Americans can't find doctors in sick system, but docs whine too loudly on debt, ignore excessive earnings

In the current AARP Bulletin (pay wall, Apple News), New York Dr. Howard Zucker capably explains why Americans are being squeezed by a doctor shortage. But two points of Zucker's explanation too easily let doctors off the hook and require clarification.

I hope tomorrow to meet my primary care physician (PCP) for the first time, after he's nominally served in that role for two years. I've seen five PCPs come and go in as many years, which is really like not having a PCP at all—oddly, as my insurer insists that I must have one. The annual checkup has become biennial at best, and it's not for my lack of trying. At that, with my mediocre employment-based healthcare coverage, I'm more fortunate than many Americans.

Zucker describes the many circumstances converging to deprive Americans of access to healthcare providers. A leading problem is poor planning by the medical profession, embodied by the American Medical Association (AMA), for an increasing and aging population.

Another factor, which is familiar to patients, is the pressure by profit-driven healthcare proprietors, such as CVS, to commodify patient care, superseding the doctor-patient relationship and thoughtful care with the churning cauldron of the billable quarter hour. Workplace conditions for front-line PCPs are not only maddening patients, but driving some healthcare providers, literally, to madness.

Nevertheless, there are two ways in which Zucker goes too easy on doctors, letting them off the hook for responsibility in this mess.

First, Zucker is wrong that a doctor can't get by with medical school debt and a PCP wage.  

He wrote that the average medical student finishes school with $235,000 in debt. Specialties pay some double the wage of primary care. Research posts pay well and don't have insurers dictating terms. So debt-burdened students are disincentivized to enter family practice or to work directly with patients at all. 

Still, Zucker wrote: "Now consider that the average [PCP] in internal medicine, geriatrics, pediatrics or family medicine makes about $250,000 to $275,000 a year. Becoming a PCP just isn't financially feasible for most recent graduates."  Just for the record, that's more than I've ever made at any job, and I've had a law degree for 28 years.

Not financially preferable I can see.  Not financially feasible is plain wrong.

For comparison, the average indebtedness of a U.S. law school graduate is $130,000, according to the Education Data Initiative. For the law school where I work, it's about the same, $125,405, U.S. News reported. The median law graduate salary is $89,250, according to U.S. News. My school's is about $68,000, according to LSD.Law. Ballpark monthly repayment, using, for these gross purposes, a 4.5% rate and 10-year term, means a monthly payment of $1,347, according to the SmartAsset student loan calculator.

To be sure, that's too much debt to make law school an appealing option. The Consumer Finance Protection Bureau recommends limiting borrowing to hold monthly payments at 10% of gross income. Those median salaries yield a monthly gross of $7,438 or $5,667, respectively, so a monthly payment at 18.1% or 23.8%. 

But it is possible, depending on one's needs. An annual $89,250 or $68,000 should yield a monthly take-home of about $5,600 or $4,400, according to the SmartAsset paycheck calculator. On the one hand, the average American household requires $6,440 per month, according to multiple sources. On the other hand, a single adult with no children can get by on $3,439 in the Massachusetts county where my school is located, according to the MIT living wage calculator. The overall average American individual is bringing home only about $4,000 monthly, using Bureau of Labor Statistics (BLS) data, so one salary isn't meeting household expenses in any event.

Accordingly, using the same metrics, the medical graduate's monthly debt payment would be $2,434. The PCP monthly take-home at the low end would be about $14,200, on $20,833 gross. That's a payment to gross ratio of only 11.7%, with $11,766 to spare for monthly household expenses. Even at a student loan rate of 9%, the monthly payment hits only 14.3% of gross, still sparing more than $11,000 to meet expenses. (A first-year medical resident starts at only about $55,000 annually, U.S. average, but lean residency years are the quirky if objectionable norm in the profession regardless of later specialization.)

Once debt is paid off, doctor's circumstances become downright luxurious. BLS estimates the median American's lifetime earnings at $1.7m, a lawyer's at $2.3m, and a doctor's at $7.5m. 

So it is feasible to invest in medical school—even potentially lucrative—and even still to be a PCP for a few years.

Second, Zucker fails to recognize the economic protectionism of the medical profession and bloat in the salaries of U.S. doctors—even PCPs.

Zucker did fault the AMA for choking medical school admissions in the 1980s. But Zucker blamed the AMA only for bad math. The truth is more sinister.

The AMA doesn't control medical school admissions directly, but it does lobby hard for legislators to limit the number of medical schools and to limit subsidies for residencies, thus effectively controlling supply in the market. This isn't about the quality of medical training, but about economic protectionism. The AMA, that is, its members, doctors, don't want to see salaries go any lower than those dizzying quarter-million-dollar heights.

(Read more in Derek Thompson, Why America Has So Few Doctors, The Atlantic (Feb. 14, 2022).)

That's what's happened in law as antitrust rumblings have compelled the American Bar Association and state bars to let up on the gas in their economically protectionist motives over the last four or five decades. The market in legal education has become more competitive—even problematically so, from a quality standpoint, it must be admitted—and salaries have fallen.

At the same time, persistently burdensome accreditation gateways in education and strict state licensing requirements in the practice have maintained such a chokehold on the student-to-bar pipeline that the lower paid lawyers who result cannot afford to meet the market demand for legal services for ordinary people, in contrast with corporate clients.

So law is not a model to follow, to be sure. At the same time, one doctor in America does not need to take home an excess of nearly double what's required to keep up an American household, nor to make more than four times the median American lifetime wage. European doctors are paid only half as much as U.S. doctors. In fact, there's a huge gap between U.S. doctors, at an average annual gross of $352,000, and doctors anywhere else in the world—ranging from an average $19,000 in Mexico to $273,000 in Canada, according to news outlet Medscape.

Zucker didn't mention the bloat in salaries of U.S. doctors in the AARP Bulletin. Incidentally, when Dr. Zucker was New York health commissioner, earning $210,000 annually on the public payroll, he took some heat for failing to disclose a side-gig income of $75,000 annually from a health research firm, e.g., the Times Union reported.

Our healthcare system is badly broken.  Like our legal services.  Like our bridges.  The list goes on.  What I fear is missing from the solution is the willingness of Americans in the highest income brackets to bear any sense of civic responsibility. In this regard, the medical profession is not exempt.

No right to physician aid in dying, Mass. high court holds, rejecting analogy to same-sex marriage right

In 2017, Rep. Eleanor Holmes Norton (D-D.C.) and D.C. residents
protest to protect "death with dignity" law from congressional meddling.
Ted Eytan, MD, via Flickr CC BY-SA 2.0

There is no right to physician aid in dying in the Massachusetts constitution, the commonwealth high court held in December, leaving room for legislators to fill the gap.

A cancer patient and a doctor brought the case. The plaintiff patient, a retired physician with metastatic prostate cancer, wanted counseling on physician aid in dying; the plaintiff doctor wanted to give counsel to his patients struggling with potentially terminal illness. Both plaintiffs argued that they could not get what they want for fear that doctors can be prosecuted for the state common law crime of manslaughter, that is, reckless killing, or worse.

The court opinion refers consistently to "physician-assisted suicide" (PAS), but I'm here using the term "physician aid in dying" (PAD), a difference I'll explain. The medical action at issue here is the ability to "prescri[be] ... barbiturates [with] instructions on the manner in which to administer the medication in a way that will cause death." But the plaintiffs confined their demand to patients facing fatality within six months. 

In a footnote, the court said it used "PAS" because the American Medical Association (AMA) prefers the term. The AMA regards "PAD," or the more modish "medical aid in dying" (MAID), preferred by the plaintiffs, as unfavorably "ambiguous."

Massachusetts remains with majority of states in not recognizing PAD right.
Terrorist96 (upd. Apr. 2021) via Wikimedia Commons CC BY-SA 4.0

Facially, both terms are potentially ambiguous; the quibble over semantic precision faintly masks the policy disagreement. "PAS" implicates suicide in the conventional sense, comprising the intentional ending of one's life for any reason, including the expression of mental illness. That's a bigger ask in terms of constitutional entitlement. The 10 states (plus D.C.) that allow PAD, such as Oregon, require a terminal diagnosis and purport to exclude conventional suicide. "PAD" and "MAID," accordingly, mean to narrow the fact pattern to a patient who is hastening a process of natural death that already is under way, or at best ending an inescapable and intolerable suffering.

I learned about this distinction, and more in this area, only recently, as a student in my Comparative Law class is working on a research paper comparing MAID laws in Oregon and the Netherlands. In her early stage of topic selection, I referred her to, and recommend to everyone, my top This American Life segment of 2022, "Exit Strategy." The heartbreaking segment comprises excerpts of Connecticut writer Amy Bloom reading from her book, In Love: A Memoir of Love and Loss, which documented the figurative and literal journey of her and her husband to end his life in Switzerland after his diagnosis with Alzheimer's. I might one day read the whole book, but I'll need to work up the emotional strength.

The court's thorough opinion by Justice Frank M. Gaziano largely tracked the reasoning of the U.S. Supreme Court in declining to recognize PAD as a fundamental right, because it's supported neither by historical tradition nor widespread acceptance. Insofar as PAD is a reality on the ground for doctors and terminally ill patients, it still carries a stigma, the Massachusetts opinion observed. The medical community itself is divided over PAD, evidenced by amici in the case. In the absence of a fundamental right, state criminal law easily survives rational-basis review for substantive due process.

The Supreme Judicial Court recognized its own power and responsibility, in contrast with the more conservative U.S. Supreme Court, to tend and grow the scope of fundamental rights protected in Massachusetts, adapting the state Declaration of Rights to new social challenges. The Massachusetts court exercised that very power when it approved same-sex marriage in the commonwealth in Goodridge v. Department of Public Health (2003), 12 years before the U.S. Supreme Court did likewise for the nation in Obergefell v. Hodges (2015).

Voters reject the PAD initiative in Massachusetts in 2012.
Emw & Sswonk via Wikimedia Commons CC BY-SA 3.0

But the milieu in Massachusetts is hardly conducive to Goodridge delivering this plaintiff ball across the goal line, the court concluded. To the contrary, the court observed, Massachusetts voters rejected a PAD ("Death with Dignity") ballot initiative in 2012 (51% to 49% in "ferocious political battle"), "over a dozen bills" to legalize PAD have failed in the legislature, and statutes regulating healthcare affirmatively disallow PAD counseling.

The court opinion includes an intriguing discussion of standing. The case was something of a put-on, because local prosecutors did not threaten the plaintiff physician with prosecution. Again, the court acknowledged that doctors engage in PAD now, if quietly, criminal law notwithstanding. In reality, there is not a bright line between PAD and appropriate palliative care, or between "terminal sedation" and "palliative sedation." Prosecutors helped plaintiffs to sustain the case by saying that they would not decline to prosecute.

In the end, the court decided the case only in the matter of the physician. The court rejected the plaintiff patient's claim because he had not been given a six-month prognosis, and his cancer remained susceptible to treatment by multiple options. In the patient's defense, I'm not sure someone with a six-month prognosis would have time to prosecute the case to the high court, nor should be expected to. Justice Dalila Argaez Wendlandt aptly dissented on the point. The patient here submitted that he did not necessarily want PAD, but wanted to have the option to be counseled for it if the need arises. Anyway, the court allowed standing for the doctor on a theory of jus tertii ("third-party right"), when one person is allowed to assert the rights of another upon a close nexus of interests. This notion is implicated on the issue of standing in the mifepristone case now before the U.S. Supreme Court.

In separate opinions, Justices Wendlandt and Elspeth B. Cypher left the door ajar to a rights argument on the right facts. Justice Cypher wrote that some "constitutional zone of liberty and bodily autonomy" should preclude prosecution for "late-stage palliative care." Justice Wendlandt reasoned similarly that as a patient approaches death, the state interest in preserving life by way of criminal law wanes, eventually even as to fail rational-basis review of a "nonfundamental right."

Nothing about the court's opinion precludes the state legislature from reengaging with PAD, which has been legalized in the northeast in New Jersey, Maine, and Massachusetts neighbor Vermont.

The case is Kligler v. Attorney General, No. SJC-13194 (Mass. Dec. 19, 2022), available from the Alliance Defending Freedom, a conservative religious freedom advocacy group that participated as amicus on the side of the Attorney General.