Devalued Doctors

Here is an interesting article from Washington Post editorial page:

Devalued Doctors

By Jean A. Schoonover
Monday, August 11, 2003; Page A17

The MTV show “Cribs” featured a special on celebrities’ cars rather than, as was usually the case, their mansions. My husband and I were on vacation, and so we snuggled together in the basement and watched as basketball players and rap artists boasted six Bentleys or Lamborghinis with tires worth more than our Volkswagen Jetta. One celebrity, whose name I had never heard before this show, obliged us with a tag-along documentary as he car-shopped for another Aston Martin. He pronounced Aston “Austin,” as in Texas.
My ‘94 Ford Escort had more than 120,000 miles on it before I finally took out a loan to buy a new Ford Escape. It is a great vehicle: the shiniest truck on the block in our modest light-blue-collar neighborhood in southern Maryland. From here my husband can make it to work in our nation’s capital in about 45 minutes when the traffic complies. But it seems to be the new $400 monthly car payment that is the latest setback in our suffocating budget. Maybe I should have gone with the Honda Civic after all. But, then, I really did appreciate the big tires and the four-wheel drive this past winter driving to work in La Plata. And I certainly could not have afforded to miss work, given the money situation.
What is it that we do for a living, you might ask. Am I a waitress and my husband a bus driver? Do I perhaps clean houses while my husband surfaces driveways? Are we getting just what we deserve doing menial labor after goofing off and getting married right out of high school? Should we have planned better so that we would have two nickels to rub together?
My husband and I are both physicians. I am in private practice in internal medicine and he is an ophthalmologist. Our training consisted of four years of college, four years of medical school and four years of residency. Each. Our collective student loan debt is more than a quarter of a million dollars. Each month I pay Nelnet $1,003, Sallie Mae $300 and SunTrust $881, just as an example. Nelnet is a graduated payment. This is the lowest it will be as I pay it off over the next 15 years. When I am 47, I hope to be out of debt and to begin saving for retirement. It is not clear yet when we will be able to afford to have children.
Our mortgage is less than half as much as the loan payments: We save hugely by not living in the city. Some of my husband’s loans are fortunately still in deferment, but they are collecting interest all the same. He has another year of residency before joining a practice. His colleagues inform him that the average starting salary for an ophthalmologist, a highly specialized surgeon trained to perform Lasik and extract cataracts, is less than $90,000 in the D.C. area. We have done the math at our dining room table many a Sunday night. His paycheck will not come close to covering his loan payments once his grace period ends.
Something is wrong with our nation’s outlook on health care these days. I have come to name this phenomenon the “Devaluation of the Doctor.” As I hear grumbling about Congress’s making more Medicare cuts and my patients’ complaints about $10 co-payments while they dig $300 cell phones out of their Gucci bags, I am getting just the slightest bit bitter. Somewhere along the way, as we sat back and let insurance companies turn caring for the sick into an industry, we lost sight of the importance of medical care and those individuals who sacrifice their entire twenties to learn how to save lives and keep us healthy. HMOs have bred a population more interested in paying for a cellular phone plan than a physical. It saddens me to meet a new patient who is “transferring his care” to me (after sticking loyally to the same doctor for 40 years) just because "Doc So-and-So stopped taking Mamsi."
It’s a rainy day, and the neighborhood kids aren’t playing basketball as usual. If they were, I’d be tempted to open the front door and holler to them, “You go, boys! Forget about algebra and focus on your three-pointer.” After all, what have my hard-earned straight A’s and Honor Society tassels gotten me but a fear of foreclosure?
The writer is a physician in Maryland.

© 2003 The Washington Post Company

I dont know what these 2 crazy kids are doing in Maryland to make their salaries so low:…an-salaries.htm
These are pretty comfy numbers (net) to me.

I actually saw this article in the paper the other day. I thought it was interesting. I sometimes wish we were under the “old system” - i.e. you went to a doctor and paid him/her out of your pocket. Service paid for services rendered and there were no “middlemen” - no HMOs, PPOs, etc. It saddens me b/c I think we don’t develop personal relationships with our doctors. But, now we’re all so used to health insurance, if we’re lucky enough to have it, that we don’t want to pay extra to go to an out-of-network doctor. Well, I don’t anyways so I shouldn’t assume the same about others I guess. For example, my OB-GYN has no clue who I am–that I’m one of his patients–even though I frequently run on to him at the hospital where I’m volunteering. This is probably b/c I’m a single female who he sees for 15 minutes once a year for my annual check-up. I suppose if I was pregnant, I might be on his radar screen.
But, back to the article, as far as the debt of the two doctors in their article, well they should have known they were going to have a lot of debt. That’s the price you pay for becoming a physician. But, I agree with the last poster that their salaries did seem low. Maybe I’m seriously misguided but I thought almost everyone made 6-figures–after residency of course.

drd, you are right.
Opthos making 90k AVERAGE? Thats way too low. Either somebody gave her some bad information, or the optho market in DC is the worst place in america.

Thanks for that link drd, and yes, those numbers look fine - I wonder what's up with those people in the article.
I have one question. My plan is to go into family practice, perhaps with a concentration in internal medicine, and I plan to practice in an underserved area, rural is what I prefer. Since I will be in a small town, I just assumed that I would not be making a good income. Do you think those numbers hold under my conditions, or are they the average for the city or suburban folk (which I've had enough of thank you very much)?

Hi there,
The ophtho market in DC is very tight because of a few folks who got into Lasik early and closed the market. They tend to get most of the high paying business leaving the lower paying cataracts to folks who have been left out in the cold. The market is very saturated in DC with many newly trained opthos working for(at a substantially lower salary until you can buy into the company) folks who have cornered the market or having to move elsewhere. If you decide to try to open your own Lasik center, you have to compete with the guys who have million dollar advertising budgets and huge centers located in shopping malls.
The outlook for Internal Medicine is pretty dismal too. DC and the surrounding burbs have too many physicians concentrated in a very small area. The inner city is pretty open but the burbs are saturated. Geriatricians are in dire need but even Family Practice folks who do not do geriatrics are frozen out of the market in many cases. Many of the smaller hospitals will not grant admitting privledges to new physicians because of the saturated market. If you join a group practice, you may be able to get courtsey privledges but that is about all.
In Fairfax County, home of the highest dollers billed to dollars collected hospital in the country(Inova Fairfax Hospital), no new privledges are granted to physicians wishing to admit patients to Inova Fairfax Hospital. If you join an established group practice, you are not granted admitting privledges unless one of your partners is willing to drop out. The attrition rate for practicing physicians at this very wealthy suburban hospital is very low. This hospital operates at near 100% capacity on a daily basis.
If you attend one of the private medical schools in DC and take out loans for the total cost of attending school there plus your undergraduate loans, you could easily end up owing more than $250K with payments being pretty steep. Many folks at GW and GT do join the Public Health Service Corps or have Armed Forces Health Professions Scholarships. Otherwise, expect to owe a pretty sizable chunk of money to the Feds when you are done. (Though Howard is private, it is chartered by the Feds so that tuition is less than half of GW or GT). DC is one of the worst markets in the country. The entire state of Virginia except for a few areas in Southside is pretty saturated with physicians because of the lower cost of malpractice. Many West Virginia folks tried to get into the state but were frozen out by local medical societies who will not approve credentials.
Nat (From a family of ten physicians, all practicing in Virginia)

if what you say is true, then these people should work in another area.
It makes no sense to work for 90k in DC when you can EASILY get at least 180k in another area.
90k is FAR BELOW the average salary for an optho. I've never heard of an optho making that low of a salary.

After reading this article, I had to wonder who at the Washington Post thought this was news worthy (even as an editorial). I found this article irrational and muddled. It seems to me that the entire point was the slam on HMOs.
My HMO never told me to pay for a cellular phone at the expense of my health care, but apparently the author’s patients had a different HMO providing coverage.

HMOs have bred a population more interested in paying for a cellular phone plan than a physical.

I do not disagree that there is something off with patients who complain about a $10 co-pay while financing large cell phone bills, but how does this correlate with HMOs and the nation’s outlook on health care?
The author’s rampant affliction with Affluenza appear to me a greater problem with her situation than anything else she mentions. She belittles the working class by comparing her financial situation with those of menial laborers. She describes her appreciation for her “shiniest truck on the block in [her] modest light-blue-collar neighborhood” while complaining about not being able to afford loan payments on an education she elected to pursue. Then she finishes with complaints that all her academic efforts have not afforded her instant wealth.
Her special phenomenon, the “Devaluation of the Doctor” makes for a great political rally cry, its symptoms and cure elude me. However, the etiology is clear - HMOs!
Color me jaded, but I don’t see the author’s situation as dire, nor specifically related to the state of health care in the United States.
Just one opinion, I’ve got more.
– Rachel

Hi folks,
I think these folks do need to move out of the DC market. Housing is very expensive and doing any kind of commute is totally crazy. If they were willing to live in downtown DC and practice medicine in the inner city, they would be doing fine. Even the opthos and internists doing academic practice at Howard are doing very well. One of my colleages is an optho practicing out of Howard who makes far more than $90K just doing cataracts and covering the ER for his specialty.
Natalie smile.gif

When I first read this thread, I just laughed at the author of the article. Give me a break, was all I could think. But now I'm rereading it, and her attitude makes me mad! Patients aren't upset with the healthcare system over $10 co-pays! They're mad because insurance is freakin' expensive, overly complicated, and for millions of Americans, just plain out of reach. If the author thinks cell phones (which don't cost $300, do they?) and gucci purses are the causes, she's really out of touch. But I'm not THAT surpised. One doctor I saw recently had never heard of COBRA insurance, had no idea that it costs oh, about $700 a month, and didn't really care either.
My mom drives a Ford escape, and that car's a gas guzzler! If these guys were willing to live in a modest home (or gasp, and apartment) close to where they work, and curtail the four wheel drive, maybe they wouldn't have to feel so sorry for themselves.
Also, telling her kids to not bother studying anymore just because it might not make them rich later on? I guess if that's how she's looking at things, it's no surprise she's disappointed.

Great. So glad that was in the Washington Post. I am surprised my mother hasn't called to tell me about it and remind me why she thinks I am screwing up my life.

I’ve been watching all week for the letters in response to that column. I, too, thought she was a whiner. The phrase that REALLY stuck in my craw was “sacrificed our twenties.” Well, geez, does she want a medal or something? Did someone BEG her and her husband to do this? Are we all supposed to line up and thank her? (and yes, if she wants to see gratitude for her presence, she’d be a lot better off in an underserved area)
Anyway, here are the letters in today’s Post:

About Those 'Devalued Doctors'
Saturday, August 16, 2003; Page A19
The story of two medical specialists in dire financial straits is indeed touching ["Devalued Doctors," op-ed, Aug. 11]. Numerous studies and surveys show medicine to be one of the highest paid professions. Data Bulletin No. 24, published in March by the nonpartisan Center for Studying Health System Change, states that the mean reported income in 1999 for specialists was $219,000. Reports on incomes by the American Medical Association show similar numbers. If those numbers are accurate, this pair of doctors needs some good professional counseling.

-- Arun Guha
I read Jean A. Schoonover's column "Devalued Doctors" with interest. I am a young orthopedic surgeon living in the Washington area. I happily work for an HMO.
Do I make less -- much less -- money than my surgeon friends practicing in Tennessee or North Dakota? Yes. Did I go to college and medical school and do my surgical residency at some of the finer institutions in this country? Yes.
Did I have big loans to pay off? Yes.
Do I feel devalued? No.
Do I feel entitled? No.
I chose to go to four years of college, I chose to go to four years of medical school. I chose to go through five sometimes-hellish years of surgical training. And along the way I made the decision to enjoy myself and not sacrifice my entire twenties, so I chose to live and work in a doctor-saturated and desirable environment.
I still make more money than my father ever could have, and he went through more schooling and has a PhD and raised four kids as a single father. And I make more money -- much more -- than I did when I worked as a waiter at Hamburger Hamlet and when I surfaced driveways in Potomac. And I live, as best I can, in a great metropolitan area that sometimes feels like the hub of the world.
The other day in the operating room, I leaned over to my assistant and whispered, "Hey, don't tell anybody, but they actually pay us to do this!" He winked at me and said, "Right on, doc."
-- Don Saroff
I am astounded at Jean A. Schoonover's carping about the unfairness of young doctors living the life of the middle class. Schoonover evidently believes that, as a married couple of physicians, she and her husband should be entitled to an affluent lifestyle where money is no object.
Anything less apparently constitutes proof that the medical profession is now seriously undervalued in America. As the husband in a double-PhD couple, I would like to reassure Schoonover that there's nothing unusual or degrading in highly educated professionals earning less than $90,000 each and having to watch their budget. A little research on doctors' salaries in other industrial countries -- not to mention some awareness that medical practitioners were once undistinguishable from barbers -- would have set Schoonover straight: After decades of extravagant overvaluation, U.S. doctors are getting paid what they deserve.
-- Gianfranco Corti

I would like to meet Dr. Saroff and shake his hand and go out for a beer with him. He has the right attitude. If you ask me, one of the BEST things about being in medicine is that you can have a ton of fun in your job. How many people get to say that? If you are fortunate enough to be able to forge a genuine bond with your patients and feel appreciated, well, that's great but for cryinoutloud, don't make that your motivation for going into it! (and hmmmm that prompts a thought: how many people are conscious of a desire 'to help people' but perhaps unconscious of the corresponding desire to be applauded for that help?)
Okay enough ranting from me for one day! tongue.gif

I agree 100% with the Dr. Saroff…It appears that many others here also feel that going into medicine and getting into debt, etc is a choice and that the payoff should be the satisfaction of serving as a physician and the fact that practicing medicine (even if you are ‘only’ earning 90k as an opthamologist) means that you earn much more money than the average Joe…so…does this mean that all of us here support some type of universal health coverage even if it might mean that the radiologists won’t rake in their 450+k annually? I know that I am in support of a universal health coverage plan whether it be instituted by requiring employers to provide health insurance benefits to all employees or having the govt. step in to help those that are uninsured or underinsured. I think it’s scandalous that in this ‘great’ country we have 42 million uninsured…of which about 80% are hard-working americans…not bums trying to suck off of the system. Everyone should be entitled to basic healthcare, but I think that people who work hard to support their families regardless of whether they are doctors or customer service representatives deserve healthcare benefits…Much of the moaning comes not just from the public, but from within the medical profession…you hear the whole “we’ll earn less” complaints and fears that any type of universal coverage would result in lower physician salaries. So…I support universal health coverage even if physician salaries would fall a bit …would you?

It sounds like that couple need to consolidate there loans and that they need some financial counseling. The reason I say this is that I used to work for a Finance company and I couldnt tell you the number of professionals that had money problems not due to the profession yet to there own mismanagement. For example i had to work a payment schedule for a physician(an internist) due to how much personal debt he had. A lawyer had over 50,000 in unsecured debt and had to file bankruptcy. And the worst situation I saw was a guy who had a huge business that lost a contract. He had over 90 different credit cards averaging about 3000.00 per balance. It really doesnt matter what you make sometimes if you mismanage it. A person can live like a king on 20,000 if they do it right. Big Bill

QUOTE (Kris @ Aug 16 2003, 04:17 PM)
I think it's scandalous that in this 'great' country we have 42 million uninsured..of which about 80% are hard-working americans..not bums trying to suck off of the system. So...I support universal health coverage even if physician salaries would fall a bit ....would you?

I'm curious why you automatically associate universal health care with lower salaries for health care professionals?
I find a CEO who makes 10, 25, or 50 million dollars a year while his employees go without health care coverage to be a far more scandalous figure than a doctor who has effectively spent half his life in school, has graduated with a quarter million dollars in student loans, and who has a salary in the low six figures.
If you want to mandate universal health care, start by passing legislation which demands that every business with more than 5 employees provides health insurance and cap malpractice awards at $250,000. That will go a long way towards solving the problem you see without establishing a new government bureaucracy.

If you think that universal health care works, get a quick education by looking at England - sounds good, but it just does not work - at least the way they have implemented it.

Universal health care coverage works in Switzerland, where every individual is required to carry basic private health insurance. This is not paid or even subsidized by the employers. If an individual cannot afford the insurance the government steps in with a plan to help them pay for it.
Doctors also receive reasonable salaries here, though lower than the US. (med school tuition is paid by government so there's not this justification for high salaries) Somehow it works. Switzerland has one of the lowest tax rates in Europe (about 25% compared to over 50% in Sweden for example where they have NHS). Unemployment is relatively low so I assume this helps. And there are not huge disparities between income levels. One pays alot for services (very high cost of living) but all people receive a living wage, so if you are working there is no reason why you can't afford the insurance. They are starting to see the wage inflation problem with senior executive salaries, due to the influence of international economy (i.e. US) but up to now it has not been the case.
This is an example of a universal coverage system that seems to work - for them at least.

Interesting Laramisa,
I always thought universal health care could never work, giving the two cases that I knew about - England and Canada. It is easy to say that it works simply because a country has it, heck, I even heard people say that it works in England and Canada! Do you have any more detailed information on how the plan works in Switzerland? Perhaps if one of the think tanks in this country did a study on it, it might turn out okay for us?

It is easy to say that it works simply because a country has it

It's just as easy to claim something doesn't work because countries A & B have it and it doesn't work there. There are many who disagree with you about Canada, for instance. But that really isn't the issue. Democracy wasn't something that worked, and still doesn't in many places, for a long time but we tried it and seems to be ok here. Not perfect but better than the alternatives.
Can a national health service work? I am inclined to think one could but that of course doesn't mean I have the answers for how it could. One day maybe.

I still have my bumber skicker "You have a right to an attorney, how about a doctor?"
I always thought universal health care could never work, giving the two cases that I knew about - England and Canada. It is easy to say that it works simply because a country has it, heck, I even heard people say that it works in England and Canada!

Re: does it 'work'. I guess you are referring to quality issues: Quality of health care is very good in Switzerland and there are no issues with waiting for services, such as they have in the UK and some of the other NHS countries. In some cases at least it is superior to US care (e.g. when you have a baby you stay in as long as you need to - usually 6 days). This is not an NHS system (not that that shouldn't also be able to work if it is well-managed and adequately funded) - it's mostly private, though of course there are teaching hospitals associated with the universities and some county clinics. In terms of quality, I guess you get what you pay for.
Maybe the question to ask is: what particular things do work well and what things don't work well in countries that have NHS or other forms of universal coverage and analyze why. I also don't think everything about NHS is bad, even in the UK.
I don't know why universal coverage seems to work fairly well in Switzerland and not always so well in other places, but I try to ask questions about it & to understand what is so different here. Maybe I am missing something.
I just feel strongly that there is little excuse for affluent countries not to have at least basic health care services available to everyone in the society.
Here is some more info on the Swiss insurance system if you're interested:
There are 3 levels of coverage. The government mandates the basic level of services, which essentially covers everything you might need but may not pay for the most expensive private clinics or the 'chief' doctor in a clinic.
The higher 2 levels just add extras, such as more options where to get your treatment, more alternative medicine treatments, health spas, discounts for health club memberships, dental coverage, guaranteed private or more luxurious rooms at hospitals, lower copayments (basic has a 10% copayment) etc...
Another key point: companies cannot reject anyone for coverage and cannot limit payments for treatment of pre-existing conditions. For medications they can limit payments to those drugs on the approved reimbursement list (national health authority list). They may try to avoid paying for the most expensive drug, but will usually give in if the doctor writes a letter with a justification.
These things are mandated so obviously at some point in the past these things must have been issues and the government stepped in to regulate it.