to a college education –

    The Institute of Electrical and Electronic Engineers did a study of all engineering salaries from 1992 to 2002 http://www.ieeeusa.org/policy/POLICY/2002/12nov02.pdf .

    At the bottom of that document, there is a chart that shows engineering salaries adjusted for inflation. Over the 10 year period, salaries were stagnant. There’s no reason to think this has changed since then. There’s also the trend of engineers having to work longer hours for their stagnant incomes (see document), meaning that they have a net decrease in income.

    And then there is one issue that doctors may not take into account when they compare themselves to their counterparts who work in industry as scientists or engineers, and that is the issue of unemployment, either due to company bankruptcy, mergers, layoffs, or being simply being fired. This is a specter that hangs over anyone who works for a corporation.

    The document discusses several reasons why engineering is a less attractive career choice than years ago: “U.S. students are influenced by their peers’ attitudes about the scientific and technical professions. They are also influenced by their experiences at the pre-college and introductory level courses within the discipline. They take stock of the employment opportunities and salaries available to recent graduates in these various degree fields. In weighing these considerations, they choose from among a number of attractive professional alternatives, including business, law, and medicine. In today’s work environment, college students often decide that engineering and related degrees do not offer enough benefits to warrant the more rigorous curriculum.”

    One must wonder, if the best and the brightest aren’t going into medicine, and they’re not going into science or engineering, where are they going?

  19. #19 Sid Schwab
    June 30, 2006

    Hyperion: that was a very well-done analysis, and I appreciate the opportunity to read it. Several years ago, at the heigth (or depth) of the reimbursement-reduction frenzy by insurance companies, my community had essentially two competing large medical groups. I used to imagine an insurance executive meeting where a guy reports, “Well, I went up to Everett, and made them an offer. And guess what? THEY TOOK IT!!!!” Laughs, and the lighting of cigars all around.

    Eventually, the really hard questions of healthcare costs are going to need addressing: how much can we afford to spend, and what’s the best way to spend it? Which means, in other words, prioritizing (read: rationing) care. And equally hard: what ways of providing care make the most economic sense? Which doctors are providing better care, and what is it that they are doing that can be taught to the rest? When that happens, you might be out of a job. But I’d guess in helping to answer the questions, you’d be able to rack up enough to retire on. Maybe even enough to pay for healthcare.

  20. #20 epador
    June 30, 2006

    Interesting, but I don’t see a lot of folks flinging poo at what lawyers or certain professional athletes make.

    Just an FYI: A Board Certified PCM working locum tenens makes about $45-55/hr and a specialist (not a surgeon) $85-120/hr. This is usually calculated on about 50% overhead, so double the rate for gross charges. You get no health care or retirement benefits.

    What do unionized labor folks get, PLUS benefits? What does your attorney, or accountant, charge per hour? Doctors still making too much money?

  21. #21 DNR Bflo
    June 30, 2006

    I graduated from medical school in 2002 with $250,000 in debt (grad and undergrad total). That doesn’t even include my used car debt! Where I did my residency a lot of the med students were running $200,000-$300,000 in debt. I would practically kill for that mean debt of $100,000! I did primary care briefly and then realized that to get out of debt in my lifetime I had to go on to fellowship and sub-specialize. That is what I am doing now, and that is what I see my residency colleagues doing.

  22. #22 J Bean
    July 1, 2006

    Renee, they’re going into finance. There was a story in Time a few months ago. Wall Street has turned to science undergrads to find a pool of numerate and hard working graduates.

    For most of the rest of us in the middle class, salaries have been stagnant. Those of us with graduate and professional educations have paid a heavy price in the form of lost earnings and may not be able to make it up in the shorter number of years that we have to save for our retirements. I was an engineer before I went to medical school and I did a little back of the envelope calculation a while ago and came to the conclusion that medical school had cost me close to $1M in opportunity costs. To add insult to injury, my Ph.D. husband out earns me.

  23. #23 Graculus
    July 1, 2006

    Sid : You get what the payer says it’ll pay, and what they pay makes no mind of whether one doctor does a better job than another. It in effect disincentivizes hard work to acheive superior results.

    As, for the most part, the “customers” don’t have a choice about who will treat them, you still have no incentive in the system. Free market fantasies only work in things that are ammenable to being teated as commodities.

    Health is not a commodity. Patients are not customers.

    In or eeeeeevil “socialized” (one payer) system, doctors get collective bargaining rights. The patient can go to any doctor they want (the only caveat is that they must be refered by their primary care physician, who they can choose themselves, too). Our system is far from perfect but the US system is a nightmare, with both the patients and the doctors held hostage by bean counters in the private sector. Our system also delivers better, more universal patient care for less money (measured by GDP).

  24. #24 epador
    July 1, 2006

    Just wondering, Graculus, do more physicians leave your country for the US or is it the other way around? Do more patients come from our country to yours for treatment or is it the other way around? I know the answer about prescription drugs, but that IS a commodity, not a service.

  25. #25 Robert
    July 1, 2006

    Epador wondered:

    Do more patients come from our country to yours for treatment or is it the other way around?

    I don’t know where Epador lives, but I split my time between the US and France. In terms of outcomes, I don’t see much difference in quality of care–and I do health services research on the quality of care so I’ve been looking. However, in terms of cost and patient satisfaction, the differences are huge. If I’m on the cusp of needing to see a physician near in time to one of my trips, I either delay or accelerate my visit in order to do that in France. I know several Americans in France and French in the US. Anecdotes are the weakest form of data, but I know no one who chooses differently.

  26. #26 J Bean
    July 1, 2006

    epador: You are trying to imply that the conditions in single-payer countries are not good for either physicians or patients. Believe it or not, there is data on those kinds of questions. A few years ago there was a study that showed that only rarely do Canadians cross the border for medical care.

    Physicians do better in most western European countries. Despite shorter working hours, they actually make slightly higher salaries. Last year the average Canadian primary care salary was $185K CDN (found that using google.fr), the average British primary care salary was $170K (Guardian article no longer available free on-line), and the average U.S. primary care salary was about $160K (according to what recruiters send me, the ACP gives lower figures). Now, $160K is nothing to sneer at, but you can certainly do better north of the border. French docs make a bit less than U.S. docs, but also work substantially fewer hours and actually make close to the same per hour as their American counterparts which, given the different salary structure in France, puts them at a comparative advantage. The foreign medical graduates that come to this country are mostly immigrating from third world countries; India, the Philippines, and Africa. Few M.D.s immigrate to the U.S. from Canada, western Europe, or the rich parts of Asia for purely monetary reasons.

  27. #27 Graculus
    July 1, 2006

    …trying to imply that the conditions in single-payer countries are not good for either physicians or patients.

    That is the implication.

    For the last year for which data is available (2004) the number of doctors returning to Canada from abroad is greater than the number emmigrating. This does not included non-Canadian doctors who are immigrating to Canada.

    The Great Canadian Brain Drain has always been a bit of a myth. The largest emmigration from health care sectors occured when the free marketeers tried to destroy the healthcare system (mid 90s), but it was not significant enough to affect the actual ratio of doctors per thousand people.

    I never said the system was perfect (no system is), but judging from raw numbers like life expectancey, infant mortality, number of uninsured and percentage of GDP spent on healthcare, the Canadian sytem is better *and* cheaper than the US system.

  28. #28 tax
    July 1, 2006

    One must remember that there is that little thing called the progressive income tax. The physician will see only 60% of his income go home. The incentive for further effort is even worse, as the marginal tax rate, the rate on each additional dollar earned, is substantially higher. Many will take home less than 50% for each dollar of extra effort. Compare this with the tax rates of the average family where 85% of pay is take home.

    One must also remember all of the regressive taxes that people pay, like social security and many state and local taxes. When you take all of these into account, you find that the different in tax burden between the top and middle quintiles is a few percent. See the chart from the New York Times (Jan 20 2003).

    You may complain that you pay much more or less than the overall amount from your quintile, and that’s likely to be true. The largest tax differences in the US are between people with the same income, due to different taxes on different types of income and the tremendous number of deductions available. I’ve done taxes for two people, both making $100,000 +/- $5000, yet one paid about $50,000 in taxes, while the other paid about $10,000.

  29. #29 Matt
    July 2, 2006

    “The second thing Radagast neglected is that $100,000 is only the mean debt. The distribution is such that there are quite a few medical students finishing with debt loads of $200,000 or more.”

    What is the average cost of medical school at a public university for in-state students?

  30. #30 Matt
    July 2, 2006

    “You can speculate for yourself what all this means for the quality of American medicine when you and I are reaching the age when we start to need lots more medical care and decide if the present situation concerns you or not.”

    So what do you propose to do about it?

  31. #31 Barry
    July 3, 2006

    A few comments:
    “…and one of the primary activities of the American Medical Association was lobbying against any kind of regulation of the medical profession, with frequent appeals to the glories of the free market.” The AMA has lobbied extensively for regulation of the medical profession. If you doubt this, just practice medicine without a license, and see what happens.

    epador: “What do unionized labor folks get, PLUS benefits? What does your attorney, or accountant, charge per hour? Doctors still making too much money?”

    ‘Unionized labor folks’ get from $8-$60/hour, including benefits. The ones who are getting a lot (heavy industry, for example) are getting it because some people fought for it fifty-sixty years ago. And the second that they lose strength, they lose the pay and benefits (see Delphi for current examples). It’s balance of power, with market forces being only one part of the system.

    “Renee, they’re going into finance. There was a story in Time a few months ago. Wall Street has turned to science undergrads to find a pool of numerate and hard working graduates. ”

    Of course – engineers have been taking it on the chin for a couple of decades, as well. Going for a science Ph.D. usually means 5-7 years of grad school, followed by a few years of post-doc migrant-labor drudgery, followed by leaving the field.

    “For most of the rest of us in the middle class, salaries have been stagnant.”

    IIRC, since 1973 there have been three years in which real median wages have increased – all during the Evul Klinton years.

    ” Those of us with graduate and professional educations have paid a heavy price in the form of lost earnings and may not be able to make it up in the shorter number of years that we have to save for our retirements. I was an engineer before I went to medical school and I did a little back of the envelope calculation a while ago and came to the conclusion that medical school had cost me close to $1M in opportunity costs. To add insult to injury, my Ph.D. husband out earns me.”

    You’re still probably better off with an M.D., considering that the world-standard salary for experienced engineers is probably $10 US/hr.

  32. #32 Jim Stone
    July 6, 2006

    I can see both sides of it. My wife is a pediatrician that doubles the average income in that specialty, works bankers hours, loves her work and had minimal loans that she had paid off before I got on the scene.

    We deal all the time with doctors who are truly struggling financially, are in debt up to their ears and don’t know what to do. Unfortunately the consistent variable with most doctors who struggle to earn a decent wage is that they are in the biggest, nicest cities where there is the greatest level of competition and least amount of bargaining power.

    Jim

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