Equal salaries for all?

[71263]

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I was having a discussion with a friend of mine the other day, and he brought up an interesting thought:

What if ALL medical specialties had the same hourly salary?

This would mean that ALL residents, regardless of field, would receive the same salary, and ALL attendings regardless of field, would receive the salary.

For one, this would certainly affect the specialties that people would apply for. With salary no longer an issue, people would be more prone to choose the fields that they truly wanted to go into, rather than the fields which pay the best. Hell, even lifestyle wouldnt be as much of an issue, since those who worked longer hours would be compensated as such.

Sure, some might argue that fields with shorter residencies would start making the big money faster, but if all salaries are truly the same, then the couple of extra years would be negligible in the long run.

On the other hand, one could argue that there are certain costs inherent to certain medical fields (ie, higher malpractice rates for OB/gyn or surgery vs. derm, radiology, etc), and as such, a higher salary would be necessary for those.

What do you guys think?

 

[WiscDoc]

Have you also considered that some specialties are more taxing physically/ mentally/ socially? You need incentives to compensate for the level of difficulty/ boringness/ problems/ schedule nature/ ....etc. Plus, The extra "few" years in residency are some of the most valuable years of ones life (can be the difference between 3 yrs and 9 yrs of training!). Unless you start paying ALL 4th year residents the same salary as attendings, and considering lifestyle issues during residency, this just won't work well. It is complicated, but you know what, overall I think it would attract only the truly interested in each specialty, which might make some specialties having a huge shortage. Interesting thought!

 

[Trismegistus4]

First of all, most docs are not paid by the hour. They are paid for performing specific units of work, regardless of how long or short a time it takes them to do it. I.e., examine a patient complaining of cough and write them a prescription = $50; remove someone's appendix = $2000; perform esophagogastroduodenoscopy = $500 or whatever.

Second, the word "wage" typically refers to an hourly pay rate, while "salary" typically refers to a fixed amount of money paid per longer unit of time worked, like 2 weeks or a month, without regard to the number of hours worked during that time period. Most docs are not on a salary arrangement either.

Third, though the free market in medical care has been vastly distorted by government intervention and large insurance companies, most doctors, being neither hourly nor salaried employees, still at least technically make whatever they can reasonably bill. So there is no vast overarching entity deciding how much money all doctors make that can just set this "salary" at whatever it deems best. What you are suggesting would amount to a complete government takeover of medicine.

 

[dilated]

Michael Bolton: That's the worst idea I've ever heard in my life, Tom.
Samir Nagheenanajar: Yes, this is horrible, this idea.

 

[dd128]

Can we all say socialism???

 

[MrBurns10]

Besides, I would argue some professions deserve to make more money independent of the number of hours they work in a week. If someone can perform brain surgery (you know, effectively), then by all means they should make more money than me.

 

[Goran]

Just out of curiosity, why are procedural specialties assumed to be more valuable to society and therefore deserving of higher reimbursement rates? Every speciality comes with its unique challenges. Providing palliative treatment to terminally ill patients seems no less challenging cognitively and emotionally than performing complicated surgical procedures, as an example.

It seems that we, perhaps erroneously, attribute the greatest value to specialties with the most dramatic outcomes, and those that can be easily measured. It's hard to track the subtle improvements in a patient's quality of life, it's hard to track the impact of preventive medicine and counseling of patients. In stark contrast, the removal of a brain tumor has very obvious impacts.

I don't necessarily see the elimination of financial incentive as a bad thing. If people do what they love, they'll be better at what they do. Also, if you balance out the high salaries of certain specialties ($300-400,000) with the lower salaries of FP and such (100-150,000), you get an average that seems very reasonable for all physicians. Would $200-225,000 for an average work week (what is it these days, 65 hours or so?) not be sufficient? Of course, physicians who work longer hours, like the revered neurosurgeon, would make proportionately more money.

If paying all doctors the same amount seems unfair due to varying levels of skill, why not increase pay for doctors with better patient outcomes. That maintains the financial incentive to perform well in your chosen field. However the issue comes up again in non-procedural specialties of how exactly one might measure improvement in outcomes.

 

[MossPoh]

I agree that patient outcomes should be factored in. Cranking out procedures for income is not that uncommon. I do disagree that it should all be equal. There has to be some incentive for people to go into every field. I think it is ridiculous to give every one the same amount regardless of the work they do. Bad doctors should be penalized and good doctors should be rewarded. Unnecessary procedures need to be eliminated, but the guys doing the procedures need to be compensated fairly so they don't need to do ridiculous amounts of surgeries to keep a fair lifestyle. Its not an easy trick to balance. I do think the gap should be narrowed between specialities, but there has to be a time component, a difficulty component, and a success component along witha proper way to monitor it...Oh, and the insurance companies have to be held in check. Good luck

 

[TheRealMD]

Equal salaries would require trusting the government with my salary. They're not doing too well with Medicare and Medicaid. No. 🙄

 

[45408]

No, this would just encourage laziness. Payment per procedure/consult/whatever is better than an hourly wage. Doctors would just take longer lunch breaks, take their time on the phone, chat with the patients about the weather, etc.

 

[bubbachuck]

Equal salaries would require trusting the government with my salary. They're not doing too well with Medicare and Medicaid. No. 🙄

the medical community could decide this amongst themselves. think of professional sports.

i think the idea is a step in the right direction. i'm all for a little more "socialism" (don't treat it like its the black plague) if it means people go into what they want, not which has the most cushy lifestyle. i'm only a 1st year and i'm pretty disillusioned by the field of medicine already...more socialism please.

 

[lord_jeebus]

Everyone would go for the specialty with the most no-shows

 

[ChubbyChaser]

Isnt this the equivalent of Socialism? ummmm no.

 

[Droopy Snoopy]

the medical community could decide this amongst themselves. think of professional sports.

I'm all for having a pay scale similar to professional sports.

The 'medical community' as a cohesive entity is a myth. It took my state 15+ years of getting raped by litigators to come together and help pass tort reform. The AMA has been grossly incompetent on any number of issues (*cough* midlevels). Let's say we scrap the free market model so docs will have make guilt-free choices regarding residency 🙄. Government would have to pass a salary cap law that would shortly after get shredded by the Supreme Court, because there's nobody above the cut line is voluntarily giving up salary. Or, it could explode the deficit by buying out the tens of thousands of private hospitals, clinics, and corporations that in the real world make up the 'medical community'.

 

[njbmd]

Moved to Topics in Healthcare.

 

[AmoryBlaine]

Just out of curiosity, why are procedural specialties assumed to be more valuable to society and therefore deserving of higher reimbursement rates? Every speciality comes with its unique challenges. Providing palliative treatment to terminally ill patients seems no less challenging cognitively and emotionally than performing complicated surgical procedures, as an example.

It seems that we, perhaps erroneously, attribute the greatest value to specialties with the most dramatic outcomes, and those that can be easily measured. It's hard to track the subtle improvements in a patient's quality of life, it's hard to track the impact of preventive medicine and counseling of patients. In stark contrast, the removal of a brain tumor has very obvious impacts.

I don't necessarily see the elimination of financial incentive as a bad thing. If people do what they love, they'll be better at what they do. Also, if you balance out the high salaries of certain specialties ($300-400,000) with the lower salaries of FP and such (100-150,000), you get an average that seems very reasonable for all physicians. Would $200-225,000 for an average work week (what is it these days, 65 hours or so?) not be sufficient? Of course, physicians who work longer hours, like the revered neurosurgeon, would make proportionately more money.

If paying all doctors the same amount seems unfair due to varying levels of skill, why not increase pay for doctors with better patient outcomes. That maintains the financial incentive to perform well in your chosen field. However the issue comes up again in non-procedural specialties of how exactly one might measure improvement in outcomes.

I don't know that we consider them more valuable in a philosophical sense but they do harder stuff.

I might get burned for this (even though it is patently true) but Neurosurgery is harder than Psych. While the OP's idea is not wrong per se, we are never going to convince anyone to pay the same for adjusting SSRIs as we do for removing posterior fossa tumors.

I think the OP's question dovetails with some of the Doctor of Nursing Practice threads that have been bouncing around. The only reasons that DNPs/PAs are trying to encroach on certain fields is that a nurse/PA can function effectively alot of the time in FP/Peds and even in my own field EM. No one is suggesting that PAs be allowed to operate on the brain. I think that says something.

 

[Blesbok]

You would have thousands of general practitioners and no specialists. Why the hell would anyone go through a 5 year residency and a fellowship with 80 hour work weeks when they could make the same money in a 3 year residency with better hours?

Why don't we just start paying janitors the same as doctors?

 

[Blesbok]

Just out of curiosity, why are procedural specialties assumed to be more valuable to society and therefore deserving of higher reimbursement rates?

Why is a doctor considered more valuable than the guy that properly installs airbags in your car? Both save lives. We need both of them for society to function properly. Oh...I forgot...one takes a hell of a lot more work to learn the profession and therefore is reimbursed at a higher rate and it has absolutely nothing to do with the value to society.

 

[lord_jeebus]

Society doesn't "decide" what doctors should get paid.

Market forces are the governing factor. That is why fields with physician shortages have higher reimbursement.

Medicare and insurance companies do set rates for compensation, but in the end if they undershoot the market rate too much, doctors will simply refuse to accept them.

 

[Faebinder]

If you are going to pay everyone the same... then no one will do procedures. Why would I do a 7 hour procedure that has a high chance of coming back to the hospital with issues when I can see people in the clinic and earn as much?

Bottom line, procedures get paid more cause they need: more training, more time, and have adverse events / complications that need more work/time. On equal footing, these things dissuade the average physician from doing them.

 

[plauto]

No hourly pay for me either, please!
Plus, do you realize that all residents do get paid the same? The feds pay their salary. It only slightly changes based on cost of living in the area and yrs of experience, not specialty.

 

[ColinHay]

You would have thousands of general practitioners and no specialists. Why the hell would anyone go through a 5 year residency and a fellowship with 80 hour work weeks when they could make the same money in a 3 year residency with better hours?

Why don't we just start paying janitors the same as doctors?

the trend is actually going the other way - we are going to pay doctors the same as janitors

 

[nutsack johnson]

I think it's frightening that there are people in the medical field who actually believe that fixed salaries are a good idea.

 

[Miami_med]

I don't know that we consider them more valuable in a philosophical sense but they do harder stuff.

I might get burned for this (even though it is patently true) but Neurosurgery is harder than Psych. While the OP's idea is not wrong per se, we are never going to convince anyone to pay the same for adjusting SSRIs as we do for removing posterior fossa tumors.

I think the OP's question dovetails with some of the Doctor of Nursing Practice threads that have been bouncing around. The only reasons that DNPs/PAs are trying to encroach on certain fields is that a nurse/PA can function effectively alot of the time in FP/Peds and even in my own field EM. No one is suggesting that PAs be allowed to operate on the brain. I think that says something.

It is practically true that it is more physically demanding to do a whipple than to adjust BP meds. That being said, it's completely irrelevant. Knowing what something is "worth" requires a market to determine a price. Under communist rule, the soviets used to price goods based on the relative values in the Sears catalogue. In medicine, before Medicare, when patients paid their own bills, we never had a problem with what a certain specialty was "worth." It is clear that some specialists will and should earn more money than others, though there is no objective manner to determine what that differential is without a free market to determine relative worth.

Making two obviously false assumptions (for the purpose of an example), that there are the optimal number of training programs in each specialty AND that most medical students are capable of learning most specialties competently, one can gauge the appropriateness of pay in a specialty by the competitiveness of getting it. It's clear that the specialties that overfill and reject a lot of people (Derm, Optho, Rads, Urology, Ortho, fellowships in GI or Plastics, etc...) may be overpaid, because a relative decline in salaries would still allow them all to fill and put out the theoretical optimal number of attendings each year. Mid-level of competitiveness specialties (EM, surgery, etc...) are probably paid appropriately with this logic. This would make IM, FP, etc... underpaid. This doesn't of course take into account increases in salary that should exist to attract more competitive applicants as opposed to "just filling." However, there is no inherint reason that Derm needs more qualified applicants than medicine, etc...., so this probably doesn't hold up in the real world.

The distortions are the result of limitations on residency spots, controlled funding and pay, the rigidity of the training system, practice restrictions, etc....

 

[Miami_med]

Why is a doctor considered more valuable than the guy that properly installs airbags in your car? Both save lives. We need both of them for society to function properly. Oh...I forgot...one takes a hell of a lot more work to learn the profession and therefore is reimbursed at a higher rate and it has absolutely nothing to do with the value to society.

It's not the amount of work. It's the fact that a physician skillset is a lot more rare, and that lowers supply, which puts its dollar value higher on the supply and demand curve. The amount of work is what makes the skillset more rare, but it isn't a direct relationship.

 

[Begaster]

No, this would just encourage laziness. Payment per procedure/consult/whatever is better than an hourly wage. Doctors would just take longer lunch breaks, take their time on the phone, chat with the patients about the weather, etc.

Procedural payments are a disastrous idea through and through. You incentivize assembly line medicine, where the doctor runs from room to room like a chicken with his head cut off, spending the bare minimum amount of time with each patient. It might work well for surgery, but for fields that require delving into the person's habits and history, it bodes poorly.

 

[MOHS_01]

It's not the amount of work. It's the fact that a physician skillset is a lot more rare, and that lowers supply, which puts its dollar value higher on the supply and demand curve. The amount of work is what makes the skillset more rare, but it isn't a direct relationship.

I wish that this was still the case -- it was prior to 1992 and the institution of the RBRVU system. Since it's inception physician compensation has been a direct function of volume x mix -- "overhead" (with varying degrees of success) is factored into the RVU value based upon data collected and provided by specialty societies. While it is true that the work component of the RVU value does take into limited account the time, training, "expertise" level involved, etc, I believe that it would be a mistake to assume traditional free market philosophies such as supply and demand have much impact on physician pay (aside from starting salaries) -- with the notable exceptions of cosmetic care and physician shortage areas. Compensation is predominantly dictated by the payor, with little negotiating clout on the part of the provider (again, small caveat for extreme shortage areas). The only control that the provider has revolves around volume and services offered.

Side note -- I am increasingly intrigued by the comments and opinions of medical students as they represent the future of medicine. They comprise a much wider scope of opinion when compared to residents and practicing physicians. This may be related to varying levels of experience, knowledge, or understanding of the dynamics of the world, but it is interesting all the same. On a personal note, the feelings of medical students today do not vary significantly from those 5-10 years ago -- but most of us in the workforce have significantly changed our views as a result of increased comprehension of the world around us. This is in no way an insult, for medical students continue to be (for the time being) some of the brightest that society has to offer; rather, simply an observation that opinions are dynamic based upon one's experience and stage in life.

 

[Trismegistus4]

Side note -- I am increasingly intrigued by the comments and opinions of medical students as they represent the future of medicine. They comprise a much wider scope of opinion when compared to residents and practicing physicians. This may be related to varying levels of experience, knowledge, or understanding of the dynamics of the world, but it is interesting all the same. On a personal note, the feelings of medical students today do not vary significantly from those 5-10 years ago -- but most of us in the workforce have significantly changed our views as a result of increased comprehension of the world around us. This is in no way an insult, for medical students continue to be (for the time being) some of the brightest that society has to offer; rather, simply an observation that opinions are dynamic based upon one's experience and stage in life.

You didn't mention the specific opinions you're seeing in medical students vs. residents and practicing physicians, just that they're different. But assuming you're taking about the oft-cited phenomenon of medical students starting out as idealistic liberals but then being transformed by residency and practice into hard-nosed realists--i.e., more conservative--I'd like to know where you and others are seeing this. The vast majority of residents and academic attendings I've come into contact with so far seem to be ardent supporters of single-payer universal health care who want the federal government to take care of everyone's needs from cradle to grave.

 

[MOHS_01]

Tris,

Liberal vs conservative has little to do with it -- you are confusing political labels with a broader way of thinking. Many, if not most physicians (politically) are socially liberal and fiscally conservative -- placing them out of line with either mainstream movement. I suppose that it is part and parcel of our training and thought processes that led most of us to a career in healthcare to start with.

Yes, medical students (and residents for that matter) are very much more idealistic than private practice physicians -- which is both a reflection of their average age and life experiences. I would argue that this is a good thing. As far as using full time academians as your baseline for what the average practicing physician believes -- poor choice of reference point. Not only do they constitute the minority of the physician workforce, there is a fundamental difference in philosophy between most in the academic world and their private practice counterparts.

After a few years out you very well may find (as I did) that those opinions expressed in the open by your academic mentors are a facade determined by the political environment that is academics -- much like politicians -- whose unpublished, behind the scenes workings tell a very different story. Your academic types are much more likely to be "in the pocket" of industry, etc.

The single best piece of advice that I was given went something like this (and I paraphrase):

"Keep an open mind in everything that you do, for preformed opinions will cloud and taint every experience and situation that you encounter if you allow it. Never be afraid to admit your lack of knowledge or experience to have formed an educated opinion, for when you state your position in ignorance it carries the same weight as a well thought out conclusion."

 

[MOHS_01]

as far as "where I am seeing this" -- I live it every day. I vividly remember medical school discussions where colleagues took a more "liberal" view, and I have kept good relationships with these people. While they won't say "you were right", they often readily say "I did not know" or "if I had known" or "I really did not understand"... same as an admission of error by my way of thinking.

In case you are asking, I have to say the same thing all of the time -- generally when disparaging attendings for what I believed at the time to be self serving, greedy, immoral ways.

 

[cpants]

"You don't have to throw anybody out in the street, but long term you have to move toward the marketplace. You cannot expect socialized medicine of the Hillary brand to work. And you can't expect the managed care system that we have today [to work, because it] promotes and rewards the corporations. It's the drug companies & the HMOs & even the AMA that lobbies us for this managed care, and that's why the prices are high. It's only in medicine that technology has raised prices rather than lowering prices."

-Ron Paul, 2007

 

[docB]

You didn't mention the specific opinions you're seeing in medical students vs. residents and practicing physicians, just that they're different. But assuming you're taking about the oft-cited phenomenon of medical students starting out as idealistic liberals but then being transformed by residency and practice into hard-nosed realists--i.e., more conservative--I'd like to know where you and others are seeing this. The vast majority of residents and academic attendings I've come into contact with so far seem to be ardent supporters of single-payer universal health care who want the federal government to take care of everyone's needs from cradle to grave.

I don't see it with the residents as much. For residents the main pragmatic reason to support socialized health care is the belief that better preventative or primary care would decrease the number of hospitalizations as well as the notion that in a socialized system we could just deny people the primary care they seek in EDs and hospitals.

The real shift toward the right happens when docs get out on their own and start having to do free care for the indigent. I see them in the ED and the consultants pick them up on call. Lotsa work, no pay, same liability. That will conservatize most people real quick like.

 

[MOHS_01]

maybe the dermies are just quicker to catch on 😉

 

[Pinkertinkle]

Why dont we have equal salaries for all jobs? Oh wait, that's pretty much communism.