To the Editor:

I agree with Dr. Gillette’s assertion in “Why We’re in the Mess We’re In” [April 2002, page 27] that family practice remains an exciting specialty. I suspect the current stresses of caring for patients, while different, are no greater than the stress his father encountered in the 1930s. However, I question the assertion that the current cost-benefit ratio for family physicians is comparable to 70 years ago.

I suspect the degree of educational debt borne by modern physicians is greater than in the past. The average medical student graduates with a student loan balance of $140,000 or more. This staggering debt has diminishing deferral times in residency, cannot be meaningfully refinanced, is not tax deductible and usually cannot be eliminated by taking a loan-repayment job or by claiming bankruptcy. Loan payback programs are competitive and have received uncertain and unpredictable funding. Educational debt can’t be gotten rid of by selling it as one might sell a car or EKG machine if the payments get too big. One can only work to pay it off over time.

After paying educational debt each month, the money left over from the average new physician’s salary does not leave much room for saving, paying down one’s principal or living the lifestyle that most medical students assume they will enjoy. The limited personal budgets of many new physicians can be an unexpected shock. Physicians with large debt may avoid jobs that offer the potential for greater professional satisfaction if these jobs seem to carry an additional financial risk, such as start-up costs for private practice or uncertain loan repayment at government clinics. Likewise, there is pressure to forgo volunteer work, community involvement and personal time to provide such necessities as food, a car, a modest house and insurance. This unexpected pressure fosters the perception among new physicians that one must choose between paying one’s educational debt in drudgery or enjoying life while courting financial disaster. This frightening choice, combined with difficult and low reimbursements and the lack of respect and understanding outlined so eloquently by Dr. Gillette, risks being the psychological nail in the coffin of job satisfaction. It is hard to combat stress at work when that work creates inescapable financial stress at home that could last for decades.

We are in an era of medicine where limited resources force us to employ cheaper therapies when possible in order to care for more patients. Just as we can no longer ignore the cost of our therapies, neither can we ignore the cost of our education and its impact on the physicians who deliver medicine on the front line.

To the Editor:

Having enjoyed “Why We’re in the Mess We’re In,” I was taken by Dr. Gillette’s closing statement about income for family physicians today being infinitely better than what his dad made in the 1930s. There is no doubt that 40 is greater than four –unless one applies the value of dollars in a particular time. Though I do not have figures from the 1930s, I do have testimony from practicing doctors today as to what they earned 42 years ago in 1960. Since physicians in the 1930s and 1960 operated under similar free market forces in a pre-managed care era, their incomes must have produced comparable purchase power.

A buck in 1960 not only got you and a date into a movie with popcorn, but you also got change back. Today, that’s about $20 – or half of what a doctor may bill for an average encounter. A new, $1,600 station wagon represented 4 percent of a doctor’s $39,000 annual earnings in 1960. Today’s comparable minivan represents 22 percent of the average income for a family physician. Back then, a standard letter went across the continent for a few pennies; now it takes 37. A haircut that cost 50 cents now costs $10. Does the average physician make five to 20 times as much, “infinitely more,” than his counterpart did in the 1930s?

Ironically, our predecessors got paid more when they could do less for their patients – at least when measured in terms of patient outcomes and longevity. They collected their full fees, whereas today 20 percent to 50 percent may be discounted. In 1960, if 10 percent of a physician’s fees went toward overhead, it would be surprising. Today’s family physician may realize as little as 40 percent of what is collected – not of what is charged!

Perhaps my understanding of “infinitely” differs minimally when it comes to the mess we’re in. What is infinitely amazing is that as a profession, physicians have been able to withstand these blatant assaults and continue to be their patients’ advocates.

Author’s response:

Drs. Heiderscheidt and Schmidt make some interesting points, but their letters both contain errors of fact that undermine their validity. Dr. Heiderscheidt is correct in suspecting that “… the degree of educational debt borne by modern physicians is greater than in the past,” but perhaps not for the reason he had in mind. Education loans as we know them today did not exist in 1960. My medical education was funded by my parents and my wife’s salary as a school teacher and supplemented by income from “moonlighting” and summer jobs. Some of my classmates worked for a few years before starting medical school, living frugally and saving all they could. People who didn’t have the money just didn’t go to medical school.

Dr. Schmidt’s letter contains many inaccuracies, beginning with his guesses about physician income in different decades. The Great Depression was on in the 1930s, and unemployment and poverty were widespread. Very few people had any kind of medical insurance. Conditions were better in the 1960s, although not comparable to what we enjoy today. Dr. Schmidt’s figure of $1,600 as the cost of a station wagon in 1960 is only about half the actual price of a standard Ford or Chevrolet wagon that year. My practice overhead in the 1960s ran about 50 percent of receipts, not the 10 percent figure suggested by Dr. Schmidt. It’s not true that physicians “collected their full fees” in pre-Medicare and pre-Medicaid America. The poor sometimes went without medical attention, but doctors gave significantly more flat-out “charity care” than they do today.