I grew up in a solidly middle class neighbourhood of second and third generation Jewish immigrants. Our grandparents lived in enclaves like Bensonhurst and the South Bronx. Our parents moved to Queens and Long Island where they became salesmen or shop owners. It fell to my generation to earn advanced degrees and join the professional class. We had a few lawyers, some accountants, and one or two dentists. (My best friend Billy Ebenstein and I were the only ones to become professors.) Becoming a doctor was the pinnacle of success, with prestige, guaranteed financial security, and a lifetime of professional fulfillment.
As kids, our iconic physician was Marcus Welby, the eponymous lead character of television’s top rated drama series. Dr. Welby’s world of an independent private practice, free from interference from administrators and insurers, has ended. Not coincidentally, Marcus Welby was portrayed by Robert Young, who had previously played the lead role of Jim Anderson on Father Knows Best. Our doctors were parent figures, get it?
Physicians can no longer expect to enjoy similar relationships with their patients. Even the world of Gregory House, where the practice of medicine was reduced to finding the best application of diagnostic skill and modern technology, seems a distant memory. At least Dr. House held sway over his boss, Dr. Cuddy, and he never let costs get in the way of his medical decisions. When we last saw Dr. House, he was motorcycling off into the sunset with his dying friend Dr. Wilson. House got out just in time.
In the blink of an eye, the world of medicine has changed. We are witnessing massive vertical integration as providers try to make money from ACOs. At the same time, Medicare and private insurance have gone all-in on pay-for-performance. Only they have forsaken outcomes measurement and instead given us strict process guidelines. As a result of these changes, newly minted physicians can expect to spend the bulk of their careers employed by a hospital or a large multi-specialty group practice. They will not build and maintain a practice – their employer will do that for them. And they will have little discretion over diagnostic testing and treatment plans – they will instead follow strict treatment guidelines.
As a result of these changes, I see the end of professionalism. Tomorrow’s doctors will not be in loco parentis, instead, they will be more like carpenters or electricians, applying their tradesman-like skills to blueprints laid down by others. No one will place tomorrow’s doctors on a pedestal. Parents will no longer brag to their neighbours, “Let me tell you about my son, the doctor.”
Medicine will still be a financially rewarding career path. But if money is what matters, there will be far better choices. It will still take 8-10 years to finish medical school plus residency. During that time, a bright young college graduate could have instead completed three years at a top ranked law school and taken up with a big law firm, or worked at a financial firm, gone to a top business school, and taken a job in consulting. Not only would they earn money sooner, as a lawyer or consultant, they would not have to worry about Medicare slashing their fees.
Recent increases in marginal tax rates make medicine even less attractive. College students who choose medicine may give up 8-10 years of good income, but they could reasonably expect to make even more money once they finish their residencies. The net present value of a medical degree just might be worthwhile. Yet if you combine new federal marginal income tax rates that approach 45 per cent with state income tax rates that often exceed 5 per cent, then the net present value calculations do not look so good. Many college students will be wondering why they should give up a solid, steady income today in for a higher income as a doctor in the future, when the government is going to take over half of that higher income.
When I grew up, I was always told that medicine was a “calling.” Perhaps it was, though the money didn’t hurt. I don’t know how many young people will be “called” to become technicians. But technicians they will be. And with no real financial argument to support the choice, I wonder why anyone would choose to become a doctor.
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