The Internet Forums of the National Conference on Primary Health Care Access will take selected topics for discussion between National Conferences. The following topic was suggested by a recent web posting by the Forbes Magazine, which was widely disseminated by the Yahoo Finance website:
On Monday, July 19 2010, www.forbes.com, the Internet site for Forbes Magazine, posted a list of what they calculated to be the five “worst paying” physician specialties in the United States. The article, by Tara Weiss and Seth Cline, extensively quoted Dr Ted Epperly, the president of the American Academy of Family Physicians, who is an Idaho physician, with a military background and a career as a family medicine residency director.
Dr Epperly cited the comparatively low remuneration of the “primary care specialties” – particularly family medicine, internal medicine and pediatrics. Of the lowest paid specialties “family medicine with obstetrics” was listed by the Forbes authors as a separate specialty, as was the function of “hospitalist” (which is considered by some a sub-specialty of internal medicine).
Both the article and the interview with Dr Epperly took note of the increasing amount of student loans that physicians accumulate during their education, which is an emerging concern of this website. (See the articles Drowning in Student Debt: Young Professionals at the End of Graduate School and An Associate Dean’s Response to “Drowning in Student Debt”.)
It has previously been argued on this website that differences among physician specialty incomes seem not to be determined by the marketplace, nor, for that matter, through some process like “central planning”, which presumably would place a premium on those entering specialties considered most in need. Instead the differences appear to have evolved as the unintended or unplanned consequences of previous federal intervention in the health care system (principally, Medicare and Medicaid). That said, few people appear to grasp the processes by how remuneration is determined and what can be changed to make things work differently.
There are several issues to be raised. First, one of the criticism of the American health care system is that it is much more costly than any other health care system in the world. In contrast, most others rely more heavily on primary care physicians as personal physicians to patients. (A compilation of some of the evidence and arguments for primary care in the context of health care reform may be found in The Fifteenth G. Gayle Stephens Lecture – Patrick Dowling, MD, Part I and The Fifteenth G. Gayle Stephens Lecture – Patrick Dowling, MD, Part II.)
One notes that Dr Dowling, who is the Chair of the UCLA Medical School Department of Family Medicine quotes his own daughter, at that time a medical student, on the “ROAD” to high physician income (ROAD being a student acronym for the “high income” specialties of Radiology, Orthopedics, Anesthesiology and Dermatology).
The argument has been made that the particular form of the 2010 national health care reform legislation was based in part on legislation enacted in Massachusetts, and it has been argued that the lack of sufficient primary care physicians in Massachusetts impeded that state’s goals for implementing the legislation they enacted. This is something that should continue to be analyzed and discussed, since it may provide some insights as to what the consequences of the enactment of federal legislation this year is likely to be on the existing physician workforce.
There are other issues that we believe should be discussed:
- How is physician income determined?
- Who decides, for the purpose of public expenditures on health care, the relative value of the different functions that various physicians perform?
- Should the United States, as a matter of policy, adopt “evidence based medicine” as a principal determinant as to how it will be spending its health care dollars? (For a discussion of this issue with Doctor Alfred O. Berg, see: Evidence-Based Medicine: Is American medical care based on science or politics?)
Finally, it might be interesting to give some thought to the actual figures that Weiss and Cline, the Forbes authors, compiled for these five specialties. They observed the aggregate salaries that were determined for each of the four previous years – 2006-07 through 2009-2010. The lowest physician specialties were ranked by the 2010 aggregate salaries.
These are the 2009-10 rates calculated for the five “worst paying” specialties:
- Family Medicine: $175,000
- Pediatrics: 180,000
- Internal Medicine: 191,000
- Family Medicine with Obstetrics: 200,000
- Hospitalist: 208,000
However, since they provided historical data for each of the previous years, it seemed worth calculating what those data showed as the four year trend. Using the Forbes data, we re-ordered the list of the 2009-10 bottom five to show the percentage increases in salaries between the 2006-07 aggregate income and that of 2009-10.
This is the re-ordering of the 2009-2010 bottom five (highest to lowest increase in four year salary):
- Family medicine with obstetrics: 25.8%
- Hospitalist: 15.6%
- Internal Medicine: 13.2%
- Pediatrics: 9.8%
- Family Medicine: 8.7%
One observes that all of these “primary care specialties” are shown as increasing even before the health care reform legislation was enacted. If primary care medicine is a sector of our economy that is on the decline, such as, say, print journalism (reflecting the decline in revenue streams such as automobile advertisements in daily newspapers), one might expect income to be stagnating or decreasing.
These are some thoughts for which replies are invited.