Voices: Physicians Speak Out on Diminishing Income and the Death of Primary Care

Over the last month, Physician’s Money Digest has been focusing our coverage on all aspects of physician income -- from disparities in pay and diminishing reimbursements to the wider ramifications for patients and the U.S. healthcare industry as a whole.

The articles often generated emotional comments from physicians who described their own struggles with debt, revenue and income, and offered frank observations about the state and future of primary care in America.

We’ve compiled some of these comments here, to let readers themselves report on what they’re seeing within their own fields -- and encourage you to help keep the discussion going by sharing your own experiences and opinions in our comment area below.

The article that drew the most heated, and often heartfelt, responses was one featuring this clip from "the Vanishing Oath," a film by Ryan Flesher, MD, that illustrates how overhead costs, malpractice insurance and licensing fees slash physician’s take home pay to just $27.72 an hour ... or roughly $58,000 a year.

Dr. Lourdes Esteban described how day-to-day costs deplete already diminishing revenue at her practice:

“I studied at the very least 14 years to become a specialist and with the president's plan I will be paid the same as a physician who just graduated from medical school (i.e., probably $80 for initial visit of a patient who is seen for 30 minutes). Meanwhile, I pay for a hefty office lease, three secretaries, one of whom I have to hire just to get pre-authorizations for MRIs and other procedures from the all-mighty insurance companies. I pay for gas, electric, telephone, Internet, cleaners, office supplies, gas, tolls, garage (because it is impossible to part on the streets of New York), and these are costs paid every month. I forgot to mention my malpractice insurance which is $34,000 per year. So, how much do you think I get paid a day?”

Dr. Joan Lieser said the clip confirmed what she’s been experiencing for the last decade:

“Factor in skyrocketing malpractice insurance for obstetrics in the face of stagnant or decreasing reimbursement from insurance companies and you can understand why I have had to withdraw money from my retirement account to stay in practice. Why has there been no effective lobby for physicians? The American Medical Association is a joke.”

Dr. Kay Wood said she fears for the future of healthcare in light of what's she's seen in her own practice:

“My practice has a VERY STABLE PPO clientele -- I see the same number of patients today as I did last year -- my demographics have not changed (50 percent Medicare and 50 percent PPO). To my amazement, this year my income is down by 50 percent. This is not due to loss of consults -- just plain loss of reimbursement monies. I'm sure that this is just the beginning of a long downhill trend. Already our private physicians are taking early retirement. Most will not take care of patients in the hospital. The conversations in the physician lounge are depressing. Fortunately for me, I'm close to retirement, but I'm very concerned about all those young physicians out there who are loaded with debt and frankly, I'm concerned about the patients who soon will find it very difficult to find a qualified physician to care for them. We need to organize and make change happen.

In addition to diminishing incomes, disparities of income within the medical field was also a hot topic. In response to this week’s profile of the “Top 10 Worst-Paying Doctor Jobs,” as ranked by Forbes magazine, a number of readers said income disparity an accepted fact of life in medicine -- though they weren’t happy about it.

One young doctor writes:

“I am a relatively new physician -- soon to be in my 3rd year in Family and Geriatric Medicine in my hometown community. I am one of few in my class who was crazy or brave enough to start my own practice, me, myself, and I...it has been stressful, crazy hours, but a joy. The only negative has been the stress of a running a BUSINESS, who gets prepared for that in medical school and residency?

“Yes, my pay is lower than the surgeon, but my clinic and call life is different too. Disparity is something that we will not be able to get away from, less disparity would be nice, but not likely to happen. The shame of this situation is that young minds are being told to stay away from these fields because of lack of reimbursement...money talks to someone who is in debt...there is also a stigma attached to those who are in a primary care fields when you are in medical school that is propagated in residency and causes students to shy away from a field they may have otherwise chosen.”

Earlier this month Mike Hennessy, Chairman and Chief Executive of MJH & Associates, the publisher of Physician's Money Digest, The American Journal of Managed Care, Pharmacy Times, MDNG and other publications, issued a call for action for a physician leader to step forward to address the shortage in primary care.  "The profession of primary care physician in this country is dying. Fast," he wrote.

Reader Robert Comizio echoed Hennessy’s sentiments:

“Our problem is that we have and never had any organization representing us that would fight for us and counter all the misconceptions and bad press physicians receive. We need something like the teachers union! Whenever society and the politicians want to subjugate us they wave the Hippocratic oath in our faces and call us professionals; when they want to treat us like servants, they threaten us with all kinds of penalties and call us providers. And we, not knowing what to do, put up with the nonsense and the indignities and the politicians count on this inactivity. Can you imagine a one day nationwide strike of all the physicians? We need to be represented by a strong organization that will fight for our livelihoods and not a vestige of one like the American Medical Association, whose claim to fame is their campaign to stop smoking.”

One reader blamed entitlement programs for income disparity and the decline of primary care:

“The great disparity in incomes between primary care providers and specialists began in earnest when Medicare was created in circa. 1963. Much more emphasis and reimbursement was associated with procedural services and less with cognitive services. 47 years later, we have a healthcare society largely driven by specialty care in contrast to other developed countries with less per capita healthcare spend --hence our current unsustainable crisis. There will always be some people smarter and more productive than others, but in what logical system does it make sense to pay a family doc $200 to manage an ICU patient out of DKA (potentially life-saving) and pay a dermatologist $500 to $1000 to remove a benign lesion in their office?”

Still another reader lamented the level of incomes for doctors in academia -- a subject addressed this week by blogger Ed Rabinowitz, who looked at the continuing disparity in income between academic and private practices.

The reader commented:

“The worst paying -- and worst overall -- jobs for physicians are in academia. Many earn $100,000 to $125,000 per year, for a board certified psychiatrist. I did. And the working conditions were awful, with onerous call duties, numerous condescending ignorant administrators on your back, and lousy windowless offices. Sure some of the residents and students were great to work with, but more than a few were abusive and either lazy or mentally dull.”

Finally, a doctor sums up what seems to be the overwhelming sentiment for all doctors who took the time to share their thoughts on physician pay:

“I'm struck by the tone of defeat and discouragement in the comments from providers...these times and circumstances are robbing us from the excitement, joy and anticipation of something much different that we probably all had as we entered medical school.”

Readers, keep the discussion going! Physician's Money Digest wants to hear your thoughts on the state of physician pay.

What can physicians do to educate patients and policymakers and counteract the commonly held perception that “all doctors are rich?” How does this misconception affect the physician-patient relationship, especially in the highly charged atmosphere surrounding healthcare reform and healthcare costs?

How should the profession address the growing divide between primary care doctors and specialists? Are the financial, legal, and clinical concerns facing these two areas of medicine becoming so different and unique that they are creating an adversarial relationship between the two? Share your comments below.