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.
