The comparison of US physician salaries with other countries needs to take into account that in most of these other countries medical education is largely subsidized by the government. The comparison downplays the expensive education required to obtain a medical degree, the numerous years of low-paid post-graduate training, the long shifts and sleepless nights, the personal and professional risks unique to practicing medicine in the United States, and the ever-growing cost of clinical practice.
Baker also notes that teaching hospitals have an incentive to offer residencies in specialties in order to bring in more revenue per resident. The truth is that there are more primary care residency spots available than specialty spots. Many specialists are initially trained in a primary care specialty, but later move on to subspecialize. Hospitals may generate more revenue by providing specialty care, but they do not promote specialty training. I personally do not recall any training programs encouraging me to specialize. In fact, when I applied for my internal medicine residency, I feared that my plans to specialize in cardiology might hurt my chances at a successful match because programs were so eager to recruit physicians who would stay in primary care.
I suspect some of Baker’s arguments come from a 2013 article published in Academic Medicine showing that the mean percentage of physicians remaining in primary care after completing an internal medicine or general surgery residency was 37.9% and 38.4%, respectively.3 That same article reported high reimbursements for training centers offering more specialized graduate medical education programs. However, that does not mean that institutions encourage physicians to specialize. It is difficult to match to a specialty position as there are markedly fewer positions available then primary care positions. For example, my internal medicine training program had 35 spots available per year for residency training. At the same institution, there were only 6 spots per year for cardiology fellowship training. Therefore, there is no concerted effort to train more specialists. Something else is driving the flow of primary care physicians towards specialty training.
The article had some serious limitations, which the researchers themselves pointed out. First, 13% of the cohort couldn’t be accurately assigned to a training site, making it impossible to determine the final disposition of those physicians. Further, the Accreditation Council for Graduate Medical Education database that was used only allowed them to identify primary teaching sites, which does not represent the entire body of teaching hospitals. The study essentially excluded all osteopathic residency programs that often train and retain a larger percentage of primary care physicians.3
Despite the limitations, Baker is right in saying that many physicians are specializing at a time when we need more primary care providers. He neglects to show, however, how physician salaries are driving this gap. It may be that our society has created a higher demand for specialty physicians. In fact, he discusses possible causes, such as the fact that primary care providers may refer to specialists more often due to fear of the legal ramifications of trying to treat more complex issues on their own. There may also be gaps in medical knowledge that are a direct consequence of increased referrals, thus perpetuating the cycle of specialty referrals for issues that could otherwise be managed by primary care. The lack of primary care providers may in and of itself lead to overburdened primary care physicians who must refer to specialists in order to keep their patient loads more manageable. These are all symptoms of a systemic problem, but not a problem related to physician salaries.
Patients often assume that because specialists have more training, they may be better general practice physicians. That misconception has cultural ramifications even among physicians. I can recall countless times when colleagues have been asked about their specialty and when they answered, “I’m an internist” were asked, “Just an internist?” Even as a noninvasive cardiologist, I’ve been asked by colleagues whether “I’m just a cardiologist or an interventional cardiologist,” as if my training was in some way inadequate because I did not complete an additional year of interventional training. Thus, the expectations set by our society may also drive the demand for more specialty training.
In fact, I do not remember learning about cardiology salaries until long after I had decided to become a cardiologist. I do, however, recall the dread of not matching to a cardiology fellowship. The administrative nonsense in primary care seemed to drown out the reason why I became a physician in the first place. This may be part of the drive away from primary medicine as well – physicians may be grasping to preserve some semblance of what medical practice once was. The growing number of non-medicine related tasks, increased regulatory control, and the mountain of administrative work that has been dumped on primary care providers likely discourages physicians from wanting to go into primary care. Again, this is a symptom of a much larger problem.
While Baker may have quoted the data correctly, the conclusions he drew from that data about solving the growing cost of health care by reducing physician payments is likely flawed. Addressing physician salaries before addressing the other larger issues that plague our healthcare system would worsen the problem by further exacerbating the supply side of the equation. If there is to be any change towards a more efficient and cost-effective healthcare system, economists, politicians, and healthcare administrators need to sit down with physicians who routinely deliver health care.
- Baker D. The problem of doctors’ salaries: An economist argues that American doctors get paid too much. Politico. www.politico.com/agenda/story/2017/10/25/doctors-salaries-pay-disparities-000557. Published October 25, 2017. Accessed November 20, 2017.
- Health, United States, 2016. US Centers for Disease Control and Prevention. www.cdc.gov/nchs/data/hus/hus16.pdf. Accessed November 20, 2017.
- Chen C, Petterson S, Phillips RL, Mullan F, Bazemore A, O’Donnell SD. Toward graduate medical education (GME) accountability: measuring the outcomes of GME institutions. Acad Med. 2013;88(9):1267-1280.