something else is and always will be misunderstood in the health-care debate unless something fundamental changes in our political culture. The Republicans have successfully turned "socialized medicine" into a sufficiently big, scary word that everyone else has lost the ability to point out the smaller but significant details necessary to understand the situation.

To wit: the advent of a single-payer system is typically portrayed with doomsday scenarios of Americans unable to choose their doctors, unable to obtain necessary procedures and squeezed like helpless, cute, furry animals in the coils of the big, bad government-incompetence python. Giuliani may or may not even recognize the assumption involved here - he might just be using what has become a familiar term of caricature because he knows how reliably it triggers an autonomic-nervous-system response from certain corners.

The fact is, a government-run health care system that guarantees a certain minimum level of health care for all citizens does not preclude the operation of private doctors and insurance companies who would cater to those who are able to pay for their own service. This second track of care exists in Britain already (I'm not sure about Canada), and most don't see the need to use it. For those who do, I'm sure that they are grateful that it exists. But the point is that its existence does not in any way preclude the provision for everyone else. If you want your cosmetic procedure, or if your cancer has exhausted all proven therapies and you want to try an experimental treatment, you can still do it - you just have to pay for it yourself. Which, incidentally, is exactly the way it works here already, since most private insurance companies tend to reimburse patients little, if at all, for this kind of thing (and rightly so).

As a doctor, I can't really say that I am excited about the federal government having a bigger role in health care; every time it gets involved in some new initiative to improve safety, transparency, privacy, or some other objective, it manages to miss its mark while creating more paperwork for doctors, nurses, and other caregivers (thus reducing the time they could be spending with their patients). But it's an unfortunate fact that it is coming eventually, one way or another. I tend to favor letting free markets work in most cases, but health care does not and will never constitute an effective free market. Costs will continue to increase faster than our collective ability to pay them, and eventually we will reach a tipping point at which the larger economy can no longer sustain the percentage of dollars going to health care. As far as I can tell, it's not a question of if, but of when and how it will happen. We can do it in the near future, at a time and in a way of our own choosing, so as to mitigate the shock and adjustment; or, we can wait for the moment of crash and settle for what will inevitably be a half-assed, second-rate patch-up of what has become an irretrievably broken system.

While I'm generally opposed to socialized medicine, I appreciate your measured, balanced response. My primary concern has always been "wait times", "choice", and the belief that individuals should have the right to spend their money on whatever it is they want (legally). If that means healthcare, so be it. I haven't spoken to many Drs. concerning this subject and would welcome your opinion on a couple of questions.

1) Costs will have to be contained on many levels. What do you believe a fair salary is for, say, a family practitioner/primary care Doc?

2) While there are certainly many people needing health care insurance, there are also many wealthy people. Do you believe if there is a two-tiered system, the better Docs will opt for that because of less beauracracy and better bucks?

3)Lastly, I have this pain in my........just kidding.

Thanks.

The salary thing is a tough one, for a couple of reasons. First, a doctor agrees to spend the third decade of life accumulating debt when contemporaries are laying the foundation for their families' financial security; this has to be compensated somehow, but I'd have to be an economist to figure out the compounded interest and factor it back into a yearly salary. Second, that debt varies from person to person. After a few years in repayment, I have about $180,000 left to be repaid, scheduled to finish in 2033 if I don't make any extra payments to get it done quicker. My wife has more, some others much less, so I guess a sliding scale of some sort would be necessary for real fairness. And I think there has to be at least some extra consideration for being willing to take on the pressure of making decisions when other people's lives and well-being are at stake; most of the time I'm just wiping kids' boogers, but sometimes my choices carry enormous and far-reaching consequences.

But really, to talk of fairness in physician salaries is to exhume a body I buried long ago. As a pediatrician, I know that I will never make nearly as much as my adult-medicine counterparts of equal training and experience. My wife (a pediatric oncologist) will make half of what an adult oncologist makes, even as she delivers demonstrably better care and cures a staggeringly larger percentage of her patients. As the sage so eloquently put it, tough titties. It's what happens when you take care of people who neither pay taxes nor vote. I chalk it up to being the premium I have to pay to avoid dealing with stinky adults as patients.

As for the better doctors choosing the self-pay system for financial or workplace-lifestyle reasons, you are probably right to an extent, but this is essentially already happening. The top tier of most medical school classes often aims for specialties that offer higher pay/prestige (surgery, cardiology), a more relaxed lifestyle (radiology), or both (the physician's Nirvana, dermatology). But among those in primary care, there are many who were not "stuck," but rather made a conscious decision that was not necessarily the most financially beneficial to them. Many of this number, thanks to what are often better listening skills, better communication, and greater reserves of simple patience, actually end up providing better care.* And it might surprise you how many good doctors would gladly accept lower pay to work for patients who treat them with respect and decency, rather than the sense of entitlement and constant air of aggrieved dissatisfaction that wealthier patients often carry with them through the doors.

And I guess, in the end, I wind up giving you a snapshot answer to your question # 1. I think, considering my preferences and individual situation, that my salary ($130,000) is fair, even possibly a bit high. I will never be "rich" in terms of accumulating large amounts of money, but I have enough to pay my obligations and get a modest premium for the extra time and effort that I have (and continue to) put in. That, of course, assumes that I will get that salary until 2033, which almost certainly will not be the case if the system crashes; and I don't for a second trust the government to help with my educational debt if this comes to pass. So I'm rolling dice with my future, carrying a very vested interest in fixing this system before it collapses; unfortunately, I'm still waiting for the grand and perfect fix to rain out of the sky onto my head. If you've heard where such a weather system can be found, please point me in that direction.

* Not me. I'm killing people off as fast as I can.**

** Joking. Please don't sue.

had limited experience with government run health care--unless you trained at a county hospital. My experience was with the VA system as part of my training, and if you want a glimpse of government run health care, consider that--or the abysmal conditions at Walter Reed which our chest thumping politicos where so appalled about...sixty seconds before they began to drag out the single payer system plans.

The single payer thing could be an OK thing for the doctor IF (big ifs) the cost of medical school was substantially covered by the government AND significant tort reform occurs. You would make less money but it would be a JOB; hey, it after office hours, take your kid to the ER, because I'm working 9 to 5. (A bit of an overstatement, I know, but hey, we had a Brit visiting professor come during my residency, and we broke for tea--with the patient open and asleep on the OR table!)

But of course, no politician wants to pay for med school for the (still) high earning doctors--and you know the trial lawyers aren't about to let significant tort reform happen.

So what you will end up with is...some docs who are altruistic, the best of the (potential docs) rest going into something where the money is better, and people who really shouldn't be doctors going into the field, because it is the bes gig they can get.

congratulations for your profession I see you and others like you as the conscience of the nation.

My thoughts on pay for doctors is this , we the tax payers pay for your education and after you achieve your degree you work for us for enough years to repay society for your education.

While you are working for us you should receive at least an upper level rate of pay commiserate with you performance.

Drs are the humanitarian face of the human race and are people we should be proud of and support them.

I have experienced care and been in the supply business in both the US and Canadian systems.

I have several phyician friends who have practiced in Canada and the US.

The US system is much more expensive and much more buraucratic and too many decisions are made by people who don't know the difference between a diuretic and diarrhea.

Yes there are waits in the Cdn system but if the required care is critical it is jumped to the top of the pile.MDs are paid a fee for service so more surgeries or consults can raise a MDs salary, the UK system is often yearly salary based. Some specialties are capped, dermatologists cannot bill more than $300k-$400k per year no matter how many pre-cancerous lesions they cryo.Plastic surgeons do moonlight with cosmetic surgery as do a few ENT surgeons but few Canadians ever pay for ordinary medical care even when they are very wealthy.

Is some care rationed? Yes! MRI's are not performed on every case and every month on patients suffering from seizures. While in the US and covered under a very comprehensive health care plan, my wife jammed her shoulder while skiing, her shoulder was quite painful and was hurting her tennis game. I had suffered a similar injury while living in Canada, went to an orthopedic surgeon's office and he administered a single injection of IA corticosteroid and in a week my shoulder was fine. I suggested that the orthopedic surgeon my wife visited would do the same.NOT! He examined her shoulder, tested her range of motion and ordered an MRI.After the MRI, which was billed to the insurance company at $850, showed nothing abnormal, the surgeon injected a corticosteroid and her shoulder was fine in a week.Why not do it the other way around, inject the steroid and if the shoulder doesn't improve order the MRI.

Probably because the surgeon had an ownership in the MRI machine.

Canadian surgeons will refuse to do a second CABG on a patient with symptoms who refuses to stop smoking or refuses to lose weight and they will control with meds.Is that wrong? These are some of the patients from Canada that go to a US hospital and get a second CABG or a stent and complain that the CDN system shortchanges them.

Malpractice is another problem in the US. If a physician follows association practice guidelines, he is unlikely to be sued successfully in Canada or the UK.

As for salary or compensation, Sawbones, you have set your sights way too low.Add another $100k to your $130k and add higher taxes and that is where you should be compensated.

There is no reason the US should be spending $6k per year for every man, woman and child, double Canada's expenditure and 2.5 times the UK rate for care that is not better.

Let every American have the socialized government paid plan that all congressmen, senators and their families have and I think we would be very pleased.

SICKO is a must see movie for any reasonable person with a somewhat open mind to watch.Sure, Moore overdoes it in Cuba and the French system has to begin making changes but the US system is killing and bankrupting too many Americans.Medicare is great, Medicaid is the pits and universal health care on the Medicare model would save us a bundle and not change care significantly.

Gerry

Interesting to hear from someone with experience in the Canadian system. Frankly, though, I'm disappointed to hear what you have to say about the US system. While it's easy to blame "trial lawyers" for what has happened to the tort system in this country, you might look a little deeper than that. Trial lawyers would point out that most people injured by malpractice in this country are not adequately compensated, and that high insurance premiums are not solely a consequence of the cost of malpractice awards. And they would be right, although that is not all there is to the story. Sure, some lawyers make an obscene amount of money obtaining awards for a limited fraction of catastrophically injured patients. And that is harmful in at least three ways. First, it has turned litigation into a high stakes arena in which few of the truly injured have real access to the system, the focus being on a select set of high money cases. Second, where so much of the focus is wringing every dollar from a select set of cases, individual doctors end up being unfairly demonized, and an adversarial relationship between doctors and clients (ie. potential litigants) develops. Finally, and perversely, the lottery-like litigation environment actually limits the extent to which damages awards can act as financial incentives to improve care. But many parties other than trial lawyers benefit from this unfair situation. The insurance companies benefit by keeping overall costs down (trust me, or look it up for yourself) and demonizing trial lawyers as a justification for increasing rates. The politicians (on both sides) get to argue about "tort reform" proposals that are essentially just proposals to do away with liability for medical negligence entirely. And doctors get to distract themselves from the extent to which their own greed has exascerbated the situation. Real tort reform would involve both cost containment and _increased_, rationalized access to compensation for people who have been injured by their health care provider. It would increase rather than eliminate financial incentives _not_ to injure people. It might (just to pick an example out of the air) look a lot like the worker's compensation system. But no one is talking about that in this country. I'm a lawyer. I'm not saying that lawyers are blameless in all this. But the main way in which they are to blame is the same way in which doctors are to blame, ie., taking their profit and excusing themselves for doing so by imagining that anything wrong with the system is someone else's fault, and can't be helped. Oh, and cry me a river about the money. Take a third of $130,000 a year away for taxes, lop off another $20,000 for debt financing, and you still have a salary that most people in this country would envy. Most lawyers starting out make half of that, or less. All of the professions are experiencing job insecurity, pressure to work insane hours, increased income disparity between sub-fields in the profession -- compare, for example, profits per partner at the firm that represents your malpractice carrier with the income of, say, a solo practitioner doing divorce work and general practice. It's not that the money isn't there, in any profession, it's that the easy money coupled with a rational life-style that was possible a generation ago is history.

You've definitely got a point about the VA hospitals - the care I witnessed there as a medical student was nothing short of disgraceful, something that seemed to be primarily related to civil-service rules that made VA nurses almost untouchable (I don't know if that is still true or not). The running joke went: How is a VA nurse different from a bullet?

- You can fire a bullet.

- A bullet will draw blood for you.

- A bullet usually only kills one person at a time.

As for reform, I think you also touched on two of the big lobbies that are going to stymie any real change. For single-payer to work, you would not only have to cover the medical school costs (or pay based on a sliding scale depending how much debt a given doc has) and fix the malpractice system, but also find a way to keep drug prices in check and revamp the reimbursement system in a way that encourages prevention and health maintenance rather than expensive procedures to fix what happens when you don't prevent and maintain. When you figure in trial lawyers, private insurance companies, pharmaceuticals, and doctors protecting their incomes, I'd be surprised if any real solution escaped intact from Congress.

I think you're on-target in most of what you say, and I have to say that a big part of the reason we are even talking about nationalized health care is that doctors of the previous generation were unable to keep their collective hand out of the cookie jar. That said, your income complaint is a bit spurious; if a typical lawyer makes a starting salary of $65,000 as you suggest, then not only would he be doing so after one less year of postgraduate education (and therefore one less year of tuition debt), but also doing so without having to do a residency of anywhere form three to seven years - during which income is usually $40,000 or so, well, under that necessary to be able to make any significant loan payments. Factor in the life-and-death nature of some of the decisions made by that doctor, and your own river-crying about lawyer incomes doesn't quite stand up to scrutiny (full disclosure: my father, mother, and brother are lawyers. In what other family could I be the black sheep by becoming a doctor?).

And as far as income disparity between sub-fields within a profession, I don't think that there shouldn't be a disparity, but the way by which we arrive at that pay gradation needs to be re-evaluated. Right now, we've got a system that rewards the performance of invasive procedures, rather than the preventive efforts that could have made those procedures unnecessary, and it is a big reason for why health-care costs are out of control - it is a system that produces higher doctor billing, higher hospital costs, higher malpractice insurance (because more invasive = more risky), and higher costs overall because treatment is more expensive than prevention. There may be be pay disparities between lawyers, but those don't contribute to a systemic sickness that is causing the nation to consider overhauling the entire profession.

Thank you for providing a thoughtful and useful debate regarding health care.

I would just like to make one salient point. I don't want Socialised Medicine in the US. I do want single-payer, not for profit Medical Insurance. If that means that the federal government will have to provide the insurance, so be it. People will argue that we can't interfere with the private medical insurance market because it represents free enterprise. My response to that argument is that drug dealers and pimps also represent free enterprise. Think about that for a minute.

To compare the US private health insurance industry to pimps and drug dealers is unkind and insulting. I think you owe the pimps and drug dealers an apology.

If your doctor attended a state-sponsored med school, then perhaps some of your tax dollars did pay for a portion of his/her education. But if your doc went to a private school, he or she footed the bill. If you mean government-sponsored low interest loans provide the means for med school, I say, "So what?" Thousands of other businesses and people get much more at lower cost from the government.

Otherwise, I do indeed commiserate with them and their performance.

Tort reform -- I'm a lawyer and I'm for it, within certain limits. I'd like to see the end of non-economic damages (ie, pain and suffering), but would reserve the ability to award punitive damages in cases where there's a very high standard of proof required -- like where the doc comes into surgery drunk or under the influence of drugs, or is just a sadistic bastard. This stuff does happen, but so very, very, very rarely that I can't believe retaining a suitably high standard would have a measurable effect on medmal rates.

Otherwise, good job sb. Nice thread -- interesting.

Actually, I think that many lawyers are dramatically overcompensated, and that this creates a climate in which the only access that most people have to justice is to fork over 30-40% of their recovery to the attorney, and then only if they have the kind of case that will attract someone looking for contingency work. Which is why eliminating pain and suffering recoveries does not make sense - that money actually goes to pay the lawyer, on average. If you look at countries where non-economic damages have been eliminated, you find that they have a "loser pays" system, in which the person who wins gets their attorney's fees paid as part of their recovery. Anyway, no river crying here, just a suggestion that people in the professions tend to complain about how little they are making because they have inflated ideas about how much money people in the other professions are making.

Most patients don't feel entitled, they just want decent care. Most like their doctor (if they actually get to see the same doc more than once) but do not like or trust the medical system as a whole for reasons beyond the doctor's or patient's control.

Malpractice is a huge issue that must be solved on both sides. Law suites need to be reined in, but policing of the medical profession must also be part of the solution. Negligent doctors and hospitals should have their licenses pulled. Publication of statistics of infection rates etc. so that consumers can choose and know which hospitals and doctors are performing and which are not. If you are going to charge the patient for treating the injuries received as a result of medical negligence or even honest mistakes, shouldn't the patient be give the fair chance of avoiding the poorly run institutions?

Trust is earned and the medical system has not earned it, and has enacted policies that pretty much ensure distrust.