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Growing issue of income disparity among American medical specialties
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The best things in life are free/
But you can keep ‘em for the birds and bees/
Now give me money (that’s what I want)/
That’s what I want (that’s what I want)/
That’s what I want (that’s what I want), yeah/
That’s what I want/
— Berry Gordy Jr. and Janie Bradford, 1960 (Barrett Strong, covered by many, including the Beatles, Rolling Stones, Doors, Kingsmen, Searchers, Sonics, Flying Lizards, and Jerry Lee Lewis)
“It cannot be too often or too forcibly brought home to us that the hope of the profession is with the men who do its daily work in general practice. Our labors are in vain — all the manifold contributions of science, the incessant researches into the complex problems of life, normal and perverted, the profound and far-reaching conclusions of the thinkers and originators — all these are Nehushtan, sounding brass and tinkling cymbals, unless they result in making men better able to fight the battle against disease, better equipped for their ministry of healing.” — William Osler, MD, founding professor at Johns Hopkins University, Modern Medicine, Its Theory and Practice, Vol. 1, chapter 29 (bacillary dysentery)
Money is always a topic of interest, and not just for oligarchs, political parties and (near to my heart as I write this in April) the Internal Revenue Service. From the popularity of the original Motown hit and the number of successful covers, I suspect it surprises no one that money attracts attention and influences behavior. Medicine is not an exception. Although Sir William Osler might be speaking of pathophysiology, the true perversion in medicine today is money. Not just the money of the medical industrial complex I have written about before, but the even more tangled story of the income disparity among American medical specialties.
Widening of the gap
The widening income disparity in American society as a whole has correctly attracted the focus of the professoriate and social commentators alike. No matter the causes, and as I am not an economist I will not even venture a guess, the growing concentration of income at the very top level undermines many of the values that define America and places at risk the small “d” of our democracy. More worrisome to me as an advocate of future generations is that the increasingly sharp contrast between American meritocratic ideology and its increasingly oligarchic reality is developing into a deeply demoralizing schism within our social fabric.
Wiliam T. Gerson
Less attention has been applied to the equally dramatic income gap within medicine. My concern is not over the internecine arguments over years of training and specialized skill sets but that our family of medicine has decided to emulate the derisive status of our larger society. In so doing, we necessarily accept the twin consequences of separation within our ranks and abandonment of common purpose. Remember that it is the lack of shared prosperity and opportunity that currently weighs so heavily on society as a whole.
I never expected to make the salary I currently do, nor was I under any illusion as to the place in the salary structure general pediatrics held and continues to hold within the family of medicine. My choice of professional specialization was not particularly driven by salary concerns; medical practice in any form assured a comfortable income. I did believe that following my dreams into medicine was a substantively different career path than a fellow college classmate’s choice of investment banking — not that I even knew what that meant in 1978.
My own considerations must be placed in the context of the time — the income gap between specialties was nowhere near as large then as it is today. During the past 20 years, the incomes of dermatologists and gastroenterologists have risen more than 50%, dwarfing the 10% rise among primary care physicians. The income of dermatologists during my training years was not significantly different than internists.
Not included in these income breakdowns is the expansion, business models in hand, of physicians into the ownership of the means of their practice — the space, machines and laboratories, and thus the ability in some settings to capture professional, facility and lab fees all in a tidy bundle — if not for the individual physician, at least for the health care organization. Despite all of this, I suspect if we were to gather regionally as a faculty of all physicians, we could in a single morning agree to an income range among all specialties. In doing so, we must understand that our separation as physicians has made understanding the current reality of specialty practice by nonspecialists more challenging.
Acknowledgement of a problem
I remain optimistic about the future if we can harness the wherewithal to come together. Small steps that acknowledge the problem can be a start. Beginning with the youngest among us — medical students — might make the most sense and yield the greatest return. Today’s medical students crave standardized test results that allow entry to specialty training in areas distorted by disparate income. I don’t blame students. I do blame the bureaucracies of medical schools, the testing world and our professional organizations in allowing and perpetuating a demoralizing hierarchy of avarice.
Altering the cost of medical school, extending financial considerations to how we fund (or charge) for post-graduate training, ending high reward testing, and making a concerted effort to alter the medical malpractice landscape is a start. A suitable forum, unfortunately, does not exist for a level debate. Our current attempts at forming ACOs are designed to perpetuate the status quo and not its radical reform. Money talks, and if not loudly enough, it purchases all available bandwidths. If Osler’s cymbals and bells are only rung as a reflection of income, then we will be ill-equipped as physicians to continue our mission to heal others. We need to get more in tune as a profession and together address our own income division.
William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.