Richard Doan is a Psychiatrist with Inner City Health Associates and Assistant Professor of Psychiatry at the University of Toronto in Toronto, Ontario
During my physical assessment course as a medical student more than three decades ago in Connecticut, the surgeon generously serving as our preceptor introduced us to a patient with a post-operative infection. He mentioned treatment with an antibiotic, and I asked the mechanism of action. He gave me a bemused look: “I don’t know how it works, it just does!” A year later I used to eat my lunch in a small hospital sandwich shop, frequented by Attendings and known as the “Republican Club”. I learned there that male physicians of a certain age (and almost all were male) mainly talked about golf and money. Many years later, I find myself basically giving the same answer to my students about drug mechanisms, though thanks to the internet I can say that I am following current treatment guidelines. However, I don’t golf, and I never really talk about money. . . until now.
For a week or more week my email inbox has been figuratively stuffed with all manner of hyperbole regarding the contentious Ontario physician services agreement. Some of these messages have a Trumpian quality: the medical world is going to hell, doctors are being abused by a tyrannical government and so on. All that is missing are ball caps with “Make Medical Practice Great Again!”
So much depends on our frame of reference. For most of my career, my colleagues and peers were social workers, psychologists, case managers, and nurses. When I compared their income to mine, I felt like I was getting one sweet deal, despite my longer education and previous student debt. I suppose if my peers had been other physicians, I might have felt otherwise. No one likes a pay cut, and it is annoying to see others (who seem to have much easier working lives) get raises. That being said, there are few impoverished and unemployed doctors in Ontario. In fact, compared to other developed countries save the USA, our incomes are quite generous compared to the average wage.
In her book “The Nordic Theory of Everything”, Anu Partanen writes that Finnish doctors “earn a comfortable income, but their homes are normal homes in ordinary suburbs or in apartment buildings, and no one is driving Porsches.” (Chapter 5; subsection “The Price We Pay".) According to OECD data, Finnish GPs have an income 1.8 times that of the average worker, and specialists 2.6 times. In Canada the respective figures are 2.9 and 4.6 (OECD, 2015). Of course these are crude comparisons since the majority of Finnish doctors are salaried and receive benefits, as opposed to largely self-employed Canadian physicians.
But Canadian physicians prize their independence. At this point in my life, so do I, but when I was younger I was an employee, first (horrors!) as a civil servant on PEI, and later as a child psychiatrist at a children’s mental health centre in Ontario. Of course my income was lower, but I received benefits, including a pension, which - as I approach retirement - turns out to be a godsend. What's more, my bosses were understanding and supportive - probably related to the fact that I was working in underserved areas and was therefore very much appreciated. I was also willing to be a team player, which meant I didn’t have to be the team leader. While subsequently working as an “independent contractor” (staff physician) in hospitals, I have sometimes been subject to a far less benign style of management by other doctors.
Canadian physicians also work longer hours, but this too is partly a choice. I was the only child psychiatrist on PEI for most of my time there, and while at the centre in Ontario I was the only child psychiatrist for the entire county except for one visiting half time child psychiatrist. I could have hung out my shingle and have never slept for the flood of patients. But I opted for a saner life that built on an interest in serving as a resource for other mental health caregivers, which assured that I only saw patients who absolutely had to see a child psychiatrist. Sometimes physician organizations seem to go out of their way to block efforts to make health care more efficient, limiting the roles of pharmacists, nurses, and nurse practitioners, not only increasing physician workload (and perhaps bottom line), but also possibly preventing the right patient from seeing the right caregiver.
Medical student debt now borders on insane. However, I have noted that medical students seem less resigned than years ago to a life of genteel poverty. Also, we should embrace a solution to student debt: I had a payback agreement in return for two years of government funded medical school tuition. I ended up taking a job that was certainly not what I would have chosen otherwise, but in the end I grew as a physician and it was a positive experience. I feel Canadian medical students should at least have this option, which might improve care in underserviced areas.
Also insane, in my view, is the remuneration of different brands of physicians, an issue that doctors themselves seem incapable of resolving. Many years ago, I noticed a Porsche in the parking lot of a medical building I was visiting. Turns out it belonged to the specialist to whom I had been referred. He was younger than me. I received great care, and there was no doubt he worked far, far harder than me. I didn’t begrudge him his Porsche (all right, a little bit, since I was driving an old, inherited Buick). But I think that if a medical student thinks that owning a fancy car should be part of the doctor package, he's ended up in the wrong professional school, a true failure of the admissions process. Surely if you believe that that a Porsche or BMW is your due it might be better to do something that society appears to value in monetary terms and admire even more than being a physician, like being a hedge fund manager or malpractice lawyer.