I am often told, usually by an experienced physician, that other physicians owe something to society, usually in exchange for the cost of their training. This is in response to several scenarios. It could be:
- Someone retires early
- Someone who works part-time
- A doctor having a baby or “going on the parenting journey”
- Someone who burns out and changes careers or becomes a stay-at-home parent
- A doctor taking parental leave, or most recently
- A physician who chooses a concierge or direct patient care business model
Here’s an example of how it’s said:
“I just listened to your video explanation about concierge…I mean this is an open discussion and holds no animosity towards you or your excellent presentation. What about the moral/ethical aspects of this? Almost all physicians in the United States have their training heavily subsidized by the federal government. If they go to concierge, they can go from an actual average patient load of 2,000 to 200. Where do those 1,800 others go? On this moment they go to the concierge. a rapidly growing queue for general or subsequent specialist care, which is why the waiting lists are unreasonably long at the moment. Are concierge doctors taking this into account? This explosion seems to coincide exactly with the explosion of concierge medicine with an open mind.”
Hippocratic oath?
I really don’t know where this view comes from. Perhaps it’s because of the oath that many new doctors repeat upon graduation, that is, a version of the Hippocratic Oath. This is one of them the older versions:
‘I swear by Apollo Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, and make them my witnesses, that I will, according to my ability and judgment, fulfill this oath and this contract.
To equate my teacher in this art with my own parents; to make him a partner in my livelihood; if he needs money to share mine with him; to regard his family as my own brothers, and to teach them this art, if they will learn it, without fee or contract; to give precepts, oral instructions, and all other instructions to my own sons, the sons of my teacher, and to indentured servants who have taken the oath of the Healer, but to no one else.
I will use those nutritional plans that will benefit my patients, to the best of my ability and judgment, and I will do them no harm or injustice. Nor will I administer poison to anyone if asked, nor will I suggest such a course of action. . . . But I will keep both my life and my art pure and holy. I will not use the knife, indeed not even on people who are bothered by stone, but I will give room to people who are craftsmen in it.
Into whatever house I enter, I will enter to help the sick, and I will abstain from all intentional trespass and harm, especially from abusing the bodies of man or woman, bond or free. And whatever I may see or hear in the course of my profession, as well as out of my profession in my intercourse with men, if it be anything that may not be published abroad, I will never divulge it, because I keep such things as sacred secrets.
Now if I perform this oath and do not break it, may I gain a reputation among all men forever for my life and for my art; but if I break it and renounce myself, may the opposite happen to me.
As I read that, I see nothing that requires a doctor to work long hours, for many years, or for free – except teaching the children of those who taught me medicine. So maybe there is an obligation to teach medicine for free, but nothing says I have to practice it for free or that I am responsible for the access to care problems we see in our modern healthcare system.
Do doctors owe society for their training?
Who pays for a doctor’s training? In the case of many physicians, it is – to the tune of literally hundreds of thousands of dollars. Sometimes that guilt is carried well into mid-career and beyond. This is very different from today’s senior doctors, who may have faced an annual tuition bill in the low four figures. If they attended public school, the state might subsidize the education somewhat, usually in the hope that the doctor would choose to continue living and practicing in the state. But if the government actually wanted to contract the doctor to stay in that state, it should have done so. Those contracts exist, but they generally pay much more than the difference between in-state and out-of-state tuition.
Maybe the doctor paid for their medical school the same way I did: with a contract. I signed a contract with the US Army. The Army paid for school, and I agreed to work there for four years regardless of where the Army sent me or what it asked me to do. The Army honored the contract, and so did I. We no longer owe the other anything. The same applies to a National Health Service Corps, Indian Health Service, or MD/PhD contract program. Yes, if you have signed a contract, you must comply with the terms of that contract. But that is not the case with most doctors.
What about the accommodation, you say? Hospitals that offer residency programs receive a significant amount of funding through Medicare, which is paid for with payroll taxes. The most recent data I have seen shows that Medicare pays $150,000 per year per resident. My first question when I hear that is, “Who cares? Where is it all going?” The majority certainly does not go to the resident. Even a well-paid resident has a compensation package worth no more than $80,000.
Now, I’m not going to say that a PGY1 resident is worth $80,000. But a senior resident is worth much more than $80,000. Heck, over $150,000. On average, the compensation is probably about right for the value offered. What is a supervised practitioner worth? That’s relatively easy to see, given the prevalence of Advanced Practice Clinicians (APCs such as PAs, NPs, CRNAs, etc.) in our system. They get paid a lot more than a resident, even a senior resident. Regardless, there is no contract, and there is nothing in the Hippocratic Oath or in their contracts that requires doctors to work for extended periods of time – let alone for free – just because Medicare helps pay for residencies.
Docs owe society nothing for their residency training. And even if they did, doctors and similarly high earners suffer the most from the progressive tax law. The more you earn, the higher your tax rate. There is no REPS status for medications. There is no carried interest on medicines. There are no stock options in medicine. Everything you earn is taxed at regular, old, ordinary income tax rates. And any portion of that income (unless an S Corp is involved) is taxed for Medicare at 2.9%-3.8%.
We all pay for those residents. A doctor making $800,000 pays about $30,000 a year in Medicare taxes, but receives no more benefits than someone paying $1,500 a year in Medicare taxes. It doesn’t take many years to reimburse Medicare for the cost of your stay.
More information here:
Are doctors who retire early abusing the system that made them rich?
How to retire early as a doctor
Why is this argument limited to doctors?
For some bizarre reason I never hear this about any other profession. No one is saying that lawyers have to work 80 hours a week until they are 75 because society trained them. No one applies this to engineers, astronauts, pilots, teachers, judges, or anyone else who helped raise society. I don’t even hear about nurses. Just doctors. And interestingly enough, it’s almost entirely by doctors. Maybe it’s time to stop shaming each other and doing a burnout-inducing amount of work.
What about EMTALA?
While we’re on the subject of liabilities, let’s also talk about the largest unfunded legal obligation facing physicians: the Emergency Medical Treatment and Labor Act (EMTALA). This is the anti-wallet biopsy bill. While it applies primarily to emergency departments and labor and delivery, it also includes any doctor who is officially on call to an emergency department, and that’s an awful lot of doctors.
Basically, you can’t ask a patient to pay for his or her medical care until you have stabilized his or her emerging medical condition. I actually have no problem with EMTALA. I think it is a very good law. My problem with EMTALA concerns the financing. It is mainly the fact that there is no financing. It is an unfunded mandate. Unlike anyone else in America, emergency physicians are federally mandated to work for free. And yes, patients do benefit from that. Uninsured patients are technically “self-pay.” If you do not collect the money in advance, paying yourself is in reality the same as not paying. The self-pay rate in the emergency departments where I have worked is about 3%, which is essentially 0%. At a 20% uninsured rate, this basically means I work for free every Friday. And I’m doing well. Many emergency departments have an uninsured rate of 40% or even 50%.
No, I don’t owe society anything. And if I did, I was rewarded long ago with all the free care I’ve provided to every fifth patient over the past twenty years.
Problems with access to staff and patients
Yes, there are staffing issues when doctors work less or retire early. Yes, there are patient access issues when physicians decide not to see seven patients per hour or adopt a concierge model. These are very real, complicated problems. But these are problems that our entire society must solve, not problems that can or should be solved by doctors alone. Anyone who thinks these are easy to solve problems doesn’t understand the problem. But doctors cannot take the entire medical system on their shoulders and take it to the promised land. But maybe they are trying – which explains the burnout rate of 37% to 63% depending on the specialty.
More information here:
Which medical specialties are the most burned out?
What emergency documentation can do to beat burnout
The bottom line
If you want to work part-time, have a baby, start a concierge practice, take Wednesday afternoons off, go back to full-time, retire early, or quit medicine altogether, go ahead and do it. You don’t have to feel guilty about this. You owe nothing to society. You didn’t steal someone else’s spot in medical school or residency. Give me a break.
What do you think? Do you think doctors owe anything to society? Why are doctors the only ones who ever feel guilty for not working enough?
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