The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Thursday, April 27, 2006

The "Business" of Medicine

When I was young I knew I wanted to be a doctor. The picture I had in my head was that of the typical family doctor-- nice clinic, friendly secretary, breezing in and out of patient rooms with a smile. By the time I started medical school, the only specialty that I knew I didn't want to practice was family medicine. Okay, maybe not the ONLY one, but I definitely wasn't into it. Why? Because I don't want to run a business. Ever.

Family medicine is a business. As a family doctor, you are a small business owner. Regardless of what fee schedule you follow, you have to consider your overhead. This includes office rental, cost of permanent equipment (like examining tables, otoscopes, computers), cost of disposable equipment (urinalysis sticks, gloves, disposible speculums), office supplies, office staff (a medical receptionist/office manager and possibly a nurse)... I could go on, but you get the sitch.

A study done a few years back asked a few hundred Canadians what they thought their doctor got paid for an office visit. The answers were hugely variable... the average was around $100, but the guesses ranged from $50 to $500 and up. What does your doctor really get for an office visit? Well, if it was a typical visit that reviews two or more body systems and examined or reviews more than one problem, the doctor bills $29.20. Yup. That's it. And you wonder why you're rushed out of the office. If it was just for a single problem that was pretty straightforward (like a prescription refill) your doctor bills $17.75.

But your family doctor won't necessarily see that money. Claims are rejected for lots of reasons... if you forgot your health card, or didn't tell the doctor that you got a new card (the new one will have a different version code), the money doesn't come. If there is any missing or questionable information on the claim form (let's hope you have a really good billing company or secretary so this doesn't happen often) the claim is denied. If it's for a form or a WSIB injury, your doctor can't bill and has to get paid directly from the patient. Doctors aren't bill collectors-- many give up if the bill isn't paid promptly.

Now I'm getting boring, but these are all things that eat into the average doctor's salary. A recent article by The Walrus explored the rare breed of medical practitioner known as the family doctor:

Visit any medical school in Canada and ask, "Who plans to practise family medicine?" and too few hands will go up. Having competed with thousands to get into these prestigious schools, and already deeply in debt, most of these ambitious young adults feel they cannot afford to become family doctors in Canada. Without fringe benefits, and after the expenses of renting a clinic, paying for receptionists and nurses, and buying equipment and supplies, a family doctor working forty-hour weeks could expect to take home roughly the salary of a union plumber, auto worker, or skilled bricklayer (around $70,000). This, after at least 7 years of university, with medical school costing $15,000 a year in tuition alone.

Sad, isn't it?



Anonymous Anonymous said...

I know where you are coming from...still considering my options for after grad, but I definitely have done the math on a family practice and it isn't promising. It's not that I want to be a doctor to make money but it would be nice to make enough to pay off my $100 000+ debt from medical school and have a reasonable quality of life.

On the plus side there are many people in my class leaning toward family medicine especially since the training is only 2 years and they are eager to get out and start practicing.

10:04 PM

Anonymous Anonymous said...

well, considering that any other small business owner doesn't work 40 hours a week, but can work 60 or even 80 and up hours a week, a family doctor could be making way more (especially, considering, that the majority of expenses are likely fixed, except for salaries, of course)

that's both a pro and a con of being a small business owner, you have to work longer hours, but you have the potential to make more than if you worked a pre-defined 40 hour week

10:55 PM

Blogger Medstudentgod said...

I had originally thought about being a family physician and have kept it on my top 5 list, but overall I have looked at specialties that allow me time for my family, good pay, and aren't terribly boring. I think that this is one of the reasons so many US medical students refuse to head into GP practice - too much of a headache without enough compensation. Couple that with an astronomically inflating cost of medical education and it's a no brainer.

10:20 AM

Blogger Couz said...

I'm not sure I agree that a family doctor can be compared to a 'small business owner'. A family doc is providing health care, not selling Avon products. A family doc can't set the prices on his/her services, the government does. A small business owner can start up with no education and a dream-- a family doctor has been in school for many years, at substantial cost (most med school grads in Ontario have amassed over $125K in debt to put themselves through school). So sure, I could work 80 hours a week to make a decent living... but should I have to?

Maybe I'm just not understanding the comparison.

11:00 AM

Anonymous Anonymous said...

First off, you can't compare union and non union wages, hours, or anything else. You just can't. Apples and oranges.

I don't think you should have to work 80+ hrs a week. Frankly I have never understood why train engineers can only work ridiculously few hours for so much pay because of health and safety reasons but the people we put our lives in the hands of (that would be you) are run ragged, tired, sleep deprived, not thanks.
As for the standard 40hr week - don't forget that all of us on salary are typically expected to put in far more than 40hrs with no additional compensation. Many of these people have PhD's, and they are still making $70K. They may not have $125K in debt and only spent only 3-4 years post grad, but neither do most get any sort of government forgivness of their debts as some medical students do. True we can ask and receive a raise, but it is the discretion of the employer and the only recourse is to quit or find a new industry.

All I'm saying is that the world isn't fair and direct comparisons don't work for private or public employment. I agree you should be compensated fairly as should everyone.

3:26 PM

Blogger Couz said...

Just to clarify, the government doesn't "forgive" anything.

You CAN, however, sign a contract binding you to work in an underserviced area for 4 years after finishing your residency. This is called the "Tuition Reimbursement Program" even thought the maximum they'll give you is $10K for each year of medical school (so only 2/3 of medical school tuition).

Plus, since OSAP doesn't recognize any tuition charged over $4500 or so, the max we can get in goverment loans is about $11K a year. Not even enough to cover tuition, let alone living expenses. So we all have lines of credit through private banks. And they don't forgive anything either. ;-)

4:18 PM

Anonymous Anonymous said...

Wow Couz. Your post really brought to light the mysteries of family medicine. As a medical student, I was aware GP's are underpaid for their services and overworked but I had no idea the extent.
I am still considering a residency in family medicine but am scared to death of the implications of paying off my massive debt while making 70,000/year and- if I am lucky- finally starting to start have children, buy a home, get a car, etc.

12:40 PM

Blogger UptownGal said...

Maybe u all should all migrate to Singapore.. haha... our GPs here earn good money.

11:32 PM

Blogger ArizonaDB said...

Dr. Couz,

Your post entitled "The Business of Medicine" was very interesting and brought to my attention some major differences between the healthcare systems in Canada and the US. I would love to see a post about the major differences between the systems from your perspective. Or perhaps a list of aspects to the Canadian system that you have found lacking as well as positive. I have researched both systems, but it would be great to hear your inside perspective on the system of which you are a part. Just a suggestion, keep up the great posts.

6:18 PM

Anonymous Anonymous said...

Ok, I'm confused. In your blog, you said a family doctor is essentially a small business owner, and then in the comments you don't see the comparison.

11:29 AM

Blogger Couz said...

The comparison I drew was that the fact that you have to be worried about overhead and manage the finances of a business on top of clinical duties. I don't think that a family doctor SHOULD be a small business owner, I think they should be allowed to concentrate on what they do best-- medicine.

Sorry if that wasn't clear.

3:41 PM

Anonymous Anonymous said...

I'm the original anonymous posted who compared docs to small business owners :)

A doctor essentially IS a small business owner. The fact that the prices are set for him, is not so unusual. For a small business owner, the market sets the prices.

A doctor (especially a family doctor in the Canadian medical system) will always be in demand, whereas a business owner has to:

1) come up with an idea
2) finance that idea (often through private loans, mortgaging of his house, etc.) - often putting his family at risk
3) market the idea
4) work way more than 40 hours (unfortunately, this is often not optional)
5) manage the same ins and outs of a business as does a doctor

many business owners also went to school (including graduate school - getting a Masters, MBA [with tuition {only} for 2 years being as high as $60K in Canada, and way higher in the US], PhD, I'm sure some have gotten post-gradute work done too, bringing their education up to 12 years)

I find the question "should I have to work for 80 hours a week to make a decent living?" odd. No, you should not have to (nor do I think you do). You make a choice regarding how much you want/need to make to pay off your loans, to live a lifestyle you like, to support your family/business/whathaveyou.

You, unlike many others (including some small business owners) have that choice. You could join someone else's practice, and then you wouldn't have to do the business stuff and would be an employee, likely not required to work 80 hours (at least this is how dentists seem to work), correct?

As far as the cost of education, I assume that you were at least somewhat aware of what it is before you decided to become a doctor, right? And I assume that you decided to become a doctor for "higher" reasons than to make a lot of money with little work, right? So at the end the fact that you know you are helping people should at least somewhat compensate you for your hard studies and work (in addition to the actual money). Unfortunately, many people don't get that satisfaction and often have to be essentially work drones without much satisfaction, compensation or choice.

9:56 PM

Anonymous Anonymous said...

Honestly, I wouldn't worry a whole lot about money when you're choosing a specialty--go with what interests you and what you're passionate about. You can have a terrible or a great lifestyle in any specialty, including family medicine--it's all how you plan things.

There are so many options now for family doctors where you are on salary or a variation, someone else is doing the business part of things, and you have complete control over where and how much you work. Being hospital-based isn't all it's cracked up to be--you lose a lot of autonomy, and you're in school at least an extra three years (plus fellowship, plus MEd often these days, then applying for OR time/academic positions that may or may not be what you want...)

I finished a family med residency in 2000 with $90 000 in debt and paid it off in a year. Do not worry about the money, it will come. You feel poorer than your non-medical classmates right now, but you will catch up very quickly once you're out. Seriously.

9:42 PM

Blogger Liana said...

Yay, anonymous... I very happily chose rural family medicine for my specialty. I'm not out in practice yet, but one of my preceptors have ever billed less than $1500 a day, and I'm not counting the deliveries, hospital visits, minor surgeries and rounds which were on top of that.

What I appreciate the most about family med is the flexibility and autonomy. I'd be more than happy to take a pay cut if it meant I only had to work 6 months a year, or 3 days a week.

12:55 AM

Anonymous Anonymous said...

You could always work with the Canadian Forces, make over $120,000 (right away, on top of recruitment bonuses) with no overhead.

4:40 AM

Blogger Jessica said...

I don't want to do the 8-6 + charting, the hiring a locum while I'm away, seeing DM/HTM/asthma/prenatals all the time. I fear monotony.


locums. rural practice. R3s. international health. consulting. teaching.

Think about the money you save doing the shorter FMPR residency. The variety. The fact that it's one of the most flexible streams.

Frick yes!

2:28 AM

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