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Are Doctors Businessmen or Professionals?

August 5, 2008

A debate is raging in the medical blogosphere over a post by The Happy Hospitalist regarding the solvency of Medicare on Kevin, MD’s site.

Maggie Mahar, who writes an excellent, in-depth health policy blog, provides a well thought out response to the original post on her own blog.  I’m not going to weigh in on their debate, except to say that I generally agree with Mahar’s position.

What caught my attention was something Mahar said at the end of her response:

Too many doctors define themselves as “entrepreneurs” rather than as professionals.  Anybody can get an MBA and become an entrepreneur. Only very talented, and one hopes, committed people can make it through medical school and become physicians. These are the folks who can help us wring the hazardous waste out of our money-driven healthcare system.

I think Mahar likely meant for this comment to be a rallying cry for physicians to step up to the plate and reign in costs through sound medical decisions (not decisions based on “business models”).  However, the way she phrased it made me start to think about the dual roles physicians are forced to play and why.  By and large, I think the vast majority of physicians would consider themselves “doctors” long before they ever think of themselves as “businessmen.”  However, two key aspects of our current healthcare system force them to wear both hats.

1)  Medical school debt

The average debt medical students graduated with in 2007 was nearly $140,000.  Many students have debt loads of $250,000 by the time they finish residency and begin to pay down their debt.  For most people, such a large debt load is spent on tangible assets that can be liquidated if needed (read: most people spend that much money on their house and could sell it–usually for a profit due to appreciation–if they needed the money).  A simple student loan calculator estimates that the monthly payments on $140,000 in educational debt would be over $1,600 per month and would necessitate a salary of $193,000 to comfortably take on this debt load . Med school graduates are forced to take on an “entrepreneurial” outlook just to ensure they can make their student loan payments.

2)  Private practice structure

Doctors entering into their own private practice are by definition “entrepreneurs.”  When a doctor decides to open his or her own office, they are opening a small business.  Thus, they must consider the amount of money coming in and the amount going out in expenses and adjust their practice to make sure more money is coming in than going out.  This has always been a fundamental flaw of our healthcare system.  This structure forces physicians to focus on their “business model” rather than patient care.  Integrated models of care, such as at the Mayo Clinic, have physicians on salary and allow them to focus on patient care rather than spreadsheets detailing cash flows.  These integrated models of care also happen to generally produce better patient outcomes.

The first problem is relatively easy to deal with.  Our country needs to come together and develop a strategy to reduce medical school debt.  Free medical school for all, although tempting, would probably create many unforeseen problems.  At the very least, the federal government could provide very low cost loans with deferred interest while doctors are completing their training during residency.  Most medical students are just looking for some help, not a handout.

Dealing with the structure of private practices can only be characterized as “complex.”  Many hospitals and insurers are moving towards integrated systems of patient care with staff physicians on salary.  This will likely become more and more popular as small practices find it increasingly difficult to maintain the business side of their practice and become frustrated as “doing the books” takes more time away from patients.  These trends began many years ago and will only continue.  However, health systems will never engulf each private practicing physician.  Medicare and private insurers will have to develop sophisticated ways to pay private physicians to ensure patient care, not reimbursement, is their main focus.

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