Are doctors paid well ? Determining Justum Pretium for medical care..

If I am practising as a GP and a patient comes to me with fever cough and respiratory distress  since 5 days and I prescribed them a few medicines including antibiotics, routine blood tests and charge a fee of 150(2.5US$ ), their total expense will run into 600/- and they will call me a shark.I narrated this to a non-medical friend and she said she will, also, call me a “Shark.”

Am I a shark ? Asked a dear friend of mine obviously hurt by him being labelled so in spite of all his good intentions. Medicine with all its service to humanity is also a profession and is now under the Consumer Protection Act(CPA) too!!

But in spite of this in India and world over doctors are increasingly being labelled “sharks”, “dogs”, “crocodiles” or any animal which their culture has demonized as filled with greed for asking for legitimate fee for the services they render!!
I was more surprised by the mail of my friend since he practices in a posh Calcutta region and his “clients” hail  from the upmarket middle class breed who watch movies in multiples every weekend together with popcorns and coffee for 1000INR per head . ( 16US$)

So the questions  in reality is what is the just price or Justum pretium for medical care ? Are doctors actually overcharging and are sharks or are they are being labelled so by a hypocrite society which  thinks it is fair for doctors to be under the CPA act but not to charge consumers!!

Follows below is an analyses on the issue of Justum pretium of just prices for medical care provided by a physicians. The analyses is by Dr Hemadri : Blogger, Surgeon, Healthcare Improvement Enthusiast from UK and is reproduced below with his kind permission.

A person known to me did an internship with a bank/financial services firm during the summer break at the end of the first year of a three year degree course. For those two months this bank intern was paid including allowances which works out pro-rata to about £21000 per annum. The hours were very long, typically from about 8.30 am to 10.30 pm the work was very demanding including working on live projects. The output was measured and critical developmental feedback was provided very frequently with no tick box exercises or euphemistic language. The allowances included dinner and taxi back home if the intern worked after 8 pm. On the first day the Managing Director of the firm set aside time to meet the intern before the start of the internship. Just before leaving the team gave the intern a farewell lunch at a Michelin starred restaurant.
All this for an intern with one year university education doing a summer job for eight weeks.
I know reliably that internships in banks after the second year in university is much more common and those youngsters are paid a little bit more.

The starting salary for investment banking and other higher profile areas in banking after a bachelors degree are $100000 to $150000 after bonuses. Starting salaries with an MBA ranges between $120000 to $220000. In the UK for a first year analyst in investment banking is £60000 without bonus (I learn that a few first year analysts make more than £100000 after bonuses). For other areas of banking the first year pay ranges from £40000 to £60000.

Young doctors

I looked at my junior doctors, house surgeons (now called Foundation Year One trainees) in the UK. After five to 6 years in medical school they are first responders to many critical situations that could involve risks to life and limb – their pay is £22636. They get no food from their hospitals even if they worked through their lunch/dinner breaks which many often do. They do not get any allowances. I am informed by quite a few house surgeons from many hospitals that they had not seen their consultants for up to five days and not seen their clinical directors for longer. When these house surgeons leave after four months of work (it used to be six months) it is not always they get a send off dinner and never in a Michelin star restaurant.

Cowry_money_Monetaria_annulus_1

Hull York Medical School has recently required their senior medical students to do night duties which involves more than simply shadowing, possibly actual work such as clerking etc; these medical students are not paid for it. I am sure HYMS are not alone in this. I know of no medical student who worked in a hospital or GP practice doing supervised clinical work for which they got paid.

Some/Many India private medical college house surgeons see and treat patients without pay after having paid lakhs of rupees as capitation fees to enter medical school and then lakhs of rupees as course fees for 5 years.

Young doctors and young bankers, both need to have consistent excellent academic record and great CVs. They need to perform under high pressure situations within very narrow time constraints. The number of newly qualified doctors more or less matches the number of young graduates who enter the banking industry. Doctors work shorter hours, banking analysts do 100 hour weeks; however I have many years ago as a young doctor before the EWTR worked 80 hour weeks for many years and the pay was not equivalent to young graduate analysts in banking. Surely someone is bound to come up with the emotional argument of public money, please give it a rest for at least two reasons, junior doctors working with private healthcare providers do not get any higher pay and we constantly hear from the BBC and other public sector bosses about the need to pay themselves competitive rates when compared to private sector.

There is no question that doctors especially young doctors are not paid well. Add to that the longer very demanding education, the stress of dealing directly with individual members of the public’s health in often resource constrained circumstances and the very restrictive regulatory atmosphere – the mix is quite a downer for most doctors. Having made a choice to do medicine most people switch to serving the public, relieving pain, noble profession type of thinking to validate their thinking and keep their sanity.

Any doctors in the rich lists?

Four out of 400 in the Forbes USA rich list have medical qualifications. Of these four only Gary Michelson ranked at 328 seems to have made his money from his practice as a doctor – he is an orthopaedic surgeon with 250 patents. Thomas Frist Jr is a medical doctor who made his money by running hospitals. Two other doctors made their billions by their involvement in pharma.In the Forbes world rich list there is only one person who has made his billions through healthcare. Thomas Frist Jr of HCA comes in at 262 in the world rich list, as already said he owns hospitals.

In the UK’s list of billionaires there is no one who made their cash through healthcare (unless you include Branson who owns Virgin Health but I am not sure he made his billions from it).Considering the fact that the need for healthcare is universal and eternal (as opposed to cola drinks or branded retailing being a non-essential option) it is very unnatural, strange that there are no doctors in the rich list.

 Financial motivation is normal. Are doctors normalised to the abnormal?

Being a hands on doctor treating patients does not pay great.

So, not only a junior doctor is paid a fraction of what their banking colleagues are paid, they do not have a hope of every making it rich by treating patients as a clinician. Our reward systems do not seem to rate the direct saving of life, direct relief of pain and other direct clinical forms of patient contact very highly. There is no financial case for young highly intelligent, hard working high achievers to be doctors. Further, there are no future financial opportunities for doctors.

We may or may not want to or be able to remedy it. However when we look at the big picture and recognise that doctors are also normal human beings with normal emotions but have adjusted to the low finance reality there may be a certain element of hidden, difficult to explore, difficult to understand, motivational deficit which may be impossible to resolve. After all doctors may not be paid as much as bankers but they are paid much more than the rest of the working people; so any doctor who argues about not being paid well could be seen as greedy, unethical and unprofessional – so it is not the done thing.

One major motivation in life, a normal wish that rewards are linked to effort, especially for the young does not exist for doctors. The medical profession will have this permanent cloud, this eternal chain to its feet in the form of direct financial or motivational levers which are unavailable.  That will have its impact on society. The profession is now normalised to it hence unable to argue forcefully or think of innovative means to break through.

The medical profession is fighting the phenomenon of normalisation of the abnormal by confronting a large number of bad practices to improve patient safety (hand washing, routine catheterisation for surgery and many others come to mind). Will they be able to do the same for generally superior financial rewards for the whole of the profession?

©M HEMADRI

Follow Author on Twitter @HemadriTweets

Blog originally Posted here. 

Image Courtesy Wikimedia Commons.

Selected sources:

http://www.businessinsider.com/10-richest-people-in-medicine-2012-9?op=1&IR=T

http://www.forbes.com/sites/edwindurgy/2013/03/04/the-worlds-richest-billionaires-full-list-of-the-top-500/3/ http://www.forbes.com/billionaires/list/#page:1_sort:0_direction:asc_search:_filter:All%20industries_filter:United%20Kingdom_filter:All%20states

http://www.careers-in-finance.com/ibsal.htm

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