Wednesday, July 9, 2008

Delayed Gratification - Numbers Don't Lie

I'm a little bitter. I admit that. It is difficult to be in my mid-thirties and still struggling, still living not unlike a college student. I am tired of Ramen, you know? To make it worse, I am constantly confronted with those who chose other career fields and whose lives seem so much better than mine. I see trips to Europe, new cars, big houses - all for the people that, according to our guidance counselors - "weren't going to be able to make it without a college education". I know how this sounds - jealous. Guilty as charged, I guess, but more than anything - disappointed. I'm disappointed that my work seems like it is never going to pay off. I'm disappointed that the future seems to look more bleak all the time. Most of all, I am disappointed that people are so wrong and bitter toward me for what they apparently imagine my life to be like.

Doctors are all super-wealthy. Isn't that the common notion? I suppose all professions suffer at least to some degree from the false perceptions of those outside the loop. Medicine is no exception. At least once each week, a patient that is either bitter enough or socially clueless enough to be completely honest about his feelings accuses me (usually with veiled sarcasm or in the guise of a jest) of doing extremely well for myself in my chosen career field.

Physicians have traditionally felt uncomfortable addressing this subject. I think there are a few reasons for this. One reason I feel uneasy denying this misconception is that I don't want to be further accused of whining. I guess I feel like "If this guy already thinks I'm a spoiled doctor, it'll just make things worse if he thinks I am also ungrateful for the giant imaginary fortune I am amassing". The second thought that usually creeps into my mind is the thought that if (a) he thinks all good doctors are filthy rich, and (b) I admit to continuing to live very modestly, then (c) I must be a pretty lousy doctor. Suspicion of false riches is bad enough - an accusation of professional failure is downright intolerable. Finally, and most pathetically of all, I continue to hold out hope against all evidence that someday, in the distant future, I may actually begin to reap some of the rewards from the lifetime of study and hard academic work it took to become a doctor. I would hate to jinx that. Almost all doctors are at least a little superstitious.

Eventually I'd like to discuss the loss of prestige, professional pride, respect, and sanity felt by so many of my peers. Today, though, I would like to partially tackle the false rumor that today's family doctors make a fortune.

Insurance is the obvious target, and probably is, in fact, the biggest contributor to the decline. They have made a very comfortable profit for years by frightening people into paying a middle-man for a vital service. Following Medicare's lead, they have worked to prevent physicians from working together to bargain for better rates while doing the exact same thing themselves, creating an uneven playing field. This has had a negative effect on all specialties, but has hit the already-lowest-paid primary care practitioners the hardest.

The increasing medical school debt to income ratio is another element of the decline. During a period in which medical school costs have shot up drastically, physician salaries have remained flat. For a neurosurgeon making $400K/year this is frustrating - for the primary care physician it can be devastating. It is estimated that family physicians pay up to 20% of their post-tax income for medical school loan repayment.

This amounts to a game of catch-up for the primary care doctor, with the deck stacked against him. The average starting salary for a family physician is $120,000. A salary of $120,000 seems like a fortune to a poor kid - it did to me, at least. And perhaps it would be, except for all the hands dipping into it. At a salary of $120K, the doctor is in a fairly high tax bracket, even under today's much lower taxation levels. After taxes, the physician has about $92,300 left. The typical physician owes between $150,000 to $200,000 in school debt. The payment on that debt will be approximately $1500-$2000, even with very low interest rates, and will take the doctor 15-25 years to pay off. Take home pay? Around $71,000. And we mustn't forget about malpractice insurance, which will run at least $10K/year. After all is said and done, the physician takes home about $60,000 a year - about half of what he started with. And considering that most physicians work between 50 and 60 hours a week, that comes out to just over...are you ready?...just over $21 per hour. Just over $21/hour after 11 years of education.

Compare that with a nurse, who goes to school for 2 to 4 years, and can expect to make $50/hour before taxes, a construction laborer who makes about $18-20/hour plus overtime, an get the picture. It will take the family doc in the scenario above about half his career just to catch up with the lifetime earnings of the laborer with a high school education and no school debt, who has been taking home $20-25K each year.

So please forgive me if I'm a little bitter. I had hoped that I would be able to enjoy some of the fruits of my many labors before retirement. But don't dare accuse me of being a "rich doctor". I just may hit you in the face.