So Long Marcus Welby, Hello Worker Bee
The announcement last month that doctors’ incomes have dropped after decades of steady growth didn’t cause too many nonmedical tears to shed.
After all, the American Medical Assn. study showed that even though the average income for physicians declined 4% in 1994, it was still a healthy $187,000.
“A lot of peoples’ incomes are dropping,” noted Charles Inlander, president of the People’s Medical Society in Allentown, Penn, a consumer advocacy group. “You don’t get out the crying towel just because an anesthesiologist went from $224,000 in 1993 to $214,000 in 1994.”
The big losers were the higher-paid specialists, with decreases reported in almost every specialty, particularly for anesthesiology and obstetrics / gynecology. The lower-earning doctors, mainly the family practitioners and internists preferred by HMOs, stayed the same or saw modest rises.
Considering that physician incomes had continued to increase “significantly” even during the early 1990s when corporate mergers, layoffs and buyouts were daily headlines elsewhere, there was a sense of “welcome to the real world” from many quarters when the AMA report came out.
“It happened in the defense industry and in corporate America when companies were attempting to downsize,” commented Gail Wilensky, who heads a congressional advisory commission on Medicare payments to physicians, “but people in health care thought it would never happen to them.”
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Beyond simple economics, the news of falling doctor income crystallizes sweeping changes in the iconic role of the American physician. After all, this is a nation whose image of the family doctor was honed in the late 1960s by the kindly, all-knowing, fatherly Robert Young, television’s “Marcus Welby, M.D.,” and whose legendary advice columnist Ann Landers has long suggested “talking it over with your doctor” to agitated readers.
But the real news behind the AMA study--that the sudden earnings drop was mainly attributed to managed care, which has been steadily working to control costs--has larger implications for doctor and patient alike. Patients may shed some tears, after all.
It means that physicians may be losing their controlling voice in the U.S. health care delivery system. If current trends persist, warned an article in the August AMA Journal, a majority of physicians will be working for the new “medical-industrial complex” with their practices subject to an increasing degree of bureaucracy.
Doctors becoming employees? That’s an unsettling thought. Even in Southern California, a leader in managed care over recent years, most people, according to polls, say they like their own doctor no matter how they gripe about the system.
“I love my doctors--to me they are like surrogate parents!” exclaimed Dan Harary, 40, president of Asbury Communications, reeling off the names of his internist, allergist and ophthalmologist with reverence. “They have this legendary status in my eyes and I don’t want it to ever change.”
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Many consumer advocates have long complained that medical schools don’t prepare doctors for economic reality. “Medicine has been a road to riches for many years in this country,” complained Inlander. “There have been too many doctors doing procedures for money, not for need. We saw the prices go up and these people got richer and richer and people were getting angry about the care.”
In its crusade for a more responsive, less expensive medical care system, his group publishes newsletters and self-help books including the comprehensive “People’s Medical Society Health Desk Reference: Information Your Doctor Can’t or Won’t Tell You” (Stonesong Press, 1995). “We get 1,000 letters a month from consumers,” said Inlander, “and none of them are saying ‘Isn’t it terrible what is happening to doctors’ incomes!’ ”
In truth, the doctor-patient relationship has been in constant change since colonial days when educated doctors tried without success to reproduce the professional institutions that gave them status in England.
In the Jacksonian backlash of the 19th century “state legislatures voted to do away with medical licensure entirely,” writes Paul Starr in his Pulitzer-Prize winning “Social Transformation of American Medicine.” (Basic Books, 1982). Many Americans who already had a rationalist, activist orientation to disease refused to accept physicians as authoritative.”
The suspicion of doctors extended well into the 20th century as doctors and patent medicine makers competed for authority, he writes.
As a profession, medicine only took on its real luster after World War II. Starr traces how the new enthusiasm for science and such miracle drugs as penicillin, plus a public affluent enough to have the luxury of worrying about its health, changed the face of American medicine.
During the 1950s and ‘60s, in upwardly mobile America, a doctor was the ultimate symbol of success--for a young man to become, and a young woman to marry.
“My father loved being a doctor,” recalls a Los Angeles woman. “Everything about it--the importance, the ability to help people, the respect. It was like the ‘Toreador Song’ playing every time he walked in to a room.”
If this was the high point of prestige for the American doctor, complete with the $70,000 Mercedes, vanity license plates and Wednesday afternoon tee-off time, it was the low point for the patient, Inlander says.
“That’s when we as consumers lost control. We put these people on a pedestal. That’s when you began calling the doctor ‘Doctor’ and he began calling you by your first name.”
The pedestal began to tip by the 1970s when the women’s movement touched off wide-scale criticism of paternalistic doctors and sexist medical schools. These developments extended to a wider interest in holistic medicines that continues to grow.
Today, not only are consumers armed with books, health and wellness newsletters and sophisticated online information, they have access to an increasing amount of technology for home blood-pressure or other tests.
Amrika Padus editor of Prevention magazine in Pennsylvania, which has long advocated personal responsibility in health care, says managed care changes all the doctor-patient rules. Even if you are seeing the same doctor, he or she may now be working under guidelines created by an insurance company, based on what is most cost effective.
“You have more leeway than you think,” she said. “The people who are the most assertive, who arm themselves with the most information, and insist and ask and talk to their doctors are going to get the best care.” Dr. Thomas Reardon, vice chairman of the AMA’s board of trustees, agrees that the relationship is shifting. “The entire medical environment is changing,” he said.
Not only are more doctors having to adjust to some sort of employment, he said, patients become more sophisticated every year. Even though the doctor continues to be a patient advocate in a very complex medical system, he said, “I think the time when a physician could say ‘Take this prescription and don’t question me’ is long gone.”
How doctor roles shape up in the future depends a lot on the coming battles, as doctors form their own provider groups, bypassing insurance companies, and even look toward unionizing, in attempts to regain a foothold against HMOs.
“Unequivocally, the future is a big mystery at this point. Doctors, at least for the short term, will have less and less freedom and autonomy,” said Dr. Hillel Swiller, who directs the Division of Psychotherapy at Mt. Sinai School of Medicine in New York and is a visiting professor at Harvard University.
The income drop won’t drive people out of medicine, but the loss of autonomy might, he said. “There is a public perception that doctors make too much money, and some do. But I would say to anybody that if you are really interested in making money, medicine is a bad idea. Most doctors make a handsome income and that income will go down. If you want to get rich, be an entrepreneur like Bill Gates--that’s where the money is.”
He is heartened that applications to medical school continue to rise and good students still see medicine as exciting and fulfilling work. “I love being a psychiatrist. It’s a privilege,” he said, “but I do think it is going to be much tougher to have a rewarding professional life in the future.”
