"Vacations? Are you kidding?" Mark Fox is a physician. he's got a handlebar mustache, a sharp widow's peak, a bright tie, and his own private practice in Scarsdale. He's 53, in the prime of his career, and just now, seated behind the desk with a life-size plastic nose on it -- he's an ear-and-nose specialist -- he is recalling how he used to take vacations. "Every winter and every summer," he says. Photos of high-mountain camping near Mount Rainier hang on his office walls. First the summer vacations disappeared. "Haven't had one in five years." This year he skipped the winter vacation. Fox's own doctor has urged him to take some time off. He doesn't disagree. "I have increased stress, high blood pressure," he says. He's so wound up by the time he gets home from the office that his wife won't talk to him for an hour afterward. He's watched a couple of physician friends undergo open-heart surgery. Still, he's reluctant. His income dropped 25 percent in one recent year. And if he's not working, he's not only losing income. "I'm still paying for the overhead," he says, and it's doubled in recent years. So what does he do? "I tighten my belt and get a headache," he says.
Dr. Bernard Schayes, a 43-year-old internist on the Upper East Side, is the kind of doctor who puts his cell-phone number on his office answering machine. He likes to be available to patients. Of course, when he was starting out, availability was easier -- he lived around the corner in a two-bedroom apartment. But he had two kids and private-school bills of $30,000 a year. (He also owned a Mercedes and a Jaguar.) Then his income dropped. "There's no way to live in the city anymore," he says. He moved to Roslyn, Long Island, where his children attend public school. Now he wakes at 5 a.m. and gets in his Acura, occasionally fielding phone calls from patients on the way. First, he heads to his part-time job at a nursing home, where he works before his own office hours begin.
Not long ago, doctors had it all. They did challenging work -- they saved lives! -- and didn't have to worry about money: They earned tons. They regularly visited the Mercedes dealership. They island-hopped on vacation. They owned the best real estate. Their kids went to private schools. Everybody wanted to marry a doctor. Or be one. Half a dozen years ago, most doctors -- three fourths in one survey -- were happy.
No longer. Doctors still say it's a privilege to be a physician, to intervene in people's lives in times of need. "But there's a gloom now," says one family doctor. "A lot of sitting around the dinner table and asking each other, 'Where did we go wrong?' "
"The general population decided we weren't worth all that much," says Dr. Bernard Schayes. Or, as he sometimes puts it, "people decided they wanted us to drive Acuras."
Doctors have lost ground. Insurance companies have ganged up on them. "I have anxiety about staying in business," says an internist who's put his own money toward payroll. The trouble isn't just financial. Perks, privileges, esteem (self-esteem too) have all been hit. Many physicians work longer hours. And now, it seems, all kinds of people -- including clerks! -- are telling them what to do.
Now, announces the New England Journal of Medicine, "many American doctors are unhappy with the quality of their professional lives." The literature on this reads like the intake form at a depression clinic: "increasing marginalization," "discontent," "confused," "angry," "insulted." (Is it any wonder med-school applications are down again this year?) Yes, the doctor is in, but in case you haven't noticed, there's a good chance he's seething. "It's no fun being a doctor anymore," is the way one puts it.
Medicine hasn't always been a path to privilege. For most of this century, doctors might have been stars in high school and college, but they were solid upper-middle-class earners, a notch above your general contractor, maybe. Then, starting in the sixties, Congress enacted Medicaid for the poor and Medicare for the elderly. The number of paying customers per doctor eventually quadrupled. "That was the goose that laid the golden egg," says Dr. Jerome Breslaw, a Manhattan gastroenterologist who began practicing in 1973. Doctors bought themselves Mercedeses, Cadillacs, Beemers. They went from upper class socially to upper class financially. Even in the eighties, when family doctor Mark Horowitz attended medical school, he thought, "Doctors are rich people." Mostly, he was right. Society's bargain with physicians seemed to be this: Spend ten years training, then you'll be taken care of. Shortly after Dr. Schayes, the Upper East Side internist who owned a Jaguar and a Mercedes, left his residency, he worked hard -- including nights and weekends -- but in the early nineties he earned upwards of $300,000 a year.
By the mid-nineties, circumstances had changed. "The general population decided we weren't worth all that much," says Schayes. Or, as he sometimes thinks of it, "people decided they wanted us to drive Acuras."
Actually, it was business that first made that calculation, since in large part business footed the bill for double-digit medical-cost inflation. Managed care was one result. This insurance scheme was sometimes hailed as a way to encourage preventive medicine and ensure quality, but its initial intent was to trim costs. Doctors could once charge as much as they wanted -- a rare thing in business. In medicine, the law of supply and demand didn't seem to hold. No matter how many doctors crowded into one area -- like Manhattan -- fees seemed to do nothing but rise.
One way managed-care companies attacked costs was simply to reduce doctors' fees. "Where a fee was $1,000, now a doctor is getting $300," says Andrew Kleinman, a plastic surgeon in Westchester County. Once, patients were responsible for the shortfall. In managed care, physicians swallow the loss. "The insurance industry has created a slave workforce out of the doctor," says Moshe Rubin, a gastroenterologist at Columbia. That may be an overstatement, but no doubt that's how it feels. And as if reduced fees weren't enough, insurance companies have sometimes, willy-nilly, not reimbursed anything. "We're fed up but we're taking it," says Kleinman. Not always. (Recently, a group led by Kleinman went to the New York State attorney general's office, which threatened to sue before Aetna settled.)
Reduced revenue is only part of doctors' new burden. Managed-care companies also created all kinds of paperwork, tons of it, which they, using the jargon of the day, outsourced. In this case, they outsourced it to doctors. Suddenly, physicians had to beef up their staffs. Steven Fochios, an internist, has one employee who handles almost nothing but the referrals required by managed-care companies. Ten years ago, Fox had one assistant; now he has four staffers to deal with the 64 different insurance plans he takes, most of which have different rules. His overhead accounts for almost 60 percent of revenue.
Reduced fees and increased expenses put pressure on income, especially of primary-care doctors and pediatricians -- the doctors most of us see most of the time. "I never expected that as my career progressed, my income would contract," says Mark Horowitz, a family doctor. "In the mid-nineties, it was easy to save and invest. Now there's less money in the kitty at the end of the month." These days, after eight years of training, a 30-year-old pediatrician can expect to earn $95,000. Starting internists probably earn $100,000 to $110,000. Not bad, perhaps. But the first year at one of the city's better law firms -- that's after just three years of law school -- will bring you close to $150,000. "And I can be on vacation and I'm always available to my lawyer friends," points out Adam Stracher, an internist at Cornell Medical Center. "And they have secretaries. They have expense accounts. You think we get tickets to Knicks games from our firm?"