I am qualified to opine on physician compensation formulas, because I’ve spent hard time on both sides of the payment seesaw. For the first 10 years of my career, I was on salary. We were told, however, that we could earn productivity ‘bonuses’, but these rewards were trivial. An ‘employee of the month’ parking spot near the entrance would have been worth more, especially during the frigid Cleveland winters.
After 10 years, I moved over to the dark side, where I was paid for each service I provided. In Part I this week, I present pros and cons of salaried medicine. I suspect that I've overlooked some of the advantages and drawbacks of paycheck medicine, so I hope that readers will correct my errors and omissions.
Good Stuff About Paying Gastroenterologists a Salary
- Lowers health care costs by underpaying specialty physicians
- Eliminates financial conflicts of interests. The colonoscope is not a capitalist tool.
- Reduces unnecessary medical procedures as gastro docs would rather read The New York Times than scope for free. This not only increases gastro docs’ knowledge of the world, but also reduces job cuts at the Times and other newspapers facing financial challenges.
- Lowers medical costs by reducing the volume of GI consults, since primary physicians know there is a high threshold for pulling the ‘scope trigger’.
- Dinner with the family every night since salaried physicians turn their beepers off at the appointed hour.
- Strengthens character by shielding salaried specialists from greed and other sins and temptations.
- Creates more relaxed and rested GI specialists. Every minute of alloted leisure time is taken. Hey, the boss is paying! I know this because I've been there.
- No need to devote even 2 neurons to payroll, overhead and cash flow issues.
- No hustling for patients. For me, this was the sweet spot of salaried medicine.
Crummy Stuff About Paying Gastroenterologists a Salary
- Eliminates an important incentive to increase performance.
- Patients often told that the schedule is full. Why squeeze in a patient ?
- Patients with acute issues are often directed to urgent care centers or emergency rooms by staff personnel, or physicians, who have been affected by the shift work mentality of a salaried culture.
- Creates fun turf conflicts when salaried gastroenterologists spar with salaried primary care physicians over which of them should go the to ER to see a diverticulitis patient at midnight. Since neither will get paid for the encounter, each graciously volunteers that the other do the doctoring deed. Here’s a hypothetical conversation that every emergency room physician has heard repeatedly.
Internist: “Diverticulitis is a pure gastrointestinal condition and you should admit the patient STAT!”
GI Guy: “I did an internal medicine residency also. We never dumped on our specialists. Aren’t you an internist? Would you ask a pulmonary specialist to admit a patient with a cough? Would you ask a nephrologist to admit a patient with a urinary tract infection? Are you a real doctor or a triage machine?”
- Loss of professionalism when medical policy and employment edicts are issued by ‘suits’.
- Measurement, monitoring and tracking of absurd performance standards that can be used to provide ‘bonus’ payments to compliant physicians. Read: You will be docked if you don’t fall in line.
When I enter a hardware store that is a family business, I am greeted at once by smiling human beings who are anxious to assist me. When I enter a big box warehouse retail outlet, I have to hire a private investigator to track down an employee who is under cover, hoping that I will at least be told the longitude and latitude of my desired purchase.
Fee-for-service medicine is often demonized, but is it really the enemy?
Next week, Part II: the good, the bad and the ugly of coming off salary.