Should Medical Doctors' Salaries be Slashed?

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The unfortunate thing is that GPs usually don't spot the outlier and someone is sent home to get over his case of the "flu" when in fact he is dying of renal failure and needs to go to the hospital immediately. This is one problem with all forms of discount medicine: All you need is one fool in the diagnostic sequence and simple problems can be transformed into gigantic catastrophes, so the presence of the discount-medicine moron can actually act to augment the total size of the disease burden in society, not only because misdiagnosis encourages delay in proper treatment, but also because it might lead to improper treatment which makes things worse.

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The unfortunate thing is that GPs usually don't spot the outlier and someone is sent home to get over his case of the "flu" when in fact he is dying of renal failure and needs to go to the hospital immediately. This is one problem with all forms of discount medicine: All you need is one fool in the diagnostic sequence and simple problems can be transformed into gigantic catastrophes, so the presence of the discount-medicine moron can actually act to augment the total size of the disease burden in society, not only because misdiagnosis encourages delay in proper treatment, but also because it might lead to improper treatment which makes things worse.

So how does that compare to the person who doesn't want to go to the doctor because it is too expensive? People always do a self-diagnosis first. And if the doctor is expensive and they think it is a minor sickness, odds are they won't go. So the absence of the cheaper, if less trained, practitioners also makes things worse -- and more expensive besides.

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Your assertion that gps in general are not fulfilling their duty of referral is baseless - certainly some gps are bad at their jobs (anyone care to suggest a profession that has no slackers?) but the vast majority of specialist referrals come from the family practitioner. What makes you think gps are discount medicine? They are not cheap and they are trained to the same standard as hospital physicians.

You continue to contrast doctors and archaeologists - 3 year degree 3 year phd; and you are as well academically qualified as you can be; most medics in England finish taking exams in late twenties early thirties with their memberships - that's ten years training. I am also unsure that archaeologists continue to be reviewed theoughtout their working lives to ensure they have kept abreast of latest ideas. And if an archaeologist screws up , it will be in the very rarest case that they will be sued for multiple millions

Take a look at the gains in life expectancy and disease survivability - they are pretty good, and getting better, Drs cannot take much of the credit for that, but they can takes great deal.

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Archeologists more probably do a four-year B.A. followed by a six- or seven-year Ph.D., which equals or exceeds many medical qualifications.

Most gains in life expectancy have come from better diet and improved hygiene rather than medical interventions. The Bible speaks of the natural lifespan of people as being three score and ten, which is not very different from what we see today. The slow progress through the cursus honorum in Ancient Rome also suggests that it was expected that people would live a fairly long time. Now gains in life expectancy in the developed world have levelled off, and in some areas they are actually starting to decline for the first time since records were kept.

One indication of the arbitrariness of doctors' salaries is that in Germany, dentists earn about double what medical doctors do, since dentists are regarded as medical specialists, given that they deal primarily with the teeth, jaw, and gums, while doctors have to deal with the entire body. In America the relation between dentist and doctor remuneration is almost the inverse, since here dentists are just regarded as people who couldn't quite make it into medical school.

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In revival of this thread, I recently read something in relation to medical doctors vs. physician assistants.

M.D.s doing residency are starting to be hired more than PAs, because these resident MDs can be paid less.

However, an MD having done residency might not be more worthwhile to hire than a PA because of the cost involved with hiring the trained MD.

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Since third-rate Caribbean M.D.s can be hired to work at American hospitals as long as they are theoretically under the supervision of a licensed M.D., we already have a situation in which cut-rate and unqualified 'doctors' are delivering a lot of care just to save salary costs. The Soviet Union and Maoist China resorted to similar expedients by graduating 'doctors' from highly compressed and streamlined courses to save training costs, yet most of these graduates are today ineligible for professional accreditation elsewhere. Even the West churned out substandard physicians during the compressed medical degree courses offered during World War II to put more doctors into military service quickly, yet many of these people were practising as ordinary phyisicans in civilian life until recently. Not many people know that you could still get a correspondence school medical degree from the University of London external program until 1952, and those 'doctors' were still practising until not long ago.

Until circa 1910 physician-training in the U.S. was essentially unregulated, and anyone could call himself a medical doctor, whether trained in Thomsonianism, homeopathy, water cures, electric medicine, or conventional allopathic medicine. Patients had the freedom to pick the practitioner they wanted, though they had the right to know how that person had been trained and what school of medical theory he subscribed to. Why not do the same today in the name of patient medical freedom? As long as the customer knows what he is getting himself into, why shouldn't he be allowed to hire a quack to remove his left arm and re-attach it to the middle of his back if he wants? The U.S. declares itself to be uniquely dedicated to individual liberty, yet in medicine it is one of the most restrictive countries on earth.

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There's another reason why this archaeologist/doctor comparison is fallacious: you're leaving out residency, which you've already acknowledged is stressful as hell. Even if we accept your premise that archaeologists spend 4 years in undergrad and 6-7 in graduate school (even though a PhD can be completed in 5), doctors still spend more time in training. A neurosurgery spends 4 years in college, 4 years in medical school, 1 year as a surgical intern, 5 to 6 years as a resident, and often 1-3 years as a fellow in some sub-specialty like pediatric neurosurgery or neurovascular surgery . Even the lowly family physician spends 4 years in college, 4 in medical school and 3 more in residency. That equals even the worst case scenario for training to be an archaeologist and every specialty trains for some amount of time between the 18 years spent preparing to be a nurovascular and the 11 years spent preparing to be a GP.

Its easy to argue that doctors are over-glorified refrigerator repair men, until something goes horribly wrong. If there's ever an aneurysm in you medulla oblongata that's threatening to rupture, you'll gladly take the helicopter ride to one of the very few hospitals in the country that can help you (Johns Hopkins Hospital, The Mayo Clinic, Stanford University Medical Center, or Massachusetts General Hospital) and when the surgeon (who spent 18 years in training for the honor of being woken up at 2 in the morning to fix you) fixes you, you probably wont care so much that nurovascular surgeons make $500,000 per year. You will however, be glad that unlike a refrigerator repair man, he can't say the problem is too complicated and throw you to the curb. You'll probably also be glad that that$500,000 salary attracted some very bright person to medicine rather than law, investment banking or management consulting.

As for your claims that medicine hasn't improved significantly recently and that doctors don't conduct original research (which you contrasted with archaeologists) you are, again, wrong. (You specifically mentioned cancer)

The National Cancer Institute reported that the survival rate of five years has made an extraordinary improvement over the last 20 years. Colon cancer survival has increased by 65%, while breast cancer shows a 89% improvement. Prostate cancer shows the most improvement of all cancers, with a 100% increase in five-year survival.

As for the "doctors don't do original thinking" thing, the only reason you think that is that most people only interact with a certain kind of physician. Its true that the doctor you saw last time you had strep throat or the doctor who set your broken arm is probably not doing any original research...unless you happened to see that doctor at a research or university hospital. Doctors at research hospitals and university hospitals often hold dual appointments as professors of medicine or research scientists and it is in their job description to do original research. Along with normal patient care, they do things like carry out clinical trails and develop experimental protocols.

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With respect to physician education, you have to take into account the fact that the course for a basic medical qualification in Europe is begun at age 19 and is not a second degree after a B.A., as is the case in North America.

Most physician 'thinking' is just cookbook application of prescribed recipes, in part because of the fear of malpractice suits because anything inconsistent with 'generally accepted' practices is extremely risky if something goes wrong. This holds thinking down to the lowest common denominator, at least in clinical practice. Also, FDA regulations (and their analogues in other jurisdictions) and professional society disciplining hold clinical innovation within very narrow bands. Even in medical research, the 12- to 15-year rituals required for the approval of new drugs keep progress glacially slow. Contrast Banting and Best, who discovered insulin in October, 1921, and were treating patients at the Toronto Sick Children's Hospital by February, 1922. They would have been doing that by 1934 the way things operate today.

Medical research is ridiculously stagnant and unimaginative. In many specialialties if you look in medical journals published 20 years ago and compare them with those published today, you will find the same sterile ground being gone over again and again, with little progress. I did a study of a topic in schizophrenia, for which I surveyed the literature from 1980 to 2005, and I found that in the 2005 journals I was just re-reading the same old debates which already seemed rather tired when Ronald Reagan was President. The stagnation of reseach is evident in the ludicrous, micro-scale, clinically irrelevant, or scientifically vacuous studies being done in many fields. "Fingernail Growth in Type 1 Diabetics as an Index of Uric Acid Levels," "Education Programs for Hispanic Patients and their Effect on Blood-Pressure Management," "Simvastatin vs. Lipitor and Muscle Wasting in the Gravid Wistar Rat" -- I just shrink in horror when I read the source of the grant money for such pointless exercises in empty publication credits, since they often come from organizations which actively raise huge contributions from the sick and their families who are hoping for a cure, not trash like this. The real howler is the two-page published paper, repeating and reaffirming something that was common knowledge in 1960, with eight authors on it! But where there is a desert of ideas and a desperation for publication credits, I guess even the person who turned the lights on and off in the lab needs his name on the paper somewhere.

The fact that life expectancy in the developed world is levelling for the first time since records were kept speaks volumes. I suspect that cancer survival rates only appear to improve, since earlier detection permits the unchanged process of decline from the initial development to the final conclusion of the case to be clocked at an earlier starting point. I don't think there is much real controversy about stagnation in medicine, given the FDA panic bulletin (2008) about the lack of new drugs appearing; the failure of medicine to overcome any major diseases in the last half century; the silting up of the population wasting away on dialysis; the increase in Alzheimer's incidence while medicine stands helpless; the increasing effort of medicine to shift the blame for disease on the general population (you don't exercise enough; you eat too much; you eat the wrong things; you have to come in earlier for more tests, etc.) so as to hide its own embarrassment at not being able to do what it claims; stagnant life expectancies; coming up soon on a century with no fundamental progress in diabetes; coming up soon on 30 years of little progress in transplant medicine; now past 60 years since Dr. Kolff complained that his newly-invented dialysis machine could only save the life of the patient by ruining it with this basic problem unchanged -- overall, the picture doesn't look as good as it should, especially when you contrast with this the progress during the same period from biplanes to jets, from Dr. Goddard's rockets to Moon travel; from the Army's room-sized artillery range calculator of 1942 to the modern laptop, etc.

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There's another reason why this archaeologist/doctor comparison is fallacious: you're leaving out residency, which you've already acknowledged is stressful as hell. Even if we accept your premise that archaeologists spend 4 years in undergrad and 6-7 in graduate school (even though a PhD can be completed in 5), doctors still spend more time in training. A neurosurgery spends 4 years in college, 4 years in medical school, 1 year as a surgical intern, 5 to 6 years as a resident, and often 1-3 years as a fellow in some sub-specialty like pediatric neurosurgery or neurovascular surgery . Even the lowly family physician spends 4 years in college, 4 in medical school and 3 more in residency. That equals even the worst case scenario for training to be an archaeologist and every specialty trains for some amount of time between the 18 years spent preparing to be a nurovascular and the 11 years spent preparing to be a GP.

I think you are being slightly unfair here in that you are basically comparing the amount of time it will take a doctor to reach roughly their final career position to the amount of time it takes a academic to reach the beginning of their career. If you want a fair comparison I would say that you should compare the time it takes a doctor to finish his fellowship to the amount of time it takes a academic to reach a full tenured professorship. In which case the time commitment would be very similar.

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I'd rather see a doctor on $200000/a than a basket ball player or a politician. Basket ball players are information workers, as they produce TV shows. Just like other information workers (actors, authors, computer-game designers, strategic planners, etc), as their product can be sold again and again and again, even a fraction of a penny/view will add up to a ridiculous wage. So, that$200000/a represents about 0.01c/view, so it's not really that bad.

Not gonna defend politicians.

Are doctors reasonably unique in that the fruit of their labour isn't information, yet they still get payed that high?

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It's also interesting to note that in the US in the 1930s, the average doctor earned about half of what the average lawyer earned, while now that is more or less reversed. In Germany the average dentist today earns about twice the salary of the average doctor, which is again the reverse of the US today. In some countries, like Mexico, a pharmacist can do much of what only a doctor can do in the US, such as dispense prescription drugs, but the pharmacist's salary doesn't reflect this incorporation of part of the doctor's duties.

All salaries are arbitrary, since fair salaries would have to be calculated on the basis of a composite analysis of factors such as pay for 1) physical danger; 2) humiliating nature of the work; 3) lack of creativity in the work; 4) stress; 5) security of employment tenure; 5) the community's need for the particular job being done to be low-paid, given the importance of the service to the general good (such as low army pay in a war); 6) a basic human equality factor, since all honest human labor has to be equally respected if we accept that humans are morally equal and have equal basic material needs for survival. I wouldn't require any additional salary for years of education, since education, properly understood, is a pleasure and a privilege, and no one should be entitled to claim compensation for it. Similarly, a job with high authority and responsibility should not command additional remuneration, since authority and responsibility are pleasures, and the famous Bell Telephone Company health survey showed that the more authority employees had, the longer they lived and the the healthier they were. On a fair salary calculation, doctors' salaries would be heavily reduced for the general lack of physical danger, for the non-humiliating nature of the work, for their chance for intellectual activity, for their relative freedom from the threat of unemployment, and for the pressing social need to ensure healthcare for all. Only for the stress factor would doctors merit any additional salary above ordinary workers. But instead, in the real world of the modern US, doctors now earn 4 or 5 times the average salary, and specialists around 10 times the average.

Edited by Marat

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"In some countries, like Mexico, a pharmacist can do much of what only a doctor can do in the US, such as dispense prescription drugs, but the pharmacist's salary doesn't reflect this incorporation of part of the doctor's duties."

my emphasis.

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I agree with your emphasis. But my point is essentially just that the way doctors are paid in various countries is not really a reflection of the different distribution of the physician's role and duties in various jurisdictions, but more of arbitrary cultural assumptions about what they should be paid. Thus those countries where pharmacists, nurses, EMTs, and physicians' assistants are allowed to assume more medical doctors' duties than elsewhere, the pay scales don't reflect that admixture of supposedly 'super-high-value' M.D. services in the 'super-low-value' nursing and EMT services and 'moderate value' pharmacist services. This is then yet further evidence of the culturally arbitrary nature of the value each society assigns to the work of each profession. In the old Soviet Union, coal miners were extremely well paid because their work was so filthy, dangerous, and stultifying, while in East Germany, doctors were so poorly paid that I can remember then walking around wearing sandals held together with bandages, since they couldn't afford new shoes.

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A recent study showed that the shortage of a public healthcare method in the U.S. resulted in about 40,000 unnecessary deaths a year, & at least part of the reason why a public healthcare method cannot be instituted is its high cost, a quantity of which results from excessively generous physician remuneration. Killing sick people for funds is not very in the spirit of the Hippocratic Oath. Since there's about 300,000 physicians in the U.S. today, if each of them took a compulsory \$100,000 pay cut..

Regards,

Cliff merchant MD

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