Ever since I was a wee Air Force brat, doctors as a class were the hardest officers to retain since they could usually make a lot more money in the civilian world. This has also been true historically, to the extent that the armed forces have their own med school and have resorted to drafting doctors in wartime. I guess the uniforms and "social status" didn't work for those doctors...particularly because the military is still looked down on by the literary elites, and doctors are also at the bottom of the military social scale, which basically boils down to combat arms officers first, support officers next, and civilian professionals in uniform last.
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And when the military manages to get them, it is precisely through monetary incentives, such as paying for their med school in exchange for a few years of service afterwards, and with stipends during residency, which are very incentivize-ing, since residency pay vs. residency hours is so low.
It's not only a good example of why doctors aren't particularly motivated by "prestige" any more, it's also a good example of why doctors are so motivated by money, for better or worse. If you have 4 years of undergrad loans, 4 years of med school loans, and 3-5 years of residency (which often aligns with marriage and children), you can be looking at hundreds of thousands of dollars in debt. Highly selective specialists might pay that off pretty quick, but the regular doctor you see probably won't be able to. Prestige does not repay your loans.
And now they get to look around the country and see how we're all debating about how we're going to pay them less. Suddenly the "prestige" of having patients get angry at you for telling them to exercise and eat healthy, while they demand anti-bacterials for their children's viral colds and complaining about how the vaccines will give them autism seem much less, well, prestigious.
That's not completely true. A great many caregivers (physicians, therapists, etc.) work at the VA largely out of a sense of duty. The same is true of free health clinics, doctors without borders, etc.
BUT, there is no denying that you are not completely wrong, either, and that a great many doctors go through the rigors and debt of medical school with a clear financial motive in mind.
To not cast judgement on the motives, let's refer to the first group as "Type 1," and the second as "Type 2."
For the "lower wages" scenario to work, there would have to be a supply of Type 1's adequate to the task. Do we have any reason whatsoever to believe that this is true, today?
There are already free health clinics in every city. Doctors without borders is a real charity. The VA has been around as long as anyone can remember.
Am I the only one to notice that the demand for these Type 1 caregivers seems to grossly exceed the supply? Just this weekend there were articles about a free care program in California that had people arriving at 1:00AM to save a spot in line.
You're not totally correct, but you are correct enough that your point is valid.
There are nowhere near enough qualified candidates for to satisfy the demand for "Type 1" doctors. Any program predicated on them is folly.
You're completely right. Certainly I did not want to describe the motivations of every doctor, and of course there is a gradient.
"There are nowhere near enough qualified candidates for to satisfy the demand for "Type 1" doctors. Any program predicated on them is folly."
I think this statement is perfect. Sure, it would be nice if doctors (or garbage men) did their job out of a sense of duty, but we don't really expect the garbage to be collected unless we pay them pretty well for it.
I'd also point out that it is precisely those Type 1 physicians who are most exploited by our current residency programs. They are so devoted to helping patients that they won't speak out against truly horrible practices. My wife calls them "martyrs for medicine."
There's also a Type 1/Type 2 crossover. I'm willing to spend a week or two a year helping people for free, but I'm not willing to get paid $50k/yr to do it all the time.
Some of the folks at the VA are there because they can't find employment elsewhere...
I disagree.
The benefit of military is you can force people to do things they otherwise wouldn't do.
What we need is the moral equivalent of war. We need to be able to force doctors to work for less, to go where we tell them to, and to do what we want them to.
Doctors are the enemy. They insist on their independence, on being paid adequately.
There was a quite amusing incident in Quebec. They had trouble staffing emergency wards. So they passed a law forcing doctors to report and serve at the designated emergency wards, with some penalty for disobedience. Other provinces facing similar shortages of staff have simply closed the hospitals, but Quebec took a more progressive tack.
Derek
derek, are you related to blighter?
First Obama wanted forced labor for the children, but I said nothing since I wasn't a child.
http://www.freerepublic.com/focus/news/2127959/posts
Then Obama wanted forced labor for the doctors, but I said nothing since I wasn't a doctor. Besides, speaking up would be racist.
And hopefully, when they come for me, the president will be white and we will be allowed to criticize again.
I love the smell of fascism in the morning! Give me a nice good whiff!
Derek - What's your profession? And can we go ahead and force you to perform the work against your will, at the time and place of our choosing, and pay you what we declare is the "right" pay for that job?
The VA is another example of what you get with low pay for physicians.
Not really. If anything, military and VA medicine exemplify two systems that have adapted, despite relatively low physician salaries, to the needs of the people for whom they provide care. Despite the polytrauma wrought by IEDs, survival rates for wounded service personnel have been higher for Iraq and Afghanistan than prior wars. There are differences in military and civilian trauma, but surgeons working in both settingslearn from each other, improving care in forward hospitals as well as American ERs.
The VA does less acute care, but gets high marks for its outpatient services, in good part because it has what is widely consider one of the best, if not the best, electronic health record in the country. The VA exemplifies how better systems lead to better quality of care.
That pretty much tracks with my experiences as an Air Force dependent during the 70's and 80's. There were a few die hards, mostly Vietnam era relics that had maxed out career wise anyway, but the bulk were doing their time to work off their enlistment obligations and immediately sprinting to the private sector.
Not only that, but some of the specialties that the military is most in need of (say, plastic surgery) pay extraordinarily well in the real world. Human nature, it's gotta be hard to drive your Chevy down to the commissary knowing that some hack cranking out boob jobs is pulling down half a mill annually.
the military makes a really poor example for any conversation about prestige. it is just not analagous to any other occupation. when a company commander walks into his building in the morning, the CQ calls "company, attention" and everyone who hears it stops what they're doing and comes to attention until the commander calls "at ease". that's a twenty-seven year old captain with a bachelor's degree and five or six years on the job. there's really no civillian eqivalent to that level of respect, but it's respect that is only given within the military. i regularly see full bird colonels and sometimes generals riding the metro, and you know what, they're just another person making the morning commute.
I think you should talk to some people who've been through residency at a major teaching hospital before you make these confident assertions about the lack of respect and prestige in non-military professions.
perhaps i've phrased this incorrectly. army retention works, in part, on the fact that the difference in respect and prestige an NCO or officer are granted within the military is so far above what they might get outside. the kind of person who can make it onto the faculty of a major teaching hospital is likely the kind of person who can rise to the top in all sorts of professions.
So what you mean is that military officers aren't actually accorded much respect outside of the military, whereas doctors are? That doesn't seem true to me. I don't really understand the point.
What I'm saying is that for military officers, the respect accorded to them, both by their colleagues and by those in broader society, is part of the incentive for doing the job.
The same is true for doctors. They are respected in society for what they do. And they have an intense culture of achievement and respect within their own professional institutions. Yglesias is saying you could cut pay to some extent, and people would still join the profession for the internal and external prestige, just like the military.
no. what i mean is that the differential between the respect accorded a military officer in command of troops and any other twenty-eight year old middle manager surpasses any comparison to other careers, even doctors. at about the five-year mark is when many officers call it quits. that is partly because it's when ROTC obligations end, but it's also about the time that an officer is facing a long stretch of staff and developmental assigments before the possibility of his next command. and the pyramid hierarchy of the military means that many will never get to that next command.
the point is that officers want to command troops. that's why most join, and why most stay. the perfunctory respect given to members of the armed services is nice, but it doesn't keep people in. i suspect that the perfunctory respect we give doctors may be enough to keep the best and the brightest shooting for medical school, but minus the chance of becoming very wealthy i also suspect that it will not be enough to keep many doctors practicing for their entire professional career. we would likely end up with a system that still produced the same quantity and quality of doctors, where the best doctors continued to be placed in the choicest assignments, but where many of the rest decided that it was simply not worth the hassle to continue practicing and instead took their intelligence, training, and credentials in search of higher compensation.
at the end of the day, though, this is all just speculation. it speaks the hubris point that i made below. human behavior is complex, and often very difficul to model in the long run. are you really willing to wager on a hunch about how doctors will or will not respond to a significant drop in compensation? i'm not. and nothing personal, but progressives do not have the greatest track record on correctly envisaging labor market outcomes. i'd sooner take foreign policy advice from a neocon.
Another one rides the Yellow Line...
I have a point-scoring system for military brass that I sometimes use to eliven the Crystal City to Pentagon section of my commute. Anything from bird colonel on up scores -- triple points if female!
There's something about the military that nobody has put on the table yet -- the pensions, and the age at which you can get them. Compensation while serving is only part of the total compensation package. Do doctors start drawing a pension at age 42?
Wombat Socho's comment is non-responsive to what Matthew Yglesias is saying. The statement "doctors as a class were the hardest officers to retain since they could usually make a lot more money in the civilian world" is not relevant to a discussion of what would happen if we stopped paying doctors a lot of money in the civilian world. Yglesias is saying that if they had no opportunity to make $500,000 a year enough would still join the profession because it's prestigious, which dovetails with evidence from every other medical system in the world, where doctors earn less but the supply of doctors seems perfectly adequate. Yglesias analogises this to military officers, who continue to serve despite relatively low pay. It makes no sense to counter "but no, because doctors can earn more." The question is precisely: what would happen if they couldn't earn more?
One useful additional analogy to consider would be the effect on the military of the profusion of private military organizations like Blackwater/Xe. As I understand it this has made it significantly harder for the armed forces to retain officers. Speaking as one member of the public, I would say that the advent of the highly paid security contractor as a major part of US military deployments has not increased the prestige of the American military establishment in my eyes; rather the reverse.
"The question is precisely: what would happen if they couldn't earn more?"
The answer is: fewer people would choose to become doctors, or at least the kinds that don't get paid much -- these are the ones we want more of. Which is precisely what we're seeing now, as physician pay has been dropping -- more going into the highly paid specialties. We already have a shortage of primary care physicians.
The other thing that would happen is that some doctors would go bankrupt. If you cut the pay of a recently graduated non-highly-paid-specialist doctor who has the kind of debt you get from undergrad/medschool/residency, they're simply going to go bankrupt.
"Yglesias is saying that if they had no opportunity to make $500,000 a year enough would still join the profession because it's prestigious"
First of all, the doctors that most people want to see more of don't make 500k. In many cases they barely make enough to pay back loans. No amount of prestige is going to fix that. The entire reason we have so many highly paid specialists and low paid generalists is precisely because doctors are responding to money incentives.
You're also thinking about prestige in terms of the people you and I know. We think doctors are prestigious. But doctors deal with two types of people all day: patients and other medical people. The other medical people (doctors, nurses, etc...) don't think it's prestigious because they deal with doctors ever day. They know good ones and bad ones, they don't really get all starry eyed when the white coat walks in the room.
The patients, well... maybe if you're a surgeon. But many primary care physicians are under the distinct impression that their patients consider them the enemy, because they keep demanding that they do all these tough things like exercise, instead of just prescribing them a get-well pill.
This theory of professional choice is not entirely wrong. But it's mostly wrong. It cannot explain the existence of graduate students in the liberal arts.
Well, if you'll allow me a minor modification, it can. The costs of being a liberal arts graduate student is much, much lower than being a doctor. Doctors not only pay a vast amount of physical money to become doctors, but they need to spend huge amounts of time both in undergrad/medschool/residency, pass rigorous tests, meet certain initial qualifications that are far more stringent than liberal arts grad students, they have to delay or cancel their relationships with friends, family, children or significant others and finally, deal with the stressful (you do something wrong, people die) environments that doctors encounter -- different obviously for ER docs than dermatologists.
These are all costs that you avoid as a liberal arts grad student. So yes, compensation is certainly not the only factor, but compensation comes in many forms -- and being a doctor has a huge number of things that count as negative compensation.
And as I said above, financial considerations, despite my comments, are definitely not everything. But even right now, financial (and lifestyle considerations) are driving so many doctors from primary care into specialties that it's starting to cause real problems. So we can debate the true impact of it, but the fact remains: it is having a detrimental impact already, and the original poster is endorsing decreasing compensation even more.
Brian:
The point about making life/death decisions stand, most of the rest just isn't true. Getting a PhD typically takes 5 to 8 years (i.e., as long as med school) and then often another 1 to 3 years as an adjunct or postdoc making about $25,000/year. They don't run up the debts that med students do, but still $25,000 to $50,000 isn't uncommon -- and can be tough to pay back on a $50,000/yr salary.
Overall, in my grad program, fewer than 1/2 of each entering class survived to get a degree and only about 60% of them successfully landed a professor job. And of course not all of them will make tenure; some will wash out. Do more than 30% of people who start med school end up as doctors? That was after surviving a 95% rejection rate to be admitted to the program in the first place.
As for time committments, most profs aimed for each class to take up about 20-25 hours/week, with a 4 course load, or a nominal 80-100 work week expected. You saw plenty of the senior (i.e., already tenured profs) at my school spending every single weekend in the office, even those with you kids (the claim about it not affecting relationships is just not true). Not to mention that academic couples often end up spending years living in different time zones but not making enough $$$ to visit each other very often.
On balance it's easier for academics, but the "hardship" factor alone doesn't explain the approximately 4x to 8x higher average salaries of doctors. Not that it needs to -- it's all about supply and demand.
s for time committments, most profs aimed for each class to take up about 20-25 hours/week, with a 4 course load, or a nominal 80-100 work week expected.
I call bullsh*t.
100 hours a week is 7am to 10 pm Monday through Friday and 7am to 7pm on Saturday and Sunday - I don't buy it for one second.
>"I call BS"
When studying for my qualifying exams, I certainly did put in that kind of time for most of a semester. One of my study group partners passed out on the subway coming in to campus from lack of sleep a couple of times.
Personally I was lower than that most of the time but I wasn't one of our star students either. Still, it was an incredibly demanding and exhausing program, tremendously harder than my BA work was at a top private college.
And the profs at that well-known research school really did put in that kind of time. We routinely got emails from 60 year old faculty members at 2 in the morning, on weekends, during the summer.
Umm...become an investment banker? Are you aware that half the people on Wall Street have liberal arts degrees?
As mentioned, i-banking or management consulting. In fact, quite a few of the recent entering students at my old PhD program had spent a few years at places like McKinsey or wall street firms, and this was before the crash (i.e., student starting in the 2004-2007 period).
Even more common though would be law school. Lots of entering law students have degrees in things like philosophy or poli-sci or history. The grades and test scores required to get into a top 10 history or poli-sci PhD program will easily get you into a top 10 law school. PhD programs are much more competitive.
And if money is the real motivator, when you factor in the earning years lost in a PhD program and the likely debt incurred, on a financial basis you're better off becoming a high school teacher than a professor. And doing so is both easier to accomplish and requires less work.
Are you aware that half the people on Wall Street have liberal arts degrees?
That explains a lot.
jmo:
You're right to call bullshit. I'm a humanities grad student with a humanities professor wife and have friends in both medical and PhD programs, and there is simply no comparison between the two experiences. As far as schooling, first, the PhD experience is flexible. You have deadlines, but you make your own schedule in how to reach those deadlines. Medical students are constantly under the gun, and there is really no equivalent of 30 hour on-calls in the PhD programs. Second, if you are a humanities student in a critical skill field, such as foreign language (as I am), you can make more with an MA than you can with a PhD, so not making it through the program does not carry the same financial implications that dropping out in the third year of medical school does. Finally, almost all of my friends in PhD programs have stipends and tuition remission. None of my med school friends will finish without at least $150,000 in loans.
As for 20-25 hours of prep per class at 4 classes a semester, that is garbage. You may teach 5 classes at community colleges, but most of those are going to be the same course. Most of the professors I know teach at most a 3/3 schedule, and none of them would prepare 20 hours a week for a class. When would they have time to research? Also, faculty positions carry with them many benefits, such as tuition remission for dependents, that doctors do not have.
I wish my humanities colleagues would stop the obviously wrong comparisons with other professions. A person who gets their PhD can be justifiably proud.
Matt, a huge number of the people on Wall Street with liberal arts degrees have degrees in econ. It is simply not true that it is easy to get a job with an english or history degree on Wall Street--it's possible (less likely with English or Comp Lit), but extraordinarily difficult.
As for the PhDs, there are fewer than ten thousand PHds in the humanities issued every year, and a lot of those are degrees in econ, which as we discussed earlier, are high-earning degrees. This is far lower than the number of doctors we graduate each year. And I don't think that anyone who has attended college in the United States would compare the experience of being even a star English or History major, and being a science student. Just getting to the point where you can apply to med school is an enormous grind.
Adam's experience with grad school costs for humanities students sounds a lot like mine: My teaching fellowship included a little bit of money, basic health benefits and free tuition. When I left (without finishing a dissertation), the job picture was pretty bleak. But as long as I was in grad school, my books pretty much balanced at zero at the end of each year.
If you think you'd like to be a professor but aren't sure, you could do worse than to look for a grad school that has a lot of teaching fellowships. You can get an education, mentoring and teaching experience for close to free while you're deciding.
Megan, the question was:
"Once you get a liberal arts undergraduate degree, what else can you do that will make you as much money as a professor?"
That is all I was responding to. One logical choice would be to get an MBA. The point is that having a liberal arts degree, you still have the opportunity to go on and do lots of very lucrative things; and yet many people choose to go on and do some very non-lucrative things, like get degrees in Hmong studies, usually because they find it interesting.
Megan:
You are confusing the universe of all history BAs with the set of history BAs who end up at decent PhD programs.
No doubt you _can_ get a History BA easily at most schools, but if you look at the people go get admitted to good PhD programs they are the very, very, very top of the distribution -- people who come from top schools, with near-perfect grades and GRE scores, and other plusses like interesting undergraduate research, internships, whatever. 99% of history grads need not apply. In sheer amount of effort and brainpower expended while earning a BA I'd stack them up against an average entering med school class, though certainly the history PhD class would be less good at math if you limited the comparison that way.
I would argue that if one regards oneself as top talent, he or she does not choose professions based on median salaries, but on top percentile compensation.
From that perspective the difference between medicine (being a doctor) and academia (being a prof) would shrink, since there is much less variance in doctors' salaries than professor's salaries.
The grades and test scores required to get into a top 10 history or poli-sci PhD program will easily get you into a top 10 law school. PhD programs are much more competitive.
Just a quick googling shows that Harvard has 1900 law students and 120 history graduate students, far lower numbers allow for more selectivity.
I got an MBA by first spending five years as an IT consultant in order to attain breadth and managerial consultant with which to apply to a decent business school. What you can do with an English degree out of school is . . . maybe apply to law school. Anyone who is pre-med has a lot more options than anyone with an undergraduate degree in any humanity except econ or math. I don't think you can make any sort of reasonable argument otherwise. At the tails, some of the humanities grads end up with high paying jobs, but the bulk of 'em don't. Pre-med students make different, less hedonically satisfying choices with their lives, and expect to be rewarded for it financially. Lower financial reward, fewer people willing to make the tradeoff. My argument was not that we would end up with no doctors; my argument was that we would either end up with fewer doctors or lower quality doctors.
There's a long-term shortage of doctors in rural areas in NZ.
http://www.nzherald.co.nz/pharmaceuticals/news/article.cfm?c_id=278&objectid=10451500
http://www.odt.co.nz/your-town/balclutha/58405/still-struggling-with-doctor-shortage
http://www.gisborneherald.co.nz/article/?id=3869
http://www.stuff.co.nz/dominion-post/national/2881304/Judge-considers-GP-shortage-at-hearing
Yglesias is saying that if they had no opportunity to make $500,000 a year enough would still join the profession because it's prestigious, which dovetails with evidence from every other medical system in the world, where doctors earn less but the supply of doctors seems perfectly adequate.
I'd have to ask what other opportunities are available in other parts of the world and what do they pay? How much does a DBA make working for ABB in Stockholm? How much does a partner at the Copenhagen office of Ernst and Young make? How much does an IT director at Nokia make?
As I understand it the earning curve is a lot flatter in northern Europe than it is in the US. So, saying that people still go into medicine in Europe, even with the low pay, only makes sense if they don't have other options. In the US there are more lucrative career opportunities and therefore more pressure to keep physician salaries competitive. The only way around this would be to limit the salaries of all Americans.
You can't expect doctors to accept 90k when 63% of Boston cops make 100k+.
The 2005 median compensation for physicians with more than 1 year's experience ranged from $156,000 in family practice to $322,000 in anesthesiology. (http://www.bls.gov/oco/ocos074.htm#earnings) That's nationwide. Doctors' salaries in Boston will be considerably higher.
Police in Boston are the highest-paid in the US; in 2006 the average Boston cop made $114,000. (http://www.boston.com/news/local/articles/2007/02/22/police_take_home_citys_biggest_paychecks/ No median data, unfortunately.) This, clearly, is silly, and Boston needs to get a handle on its expenditures and cut some overtime. Yet still, there's a lot of room there to cut before the median doctor anywhere in the US makes it down to the average salary for a Boston cop.
Matt,
I have a question for you: How much should a reasonablly smart, reasonably ambitious, BS grad from a midwestern state school expect to make by the time he's 30yo?
Actually, the money in medicine is to be made in smaller communities, not in the big cities. "Assistant professor of medicine, Harvard Medical School" is a great item on your CV, so they don't actually pay as much.
The highest-paid graduate of my residency program just started out in a college town of 20000. He's on call every third night and every third weekend (Fri-Mon). He'll make about 15% more than I will, in a large practice taking three calls a month (two weeknight, one weekend day).
1. Very, very few cops nationwide make as much as Boston cops. That's really not a useful comparison point.
2. Interestingly, people are willing to be college professors in Boston despite making less than cops. Profs even at decent area schools like Tufts or Wellesley start around $70,000, not only in literature but also in chemistry or math. How do you explain them?
1) Summers off
2) Tenure
3) Periodic paid sabbaticals
4) Groupies (for the younger ones)
5) The right to say idiotic things in public and feel smug about it
I'm pretty sure everybody gets 5) without having to take a pay cut. Perhaps especially people in finance.
I don't know about you, but if I were to go off the rails about how fluid dynamics isn't as well understood as solid dynamics because male scientists are chauvinists and prefer to study hard things like their penises instead of liquids like menstrual fluid, I'll probably be fired. Nobody wants a delusional patent lawyer.
But it's true that finance people likely have some pretty choice quotes floating about at the moment.
http://www.police.co.nassau.ny.us/recruitment.htm
Average salary Nassau County after 8 years 91k.
San Francisco:
The current annual entry-level salary for Police Officers is:
$75,868 to $101,556
http://www.sfgov.org/site/police_index.asp?id=27855
Police are a unionized cartel. In many jurisdictions it is difficult to get hired, but the pay is quite rewarding once you are hired.
In California, the Public employee unions are worth every penny in union dues they collect -- unless, of course, you're a taxpayer in which case you're stucking paying above-market wages.
Well one way of explaining it is as follows: We need fewer college professors in Boston than we need doctors, so the salary of college professors is set by a person who enjoys being a college professor of chemistry or maths much more than the salary of doctors is.
anirprof,
Very, very few cops nationwide make as much as Boston cops
I posted the salaries in the New York area, Boston, San Francisco and I just checked Chicago - after 18 months a Chicago cop makes $58,896.
http://en.wikipedia.org/wiki/Chicago_Police_Department#Pay
I think a lot of people here really have no idea what different jobs pay and are basing their resentment of doctor pay on their mistake belief that cops, firemen and teachers are all making $40k a year after a few years on the job.
jmo3, you are missing data on what *doctors* make in Boston, SF, NYC, and Chicago.
Medicare uses geographical adjustment formulas to adjust its compensation to costs of living in different areas. Compensation in major coastal cities is a multiple of compensation in the Midwest. If the nationwide median for an internal medicine doc is $166,000, the median for an internal medicine doc in Boston is going to be a lot higher than that.
Finally, you've asked yourself the very question you need to answer: why is it that cops make so much more than teachers? Is it harder to be a cop than a teacher? No. Is the training longer or more expensive? No. Is the union more powerful? Possibly, but teachers' unions are pretty dang strong. So what is it? Why would it be harder to recruit people to work as cops than as teachers?
And now let's go back to our original question. Might there be reasons, apart from the compensation, why people would desire to become doctors?
Well in a way that only further advances my point -- even though professors apparently make no more than cops or high school teachers in those cities, especially when factoring in the lack of grad school debt and the lack of years with no income, tons of people still want to be professors due to prestige and other non-monetary factors.
Why would it be harder to recruit people to work as cops than as teachers?
It's more dangerous?
If the nationwide median for an internal medicine doc is $166,000, the median for an internal medicine doc in Boston is going to be a lot higher than that.
Not really.
http://www.payscale.com/research/US/People_with_Jobs_as_Physicians_%2F_Doctors/Salary/by_City
That chart doesn't list any low-cost areas. It lists 6 major cities. The salary data it uses are clearly incompatible with the NLB data I used. If you compare your site's listing for police:
http://www.payscale.com/research/US/Job=Police_or_Sheriff's_Patrol_Officer/Salary
you'll see it shows median salary for police after 20 years' experience of $50-80,000, which is 1/3 to 1/2 its listing for physicians with similar experience.
http://www.payscale.com/research/US/People_with_Jobs_as_Physicians_%2f_Doctors/Salary/by_Years_Experience
For comparison, in France, doctors make about 50-60% more than firefighters and police:
http://www.worldsalaries.org/france.shtml
...rather than 2-3 times as much, as in the US.
I'm sure there are some doctor jobs that can be cut in half efficiently. Instead of one doctor making $150K, you would get two making $75K. A lot of people would probably take that deal if both the total number of hours and the intensity (number of patients per doctor per day) went way down. And assuming what everyone has already said about educational debt and malpractice insurance.
There are a lot of people out there who want professional jobs that require some brain power, but not super-competitive ultra-professional jobs that require 80 hours a week.
Don't know if the cost per patient would go down in that scenario. It might even go up.
And this doesn't address the costs of top-flight specialists, who only get their unique skills by putting in crazy amounts of time and energy. Splitting that time and energy across two doctors doesn't get you two specialists at that level.
But yeah, I do think you could structure a medical job that paid $75K and was nevertheless attractive. It just wouldn't look anything like the job that now pays twice that.
I'd really like to hear from Rob and Matt - How much should a reasonably smart, reasonably ambitious midwestern state school BS grad expect to make by the time he's 30?
However much someone is willing to pay you for the job you take. If you're working in academic circles you probably won't make as much as you could in IT or finance.
I have no idea. What do you mean? "Expect"? What kind of work is he doing?
What I know is that Americans' tax money and insurance premiums pay the wages of the doctors who treat them. And they currently earn more than Americans can afford to pay them. We should pay doctors less, and elementary school teachers more. And we should pay traders and financiers less, too.
Matt,
I think you're out of touch with what average 30yo state school grads are making in this country. You see "the nationwide median for an internal medicine doc is $166,000" and think that's crazy money. I see $166,000 and figure if I can make that with my BA from a no-name liberal arts school the salary seems quite reasonable. If I work with CIOs and IT Directors making 150-250k with non-relevant undergrad degrees from second tier state schools - I fail to see what the problem is.
If a union nurse at Dana Farber with 15 year of experience makes 150k I fail to see why $166,000 is a problem.
What I'm saying is that in a country where median household income is $52,000, it seems difficult to me to get to where everyone can see a doctor, if you expect the average doctor to earn 3 times that. Unless, of course, you expect the average person to pay very little of the cost of seeing the doctor, and to have richer-than-average people paying for that average person to see the doctor. But once those richer people get stuck with the cost of paying for the poorer people to see the doctor, I think you see that the richer people start to bargain down the prices being charged by the doctor.
Matt,
If the average PCP is seeing 30+ patients a day and most people don't have to go to the doctor all that often then I can certainly see how someone making 52k can afford that.
160k / 50 weeks / 5 days / 30 patients a day = $20 per patient.
I think you're out of touch. The vast majority of 30 year old graduates of no-name state schools make nowhere near $150,000. As was posted below, median income for a 24-34 year old with a BA is $41,000, with a mean near $50,000.
Only 14% of those in the 25-34 year old bracket top 100k.
Age doesn't make that big a difference, either. Even for the 45-54 bracket the median for BA holders is $54,000 (mean $70k).
http://www.census.gov/hhes/www/cpstables/032009/perinc/new03_073.htm
Umm.... what other professions are you [plural you I guess, given the abuse of "we" word] ready to render judgment on?
All of them. I have opinions. Don't you?
jmo3, median household income in the US is $52,000.
Matt,
median household income in the US is $52,000.
You realize that number includes the 70% of the population that never graduated from college?
So? Do you belong to a different class from them, and are thus uninterested in what meager gruel they may subsist upon?
Ok, so you'd prefer a world in which all salaries were in a narrower band. I can understand that. You'd prefer A world where doctors make $80k, IT Directors make 70k and landscapers make 60k. I can understand that - I just don't see why you would want to single out doctors?
Freedom, you know, the absence of slavery, requires conceptually that workers will receive different levels of wages for different work. Declaring that you should have the right to set the salaries of doctors lower and elementary teachers higher is anti-freedom and constitutes an imposition of involoutary servitude, which I thought we had put behind us with the 13th amandment. Doctors should, as should all persons should, be free to make as much as they can in doing whatever they wish to do. The government cannot be allowed to impose involuntary servitiude for doctors merely because it chooses to be an employer doctors or an insuror of medical services. This is the fallicy of the argument for more government control of medicine - it is taking the cause of the problem and and putting it in charge of the entire system. Our helth care system is not in crisis - the federal government's health care promises are in crisis.
Well, that's a fair question. I think it's because they provide a service to which everyone has a right. I don't think people have a right to an IT manager or a financial services consultant. They do have a right to decent health care.
Look. You were arguing at the start that you "can't expect" doctors to accept less than some multiple of whatever a cop makes. Why? Because a cop is a "regular joe"? Well, a regular joe in America actually doesn't make $100,000. A regular joe in America makes something under $50,000. A *poor* person in American makes $25,000 a year. So I think asking an average doctor to subsist on more than double what a regular joe makes, and five times what a poor person makes, would be a pretty decent deal.
You may have a much less egalitarian income distribution in your head; that may feel more natural to you. I just think you should bear in mind that this less egalitarian income distribution is not what America looked like in the 1940s or 1950s or 1960s. It is more like what America looked like in the 1890s, or what Mexico looked like in the 1950s.
And you are unwilling to be honest with yourself about where you fall on the income school. It doesn't really matter that you went to a non-selective college. If you make more than $150,000 a year, you're well up in the top decile of American wage earners. And good for you. But don't pretend that this is what "regular" people earn. It's what the upper class earns.
I rescind the comment about not being honest. We do it seems understand what the other is talking about. Sorry about that.
Well, if the rest of the industrialized world will just be so kind as to go out and have an enormous war in which all of its industrial infrastructure is destroyed while at the same time buying vast quantities of American goods, I think you could reasonably expect a repeat of the incomes of the 50s. Otherwise, not so much.
Devilbunny, that's actually inaccurate folk economic history. German industrial capacity had recovered by the 1950s; it was never really severely damaged by Anglo-American strategic bombing, which didn't work very well. British and French industrial capacity was untouched. The British managed to deindustrialize for other reasons, mostly having to do with a habit of building every individual Rover with its own unique and snowflake-like collection of parts, if I understand correctly.
Matt- thanks for the tip. I'll have to look into that - postwar history was about 10 minutes right before the AP exam...
Median household income for a household in which at least one individual has a BA, including all ages, is $78,000.
http://www.census.gov/hhes/www/cpstables/032009/hhinc/new01_001.htm
The median householder doesn't have a bachelor's degree. According to the Census data from 2008, ages 35-44, worked full time year round, all races: the median for a person (not household) with a bachelor's degree is $61k, with roughly 1/5 making over $100k. If you bump up to a professional degree, that's a median income of $100k with over half making over $100k (I'm not sure how that works; I think maybe their data aren't that granular and it's just topped out). Since PhD's are the preferred comparison, doctoral degrees had a median of $91k. Source: http://www.census.gov/hhes/www/income/dinctabs.html
A good question is why nobody complains about how much dentists make. jmo3's table from the last topic had orthodontists at $177k (with the highest field of all being anesthesiologists at $184k, while general dentists pulled in $140k). Dentistry is a demanding school program, and orthodontics residencies are hotly contested, but they don't have nights or weekends, and while preventing abscessed teeth certainly saves lives, screwing up an extraction will almost never kill someone.
Furthermore, they have to make money in a competitive marketplace - plenty of people pay cash for dental care and can go elsewhere or haggle.
Dentist are a great example of health care with less government distortion of the market. Dentist pretty much make as much as they can from people who choose to pay for the service. Doctors should not be treated worse than dentists because someone declares that a "human right" to a doctors services exists. Why does someone have the "human right" to force me to pay for their doctor bill while I work hard, make productive choices take care of my responsibilities and they stay out all night doing drugs or drinking? or spending all their time playing video games. I cannot understand why left wingers are unable (unwilling?)to understand that it is much more "just" to reward positive behavior that benefits society (you knonw, like completing medical school and helping to heal people) over trying to make everyone "equal" no matter what behaviors they exhibit or what choices they make (like druggies, video game fanatics or permanent juveniles. People should be incentivized to do things that help society and civilization, like work hard, increase the wealth of the society, not commit crimes, not do drugs and be good fathers and mothers.
Well, that's a fair question. I think it's because they provide a service to which everyone has a right.
OK, so two quesitons: Would you think it fair to say that this "right" is a "right" not to an absolute standard of health care, but rather a "right" particular degree of inequality? That is, poor Americans in 2009 enjoy better health care in many, many ways than rich Americans in 1909, and also probably better health care than median Thais or Vietnamese (although you can correct me if I'm wrong.) Yet you regard this as insufficiently "decent." Does this mean that the standard of decency will be subject to creep? I'm not trying to troll here, I'm trying to clarify what you mean by "right."
Second, do you reject the notion of an upward-sloping supply curve in medicine? That is, you seem to want more health care to be delivered than happens at the moment. In most fields, we would think that forcing providers to accept lower payments (by whatever means) would lower the available supply. Yet you seem to think it will increase it, or at least hold it steady. Why is that?
Yes, I definitely think the right to health care comes down to a right to a decent minimum, rather than a right to exactly the same treatment as anyone else. This view is, in fact, the view embraced by the American public. Otherwise there wouldn't be a Medicaid. I think an immense amount of the ineffectiveness and craziness in the American health system results from Americans resisting admitting to themselves the actual things they believe and resisting putting those things together systematically.
Anyway, yes, the standard is subject to creep, or, to put it another way, as what's available improves, the stuff you think no person should go without in your society, if it's a halfway decent society, goes up. After triple therapy was invented, it was for a time too expensive to guarantee to every American with HIV. At some point the prices came down to a level where we could no longer in good conscience allow that some people would die of AIDS because they hadn't been able to afford the drugs, and we put in place a blizzard of weird cross-cutting programs (viva the American way!) that pretty much guarantee nobody in the US will go without needed ARVs. This is "creep". What the precise nature of that decent-minimum bargain is, is something that every society works out for itself in the political arena.
I am too tired to answer the final question well. It's a combination of things. First of all, the "supply" of medical goods we're getting right now includes, I am convinced, a huge amount of stuff that is not doing anyone any good. Procedures are being carried out that do not improve people's health, because everybody in the system makes money that way. In other words, I hope the "supply" will go down, because I think a lot of the supply is stuff that does nobody any good except the people selling it. Second, I think career choice is probably the stickiest possible economic decision. I don't actually believe that many people are going into medicine right now because they can make huge amounts of money at it; I think they want to be comfortable and solid. The ones who do go into it to make huge amounts of money are, I think, not the best doctors. And I think if we compressed the salary scale, taking into account that docs do need to pay off their med school bills, you'd still have plenty of people entering the profession, because their mothers will continue to nag them to do so. So I don't believe that you're going to see marginal changes in salary that reduce medicine from an extremely wealthy profession to a merely well-off one resulting rapidly in a reduction of the supply of doctors. I think the underlying assumption that the number of doctors in the country is determined through an efficient calculation of return on investment is just not true and not a good assumption to have about the way the world works.
All that said, I understand doctor salaries are actually a pretty small part of the overall health system so I don't think this is a crucial part of how we control medical costs in the US; it's just one part of the puzzle.
woah! you just made one heck of a logical leap. there are any number of reasons why we have Medicaid that no way involve a positive right to health care, many of them being simple political economy considerations (i.e. a constituency developed with the political clout to successfully advocate for it).
if i have an unspoken-for dollar in my pocket, sometimes i'll give it to a homeless person. i do that, yet you would never hear me say that he has a right to that dollar, or even a right not to be homeless. if asked why i gave it, i would simply reply that i was being charitable. that is, at that moment i had the abilty to offer that man something he wanted but did not have. likewise with health care, we have a society in which we create enough excess that we can afford to be somewhat charitable in regards to a number of social services. we have made a collective democratic decision to provide a certain level of health care, education, old age insurance, unemployment insurance, etc. again we could talk for a long time about why we do these things without ever once speaking of an actual right.
this is a common, especially now, progressive mistake: 'because people support health care reform, it must mean they believe it is a right.' it seems that most people support reform because they find their medical bills too high, and when some politician tells them they can lower those bills, they jump on board. there is a certain hubris runing through the whole progressive side of this debate and this argument about increasing doctor's prestige is indicative. just how do you go about getting 300 million americans to spontaneously start to putting doctors on a higher pedestal than they already occupy?
I agree with JR. Nobody has a right to medical care on someone else's dime. We provide it to poor people because that's a reasonable thing to do, but they don't have any right to demand it.
Matt,
The point is that having a liberal arts degree, you still have the opportunity to go on and do lots of very lucrative things; and yet many people choose to go on and do some very non-lucrative things, like get degrees in Hmong studies, usually because they find it interesting.
You raise an interesting point. When you talk about those making less than 50k, how many are in that position as the result of perfectly ration choices to pursue their own interests? Many people chose not to study or work hard and rather enjoy time with friends, pursue their hobbies, etc. Many people don't want wont to work hard in high school, so they can get into a competitive college, so they can get into a competitive grad school, so they can make 350k as a grunt at Bain or McKinsey or Mass General or Skadden Arps.
Now, when people make choices that result in low incomes - how much of a role does the government have in preventing those people being subject to the natural result of their choices?
* I would note that many people also work hard and devote considerable time to things they are passionate about, but which aren't particularly remunerative. Again, if you devote your life to your passion for medieval latin, pot appreciation, dance, cooking, or any number of other non-lucrative niches, how much of a role does the government have in preventing you from facing the natural consequences of your choices?
Well, I don't know, but...I may be too sleep-deprived, but I don't quite see how this fits into the argument. I think what I meant was that pretty much all the docs I know went to med school because they wanted to be docs. They wanted to be financially secure, usually. But I don't think they needed to be filthy rich. And in many cases they had an interest in medical research; those are the docs I tend to know, for various reasons. But I think choosing a medical career is a little more like choosing Hmong studies than it is like going to law school. I don't think I know anyone who threw up their hands at 25 and said, well, I still can't figure out what to do with my life so I guess I'll just go to med school. (Well, maybe one. She of course turned out to be the best, most intense doc I know.)
If what you mean is that people who end up poor because of bad career or life choices shouldn't get medical care, because that's "the natural result of their choices," I simply think that's wrong and immoral. In any case, given the actual vagaries of the real world, the fact that someone is poor gives you essentially no reason to believe that they made bad choices of any kind. Neither you nor I nor any private or government agent is going to be able to determine whether they are the "deserving" or "undeserving" poor, and I'm not even sure I accept the idea that anyone can through their actions lose the basic element of their humanity that entitles them to be treated for their illnesses, or that we, the self-proclaimed "deserving" wealthy, can make such a judgment about them without becoming moral cretins ourselves.
If what you mean is that people who end up poor because of bad career or life choices shouldn't get medical care, because that's "the natural result of their choices," I simply think that's wrong and immoral.
I think that's where we differ.
If a person, of their own free will, decides to puruse ignorance and idleness, I don't think the government has any place trying to shield them from the natural results of their choices.
If someone has to wait tables because the market for those with a degree in Hmong Studies is weak, and they can't afford health insurance because they are paying off their Hmong degree, then too bad.
They made a choice, they need to live with it. They can't expect the rest of society to shoulder the burden of thier poor choices.
jmo3, sometimes I find I respect what you write. But I have no respect for this. It's naive, self-satisfied, and boastful. You write like someone who has either never known a poor or middle-class person, or has despised half the ones you have known. It violates the teachings of any religion I can think of. No American doctor will ever accept this moral code. That is why America has a decent health care system, unlike places like China or Russia, where many doctors would actually refuse to treat anyone who can't pay. A poor person who shows up at an American hospital with an urgent complaint will be treated. (By law.) If that poor person cannot pay, they will be enrolled in Medicaid. If you were to eliminate Medicaid, doctors would pay for the treatment they offer poor people by upping their fees to you, and your health insurance premiums would rise.
People in Hmong studies program have no problem with health insurance; they get it through their university. People who wait tables are the ones who, increasingly, cannot get health insurance in the US. That is EXACTLY the demographic our current system screws: people who work low-wage jobs without long-term contracts for small businesses that don't offer health insurance, and who make too much money to qualify for Medicaid. Do you think people who wait tables have "of their own free will decided to pursue ignorance and idleness," and should therefore not be covered by health insurance?
Matt,
I think I may have been unclear. I've said on numerous occasions that everyone should be obligated to purchase health insurance, and for the truly destitute coverage should be provided by the state.
What I have a problem with is having subsidies extend very far up the income ladder. If someone chooses to embrace ignorance, idleness, a useless degree, or decides to pursue a hobby rather than a career, that shouldn't relive them of duty to come up with $200 or $300 a month in health insurance premiums.
Okay, that was definitely a lack of clarity, then.
I agree that your formulation is in principle a good way to structure a health insurance system. The problem comes down to specific amounts of money. The average bread-and-butter individual health insurance premium on the private market these days in the US is significantly higher than $2-300 a month; as I recall it's up over $4000 a year. The average family premium is in the range of $13-14,000. The information emerging from the CBO scoring of various proposals in the Senate Finance Committee is that if you don't extend significant subsidies to people making 400% of the poverty line, you're going to end up with a lot of people who simply can't realistically afford insurance. The poverty level for a family of 4 is $22,000 (http://aspe.hhs.gov/poverty/09poverty.shtml). If subsidies stop at 300%, you're looking at a family with income of $70,000 (and there are a lot of them) having to pay like 18% of its income just for health insurance. And that will still leave them with significant out-of-pocket health expenses. I'm not clear on whether the subsidies are based on before- or after-tax income but either way this just seems crushing to me, for a lot of the regular working class.
It was not clear to me before the CBO started scoring the proposals in the Senate that the numbers would come out looking so unfavorable. But what this has made clear to me is that there is something horribly awry with the pricing of medicine in the US. It just isn't that hard to do universal health insurance. I keep ranting about my experience of buying health insurance in the Netherlands, because it's such a crystal clear difference. There, you can buy private insurance at a price that makes sense. In the US, you can't. It looks like in the long run we are going to need far-reaching reforms, basically ripping the guts out of the system and rewiring it, to get to the place that every other OECD country is at. Basically, I agree with you; but I think the price of health care (insurance plus out of pocket) can't hit 10% of a working-class family's income, or you're getting into the zone where people just can't make their budgets work anymore.
Let me put it this way, to synthesize this back to doctors' salaries. I think much of the reason why doctors make so much money is that the government pays much of their salaries, and insurance companies pay the rest -- i.e., third-party buyers who don't do a good job of bargaining down prices. This is inevitable, because health care must be bought through insurance, an all out-of-pocket system means mass misery a la contemporary Russia or Africa. But all of that government and insurance money flowing into the system drives prices up. And that means that working-class people, everyone in the bottom end or maybe even bottom half of the market, get priced out. If their employer pays, they can still stay in the game, at the price of sacrificing wage growth. If they're out on the private market, they're just screwed. I think that in this situation, you need aggressive intervention by government to bargain prices down and counteract the effect of government/insurance money bidding prices up. You need to start by guaranteeing that your government intervention isn't bidding up prices so high that some people can't afford health care anymore -- i.e., you need to guarantee universal coverage. That can be done with a mandate/subsidy system like the one in Congress now (or the Netherlands'). But then you're also going to need government to get into the game and bargain/regulate those prices down. Otherwise you're buying universal coverage at the price of huge private profits that come out of taxpayers' pockets, and subsidies that will run way up the income scale. To sum up, I think doctors make so much money in part because they have a government/insurer guarantee of payment. Those incomes are coming out of all of our pockets. As part of getting everyone covered, we're going to need to start negotiating collectively, as taxpayers and premium payers, and get those salaries, and a lot of other expenses, down. You and I pay taxes, and we pay premiums. The doctors work for us. But the prices are negotiated through intermediaries who are doing a bad job of negotiating, and we're not getting a good deal.
it's possible [to get an I-banking job] (less likely with English or Comp Lit), but extraordinarily difficult.
Not if you go to the right school. This is one area where the name on your degree makes all the difference in the world.
Anyway, yes, the standard is subject to creep, or, to put it another way, as what's available improves, the stuff you think no person should go without in your society, if it's a halfway decent society, goes up.
I think this is perfectly reasonable, but I wanted to be clear that what we're talking about here is unacceptable inequality in health care. Not a "decent minimum" in the sense of a decent minimum in housing being a studio apartment with a functioning toilet, and unlikely to creep up to the Breakers incrementally.
Speaking of what most Americans believe, I think most Americans are health-care communists who think they should get whatever they want ("want" and "need" being indistinguishable) and never have to pay for it (it being provided by those with ability). And I think the "death panels" controversy proves my point, given that it featured millions of "free-market conservatives" equating not getting something for free from the government with death. So God help us if Americans figure out what they want and then actually get it.
First of all, the "supply" of medical goods we're getting right now includes, I am convinced, a huge amount of stuff that is not doing anyone any good.
That has been, I believe, empirically demonstrated by reviewing Medicare/Medicaid expenditures by region. And it is most easily solved by requiring patients to pay for their own damn health care (which is, incidentally, my own policy prescription, and notably shorter than the Bacchus bill it is, too), and thus undertake a cost/benefit analysis for themselves.
I think if we compressed the salary scale, taking into account that docs do need to pay off their med school bills, you'd still have plenty of people entering the profession, because their mothers will continue to nag them to do so. So I don't believe that you're going to see marginal changes in salary that reduce medicine from an extremely wealthy profession to a merely well-off one resulting rapidly in a reduction of the supply of doctors.
Not rapidly, certainly, and neither did UAW pensions result in the rapid demise of GM. But I can't imagine that we won't have some effect, as it already does with GPs vs. specialists. We need a heck of a lot more doctors than we need interpretive dancers, so I don't think you can rely on the kind of passion that drives humanities PhD's to supply us with GPs.
And I think the "mom nagging you to be a doctor" might be something you experienced more than I did, though I would hate to traffic in ethnic stereotypes.
I went to one of the right schools. Its name did not overcome the powerful stench of my degree in creative writing . . .
Something like a third of my class went to Wall Street, and they weren't all econ majors. Of course, we didn't have a degree in creative writing, so it's not really a fair comparison.
Pay doctors extra money and they'll give you better health care. The Archives of Internal Medicine reported about a year ago on a study where physician clinics referred Minnesota patients to a tobacco quit line -- or not. Researchers compared clinics that were paid bonuses for making referrals to the tobacco quit line ($5,000 for 50 referrals and $25 for each referral beyond the first 50) to clinics that did not receive any financial incentives to make referrals.
Guess what? The physicians who were in the pay-for-performance program made more than three times as many referrals to the quit coming line than the non-paid physicians. Ethic Soup blog as a good post on "Quality of Care Tied to Physician Pay" :
http://www.ethicsoup.com/the-doctor-posts-.html
Doctors have a lot of opportunies to make extra money-- and they take them -- whether ethically disclosed or not.
Whether he realizes it or not, Matt's argument of "Health care is a right, and so doctors' salaries should be capped" is identical to Marx's most famous economic statement, "From each according to his ability, to each according to his need."
The terminology has been changed to add some sugar to the bitter poison, though.
In Matt's argument, the people have a "right" to healthcare. Changing a "need" to a "right" gives the government a mandate to fill the underlying need. Declaring something a right means the exact same thing as "to each according to his need."
Now you have a "right" that must be filled, and there is presumably a gap between the need and the ability to pay for it. How does the goverment close this gap? By compelling doctors to provide their services. "From each according to his ability." Docs can perform the service; they won't starve if you cap their pay; in short, they can afford the pay cut.
To sum up: Matt's argument is that doctors have both the technical and financial ability to fill the need of the proletariat.
As to compensating them with prestige, we can always give them an "Order of Lenin" medal.
There are some ironic or Orwellian aspects to the idea that doctors should be paid in 'prestige.' In the first place, the government can only control what doctors are paid if it controls it by law. Thus doctors at that point are not free agents in a marketplace. There is no marketplace. What they are paid is at the mercies of the government. Their pay is determined in the same transactional way as what pay black people were given for picking cotton in the Old South. But, heh, if this works out we can increase the self esteem of black people during Black History Month by pointing out that the South fought a war to retain their 'prestigious' status.
I think it's because they provide a service to which everyone has a right. I don't think people have a right to an IT manager or a financial services consultant.
As you may know, it takes more than just doctors to deliver health care. For example: Most hospitals try not to use traditional film for diagnostic imaging. They use what is called a PACS system (Picture Archiving and Communication Systems) as it is much cheaper and more effective to store these images on a server than in a room full of actual film.
Those who have the skills to build and maintain this system and its servers, can earn a very comfortable living. Should they also have their salaries reduced - as the are vital to delivering a service "to which everyone has a right"?
As a physician, I am not worried. If physicians earn only $60k, that also implies no more risk of $1million+ liability lawsuits (how could I pay the $100k+ in malpractice insurance premium out of $60k, for example http://www.med.umich.edu/opm/newspage/2005/obgyn.htm).
That would be the loss of a major source of income for lawyers. Is not going to happen...
"doctors are also at the bottom of the military social scale, which basically boils down to combat arms officers first, support officers next, and civilian professionals in uniform last"
Perhaps true in the US military but not necessarily in others and it depends what the job is. Regimental Medical Officers are seen as part of the batallion and "real officers" while specialists are seen more as civilians in uniform. It's perhaps worth noting that there are only 3 people in history to have one 2 Victoria Crosses (roughly the equivalent of the US Medal of Honor but in practice much more sparingly awarded): 2 of those were medical officers.
Everyone seems to be avoiding the hard part of the question.
Yes, we can come up with examples of people who take on difficult careers for low pay because those particular positions have high levels of prestige.
BUT, we can't control prestige. There is no federal department of prestige allocation that can be ordered to divert 50% of next years prestige from gangsta rappers and movie stars and send it to primary care doctors. How would you even start to do that?
This is like arguing about the best way to colonize Mars if we had antigravity technology. We don't. We can't do it.
I suppose we could try, pass a law that no future movies or tv shows are allowed to depict doctors as anything other than selfless heroes. (Such a law is apparently already in place for prostitutes. Have you ever seen a movie where a prostitute is anything other than an innocent victim or a brave heroine? And look at how high their prestige is...)
We need a Prestige Czar. That will fix the problem.
Clearly, the solution is to take Matt Steinglass, put him through med school and residency, work him 60-80 hours a week and pay him about $50,000/yr. Afterall, we have a right to having him service us.
Or, we could pay him $25,000/yr. Really, he shouldn't need more than that to live on.