Does anybody have a source of the average physician salary by decade going back as far into history as possible? It would be interesting to see just how good or bad we have it now.
Average physician salary by decade?
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...honestly, it really wouldn't be very interesting for you to know. It would be very depressing. Just pretend you're making more than anyone ever did and feel happy
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Actually it would be interesting for him to know since he stated so explicitly in the OP.
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Actually I think everyone would be surprised to know that doctors didn't really make a lot of money until the mid 80s. Before that clinical work was considered more of a public service than a business transaction.
From my copy of The Medusa and the Snail by Lewis Thomas:
"I had forgotten what things were like in the good old days of medicine, and how different...I found in the other day while glancing through the yearbook of my class at Harvard Medical School at the time of graduation, in 1937...Coons, as editor, decided to do something more ambitious for the yearbook than simply record the class statistics, and prepared a long questionnaire which was sent to all the alumni of the medical school from the classes which had graduated ten, twenty and thirty years earlier...To everyone's surprise 60 percent of the 265 alumni filled out the questionnaire and returned it...The findings of greatest interest, presented in some detail in the yearbook, concerned the net incomes of the alumni, which were, by the standards of the day, significantly higher than the AMA's figures for American physicians in general...We knew that interns and residents got room and board but no salary to speak of. We were glad to hear that Harvard graduates did better financially once out in practice...
The median net income of the group of 165 HMS graduates, ten to thirty years out of school, was between $5,000 and $10,000 a year (about 80K to 160K in today's dollars). In the ten year class, 43% made less than $5,000. Only five men earned over $20,000 (~300K c. 2015) and a single surgeon, twenty years out, made $50,000 (~700K). Seven graduates of the class of 1927 had incomes below $2,500 (below 40K).
The alumni were invited to send in comments along with the questionnaire, in a space marked "Remakrs", with the understanding that since so much of the form was directed at finding out how much money they were making they might like to say something about life in general. As it turned out, most of the "Remarks" were also about money, a typical comment being the following: 'I am satisfied with medicine as a life's work. However, I should recommend it only for the man who has plenty of money back of him. Many men never make much in medicine.' Forty one years ago, that was the way it was (LT wrote this in the 1970's)."
Everything in parentheses was written by me to provide 2015 dollars using a couple of online inflation calculators that seemed to roughly agree on those numbers. I bolded the bits I found the most interesting.
Things to take away:
1) Docs probably didn't make as much in the "good old days" as you think they did, barring the 80s-90s.
2) The more things change the more they stay the same (regarding med student and physician attitudes about the profession and financial compensation).
3) Yup, back then you lived in the hospital as an intern. No salary. Just enough to live and eat at the hospital.
Ahh, but what did tuition cost back then eh?
According to UPenn's historical data, tuition for medical school in 1937 (per year) was:
Tuition: $500 (About 8,000 in today's dollars)
General Fee: $15 (~80-100$)
Room and Board: $520 (About 8,000 in today's dollars)
HMS' fees would most likely be a little less if not on par with UPenn's figures. I was unable to find HMS data. What does this mean? This means that in 1937 one could attend an elite private medical school (to be fair, there were far fewer so this most likely had less meaning) for $16,000 dollars a year...in other words, a little less than tuition at, say, UTSW or Baylor today (a testament to just how cheap Texas medical schools are).
Furthermore, according to Encyclopedia.com, medical doctor salaries in the 1950s ranged from $8,272 to $28,628 for a neurological surgeon. The average salary of a physician was $11,058. In today's dollars that ranges from about $26,000 to $248,000 with the average sitting around $100,000. Given Lewis Thomas' commentary on salaries for attendings in 1937 this means that HMS grads were certainly making much more than the average physician in 1937. I'll update if I can find a general source for all physicians in 1937. In 1955 medical school tuition + room and board at a private medical school (using UPenn archive numbers again) was roughly $16,400 in today's dollars (around 1800-2000 then) thus showing that medical school attendance costs had not changed very much from 1937.
Government data also indicates that both in the 1930s and 1950s physicians were making around, or at most the double of, the average income in the US and far above the average income for health care service workers in the US.
Another study from 1992 takes a look at physician income trends beginning around 1982. From the charts, we can see that Surgeon salaries have always been significantly higher than average physician or specialist salaries. In those days, specialists made less than the average physician (certainly this is skewed by surgeons; it is not clear whether surgeons were left out of this calculation or not) and general practitioners have always made the least. Around 1985 significant spikes occur, especially in surgeon salaries. General practitioner salaries tend downward near the early 90s. The report is interesting and I recommend you skim it. The report had this to say as to why salaries rose:
Reasons for Income Increase
"Greater volume and profit per service. Provision of more services and higher profit per service contributed roughly equally to physician income growth in the 1980s. We estimate that 42 percent of the growth from 1982 to 1988 in real net income per office-based physician was due to a greater number of services provided per physician, and the remaining 58 percent resulted from higher unit-profit margins. Since physician supply increased rapidly in the 1980s) across all physicians as a group, growth in volume of services was the dominant factor explaining rising net income. It accounted for two-thirds of aggregate income growth, while increased unit-profit margins explain only one-third. These conclusions are consistent with other evidence. Studies using Medicare data have shown large increases in volume for many procedures, especially surgery, radiology, and special diagnostic tests. Moreover, many of the procedures that are increasing most rapidly are among the most profitable relative to physician time and effort. These include cataract operations, coronary artery bypass graft surgery, and upper gastrointestinal endoscopy. Conversely, cognitive services such as visits, which are thought to be relatively underpaid, have not grown as rapidly.
In addition to raising charges faster than expenses are increasing and providing a more profitable mix of services, physicians have attained higher unit-profit margins by lowering their cost per service. Specialists have achieved enormous economies of scale and productivity gains for certain procedures through “learning by doing,” as techniques have been refined and volumes have risen. Despite a mid-1980s fee freeze and some “overpriced procedure” reductions, fees for such services as cataract surgery and coronary artery bypass grafts have not fallen enough to reflect productivity gains. Moreover, as volume has grown in the 1980s, physicians have been able to spread fixed practice costs such as office rent, equipment, and malpractice insurance over a greater number of services. They have also lowered costs by providing related services jointly (for example, completing a diagnostic test during an office visit). Fees have not been reduced to fully reflect lower costs.
Another reason...
Slower increase in physician supply. The physician supply and the physician-to-population ratio continued to grow rapidly in the 1980s. Nevertheless, the rate of increase in supply slowed. The average annual rate of increase in patient care physicians per person (excluding residents) fell from 3.7 percent between 1978 and 1983 to 1.9 percent between 1983 and 1989. For a given rate of increase in the demand for physician services, a slower rate of supply growth implies a higher rate of increase in income per physician. The average annual rate of growth in real income per physician was nearly three times as high between 1983 and 1989 (3.1 percent per year) as it was between 1978 and 1983 (1.1 percent per year). Nevertheless, the rate of increase in the aggregate real net income of physicians as a group was virtually identical in the two periods (6.0 percent per year versus 5.9 percent per year). The higher growth in income per physician was almost entirely due to the reduction in the rate of growth of the physician supply from 1983 to 1989 (2.9 percent per year) as compared with the period from 1978 to 1983 (4.8 percent per year). Moreover, over the past decade (1978–1989), the number of surgeons grew less rapidly (2.8 percent per year) than the overall number of patient care physicians (3.8 percent per year, excluding residents). This helps to explain surgeons’ rapid income gains.
And...
More comprehensive insurance coverage. Out-of-pocket expenses as a proportion of total spending for physician services have been falling for a long time, and the trend continued in the 1980s. In 1970, 42 percent of national expenditures on physician services were paid for out of pocket. This proportion fell to 27 percent in 1980 and 19 percent in 1989.23 Lower out-of-pocket cost (that is, more comprehensive insurance coverage) increases patients’ willingness to use physician services, allowing physicians to raise their incomes by increasing both the volume of services and prices. [Lucca's commentary: More insured patients led to an increase in physician compensation??? Say whaaaaaaaa??! /sarcasm] The specialties whose services are covered most completely by insurance-particularly surgery-have experienced the most rapid income growth. Specialties whose services are less well insured-for example, general practice and pediatrics-have fared less well.
Outpatient shift and technology diffusion. Real physician income was relatively flat from 1982 to 1985; it only began growing rapidly after 1985. Although the coincidence is not exact, the timing of the spurt in physician income suggests a connection with the shift from inpatient to outpatient care with the implementation of Medicare’s prospective pay- ment system (PPS) in 1983. Private third-party payers have also encouraged the substitution of outpatient for inpatient care. The result was an explosion in outpatient surgery and diagnostic testing in hospital outpatient departments, freestanding surgery and imaging centers, independent laboratories, and physicians’ offices. Physicians’ higher outpatient earnings have more than offset their reduced inpatient revenues. They now earn an entrepreneurial return on capital (equipment, building space) and labor (aides) that was formerly appropriated by hospitals. [Lucca: And soon to be re-appropriated lol technology costs] Lower cost and convenience for patients has probably been a major reason that the volume of many procedures and tests has skyrocketed in the outpatient setting. Without a hospital admission, patients can avoid expensive inpatient deductibles and co-payments. Their time costs are also lower because of the convenience of ambulatory surgical centers and doctors’ offices. Outpatient procedures are often less invasive, less painful, and less risky than inpatient procedures and have shorter recovery times. The much less stringent utilization review afforded to outpatient activity than to inpatient admissions may be another important factor in higher outpatient volumes. Technical advances and diffusion have enabled the growth of many outpatient procedures and tests and also augmented physicians’ inpatient earnings in the 1980s. Older procedures/ technologies such as joint replacements and open-heart surgery have ‘also been refined and are performed on more patients than before because of improved outcomes.
Physicians, especially procedure-oriented ones, simply have more ways to make money now."
And the rest is history...
From my copy of The Medusa and the Snail by Lewis Thomas:
"I had forgotten what things were like in the good old days of medicine, and how different...I found in the other day while glancing through the yearbook of my class at Harvard Medical School at the time of graduation, in 1937...Coons, as editor, decided to do something more ambitious for the yearbook than simply record the class statistics, and prepared a long questionnaire which was sent to all the alumni of the medical school from the classes which had graduated ten, twenty and thirty years earlier...To everyone's surprise 60 percent of the 265 alumni filled out the questionnaire and returned it...The findings of greatest interest, presented in some detail in the yearbook, concerned the net incomes of the alumni, which were, by the standards of the day, significantly higher than the AMA's figures for American physicians in general...We knew that interns and residents got room and board but no salary to speak of. We were glad to hear that Harvard graduates did better financially once out in practice...
The median net income of the group of 165 HMS graduates, ten to thirty years out of school, was between $5,000 and $10,000 a year (about 80K to 160K in today's dollars). In the ten year class, 43% made less than $5,000. Only five men earned over $20,000 (~300K c. 2015) and a single surgeon, twenty years out, made $50,000 (~700K). Seven graduates of the class of 1927 had incomes below $2,500 (below 40K).
The alumni were invited to send in comments along with the questionnaire, in a space marked "Remakrs", with the understanding that since so much of the form was directed at finding out how much money they were making they might like to say something about life in general. As it turned out, most of the "Remarks" were also about money, a typical comment being the following: 'I am satisfied with medicine as a life's work. However, I should recommend it only for the man who has plenty of money back of him. Many men never make much in medicine.' Forty one years ago, that was the way it was (LT wrote this in the 1970's)."
Everything in parentheses was written by me to provide 2015 dollars using a couple of online inflation calculators that seemed to roughly agree on those numbers. I bolded the bits I found the most interesting.
Things to take away:
1) Docs probably didn't make as much in the "good old days" as you think they did, barring the 80s-90s.
2) The more things change the more they stay the same (regarding med student and physician attitudes about the profession and financial compensation).
3) Yup, back then you lived in the hospital as an intern. No salary. Just enough to live and eat at the hospital.
Ahh, but what did tuition cost back then eh?
According to UPenn's historical data, tuition for medical school in 1937 (per year) was:
Tuition: $500 (About 8,000 in today's dollars)
General Fee: $15 (~80-100$)
Room and Board: $520 (About 8,000 in today's dollars)
HMS' fees would most likely be a little less if not on par with UPenn's figures. I was unable to find HMS data. What does this mean? This means that in 1937 one could attend an elite private medical school (to be fair, there were far fewer so this most likely had less meaning) for $16,000 dollars a year...in other words, a little less than tuition at, say, UTSW or Baylor today (a testament to just how cheap Texas medical schools are).
Furthermore, according to Encyclopedia.com, medical doctor salaries in the 1950s ranged from $8,272 to $28,628 for a neurological surgeon. The average salary of a physician was $11,058. In today's dollars that ranges from about $26,000 to $248,000 with the average sitting around $100,000. Given Lewis Thomas' commentary on salaries for attendings in 1937 this means that HMS grads were certainly making much more than the average physician in 1937. I'll update if I can find a general source for all physicians in 1937. In 1955 medical school tuition + room and board at a private medical school (using UPenn archive numbers again) was roughly $16,400 in today's dollars (around 1800-2000 then) thus showing that medical school attendance costs had not changed very much from 1937.
Government data also indicates that both in the 1930s and 1950s physicians were making around, or at most the double of, the average income in the US and far above the average income for health care service workers in the US.
Another study from 1992 takes a look at physician income trends beginning around 1982. From the charts, we can see that Surgeon salaries have always been significantly higher than average physician or specialist salaries. In those days, specialists made less than the average physician (certainly this is skewed by surgeons; it is not clear whether surgeons were left out of this calculation or not) and general practitioners have always made the least. Around 1985 significant spikes occur, especially in surgeon salaries. General practitioner salaries tend downward near the early 90s. The report is interesting and I recommend you skim it. The report had this to say as to why salaries rose:
Reasons for Income Increase
"Greater volume and profit per service. Provision of more services and higher profit per service contributed roughly equally to physician income growth in the 1980s. We estimate that 42 percent of the growth from 1982 to 1988 in real net income per office-based physician was due to a greater number of services provided per physician, and the remaining 58 percent resulted from higher unit-profit margins. Since physician supply increased rapidly in the 1980s) across all physicians as a group, growth in volume of services was the dominant factor explaining rising net income. It accounted for two-thirds of aggregate income growth, while increased unit-profit margins explain only one-third. These conclusions are consistent with other evidence. Studies using Medicare data have shown large increases in volume for many procedures, especially surgery, radiology, and special diagnostic tests. Moreover, many of the procedures that are increasing most rapidly are among the most profitable relative to physician time and effort. These include cataract operations, coronary artery bypass graft surgery, and upper gastrointestinal endoscopy. Conversely, cognitive services such as visits, which are thought to be relatively underpaid, have not grown as rapidly.
In addition to raising charges faster than expenses are increasing and providing a more profitable mix of services, physicians have attained higher unit-profit margins by lowering their cost per service. Specialists have achieved enormous economies of scale and productivity gains for certain procedures through “learning by doing,” as techniques have been refined and volumes have risen. Despite a mid-1980s fee freeze and some “overpriced procedure” reductions, fees for such services as cataract surgery and coronary artery bypass grafts have not fallen enough to reflect productivity gains. Moreover, as volume has grown in the 1980s, physicians have been able to spread fixed practice costs such as office rent, equipment, and malpractice insurance over a greater number of services. They have also lowered costs by providing related services jointly (for example, completing a diagnostic test during an office visit). Fees have not been reduced to fully reflect lower costs.
Another reason...
Slower increase in physician supply. The physician supply and the physician-to-population ratio continued to grow rapidly in the 1980s. Nevertheless, the rate of increase in supply slowed. The average annual rate of increase in patient care physicians per person (excluding residents) fell from 3.7 percent between 1978 and 1983 to 1.9 percent between 1983 and 1989. For a given rate of increase in the demand for physician services, a slower rate of supply growth implies a higher rate of increase in income per physician. The average annual rate of growth in real income per physician was nearly three times as high between 1983 and 1989 (3.1 percent per year) as it was between 1978 and 1983 (1.1 percent per year). Nevertheless, the rate of increase in the aggregate real net income of physicians as a group was virtually identical in the two periods (6.0 percent per year versus 5.9 percent per year). The higher growth in income per physician was almost entirely due to the reduction in the rate of growth of the physician supply from 1983 to 1989 (2.9 percent per year) as compared with the period from 1978 to 1983 (4.8 percent per year). Moreover, over the past decade (1978–1989), the number of surgeons grew less rapidly (2.8 percent per year) than the overall number of patient care physicians (3.8 percent per year, excluding residents). This helps to explain surgeons’ rapid income gains.
And...
More comprehensive insurance coverage. Out-of-pocket expenses as a proportion of total spending for physician services have been falling for a long time, and the trend continued in the 1980s. In 1970, 42 percent of national expenditures on physician services were paid for out of pocket. This proportion fell to 27 percent in 1980 and 19 percent in 1989.23 Lower out-of-pocket cost (that is, more comprehensive insurance coverage) increases patients’ willingness to use physician services, allowing physicians to raise their incomes by increasing both the volume of services and prices. [Lucca's commentary: More insured patients led to an increase in physician compensation??? Say whaaaaaaaa??! /sarcasm] The specialties whose services are covered most completely by insurance-particularly surgery-have experienced the most rapid income growth. Specialties whose services are less well insured-for example, general practice and pediatrics-have fared less well.
Outpatient shift and technology diffusion. Real physician income was relatively flat from 1982 to 1985; it only began growing rapidly after 1985. Although the coincidence is not exact, the timing of the spurt in physician income suggests a connection with the shift from inpatient to outpatient care with the implementation of Medicare’s prospective pay- ment system (PPS) in 1983. Private third-party payers have also encouraged the substitution of outpatient for inpatient care. The result was an explosion in outpatient surgery and diagnostic testing in hospital outpatient departments, freestanding surgery and imaging centers, independent laboratories, and physicians’ offices. Physicians’ higher outpatient earnings have more than offset their reduced inpatient revenues. They now earn an entrepreneurial return on capital (equipment, building space) and labor (aides) that was formerly appropriated by hospitals. [Lucca: And soon to be re-appropriated lol technology costs] Lower cost and convenience for patients has probably been a major reason that the volume of many procedures and tests has skyrocketed in the outpatient setting. Without a hospital admission, patients can avoid expensive inpatient deductibles and co-payments. Their time costs are also lower because of the convenience of ambulatory surgical centers and doctors’ offices. Outpatient procedures are often less invasive, less painful, and less risky than inpatient procedures and have shorter recovery times. The much less stringent utilization review afforded to outpatient activity than to inpatient admissions may be another important factor in higher outpatient volumes. Technical advances and diffusion have enabled the growth of many outpatient procedures and tests and also augmented physicians’ inpatient earnings in the 1980s. Older procedures/ technologies such as joint replacements and open-heart surgery have ‘also been refined and are performed on more patients than before because of improved outcomes.
Physicians, especially procedure-oriented ones, simply have more ways to make money now."
And the rest is history...
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I suspect this conventional wisdom of SDN to be more myth than reality, which is why I asked the question.
Thank you so much for this incredibly in-depth response. I really appreciate the effort. My primary motivation for asking the question is that I just started reading Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care by Dr. Kenneth M. Ludmerer. The beginning the book places a large emphasis on how after the Flexner Report medicine transitioned to being viewed as a public good with doctors as public servants, but this model has changed in recent decades.
The conventional wisdom on SDN, at least from my perception, is that medicine is indeed not as heavily viewed as a public service, and that doctors are certainly not viewed as public servants. I think salary is a relatively good benchmark (though certainly not perfect) to correlate the extent to which members of certain professions are considered public servants.
I have read some non-source backed articles that discuss how New Deal reforms that increased the amount of work-place health insurance and the implementation of Medicare and Medicaid caused a significant increase in physician income due in part to dramatically increasing the percentage of patients who paid for services as well as normalizing the price of services. This to flies in the face of much of the political talk and conventional wisdom I hear on SDN about the effect tax-payer supported medical insurance. However, I am eagerly looking for some more legitimate sources to support or refute these assertion. It will take me a bit of time to sort through all of the information you provided in your post.
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The study I linked from 1992 is probably the best place to start. The analysis therein agrees with your last paragraph. Yes, I completely agree with Dr. Ludmerer. His account agrees with the account Lewis Thomas gives in his book The Youngest Science (I'm a big fan of Lewis Thomas, as you can tell) about the changes in medicine that occurred in the twentieth century beginning with Osler's nihilistic practice of medicine which turned the profession into one of prognostication and healing rather than primarily focused on intervention, to the invention of antibiotics and, finally, the rise of fee for service and the titanic biomedical research machine in the latter half of the twentieth century.
As far as legitimate sources are concerned, you may have to look deeper in academic resources such as university libraries and archives or seek out a faculty medical historian if you can.
Update this thread if you find anything as I am also greatly interested in this. Given that medicine is going through a time of intense change - socially, politically, scientifically, professionally, financially, etc - I believe it is important for current and future health care workers to know their history. It is far more dangerous, in my opinion, to assume things about the past as the past is, generally, always surprising.
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How many other public servant jobs (or people in any career for that matter) require a college degree plus 7-10 years of additional training after that with an average debt of over 200k starting the career? If physicians made as much as most public servants (under 50k/year) you might as well call them slaves.
As for the tax-payer supported medical insurance thing, the U.S. has had a steady rate of uninsured (non-elderly population) of around 17% for about 20 years. Currently it's down around 13%. Even if that uninsured rate dropped to 0, there would still be a significant percentage of the population that wouldn't utilize medical care until an emergency when treatment would be expensive enough to negate any extra profits that would be seen from the extra patient load. This can already be seen as the EM department of many hospitals is typically the unit that hemorrhages money. I believe part of the reason there was such a boom back around the advent of insurance was that people were suddenly able to afford basic treatments that they previously couldn't get and which were relatively inexpensive. People who couldn't afford to see a doc for 15 or 20 years started going in for regular yearly visits and could afford basic prescriptions. I don't know the numbers, but I'd imagine that adding millions to a patient population who require relatively inexpensive treatment would be the cause of the mass increase in profit. Add to that the fact that the landscape of the healthcare world isn't even remotely the same as it was 75 years ago and how much more ridiculously expensive treatment is, it is pretty easy to see why some would be financially concerned.
I hope so-though I am very curious to witness how much change will actually occur.
I 100% agree. Unfortunately, conventional understandings of history, which are more often obtained from political figures and editorials, are too often engineered in order to benefit contemporary agendas.
I agree that the intense education and competition to become a physician warrants a higher salary than the average public servant. However, I cringe every time somebody brings this up because it is a straw man argument to assert that anybody suggesting that income might be adjusted is claiming that it should be reduced by 75%.
The assertion that the implementation of Medicare greatly increased physician income (at the time) is that such a large percentage of medical care was offered for whatever a person could afford (which was sometimes nothing) (Hear is the unsourced article that I previously mentioned http://www.kevinmd.com/blog/2012/09/doctors-complain-history-physician-income.html). You are absolutely correct that the landscape of medicine has changed dramatically over the past decades in terms of higher costs for many more advanced treatments. It is certainly a possibility that the reforms that implemented public insurance in the 1960's that led to such an increase in physician salary of the day now have a negative effect. I do not know the answer to this. I also do not know how possible it is to discover the truthful answer with how chaotic our health care system is today. There is so much variation in cost for medical procedures that it is hard to assess the true value of care. http://www.nytimes.com/2013/05/08/business/hospital-billing-varies-wildly-us-data-shows.html and http://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/08/one-hospital-charges-8000-another-38000/
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The future is clear. Fully socialized medicine will come to America. The top 10% of the population by wealth will have no interest in inefficient, long-wait, British-style government medical establishments. A far larger proportion than 10% of doctors will move into the direct-pay top tier "boutique" medicine. Entire specialties will be unavailable to people who can't pay cash.
Reasonable people should recognize this outcome as the only logical possibility. Harry Reid has directly stated that the point of ACA was to crush the insurance industry to make way for single payer. Doctors will be paid far less than market value by this single payer, so I expect many to exit the system. This will greatly exacerbate the physician shortage on a scale never before seen. Attempts will be made to enslave doctors by tying medical licensure to acceptance of government insurance. The government will maintain as much control as possible over the system. Why? Because universal healthcare will probably not work well in a country as large and diverse as the US.
Reasonable people should recognize this outcome as the only logical possibility. Harry Reid has directly stated that the point of ACA was to crush the insurance industry to make way for single payer. Doctors will be paid far less than market value by this single payer, so I expect many to exit the system. This will greatly exacerbate the physician shortage on a scale never before seen. Attempts will be made to enslave doctors by tying medical licensure to acceptance of government insurance. The government will maintain as much control as possible over the system. Why? Because universal healthcare will probably not work well in a country as large and diverse as the US.
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Nailed it.
This comment is irrelevant to the proposed question and the discussion at hand. This thread is for discussion about the history of physician pay, not grandiose predictions about the future of medicine. Thanks.
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Yah universal health care will probably not be a reality in this country for the foreseeable future. The future is certainly not clear. Congress (on both sides) understands that the economic infrastructure is not there (How do we pay for it?) the social infrastructure is not there (Who will it serve and can they access it?) and the professional infrastructure is not there (Who is actually going to do this?) and, most importantly, the political infrastructure is not there (Who is going to pay for this?). The USA will not go the way of the NHS. However, if state government changes significantly in the future I can see something like state-wide NHS-like counterparts working in tandem with private insurers as private insurers move towards catering to a different population (read: the wealthy) and governments move to cover everyone else. I do not foresee a national NHS-like system coming to fruition anywhere in the near future. I agree that some form of incentive will probably be put in place to discourage private practice or non-hospital based care. The optimist in me hopes that future physicians foresee this and the importance of being more organizationally educated and get to the business of ensuring that these hospital systems are run by physicians.
Everything else you said is overly dramatic and is the same sort of non-sense that has been milling around the medical profession for decades.
Healthcare is going to become more public, more centralized and more bureaucratic. I do not believe there is a way to avoid this. The best hope for physicians is for them to realize that "the system" is only made up of the people who work in the healthcare field, of which they are a part and they need to start playing a bigger part in the management of that "system" if they want their interests to be accounted for.
The question is no longer "will socialized medicine work?" the question is "how can we make it work?" otherwise we will be unable to do one of two things: 1) provide quality care for the entire population or 2) sustain the current medical economic structure. As the US' economic hegemony begins to be challenged by India, China, Great Britain on the global marketplace our underlying socio-political structure - of which healthcare is a massive cog - needs to be solving problems those countries have already solved. We're two steps ahead already by providing the best care and biomedical research on the planet (if you can pay for it and know where to look...) so it would be a fool's game to underplay our hand and act like we're old men on a porch with our shotguns fighting a losing fight.
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What's overly dramatic?
The government already determines to whom one must provide loans, residential patterns, and whom one must serve.
To force doctors to accept a minimum number or percentage of Medicare/Medicaid patients would actually be easy to accomplish.
Which problems are those?
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These contradictory statements are confusing me deeply. As you have pointed out, it is not possible to make universal healthcare work and continue to provide high quality, cutting edge care. This is an economic reality as you have already conceded.
To the OP, the reason why past physician compensation matters (and you care at all about it) is to understand future developments and possibilities. That is the function of studying history.
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I wasn't trying to say that it should or would be reduced by 75%. I was just saying that using salary as a measurement of 'public servitude' is not accurate for physicians because they're training and cost to become certified/trained is vastly different from almost any other profession in which one would be considered a public servant. That's not a straw man, that's just the reality of our system. As for finding the truth to the system, that's something that takes years, even decades, and people make their careers out of trying to really understand it. I'm not going to pretend that I do or ever will truly understand it as a whole, and I'd venture to say 99% of the people who claim they do are full of s***.
We cannot provide high quality care for the entire population. We simply don't have the resources to match the demand. Add to that the large percentage of the population that is completely illiterate and ignorant when it comes to their own health and I think it is an impossible undertaking (at least for the moment). I think the question is still will socialized medicine work here because as you said we don't have the financial infrastructure to move into a single payer system. I think most people in healthcare agree that it's moving in a more centralized direction, but how far and how fast it will happen are still very much up in the air.
Personally if we end up moving into a universal care situation I hope we use a model similar to what Australia has, which is basically a 2-tier system. Every citizen qualifies for Medicare (equivalent to our Medicaid) and may receive basic treatments at public hospitals or by publicly associated physicians. It provides everyone with basic health needs and with major surgeries/treatments, but has the same issues as most other universal health systems (poorer quality due to limited resources, longer waits, etc.). The second tier consists of private insurance which is somewhat similar to what we already have. It costs more and some people don't get it because of cost (which is still typically much cheaper than here), but those who are willing to pay have faster access to what is usually higher quality care.
I think the other problem that most countries don't have is the cost of prescription medications and treatment. While I understand big pharma's needs for high income in order to develop new products, I can think of very, very few reasons why any single pill should cost a person, whether they are insured or not, hundreds or even thousands of dollars unless it actually costs that much to produce it. If we really want to make healthcare more cost efficient, then the costs from big pharma need to be brought into check somehow, but that's a whole 'nother argument with even more issues.
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To the italics, I agree. I don't think this is far-fetched at all, in fact it's likely. The overly dramatic bit is the bit about physicians basically becoming slaves and specialties being totally unavailable to a significant portion of the population. That will never happen. Where there is a need and infrastructure, there will be people willing to do it. Wait times may become a problem.
The problems I mentioned are: providing resources and infrastructure for large populations. The NHS for all of the complaints and wait times and criticisms it spawns is providing excellent care to the majority of the population, as is documented.
China and India while not giving every single citizen the best care they possibly could and having more substantial public health issues in some areas than we do (certainly this is the case for the majority of rural India and China) have systems in place for dealing with enormous populations in jam-packed cities in terms of sanitation, public health, and medical treatment. They are not perfect, but when you can get placed on a waitlist in your home city of Mumbai but if you were uninsured in America would have to travel to another city to find someone willing to see you then you are talking about a problem that shouldnt exist.
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Universal health care wont exist, as I said, in the form of a universal NHS-like system. However medicine will still become more socialized. These are not contradictory statements. There is a difference from larger, more centralized hospital based systems of care and a One Payer system funded by the govt. like the NHS.
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I agree with basically all of this.
Agree with all of these points.
I think we are talking past each other on this one. I am saying that the increase in physician income over the decades as a percentage of average income correlates (in my opinion) to physicians no longer being viewed as public servants. I am not talking about the cause of this increase (I think the cost of medical school is a big reason that needs fixing), but only stating that this increase in earned income has occurred. I do not at all view this as entirely the fault of physicians. I think that the decrease in public funds or regulations to ensure students are provided with affordable medical training is a large contributing factor to the increase physician pay because there is more of an incentive for physicians maximize profits and get out of debt. Being viewed as a public servant is a two way relationship. The public needs to show that they desire physicians to financially behave like public servants by providing the financial means to train physicians accordingly.
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Are you arguing that physicians should be viewed as public servants? I and many other future physicians would object deeply to being "public servants." I want to serve my patients, not the general "public."
The point of studying history is also to evaluate the present, and the accuracy of statements comparing the present to the past. I am not at all saying that there is no merit in studying history in order to understand the future, I just consider this too big of a task to accomplish civilly and productively within one discussion thread.
I believe Lucca is distinguishing between universal healthcare (practical and hopefully a positive progression) and a single payer healthcare system (not practical and a bad idea). I could be wrong with this interpretation.
No I am not making that argument hear. I am simply discussing the reason why physicians are not viewed as public servants.
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I think the raise in salary has less to do with physicians no longer being seen as public servants and more to do with the fact that healthcare is significantly privatized while demand for physicians and treatments has continued to grow. Those factors together allow prices to be set as high as demand will allow, and there will always be a great demand because maintaining the health of individuals will always be a huge priority to people.
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I guess I am unfamiliar with other systems that use universal healthcare without providing each citizen a government sponsored insurance plan (from tax credits, subsidies, or a govt run program). Can you explain how this would work?
The cost of healthcare is high because it is not privatized enough. Artificial price controls inflate costs. Incredible heaps of nonsensical regulation increases costs. Excessive liability increases costs. Remove regulations and you will see the price fall. Stop catering to special interests like big pharma and big hospitals and watch prices fall. Healthcare should be a nearly perfectly competitive market.
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Is there an important distinction between the two?
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These are conflicting posts so I quoted them both. If you look at the 1992 study I linked above you will see some of the reasons that were found to be causally related to the increase in physician salary (which is an increase in healthcare costs) I think @Stagg737 hit the nail on the head though. However, we must also consider how the cost of care has increased in other ways that have already been mentioned: pharmaceutical costs, technology costs, legal etc. All of those factors are now contributing economic factors not necessarily against privatization but against the formation of private practice. While private hospitals are able to foot these costs (as they have been, buying up private practices) individual physician offices cannot. The market has already decided that private practice is untenable in the current environment and regulations are not going to change that. The existence of regulation will not change the fact that in order to increase profit you need to centralize your diagnostic and treatment centers locally and be able to provide multi-specialty care - there are reasons to believe this type of practice also improves patient outcomes. The science of medicine also plays a contributing role here; finances are not the only thing driving physicians to the specialties, scope of practice is as well.
What kind of nonsensical regulations are you referring to? I'll believe that excessive liability raises costs but so does unstandardized practice of care. Regulations are necessary in a market that is not (I assert here that it ought not be) intended to be centrally concerned with profit margins but rather public service. Regulations can and do act to prevent incentives from deviating the outcomes of a market from an undesirable point: financially in the case of the stock market and socially/clinically in the case of healthcare. Again, specific references to regulations would be good here. Total lack of regulation is almost always an awful, awful, terrible idea and even more so when the largest player in the market is the federal government.
I suppose this would work by providing all people some sort of government sponsored minimum threshold of care, but still intending for private medicine to exist as a higher level of care for those who can afford it. I think if we are going to go in the direction of universal health care then the U.S. needs to develop a unique system. For example, doctors could have the right to chose a percentage of their patients that are on government insurance and then receive a certain share of their salary directly from the government and the rest from the hospital where they work. Doctors can chose whether or not they want to participate in such as system as can hospitals. Now I also would not consider a system that provides tax credits or subsidies to be a single payer healthcare system.
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His comment was actually very relevant to this discussion. Take a pause and connect several dots before you attack someone who offered a well articulated thought. Part of medicine is understanding dynamics and making predictions. There is an obvious and direct relationship between how much the government will pay for a service/procedure and how much money a doctor is paid.
