By Dr. Jim Dahle, WCI FounderI am often told, usually by an experienced doctor, that other doctors owe something to society, usually in exchange for the expense of their education. This is in response to different scenarios. It might be:
- Someone retiring early
- Someone working part-time
- A doc having a baby or “going on the parent track”
- Someone who burns out and changes professions or becomes a stay-at-home parent
- A physician taking parental leave, or most recently
- A doctor choosing a concierge or direct patient care business model
Here's an example of how it gets said:
“I just finished listening to your video explanation of concierge . . . I mean for this to be an open discussion and harbor no hostility toward you or your excellent presentation. What about the moral/ethical aspects of this? Almost all physicians in the United States received their education heavily subsidized by the federal government. When they go to concierge, they may go from an actual average patient load of 2,000 down to 200. Where do those 1,800 others go? Right now, they go to a rapidly expanding queue for either general or subsequent specialist care which is why the waiting lists are unconscionably long right now. Do concierge physicians take this into account? This explosion seems to track exactly with the explosion of concierge medicine. What do you think? I can’t begrudge a physician who’s been at it for 40 years to spend the last five or 10 years as a concierge, and I have some friends who have done that. But to see people go directly out of training into concierge seems to be a blight that we should discuss with open minds.”
Hippocratic Oath?
I'm really not sure where this view comes from. Maybe it's from the oath that many new doctors repeat at graduation, i.e., some version of the Hippocratic Oath. This is one of the older versions:
“I swear by Apollo Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.
To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the Healer's oath, but to nobody else.
I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. . . . But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.
Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.
Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me.
As I read that, I see nothing that obligates a doctor to work long hours, many years, or for free—except for teaching the children of those who taught me medicine. So, maybe there's an obligation to teach medicine for free, but nothing there says I have to practice it for free or that I am responsible for the access to care issues seen in our modern healthcare system.
Do Doctors Owe Society for Their Education?
Who pays for the education of a doctor? In the case of many doctors, they do—to the tune of literally hundreds of thousands of dollars. Sometimes that debt is carried well into mid-career and beyond. This is quite different from today's senior doctors, who may have faced a mere four-figure annual tuition bill. If they went to a state school, perhaps the state subsidized the education somewhat, usually in hopes that the doctor would choose to continue to live and practice in the state. But if the government actually wanted to contract the physician to stay in that state, it should have done so. Those contracts exist, but they generally pay a whole lot more than the difference between in-state and out-of-state tuition.
Perhaps the doctor paid for their medical education the way I did—with a contract. I contracted with the US military. The military paid for school, and I agreed to work there for four years, no matter where the military sent me or what it asked me to do. The military fulfilled the contract, and so did I. Neither of us owes the other anything anymore. The same goes with a National Health Service Corps, Indian Health Service, or MD/PhD contract program. Yes, if you signed a contract, you need to fulfill the terms of that contract. But that isn't the case for most doctors.
What about residency, you say? Hospitals that offer residency programs receive a substantial amount of funding via Medicare, which is paid for using payroll taxes. The most recent data I saw suggests that Medicare pays $150,000 per year per resident. My first question when I hear that is, “What the heck? Where's it all going?” Most of it is certainly not going to the resident. Even a well-paid resident has a compensation package worth no more than $80,000.
Now, I'm not going to argue that a PGY1 resident is worth $80,000. But a senior resident is worth a heck of a lot more than $80,000. Heck, more than $150,000. On average, the compensation is probably about right for the value provided. What is a supervised practitioner worth? That's relatively easy to see, given the prevalence of Advanced Practice Clinicians (APCs like PAs, NPs, CRNAs, etc.) in our system. They get paid a lot more than a resident, even a senior resident. At any rate, there is no contract, and there is nothing in the Hippocratic Oath or in their contracts requiring doctors to work for long periods of time—much less for free—just because Medicare helps pay for residencies.
Docs don't owe society anything for their residency training. And even if they did, doctors and similar high earners suffer most under the progressive tax code. The more you earn, the higher your tax rate. There is no REPS status for medicine. There is no carried interest for medicine. There are no stock options in medicine. Everything you earn gets taxed at the regular old ordinary income tax rates. And every bit of that income (barring an S Corp being involved) is taxed at 2.9%-3.8% for Medicare.
We all pay for those residents. A doctor making $800,000 pays around $30,000 a year in Medicare tax but gets no more benefits than someone who pays $1,500 a year in Medicare tax. It doesn't take very many years of that to pay back the cost of your residency to Medicare.
More information here:
Are Physicians 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. Nobody says lawyers have to work 80 hours a week until they're 75 because society educated them. Nobody applies this to engineers, astronauts, pilots, teachers, judges, or anyone else that society helped to educate. I don't even hear it about nurses. Just doctors. And interestingly, it's almost entirely BY doctors. Maybe it's time to quit shaming each other into a burnout-inducing amount of work.
What About EMTALA?
As long as we're talking about obligations, let's talk about the biggest unfunded legal obligation doctors face, the Emergency Medical Treatment and Labor Act (EMTALA). This is the anti-wallet biopsy law. While it applies primarily to the emergency department and labor and delivery, it does include any doctor officially on call for an emergency department, which is an awful lot of doctors.
Basically, you cannot ask a patient to pay for their medical care until after you have stabilized their emergent medical condition. I don't actually have a problem with EMTALA. I think it's a pretty good law. My problem with EMTALA involves funding. It's mostly the fact that there is no funding. It's an unfunded mandate. Unlike anyone else in America, emergency doctors are federally mandated to work for free. And yes, patients do take advantage of that. Uninsured patients are technically “self-pay.” In reality, if you don't collect the money up front, self-pay equals no-pay. The self-pay rate in emergency departments I've worked in is about 3%, which is effectively 0%. Given an uninsured rate of 20%, that basically means I work every Friday for free. And I have it good. Lots of emergency departments have an uninsured rate of 40% or even 50%.
No, I don't owe society anything. And if I did, it was paid off long ago with all the free care I have provided to every fifth patient for the last two decades.
Workforce and Patient Access Issues
Yes, there are workforce issues involved when doctors work less or retire early. Yes, there are patient access issues when doctors decide not to see seven patients an hour or adopt a concierge model. These are very real, complicated problems. But they are problems for our entire society to solve, not problems that can or should be solved by doctors alone. Anyone who thinks these are easy problems to solve doesn't understand the problem. But doctors can't take the entire medical system on their shoulders and carry it to the promised land. They might try, though—which explains the 37%-63% burnout rate, depending on specialty.
More information here:
Which Medical Specialties Are the Most Burned Out?
What Emergency Docs Can Do to Beat Burnout
The Bottom Line
If you want to go part-time, have a baby, start a concierge practice, take Wednesday afternoons off, cut back to full-time, retire early, or leave medicine altogether, go ahead and do it. You should feel no guilt about doing so. You don't owe anything to society. You didn't steal anyone 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 about not working enough?
This is more common in countries where education is almost free like France or other Western Europe countries. In America since you pay for your vacation nobody is going to ask you pay back. In France in particular there is a big deficits of doctors coupled by a financial crisis in the country. The government is asking more from the medical profession without signicant pay to already overwhelmed doctors, especially Primary Care and in emergency medicine, and they’re using the argument that society has paid their education to force them to more labor and use the hippocratic oath as a moral tool. Result: they are no more primary care or ER physician….
“Maybe it’s time to quit shaming each other into a burnout-inducing amount of work.” Bingo. Physicians are usually our own worst enemies. Unlike teachers and lawyers and other professions, we carry our competitive natures with us to the grave and we’re all worse off for it. Perhaps that’s why our incomes aren’t really increasing like they should compared to some professions. It would be a stretch to blame other doctors for most of burnout though, in my opinion. I’ve largely done it to myself. I would be lying if I said that one of the principal reasons that I’m still working is because I feel I owe a debt to society. LIke you, I paid that off with 12 years of active duty service. No, it’s more selfish than that – I don’t know if I’ll be happy not working, and not quite ready to hop into my second favorite activity (sailing) yet as a full time job, but I’m working on it. Thanks for another great article on the WCI!
As we say in the south, it sounds like someone is good starting an argument in an empty house. Don’t like the profession? No one made someone become a doctor. Want change to funding, tuition, the tax code, get it done, don’t whine. Want to give up one’s status, fine; I have seen it in my lifetime – the Marcus Welby model is gone anyway. A lot of people work overtime, odd hours, give up holidays: law enforcement, firefighters, the plumber on call (my HVAC company always has one) – heck, when a tree fell on my house, even the insurance adjuster and the contractor were there on a Sunday.
Education is expensive, but at least when the model changed in VA for funding for VCU and MCV (now VCUHealth)- it’s been over 20 years now – the medical profession endorsed it. Its only going to get worse for those doctors who remain as many age out; but they were silent this year as one candidate advocated for change to the model for paying more for physician education.
One last issue is the inability to deduct losses when self paying patients don’t pay. Technically, you are burning through overhead ie, canceled visits, fuel, malpractice ins etc.. yet you cannot write off any of this, let alone the uncompensated bill but attorneys and other professions can. This issue was glaringly overlooked when EMTALA was created.
Dr Dahle: Perfectly said. Thank you.
Thank you for addressing this. I have seen this argument many times and have always been confused by it. I recently decided to drop to part time at work, which so far has been an amazing change for myself and my family. But this “debt to society” argument was still bouncing around the back of my head! I appreciate you debunking it. Regardless, the world will probably get more years out of me now than it would have if I’d stayed on my burnout-inducing full-time schedule!
Thanks for all you do!
Please don’t complain, though, when you make less money after cutting back. And don’t ask to pay less than your share of the practice overhead.
Same thing I said here a decade ago: medicine changed the contract on me. I had hoped and planned to work into my 70s for the VA or military. My kid with a GS job (like me but lower pay and actual 40 hour work week and able to do 9 long days then one off) expects to do so. However I can no longer see 4 patients in an hour unless I postpone another 20+ minutes of paperwork on them to the end of the workday. The admin (computer) and nursing support most private docs are able to arrange has vanished. THe patients are sicker and waited longer to come in and have 2 new problems on a baseline of 3 chronic ones. THe growing hours of CE I have to perform for the job came on top of CME and a schedule that didn’t grant me any time for either during the workweek.
Add to that my own health issues plus a combination of frugality and good pay and decent planning (thanks WCI!) I no longer NEED to work 70 hours a week, and they wouldn’t offer me 40/ week (a 50% schedule). I repaid the Army decades ago with 4 years post residency, and haven’t repaid Pennsylvania for their support of my medical school there- never worked a day there. The night shifts, long hours, and exposure to sick people contributed to my health issues and you don’t even (except sometimes now covid) get workmen’s comp for days out for complications of URIs the patients kindly pass on to you.
We see now the ACA is no longer affordable when the Republicans get through with it, and all this stems from employer provided health insurance to bypass wage limits of a century ago. Good luck to us all and to the American people. Doctors can’t overwork us out of this problem and we shouldn’t try.