Americans can't find doctors in sick system, but docs whine too loudly on debt, ignore excessive earnings

In the current AARP Bulletin (pay wall, Apple News), New York Dr. Howard Zucker capably explains why Americans are being squeezed by a doctor shortage. But two points of Zucker's explanation too easily let doctors off the hook and require clarification.

I hope tomorrow to meet my primary care physician (PCP) for the first time, after he's nominally served in that role for two years. I've seen five PCPs come and go in as many years, which is really like not having a PCP at all—oddly, as my insurer insists that I must have one. The annual checkup has become biennial at best, and it's not for my lack of trying. At that, with my mediocre employment-based healthcare coverage, I'm more fortunate than many Americans.

Zucker describes the many circumstances converging to deprive Americans of access to healthcare providers. A leading problem is poor planning by the medical profession, embodied by the American Medical Association (AMA), for an increasing and aging population.

Another factor, which is familiar to patients, is the pressure by profit-driven healthcare proprietors, such as CVS, to commodify patient care, superseding the doctor-patient relationship and thoughtful care with the churning cauldron of the billable quarter hour. Workplace conditions for front-line PCPs are not only maddening patients, but driving some healthcare providers, literally, to madness.

Nevertheless, there are two ways in which Zucker goes too easy on doctors, letting them off the hook for responsibility in this mess.

First, Zucker is wrong that a doctor can't get by with medical school debt and a PCP wage.  

He wrote that the average medical student finishes school with $235,000 in debt. Specialties pay some double the wage of primary care. Research posts pay well and don't have insurers dictating terms. So debt-burdened students are disincentivized to enter family practice or to work directly with patients at all. 

Still, Zucker wrote: "Now consider that the average [PCP] in internal medicine, geriatrics, pediatrics or family medicine makes about $250,000 to $275,000 a year. Becoming a PCP just isn't financially feasible for most recent graduates."  Just for the record, that's more than I've ever made at any job, and I've had a law degree for 28 years.

Not financially preferable I can see.  Not financially feasible is plain wrong.

For comparison, the average indebtedness of a U.S. law school graduate is $130,000, according to the Education Data Initiative. For the law school where I work, it's about the same, $125,405, U.S. News reported. The median law graduate salary is $89,250, according to U.S. News. My school's is about $68,000, according to LSD.Law. Ballpark monthly repayment, using, for these gross purposes, a 4.5% rate and 10-year term, means a monthly payment of $1,347, according to the SmartAsset student loan calculator.

To be sure, that's too much debt to make law school an appealing option. The Consumer Finance Protection Bureau recommends limiting borrowing to hold monthly payments at 10% of gross income. Those median salaries yield a monthly gross of $7,438 or $5,667, respectively, so a monthly payment at 18.1% or 23.8%. 

But it is possible, depending on one's needs. An annual $89,250 or $68,000 should yield a monthly take-home of about $5,600 or $4,400, according to the SmartAsset paycheck calculator. On the one hand, the average American household requires $6,440 per month, according to multiple sources. On the other hand, a single adult with no children can get by on $3,439 in the Massachusetts county where my school is located, according to the MIT living wage calculator. The overall average American individual is bringing home only about $4,000 monthly, using Bureau of Labor Statistics (BLS) data, so one salary isn't meeting household expenses in any event.

Accordingly, using the same metrics, the medical graduate's monthly debt payment would be $2,434. The PCP monthly take-home at the low end would be about $14,200, on $20,833 gross. That's a payment to gross ratio of only 11.7%, with $11,766 to spare for monthly household expenses. Even at a student loan rate of 9%, the monthly payment hits only 14.3% of gross, still sparing more than $11,000 to meet expenses. (A first-year medical resident starts at only about $55,000 annually, U.S. average, but lean residency years are the quirky if objectionable norm in the profession regardless of later specialization.)

Once debt is paid off, doctor's circumstances become downright luxurious. BLS estimates the median American's lifetime earnings at $1.7m, a lawyer's at $2.3m, and a doctor's at $7.5m. 

So it is feasible to invest in medical school—even potentially lucrative—and even still to be a PCP for a few years.

Second, Zucker fails to recognize the economic protectionism of the medical profession and bloat in the salaries of U.S. doctors—even PCPs.

Zucker did fault the AMA for choking medical school admissions in the 1980s. But Zucker blamed the AMA only for bad math. The truth is more sinister.

The AMA doesn't control medical school admissions directly, but it does lobby hard for legislators to limit the number of medical schools and to limit subsidies for residencies, thus effectively controlling supply in the market. This isn't about the quality of medical training, but about economic protectionism. The AMA, that is, its members, doctors, don't want to see salaries go any lower than those dizzying quarter-million-dollar heights.

(Read more in Derek Thompson, Why America Has So Few Doctors, The Atlantic (Feb. 14, 2022).)

That's what's happened in law as antitrust rumblings have compelled the American Bar Association and state bars to let up on the gas in their economically protectionist motives over the last four or five decades. The market in legal education has become more competitive—even problematically so, from a quality standpoint, it must be admitted—and salaries have fallen.

At the same time, persistently burdensome accreditation gateways in education and strict state licensing requirements in the practice have maintained such a chokehold on the student-to-bar pipeline that the lower paid lawyers who result cannot afford to meet the market demand for legal services for ordinary people, in contrast with corporate clients.

So law is not a model to follow, to be sure. At the same time, one doctor in America does not need to take home an excess of nearly double what's required to keep up an American household, nor to make more than four times the median American lifetime wage. European doctors are paid only half as much as U.S. doctors. In fact, there's a huge gap between U.S. doctors, at an average annual gross of $352,000, and doctors anywhere else in the world—ranging from an average $19,000 in Mexico to $273,000 in Canada, according to news outlet Medscape.

Zucker didn't mention the bloat in salaries of U.S. doctors in the AARP Bulletin. Incidentally, when Dr. Zucker was New York health commissioner, earning $210,000 annually on the public payroll, he took some heat for failing to disclose a side-gig income of $75,000 annually from a health research firm, e.g., the Times Union reported.

Our healthcare system is badly broken.  Like our legal services.  Like our bridges.  The list goes on.  What I fear is missing from the solution is the willingness of Americans in the highest income brackets to bear any sense of civic responsibility. In this regard, the medical profession is not exempt.

RFK, Jr. hearing prompts reconsideration of civil, regulatory responsibility for vaccine misinformation

"Are you supportive of these onesies?" Sen. Sanders asks.
© C-SPAN (YouTube; license).

The showdown between Bernie Sanders and RFK, Jr., featuring anti-vacc onesies, got me thinking about articles published by a former student, later academic and bar colleague, positing tort and regulatory approaches to harmful vaccine misinformation.

I wrote in 2017 about physician-attorney Donald C. Arthur's Commercial Deception by Anti-Vaccine Homeopathic Websites: A Consumer Protection Approach, 10:1 Biotechnology & Pharmaceutical L. Rev. 1, 27 (2017). At the time, the article was behind a pay wall; it is now freely available.  Here is the abstract.

Some internet marketers offer for sale "vaccination substitutes" that can purportedly replace actual scientifically-tested and federally-approved vaccinations. Deceptive internet advertising for vaccine substitutes has dissuaded parents from vaccinating their children, resulting in a resurgence of vaccine-preventable childhood diseases. The Food and Drug Administration and Federal Trade Commission have the authority to address dangerously deceptive product claims, including those for homeopathic preparations that have thus far avoided safety and efficacy testing. This article presents the issues involved in deceptive advertising and proposes regulatory solutions.

When Dr. Arthur and I first discussed the project in the 2010s, he was thinking about a tort theory for liability for publishers of vaccine misinformation. The tort theory is fraught, but feasible. There are problems of proof, such as the attenuated causation linking the publication of misinformation with later disease, and the inevitable First Amendment defense, which at plaintiff's most fortunate still might require culpability in excess of ignorance.

Dr. Arthur split his research into two works. He published in 2016, I didn't mention in 2017, Negative Portrayal of Vaccines by Commercial Websites: Tortious Misrepresentation, 11:2 UMass L. Rev. 122 (2016), also freely available. Here is the abstract.

Commercial website publishers use false and misleading information to create distrust of vaccines by claiming vaccines are ineffective and contain contaminants that cause autism and other disorders. The misinformation has resulted in decreased childhood vaccination rates and imperiled the public by allowing resurgence of vaccine-preventable illnesses. This Article argues that tort liability attaches to publishers of commercial websites for foreseeable harm that results when websites dissuade parents from vaccinating their children in favor of purchasing alternative products offered for sale on the websites.

When Dr. Arthur wrote both these articles in 2016, it was before the first election of Donald Trump with attendant attempts to disarm and dismantle federal consumer protection systems. The tort theory looks better now. See Dorit Reiss & John Diamond, Tort Law: Liability for Anti-Vaccine Misinformation, 4 Judges Book 107 (2020) (not citing Arthur).

Dr. Arthur is an emergency medicine and preventive medicine physician.  He served 33 years in the U.S. Navy, culminating his career as Navy surgeon general and retiring at the rank of vice admiral. He served as chief executive officer of three hospitals, including the National Naval Medical Center in Bethesda, Maryland. Dr. Arthur teaches adjunct at UMass Law and for seven years practiced of counsel with the Law Offices of Beauregard, Burke and Franco.

HT @ Melissa Colten, UMass Law public interest fellow, whose curiosity reminded me of these articles.

Suits over DCA disaster will struggle to overcome discretionary function exception to sovereign immunity

View on my approach to DCA on a 2020 Southwest flight.
RJ Peltz-Steele CC BY-NC-SA 4.0

Media coverage of the air disaster at Reagan Washington National Airport (DCA) is moving on to prospective litigation, and abundant news outlets are warning aptly that the road to compensation for victims' families will not be smooth.

Potential defendants include the Federal Aviation Administration (FAA), which employs air traffic controllers; the U.S. military, which owned and crewed the Black Hawk helicopter in the crash, and American Airlines, which bears responsibility for the regional jet in the crash.

As the facts have shaken out thus far, with black-box content yet to be reported at the time of this writing, it's hard to see any fault on the part of American Airlines or its commercial operator. The plane had banked to change runways per traffic control instructions and was on a lesser used but still ordinary approach when it collided with the Black Hawk. There's likely nothing the pilots could have done to avoid the collision, if they even saw it coming.

Responsibility on the part of air traffic control has focused on the fact that one controller was managing both helicopter and plane traffic, while sometimes there are two. Thus far, though, one- or two-person staffing of the two traffic streams seems to be a choice of practice, based on the volume of traffic, rather than a violation of any rule.

Early armchair analysis points to responsibility on the part of the military. The helicopter seems to have been above 300 feet, for reasons unknown, when it was required to be at or below 200 feet. The pilot said he saw the plane and would avoid it, though it's not clear he saw the right plane. 

My cousin is a military pilot and has flown in this dense D.C. thicket, inset from SkyVector (DCA). He told me that avoiding flight paths entirely would be prohibitive, but that following the 200' rule should have averted collision even if the pilot mistook the approach of the plane.

With government defendants in the sights of plaintiff lawyers, frantic analysis is no doubt underway in an attempt to circumnavigate federal sovereign immunity.  Within the statutory framework of sovereign immunity, the concept of "discretionary function immunity" looms large in this case. Some time back, I recorded a video for SCOTUSbrief about a case in which discretionary function immunity figured, if collateral to a problem of a federal agency that doesn't have it. Here, the defendants do.

The instant case, such as it is as yet, is reminiscent of United States v. Varig Airlines (U.S. 1984), in which, in 1973, a fire on board a trans-Atlantic Boeing 707 flight killed 123. The plaintiffs blamed in part the FAA, alleging negligence in the issuance of a safety certificate.  The Supreme Court held unanimously that the FAA was shielded by discretionary function immunity.

The purpose of discretionary function immunity—which is really an exception to waiver of sovereign immunity in the Federal Tort Claims Act—is to preclude the courts from second-guessing policy determinations by the political branches of government. The government is willing to concede liability when it negligently deviates from obligatory practices, the logic goes, but claimants ought not be able to challenge policy choices just because they turned out to be bad ones, that is, resulted in injury.

The DCA crash reminded me of an excellent article from seven years ago on sovereign immunity and discretionary function, discussing Varig, in Advocate magazine, by L.A. attorney Steven B. Stevens. He parsed the doctrine.

If the use of only one air traffic controller is indeed customary and not contrary to any rule, then probably that's a staffing decision shielded against liability as discretionary function. The military might be vulnerable, though, on the issue of the Black Hawk's altitude. The 200' limit is an FAA rule for the Potomac-DCA corridor, CNN reported, and my cousin confirmed.

Even upon circumvention of immunity, plaintiffs will have to prove the usual negligence elements of unreasonable carelessness and causation with the crash. Black-box data will help, and plaintiffs might as well avail of the doctrine of res ipsa loquitur. "RIL" can afford plaintiffs a favorable inference when evidence, such as the pilot's motive, is unascertainable, and plane crashes, historically, have been fertile ground for invocation of the rule.

All that said, litigation against the government might never reach an immunity determination. Reuters reported on the history of limited government settlements in such cases.

As a frequent traveler to DCA, I hope that the airport can be made safer while preserving convenient access to the capital.

Amos, King: love one another; defend the oppressed; plead the cause of the innocent, the powerless

David Erickson CC BY 2.0 via Wikimedia Commons

On this Martin Luther King, Jr. weekend, I was blessed with the opportunity to stand in the pulpit of the historic North Scituate Baptist Church, Rhode Island, affording a rest for beloved Pastor Kim Nelson there.

I spoke to the Book of Amos, chapter 5, verses 21 to 24 (NIV), often cited by Dr. King. In the "I Have a Dream" speech on the steps of the Lincoln Memorial in August 1963 (photo), Dr. King quoted Amos 5:24: “[L]et judgment run down as waters, and righteousness as a mighty stream" (KJV).

In the history of the church, Amos at times has been controversial for its ominous depiction of God. But Amos contains a call for social justice that is as important and relevant today as it was in America during the Civil Rights Movement and in Israel in the 8th century B.C.

My wife and I are deeply grateful to the people at North Scituate for their warm hospitality.

Mother of slain scholar publishes his account of academic workplace mobbing at UMass (Amherst)

At the inaugural Niagara Conference on Workplace Mobbing at Niagara University last summer, easily the most moving and haunting presentation was that of Kimberly Lewis, whose son lost his life after being victimized by workplace mobbing.

A scholar, Joel Inbody authored a book manuscript about his experience as a victim of academic workplace mobbing at the University of Massachusetts (Amherst). After his death, his mother, Lewis, edited and completed the book in partnership with the pugnacious publisher Herb Richardson, founding editor of Mellen Press. 

Inbody wrote: "I wrote this book to critically explore an academic mobbing that sociologists subjected me to as a graduate student in 2018-2019. After thoroughly reviewing available literature on mobbing to highlight their history, severity, and progression, I analyze content from numerous records (emails, police reports, notes, letters, blog posts, pictures) and rely on autoethnography to describe the mobbing that I lived through."

A Student's Account of the Mobbing That Led to His Murder (How U. Mass Faculty Bullied Him to Death (2024) became available for sale at Mellen Press late last year.

Lewis's presentation, along with most of the presentations at the 2024 Niagara Conference on Workplace Mobbing, is available on YouTube.  The 2025 Niagara Conference on Workplace Mobbing (via The Savory Tort) is open for registration.

Q&A: