Rich people make great villains. When superheroes need a super villain, they look for bad guys with means. Whether it’s Cruella de Vil from 101 Dalmatians or Gene Hackman as Lex Luthor, we love to hate rich people.
That includes doctors, with a special class for Eye Doctors and Radiologists.
Heroes have money too, sometimes. It creates a pseudo-character flaw. Tony Stark renounces his arms-developer past and funnels profits into high-tech vigilantism. Bruce Wayne inherits wealth, but shuns it seeking penance and meaning in poverty. Reluctantly he pulls on his Batman tights and hunts rich underworld perps as poetic justice.
For many, having money indicates a character flaw, serves as evidence of some nefarious activity or, at the very least, suggests an inordinate love of mammon.
Envy
Society envies doctors for their mythological incomes. Doctors envy other doctors on the same premise, granted with more reason.
Envy is a resentful awareness of another’s good fortune. It arouses spite, a desire to harm the person holding the good fortune we believe they possess. We want their good fortune to end. We want what another person has and resent them for it.
Dante described envy as “a desire to deprive another man of theirs”. For Dante, the envious gain sinful pleasure for seeing others brought low. See also schadenfreude.
No culture applauds envy, ever. It shares prominence as one of 7 deadly sins thought to be so bad that it caused an unpardonable and total loss of grace.
Institutionalized Envy
A rigid government medical system institutionalizes envy. It offers whiffs to the envious of what they do not have. It provides all sorts of reasons to argue why doctors have too much. It marries envy and a voyeuristic snooping.
Doctors envy higher paid specialties, and the rare MD who bills over $1 million. Doctors spite their peers. They want to cause them harm.
The general public envies doctors and anyone who bills more than twice what they make. They delight in seeing them attacked by political bullies.
Envy gives us no pleasure at all. We feel sadness at another’s happiness. We feel pleasure only at when our victim suffers.
Price, Costs and Relativity
Like bread in a Russian bakery, the government defined and set doctors’ fees decades ago. They get tweaked now and then, but stand almost unchanged since the 1970s.
Price fixing rests on ‘cost’ to determine price. Cost looks to training, time, effort and skill as proxies to help determine price.
A procedure that took 4 hours, expensive equipment and carried a substantial risk of disastrous outcomes commanded a high fee 40 years ago. Today, the same task can be done in 20 minutes with almost guaranteed results. Doctors can do 20 or 30 in a day with energy to spare. But the fee stays high.
In fact, high fees now dwarf other fees. Years of ‘across the board’ raises give high fees bigger raises. Like feeding a fat cat more based on its girth, the fat cats get very fat indeed.
And the rest of us envy them. We want to make the obese kittens suffer.
Lord of The Flies
Can we see through the haze? Doctors stagger with envy like the most intoxicated journalists at the Toronto (Red) Star. Envy corrupts everyone, doctors included.
We need to admit that price fixing has nothing to do with patients’ ideas of value. Centrally controlled healthcare removes all information about what patients think. We pride ourselves in being completely ignorant of how much patients value different services; how much patients value being brought back to life versus having vision restored.
Re-Boot
We need to start over again with patient benefit at the center. What approach to healthcare turns the interests of every single person towards meeting patient needs?
State funded healthcare can stay in the game, as long as it proves to put patient needs before all else.
Providers who help the most patients, or offer the most valued services, should earn the most. We should not resent someone for providing more care. If some doctors find ways to help tonnes of patients, we should celebrate them. Give them an award, not an extra cut.
“Anti-competative agreements harm both consumers and businesses…”
— Competition Bureau, Governent of Canada
Price fixing for medical services plus central control must lead to salaries and even more regulation.
Price fixing cannot sustain in a pseudo market where patients can shop for any health service at no cost, and doctors can bill with no way to certify need or benefit. If we offer patient choice and provider freedom, then we must let patients determine the value (price) they place on each service.
First dollar coverage (‘free care’) and fixed prices necessitate rationing of medical services. It makes utilization impossible to control and spawns bizarre discrepancies in relative income between specialties.
Doctors need to work through their own issues:
- Do they believe high incomes indicate moral corruption and/or fraudulent care?
- Do doctors want salaries?
- Do they maintain faith in price-fixing?
Doctors stand at a crossroads. As Medicare crumbles around them, what do they want? More of the same, or something better?
This is excellent, Shawn!
I have said this to my colleagues for year…fear plus envy equals hate.
It is sad for us (and patients, unbeknownst to most of them) that the only thing this government has been successful at is bringing the medical profession to heel and painting us as overpaid and unworthy of same.
The media fall for it every time, because (1) they are too dense to ask the questions – like did each doctor get a 61% raise over they past 10 years? (2) they feed the public envy of physicians – helps to sell more of their media.
There are also multiple paradoxes at work here:
1) The public generally part with little or no money during their interaction with physicians. The public value what they pay for. Hence, they see physicians as having very little value and will complain about paying $20 for a doctor’s note.
2) Building on the above, even though little or no money changes hands, there is this great mystery about what a doctor actually makes. It must be too much…well because…just because you are a doctor you make too much. And you make far too much because I perceive you as having little value
3) Though people tend to really like their own doctors, generally they have disdain for the profession as a whole. It is hard for them to appreciate that when they cheer the government sticking it to the profession, that their own doctor is getting hammered, too.
4) There is this disconnect between how much a physician makes and how much service they provide and how that affects access to care. Sure all of the ophthalmologists could provide less care and less surgeries, but what would happen to the wait list for cataract surgery and macular degeneration procedures. What happens if they stop doing some procedures in their office because they cannot afford to purchase expensive equipment or pay well trained ancillary staff?
The paradoxes above (and I am sure that there are many more) all boil down to fear + envy = hate.
I tell people who come to my lowly walk-in clinic that if government continues to cut FFS, I will have to leave and close the clinic. They look at me rather blankly and assume that things will go on as usual and some other doc will come in and take over and things will go on as they always have. I correct them and say “No…the clinic is going to close. There will be no one else”. I see 100-130 people per day. What are they going to do. Where are they going to go.
It happened in 2005 when I walked away from family practice. Patients just assumed that they were going to be looked after and there would be another doctor coming in to take over. There wasn’t and they were set adrift to fend for themselves.
No one out there gets it.
The profession has essentially been enslaved to look after the masses. We have no rights or recourse other than to leave or quit. They think that they pay for 100% of our education so that entitles them to whatever they want whenever they want it from physicians. Yet, they pay the same or more of the post secondary education of all other students but aren’t demanding that fine arts students paint art for their homes. There are no such demands for dentists, accountants, lawyers etc.
Done for now…need to exhale…
Brilliant comments, Paul!
I especially like: value is proportional to price. If price = 0, then patients have a very tough time seeing ANY value in MD services.
I just spoke with my Mom and Dad. Patients do not feel any sympathy for doctors. Overhead means nothing. All businesses pay overhead. Patients will never understand unless they see Wynne’s cap on healthcare for what it is: a CAP on the medical services delivered to patients.
Practically, patients will experience shorter office hours and longer waits to see their physician. Office staff will find their hours cut.
I cannot do justice to all the great thoughts you packed into your comment. I hope readers take the time to give them the time they deserve!
Thanks for reading and commenting!
Cheers
Shawn
This is the same principle, and excuse me for being a typical female, as people paying $4000 for a purse. In the end there is nothing really special about that purse, at least not $4000 worth. But people have been trained to value the brand. So if it’s Prada or Balenciaga, well then, it must be worth paying $4000. It’s not by the way people. Anyhow, that is why Paul’s comment rings true. I have heard people accuse us of getting rich off a $10 note. Those same people will turn around and spend $250 on a purse. Shows you how valuable they think doctors are. They take us for granted because they just expect we will be there and they have a right to our services no matter how unnecessary the visit may be. I had one patient insist they needed a TSH done every three months (no thyroid disease) because they pay taxes. That’s my rant.
Great note, Lori!
I define value as what an educated customer would pay for a product or service. If educated customers see our services as ‘free’, they will act accordingly. They will make demand and assume levels of service. Not everyone at first, but we all end up operating on assumptions and demands if we believe it is our right.
Thanks for taking time to read and share!
Best regards,
Shawn
Paul, you have distilled into a couple of paragraphs what it has taken me 40 years of practising medicine to learn.
It is hopeless to explain overhead to patients. My father had a grocery store with overhead, including buying merchandise, of 90%. Even after I explained physician overheads, he still said doctors make huge amounts.
Glad, in a sick way, that you had that experience, Gerry. I just went through the same with my family today. Useless. People just don’t get it. Even if they do, they say, “But you CHOSE to be a doctor.” Oh well…
Some very good points raised by all above. So true that, no matter how we explain it, the average person thinks that Doctors make too much. Also true that they dont really care how many years and how much effort you put in, and the value of all the work. The truth is, they dont value it because it costs them nothing! I think it is high time the idea of paying for your own healthcare is broached. It happens in many countries, and the healthcare is certainly better in those countries. Perhaps we can pay les in taxes, if the Govt doesn’t have to (mis)manage it all!
Great comments, Raji!
I think Premier Wynne and her Min Hoskins have created more Medicare doubters than any argument ever could. Caps, cut-backs, mismanagement and scandal make it hard to defend government running anything.
Thanks for taking time to read and comment!
Best regards,
Shawn
Every time I visit the vet I wonder what it must have been like before medicare and if we could ever follow the model used for animal care for people ever again.
David, you used the word “could” with regard to human health care. The word you ought to have used is “should” and the reply might be “can” we afford the current model of medicare?
Personally, I believe in the social safety net but the government’s paying for all of healthcare forever is not sustainable.
Well said, Gerry!
Me too. I worked in a vein clinic for a few years. It felt REALLY weird discussing price with patients. After a few weeks, it felt normal. I found myself going above and beyond to prove to the patient that they got their money’s worth. Patients were uniformly pleased, and I felt really good about it. We need to have some aspect of a trading relationship in the provision of medical care, I think. Of course, we can figure out ways to pay for those who cannot pay for themselves. But this “free for all” approach falls apart eventually.
Thanks for reading and commenting!
Cheers
Shawn
While looking at a discussion of the recent cutbacks to all physicians in Ontario, I noticed a post that just threw in an extraneous comment about the “vastly overpaid ophthalmologists”. I have been tweeting and writing about ophthalmology for several years now but some will always cling to their stereotypes and myths even in the face of facts that show their beliefs to be untrue. Envy is a very hard emotion to combat even with studies like this:
http://www.longwoods.com/content/23135
that conclude: “ophthalmologists were ranked second when only public payments were considered but eighth when overhead was included.”
If colleagues believe the untruths, how can anyone expect the general public to believe the facts about doctors in general.
Thanks for including this, Gerry. As Jason said on Twitter, we should only look at our neighbour’s plate to make sure he has something to eat …or something like that 🙂
We have no idea what others have to shoulder in order to provide care.
Thanks so much for taking time to read and comment!
Best,
Shawn
Thank you both Shawn and Paul. I agree with Gerry I think you are getting to the crux of the problem fear and envy on the part of patients/public.
Paul I think your thoughts on physicians being enslaved to look after the masses is valid. A number of years ago when I worked as a GP in Nova Scotia the President of the Nova Scotia medical association left for the US at the end of his term in office.When asked on the radio why he was leaving he replied “I think 20 years of indentured servitude is long enough.” While the definition may not be strictly accurate I think the sentiments that he was expressing fit.
Actually I think the resentment felt by both patients and doctors has been moving slowly east to west “have not” to “have ” provinces as the mismatch between health care demands and HC capacity increases. 20 years ago in Moncton New Brunswick only 2/3 patients had a FP. Primary Care shortages now seem to be shocking people in BC.
I agree Shawn that we are at a crossroads. I think that this could be an opportunity to look at successful Health Care models from other countries and pick what would work for Canada.
Of course that would require political will and strong political leadership (very unlikely), also slashing the administrative fyfedoms of the provinces (very unpopular with bean counters) and input from Health Care Providers ( not welcomed to date because we are seen as the problem not the solution) etc etc
I know this sounds simplistic but what do we have to loose?
Other countries have survived huge revolutions in HC delivery. Netherlands quite recently. Are we so inflexible that we would rather sink than change.
Sorry getting preachy…
Thank you once again guys,
Helen
Thank you, Helen! I loved the story about the NS President. I suspect we have a ways to go before we see substantial change. But in the meantime, at least doctors can support hard work, reward for great outcomes, professionalism, responsibility, freedom, etc.
I sure appreciate you reading and commenting!
Cheers,
Shawn
Hello Shawn, once again…fantastic article. I’ve always wondered what a unit of physician time is worth. There is no question that not all doctors should be paid the same net income. However, a doctor that has the same level of patient acuity, hours of work, responsibility, and complexity should be paid the same net income. Yes, the neurosurgeon should be paid more than the endocrinologist…just my opinion but some people would argue differently. More importantly, what is a unit of physician time worth? I love the economic concept of the indifference curve…the utility of something (a good or service) determined through varying combinations of that good or service. In other words, you would be indifferent to a whole host of combinations of goods or services. Lets say we take out the sunshine list and determine a starting salary for physician (adjusted for all the other benefits that the person receives, pension, sick leave, vacation etc.). We can look at different industries to determine what that starting salary should be. For example, lets use the city manager of hamilton making $256,000 plus taxable benefits, pension, vacation etc. Would a person be indifferent paying this person that salary and a GP/ER doc that salary? I would bet that most people would say that the doc should be paid more. If that’s the case, the starting salary should be above that salary plus benefits. Otherwise, the public should pay that city of hamilton manager less money (if the doc makes less). We could keep working our way up through the public sunshine list and see what an indifferent set of salaries should be. I would bet that the Chief of Police should be paid just as well as an ER doc and possibly more. These are obviously difficult questions to answer but you get the picture. If the public is willing to pay all of these employees that have no where near the level of responsibility, acuity for patients, overhead, etc., then they must pay doctors more for the service they provide. If not, then they just don’t value the service doctors provide.
Great way to put it Mark. I have always followed what my dad told me: “stick to what you know, do it well, and the money will follow”.
I don’t apologize for my good fortune as it entails much sacrifice. However, as a business man I also have other interests in parallel to my medical practices.
I am ok, financially. However, I am feeling the disdain and sometimes hate for being ok…and that’s from my peers. A few years ago I had a discussion with another family doc as she complained about ophthalmology fees, and radiology fees. I believe my words were “if you don’t stick up for them (ophthalmology and radiology) now, when they (the government) come for your fees, they will be the first ones to turn on you”. It is the same that has happened to firearms owners. Lol
Oz
Feeding the crocodile hoping he comes for you last
Exactly!
Very wise advice, Ozzy! I hope your colleague, and others, internalize it. We – doctors, the OMA – should have fixed relativity. It’s ours. We should not resent other MDs because we haven’t been able to manage the problems. We most certainly should not be punishing doctors for working hard for patients!
I sure appreciate you commenting!
Cheers
Shawn
Fantastic idea, Mark! I am not familiar with the indifference curve but will look into it ASAP. I know readers will appreciate this.
I wonder whether most of the public would sooner chop down the city manager than pay an MD as much?
Really great comment! Sure appreciate you taking time to share it!
Cheers
Shawn