This is my column in June’s EM News.

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Here is the text:

‘But you’re a rich doctor, right?’ Have you had that conversation? There’s a certain expectation of physicians, that we’re all just filthy rich, overflowing with boxes of cash tucked neatly away beneath our gilded beds.

When we were building our house, our builder talked with my wife: ‘Jan, I want you to meet me to look for counters and cabinets. Don’t bathe the kids. Put them in dirty play clothes and don’t wear anything nice. Don’t ever tell them your husband is a doctor.’ He’s a wise man. What he knew was that the word ‘doctor’ means ‘cash.’ Or at least, means ‘cash’ to the popular mind.

I wonder if this perception is the reason patients come to the emergency department and say things like this: ‘I don’t have any money to go to the dentist, so I came here.’ It’s the belief that we come to our jobs already in possession of large amounts of money. Granted, there are some physicians who come from wealthy families. The majority, however, do not. And no one does that to any other professional. ‘I’d like a house built to order, and I know you’re a rich contractor. I can’t pay you, so get to work! Or else I’ll sue!’

Nevertheless, from patients to insurers, real-estate agents to contractors, attorneys to government and hospital officials, the belief is straightforward. MD means ‘Mucho Denaro.’ Witness the hospital in Pennsylvania that recently began charging physicians $1000 for each time a monitor saw them fail to wash their hands before a patient encounter. ‘Why sure, Mr. Monitor, I have that in this giant money clip I carry around all day. It helps when I feel a sudden urge to buy a Jaguar, or jet across to France for lunch! And buy yourself a steak…here’s some extra!’

Or consider the amount of money we pay for CME (frequently located at pricey hotels or resorts). Consider the amount of money that professional organizations and medical societies expect from members! It all points to the same assumption. In medicine, wealth is believed to be ubiquitous.

I’m not trying to sound like a whining, complaining physician. I have been able to make a good income from my work, and have been blessed to care for my family the way I wanted. I have a nice house and car. And my only real practice overhead is the fee our group pays our administrator and the amount we pay our mid-level providers. (I really don’t know how physicians make it when their speciality demands a high overhead; some physicians use up 50% of their income in overhead, which certainly makes ‘rich doctor’ a tough sell.)

Still, my costs are not insignificant. And I think this is where the ‘rich doctor’ bit becomes so tiring. Because I, and most of you who are reading this, pay out a lot of money. First, we pay a large tax burden. Yes, I agree that some taxation is appropriate. But when you add up federal, state, local, sales, property and vehicle taxes, I probably come fairly close to spending about 40-45% of my take-home money on taxation.

Next, I pay my own malpractice insurance. I am a partner in a group. So, over $20,000 (of my income) goes out each year to protect me from lawsuits (which may easily arise from people who never paid me a penny, mind you.)

Likewise, I pay my own retirement. Granted, it is matched by me…which is an ironic way of saying I pay all of it. No one contributes; no taxpayer, no employer, no one puts money into my retirement account except Ed. (And frankly, with the fluctuations of the market, Ed has done a pretty lousy job of keeping it well funded!)

I also pay my own disability insurance. And my own family’s health insurance, which runs around $1800 per month. It’s OK, though, because I also match that with contributions from…me. Again, no one conributes anything to my health-insurance costs. Which is why I was aghast when teachers in Wisconsin were angry that they would have to contribute 15% instead of 5% to their health insurance costs. I’ve been contributing 100% for my entire career.

The point is this: being a ‘rich doctor’ is getting harder all the time. We may make what sounds like a lot of money, but the money that we have to pay out is also significant. ‘Why not just work for someone, instad of having a private group?’ Well, could we all work as employees? Perhaps, but that would be unlikely to reduce the costs to patients (usually the point of such suggestions), as our employers would still pass along all of the expensive but necessary things like insurance, CME and other standard operating costs of practice.

But it gets worse for our up-and-coming ‘rich doctors.’ Students are leaving undergraduate school with vast debt loads, sometimes up to $160,000 for private schools, then going to medical school and taking out loans of over $200,000, since tuition is $30-40,000 per year. Imagine starting practice after residency, already owing on the order of $300,000. Before starting an office or group; before malpractice and employees and all the other routine costs; like having children and a home.

How could a young physician make it? Certainly, the incentive to go into lower-paying specialites wouldn’t just be a matter of lifestyle or the standard accusation of greed. A high-paying specialty might acutally be a matter of financial survival!

I think America needs to reassess what it expects from physicians, and we need to re-evaluate our finances as a profession. And we need to be vocal in our explanations to the patients, politicians and others we encounter in life.

We aren’t ‘rich doctors’ in the traditional sense. What we are is well-funded conduits of money and effort. Money in, money out, is the way it works. And if we are to continue doing what we do, if we are to continue seeing the poor, and the uninsured, something has to give. Not only in emergency medicine, but in every specialty. On this topic, if on no other, we need to stand as one profession, not divided by the tribalism of specialty.

We can put off the discussion as we have been for years, but the fundamental issue is this: in order to keep practicing medicine as it is, physicians will need to be paid more money, or be required to pay less money out both in education and in practice.

Otherwise, rich doctors (who are also smart doctors) will start to do the math. And when they do, they’ll realize that they simply can’t afford to do it anymore.

Being rich is rapidly becoming just too expensive.

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