Yes, but how do I spend it?

I don't have sound on the computer where I do most of my Internet trolling, so I can't really judge the majority of the content in a recent bloggingheads conversation between Megan McArdle and Noam Scheiber about health care reform (among other things).

[Hmmmm... can't seem to make the video work.]

However, something in their follow-up posts has caught my eye. Megan quotes herself:
We don't have a unified culture. There's no--Sweden can talk about having a Swedish culture, and to some extent a Swedish status hierarchy and Swedish values. That's just not true of America. Everyone's participating in about 97 different subcultures. So you can invent your own status hierarchy, but you can't get everyone to buy into the idea that we should pay our doctors $60,000 a year and then all love them a lot because they're doctors.
She then goes on to write:
To expand that point a little bit, I think America's income inequality in general makes it harder to force down doctor pay. It's easy to deride this as saying that doctors are greedy--but the more relevant frame is opportunity cost. If people with strong science skills can earn, say, $150,000 in some other profession, you're asking them to sacrifice quite a lot for the privilege of becoming a doctor. Some of them will do it--just as some MBAs become journalists. But others will balk. So either you have to take lower-quality candidates with fewer other opportunities, or you end up with fewer doctors. In Europe, there aren't so many other lucrative opportunities, and status is arguably more valuable than it is here, since in many cases, only a minority of your fellow Americans will recognize the status you've so painstakingly acquired. When you're introduced to a pastor at a party in the rural south, you're meeting an important person. When you meet the same pastor at a dinner party on the Upper West Side, he's a freak who is at best possibly interesting. Multiply that a few hundred times, and it's little wonder that money is the dominant form of compensation in the US--at least, unless you can get God or professors to handle your recruiting.
Scheiber restates his point thusly:
I argued in response that the ability to bathe doctors in social prestige isn't exactly a fixed feature of one's national character--it's not that Americans are genetically incapable of it, or that Europeans naturally excel at it. If doctors made slightly less money, but the system were seen as better for patients overall, the social prestige of doctoring might rise a bit and compensate them for the loss of income.
As I've stated before, Ms. McArdle can sometimes be a bit unclear about where her figures come from, so I don't know where she's getting that $60,000 number. Similarly, I don't know how Noam would define "slightly less." How much less?

For my part, I would be willing to make a bit less if it meant I did not have to worry about "efficient" coding or wrangling with insurance companies. Throw in malpractice reform (and, frankly, I really have no idea what that would mean, in terms of concrete policy), and the deal is a bit sweeter. That being said, and if I'm going to be blunt, there is no way on God's green earth that I would do this job for $60,000. I am regularly called away from home to attend to patients, often in urgent or emergent circumstances and in the dark of night, and every so often I am expected to stand between a small child and serious injury or death. I have the unalloyed pleasure of trying to explain to vaccine refusers that they are doing their children and society in general a disservice, and watching as they refuse them based on celebrity nonsense and unscientific mumbo-jumbo. And I get the pleasure of knowing that anyone at any time can lodge a complaint against my license with the state for any reason, and I would be expected to submit a lengthy defense, no matter how frivolous the substance of the grievance, to say nothing of the fear of malpractice. That is all, of course, what I signed up for as part of my profession, but it just wouldn't be worth it for sixty grand. Too stressful and demanding. Sorry. And I can only imagine what a cardiothoracic surgeon or oncologist would say.

Further, like McArdle says in the full post, who is the "we" that decides doctors will get more prestige. How is prestige quantified? Being a doctor already confers a respectable amount of prestige. (I could tell you that this had nothing to do with my decision to become a doctor, and then you could laugh at what I flagrant liar I am.) How would it be meaningfully increased, and how can something as vague and abstract as prestige be considered appropriate compensation for the loss of something as concrete and necessary as money? Would the bank accept the privilege of housing a doctor as an acceptable supplement to my reduced ability to afford my mortgage? I can only imagine the hilarity that would have ensued if, back in New York, I had called and tried to get a table at Babbo by dropping the pediatrician card.

In a nutshell, I think the "less pay, more prestige" plan is a non-starter. (Subtract the crippling debt that many doctors leave medical school carrying, and maybe there's the beginning of an argument.) I chose medicine because I wanted to have a meaningful career that would make the world a slightly better place, in which I could be helpful. You bet. But I also wanted to have a reasonable expectation of being financially secure so long as I worked. I'm not carrying my pager this weekend for the thrill of it.


  1. I understood Ms. McArdle's $60K figure to be a toss-out. But Mr. Google reveals she isn't all that far off.

    MDsalaries sez: In 2007, yearly salaries were SEK 660,000 or US$84,500 for men, SEK 580,800 or US$74,400 for women. It also mentions that there is a 50% tax rate on this income, and physicians are the highest earning profession in Sweden! This is consistent with information provided about living and working in Sweden elsewhere.

    I think the researchers in Big Pharma who spend years getting that biochem Ph.D. would make exactly the same argument as you do about the ability of increased prestige to substitute for moolah. In fact, I don't see anyone in the healthcare industry that feels overpaid, or even ready to take a double digit pay cut for the team.

  2. It's also kind of difficult to demand that people give others prestige. See: high school teachers.

  3. And I just re-read this and saw youmade that point. Sorry!