Further thoughts on financially unethical physicians

My previous post on this topic created 21 comments thus far. As I have read the exchange, I have learned a bit, and been surprised a bit.

First, I believe that most physicians act in a very ethical manner. Some physicians live in the grey zone. They do not believe that they are acting in a manner that could raise questions. These physicians are naive as to the ethics of their financial relationships. These physicians include researchers who do drug company sponsored research – and then become convinced of the need for that new drug. When I took social psychology in college, I believe that I was taught this principle. Once we make a decision (like doing drug trial research), our beliefs change. We tend to develop rationales for our decision.

Another example is physicians who take drug company sponsored trips. These trips are billed as educational retreats. If one reads about the principles of influence – Influence at Work – one understands the subtle ways that influence works. As human beings, we learn from an early age that when one does you a favor, we try to pay that favor back. Drug companies, device manufacturers, etc. understand this principle – and use it regularly. I have heard physicians tell me that they are not influenced. I suspect that the occasional physician is resistant, but I also believe that those physicians are in the minority.

Next we have physicians who benefit from labs, imaging studies, etc. They believe themselves ethical, and do not understand the conflict of interest produced by having a financial interest in their testing referrals. This problem has great complexity. On the one hand, office visit reimbursement is not adequate to pay overhead and provide a solid salary. Thus, many consultants recommend supplementing office income with ancillaries. In academic medicine, we understand this problem, as we have no access to this income. The problem with ancillaries is that a financial interest in the ancillaries induces subtle influences to perform more testing.

Unfortunately, we have a few physicians who are blatantly unethical. Some physicians being human beings look for a financial edge. I doubt that we can adequately select medical school candidates who do not have this proclivity. The rationale behind financial unethical behavior varies amongst humans. Many novels tell the stories of such “falls from grace”. We read these novels and watch movies concerning such people. We may fool ourselves into believing that we would never do anything so stupid. But how can we be certain. While I doubt that money is the root of ALL evil, it certainly is a common contributing factor.

One commenter started a long thread with this long question:

What would an incoming med school class look like if the students knew that the outcoming maximum salary would be 80,000 a year-no more.

How many of you would have not gone into medicine if the salaries were that low?

Consider the types of people who go into vet school as compared to the types of people who go into med school. Each leaves with the same debt load but one makes far less money. Very, very different types of people.

Many of you complain of having to see too many people in too little time. If it was possible to cut your own salaries in half and see half the patients but be twice the doctor, would you do it?

Like many hypothetical rhetorical question, the commentor develops a straw man argument which confuses the issue. Many readers have attacked this comment, and spurred a lively debate. As often happens, I will now rant on this issue.

We all want the best physicians. We want those physicians to be intelligent, caring and altruistic. As the great philosopher – Meatloaf – once said, “two of three ain’t bad”.

People choose careers for many reasons. Finances do matter. If one wants the “best and the brightest” to become physicians, we should at least provide a commensurate financial outcome.

Looking at physician salaries out of context is confusing. How much time and money does one invest in becoming a physician? What other profession requires 4 years of college, 4 years of graduate school and then 3-6 years of further training (at modest salaries) prior to achieving ones starting job? I doubt that many would choose medicine with $80k as their salary – assuming a $200k debt and first real job in ones 30s.

Would students choose medicine if school were free and salaries were $80k? Perhaps – but likely many potentially excellent physicians would choose financially rewarding careers which did not require the massive time investment that medicine requires. If that is true, then our pool of physicians would have great intentions, would be altruistic, but unfortunately, not as good intellectually.

Some would argue that they would be good enough. I disagree. I have trained very bright and less bright medical students and residents. I have seen students with all the right attributes except intelligence. They try hard, have a great bedside manner and mean to do the right thing. I would not choose them as my physician.

This topic – the financial ethics of physicians – troubles me. Our health care system has conflicting goals. We really want to provide the best possible health care for all patients. Unfortunately, our financial incentives are (in my opinion) currently misaligned. I do not believe that a single payor system would likely improve this alignment. We need careful thought about what goals our health care system should have, and how to best design incentives to achieve our goals. Unless we solve that problem, then we will continue to have a challenge.

Physicians are mostly great people. We do care. We try to do the right things. Our jobs are stressful; our reimbursement system makes not sense; our business model suffers from a lack of control with regards to overhead. Yet, we persist, trying to help patients one at a time.