Doctors are not indentured servants, so piss off

Someone is wrong on the internet! I read a tweet today that implied that doctors are indentured servants and should shut up and shop at the company store. Well, that’s how I read it anyway. Here’s the exact text:

If doctors stop taking medicare patients should they pay back 500k+ CMS http://www.aafp.org/online/en/home/policy/federal/issues/workforce/education.html … invested in training them?

Now, I’m not saying the tweeter thinks this is what should be done, but the premise is so completely wrong that…well, it’s not completely wrong, it’s just mostly wrong.

First, let’s chat about Medicare, the program that insures people over sixty five (and many disabled people). Medicare sets prices paid to doctors based on all sorts of formulas, but due to Congress’s inability to make financial decisions, these fees are unstable, requiring last minute fixes each year. This means that doctors that treat Medicare patients have considerable trouble planning salaries, hiring, capital improvements, and other expenses. Because of this instability and the generally lower fees paid by Medicare, it might make sense for some to simply opt out and stop participating. Medicare patients would still be able to go to the office, but they would have to pay out of pocket.

The interesting question raised by the tweet is this: since Medicare funds graduate medical education (residencies and fellowships) do doctors owe Medicare some sort of obligation?

Work has a value, and ideally the value is assigned at the time someone is hired for their work. If the worker doesn’t agree with the fee, they move on and management is denied her production. Ideally.

The ethic here is analogous to informed consent: contracts should explicitly state the obligations and benefits for both parties. Doctors pay for medical school, and exit with a debt averaging $200,000. They enter residency with the expectation that they will receive a modest stipend, one that usually doesn’t allow for loan repayment but at least pays room and board. To maintain a residency program, hospitals receive money from Medicare, and some of this money is used to pay this stipend (or salary, depending on whom you ask).

Residency is not a benefit given to young doctors: it is an obligation. In return for being taught and supervised, they take care of patient, working long hours and sacrificing years of potential earning and often family life. There has never been an expectation that they owe anyone anything.

This, then, is why I call “bullshit” on anyone who would suggest the system has other hidden obligations. To impoverish young doctors through debt, and then further impoverish them by having them pay for their training not only in service but in dollars is not consistent with how we create doctors in this country.

If we as a society decide that residency and fellowship are really tuition-based services rather than work, that would need to be explicitly agreed upon long before high schoolers enter college and decide to torture graduate students with questions about their organic chem grade.

If doctors are required to become indentured servants to Medicare, it should not be without an explicit understanding.

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2 Comments

  1. ted norman

     /  March 26, 2013

    I call “Bullshit” on your assumption that just because it has always been done this way, it is the right (only) way to do it. I agree that there is value in allowing residents to practice their craft on patients, but there is also value to the doctors for this practice, including a livable wage and placement at a teaching hospital, where they can learn. I would much rather see us, as a society, make a clear contract to pay for medical education and receive several years of service to the community as repayment. we will see…

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