Why Your Doctor Needs a Raise

The local primary care crisis runs counter to a national trend: Numbers of generalists per capita began rising in 1979, and grew by 26 percent between 1995 and 2005. The problem, for us, started when those new generalists decided where to build their practices. According to a 2004 study in the journal Health Affairs, a full 80 percent settled in places pretty well stocked with primary care docs.

Many newer generalists are foreign medical graduates recruited specifically to take the place of med students who are no longer interested in the field. (Across all disciplines, an astonishing one out of four doctors in the United States today did his or her training abroad.) Since 1997, the number of American med school graduates who pursue family medicine has dropped by half, meaning that what primary care doctors we have tend not to be educated here. Meanwhile, primary care residencies like the one at Beverly Hospital are shutting down, some for lack of interest among med students. Last year, Joseph Gravel, director of the Tufts University family medicine residency at Cambridge Health Alliance, watched three of his graduates drop out of the primary care track. Gravel was troubled, but he couldn't blame them. "They told me, ‘Dr. Gravel, I hope you don't feel like I'm a sellout,'" he says. "It's an economically bad decision to stay in primary care."

Across the country, the average salary for primary care providers has come up since 2004, but not much; it's now somewhere between $160,000 and $175,000. That's a decent wage for sure, but nothing compared to what young docs can make if they opt for specialized training, particularly in the fields that med students alternately refer to as "lifestyle specialties" and "the ROAD"— radiology, ophthalmology, anesthesiology, and dermatology—where salaries can top $400,000.

The disparity is felt even more keenly in urban areas like Boston, where the cost of living is high and salaries for primary care docs tend to be lower than the national average, at around $156,000. "If you have highly technical health problems, Boston is a wonderful place to get care," says Gravel. "But primary care hasn't been as valued in Boston as in other places. There's been a pretty large lack of attention paid to things that aren't glitzy—standard, basic stuff, like whether people are getting their Pap smears or hypertension treatments."

Doctors' salaries are determined largely by how much Medicare reimburses them for the work they do, a system that puts specialists at an advantage. A specialist's job often consists of doing procedures, scans, and tests that are easily measured, and most of which can be done quickly these days, thanks to improvements in technology. But a generalist's work is in some ways more complex. It requires extensively studying a patient's history, calling nurses and family members, searching journals to figure out which ailment out of thousands could be in play, plus checking, updating, and managing a blizzard of paperwork. Medicare doesn't pay doctors for any of that. The only reimbursement a primary care doc gets is for the time he or she spends sitting across from a patient, and even that time isn't particularly well compensated: A half-hour visit in Boston brings in a little over $100 in Medicare payments, about a fourth of what some specialists get for the same amount of time. Private insurance doesn't pay much better, and actually values specialists over generalists even more than Medicare policy does.

The process for setting these reimbursement rates is, not surprisingly, a bureaucratic nightmare, but the salient point is this: The doctors who sit on the committee that sets the rates are almost overwhelmingly specialists. Put it all together, and it's a miracle primary care docs make any money at all.
Of course, none of this is the kind of thing that doctors, especially generalists, are supposed to gripe about, at least not in public. Compared with a lot of people, even the lowest-paid doctors don't have very compelling financial complaints. After they're done with their residencies, they make four times the salary of the average American worker. Besides, in the medical profession in general (to say nothing of Brahmin Boston in particular), it's unseemly to be seen with your hand out. Instead, doctors are supposed to act in a noble spirit, as if they're above monetary concerns. A doctor's services are often treated as literally invaluable, as so important for the welfare of other human beings that they shouldn't be associated with anything as tawdry as a price tag. But doctors are people. Like the rest of us, they do care about money, especially when they're saddled with med school debt that can reach up to a quarter-million dollars.