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Monday, August 23rd 2010

The Future of the Pay Gap

The primary care-specialist pay gap is a popular target for those eager for reform. The gap is hailed independently as an example of and a cause of the lack of focus on primary care and prevention in the United States.

There is no doubt that the United States treats primary care, preventative care and triage much differently than most of the rest of the developed world. The distribution of primary care to specialists, especially procedure based specialists, favors the specialists much more here than in any other health care system, at least that I’m familiar with.

But I’ve expressed serious doubts about how payment reform might reshape the distribution of primary care versus specialists considering the per capita primary care population has grown just as fast that of the specialist, if for no other reason than the ever increasing influx of foreign medical graduates. FMGs who have picked up whatever slack was left by U.S. doctor’s perceived abandonment of primary care. We haven’t lost ground on primary care, in terms of the numbers, as the inequality between the earnings of the general practitioner and the specialist have grown.

My point, articulated better elsewhere on this blog, is that there is no doubt that a redistribution of physicians towards primary care would benefit population health in this country but revolutionary payment reform is unlikely to achieve that redistribution alone.

And amongst the editorials and blog posts that focus on leveling the pay scale, sometimes, the very reasons originally articulated for paying more for a CABG as compared to an office visit are ignored.

And so I want to make the argument for why the orthopaedist, the cardiologist, the neurosurgeon deserves to earn more, and considerably more, than the primary care physician. And to make the argument that maybe we’re not so far off the mark with out current reimbursement structure.

I would lay out the argument for the specialist’s pay like this: the training is longer and more difficult, there is a disparity in early earnings and the assumed risk is something much more.

I’m going into a specialty with better earning potential than just about anything else in medicine. I’m also perhaps more intimately aware of differences in training amongst the specialties than most. I’m currently a neurosurgical resident, previously I started a general surgery residency, I watched my mother go through a pediatrics residency and a critical care fellowship as a single parent, and I’ve watched my fiancee through her internal medicine training at two different programs. Not bad breadth and more familiar and substantial than just observation of the day to day doings of various residents, in various specialties that anyone at a teaching hospital sees. Enough to speak on I feel.

My residency training is as long as it gets. The seven years I will put in are more than double what a family medicine resident will. More importantly, and controversially, I would argue that it’s more difficult as well. Even in the age of work hour restrictions, I would argue wholeheartedly that each 80 hour work week is not created equally.

Now to be fair, there is much intraspecialty variation. I’m sure if I was training somewhere else my work load would be something different. Even so, I am daring to argue that on the average a surgical subspecialists training will be more work, hour for hour, than a general practitioners. Sometimes substantially more.

This year, through 2 months, is poised to be exceptionally more work than my time in general surgery and, I will say, at my own peril with my family, exceptionally more work than what I’ve seen of medicine or pediatrics training. And I face seven years of such.

Granted, there are some reprieves in terms of the rotations (bless you neurology) but I would argue, as a percentage of my training, those “good” months are less than what is generally found in primary care training.

Specialists are poised to do, in my case, more than twice the years of training of primary care physicians and those years promise to be more difficult; even if it all adds up to 80 every week.

And, ignoring the questions of variability and reliability that surround physician income surveys, the median income in my specialty is somewhere between 2-3 times that of a family medicine physician. That doesn’t seem too unreasonable to me.

That might be the most substantial argument for the pay gap, at least between the surgical specialties and primary care.

But there are other arguments as well. Less substantial is the early earning potential. Consider a resident in a surgical specialty somewhere with a low cost of living earning $200,000 before taxes over four years of training. A family medicine physician, who started their training at the same time as the surgical resident, has already graduated and claims $600,000 over the same period.

Add low five figures for the compound investment potential over those four years, say $20,000, and the extra $5,000 the surgical resident. Now true that $400,000+ difference in gross income has the potential to be made up in just 3-4 years once the surgical subspecialist is out of training, but it is certainly something else, albeit small, to consider when discussing the earning gap between primary care and specialists.

Finally, there are inherent risks associated with the technical craft that proceduralists dare.

I’m not merely talking about the malpractice premiums. I’m talking about the hazards of a patient’s life and function in a physician’s hands.

There should be pay associated with increased risk for the patient. Such things require more skill, more focus, more stress. Not that the primary care physician can’t do their patients harm. But there’s something different than an adverse reaction to a statin and an aneurysm bleeding while you’re coiling it or a patient losing an airway during anesthesia.

The risks patients undertake at the hands of proceduralists and the acuity of the situations proceduralists often deal in deserves credit.

And yet, despite all this, I will admit I personally feel the pay gap needs some squeezing. The primary care physician is required to call forth a breadth of knowledge that I never will have to; at least if s/he is to be good at their job. Their care is intimately important to public health. That is something I certainly cannot claim as a future specialist. I’ll never contribute to improving any of the global outcome measurements that we rightly judge the health of any cohort by.

Just not too dramatic of a squeeze.

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