Lately, lots of doctors have to pick up work on the side. Horowitz works as a medical consultant at Juilliard. One doctor got involved with a dot-com for a few years -- which was the last time he flew business-class. Some physicians augment their incomes by selling herbs, food supplements, cosmetics, even household cleaners in their offices. Schayes sells vitamins. "I buy wholesale and sell retail," he says. "It was kind of embarrassing at first. But at the end of the year it makes a big difference." Last year, Schayes, an M.D. approaching the height of his earning power, earned about $120,000 -- which doesn't come close to buying what people once thought of as the M.D. lifestyle. Soon, Schayes figures, his wife will have to go back to work. She hasn't worked in five years while the kids grow up. "She doesn't want to, but I'm making her," says Schayes. "Besides, she's a lawyer. Her earning potential is greater than mine."
Income isn't the only factor squeezing the fun out of doctoring -- and maybe not the key one. After all, doctors earn about $160,000 on average, which makes them affluent, by any measure. "I actually believe the biggest issues are not economic," says Dahlia Remler, an economist at Columbia.
Once, as Ed Salsberg, head of the Center for Health Workforce Studies, explains, "everything in health care revolved around physicians. They were king of the hill." Accordingly, they were treated in a kingly fashion. Every 50-year-old nurse remembers fetching coffee for a doctor, giving up her chair so he could sit down. The hidden curriculum of medical school is that the doctor is the decision-maker, the brain, the star. But these days, most doctors are just another member of the team. Teamwork is emphasized. Health care is thought to be a system, not something one person does to another. And so doctors have got a new title: health-care provider, a category that includes nurses and lab techs. That alone drives doctors crazy. It's like a demotion. "I'm no health-care provider," says one NYU doc testily, sounding like McCoy from Star Trek. "I'm a doctor."
Along with power, doctors had autonomy. But now the insurance companies behave like supervisory adults, like scolds suggesting -- implicitly, of course -- that doctors can't be entirely trusted. "You used to have a conversation with a patient and come to agreement," recalls Breslaw. Once, for instance, doctors could prescribe as many MRIs as they felt necessary. Managed-care companies, however, now insist they have to approve such expensive tests in advance.
These days, physicians have to get on the phone and plead their case. And with whom? "Now if I need to order a scan, I need to call not a nurse, not a doctor, but an uneducated technician," says Rubin, the Columbia gastroenterologist. Of course, no one in the industry doubts that too many unnecessary expensive tests were prescribed in the past -- especially when doctors happened to own the CT or MRI scanners. What's more, as Christine Cassel, chair of geriatrics at Mount Sinai, says, "if you look at the literature on quality of care, there were huge divergences."
Different diseases are treated differently in different places with different results. Doctors haven't always taken responsibility for making sure quality is up to snuff. Still, doctors' pride hinged on a belief that the decisions they made mattered. Now, at every turn, insurance companies generate standards of care, templates that ride herd on them, as if they were unruly kids. "It is an insult, it's infuriating," says Rubin. "Though after a few years you stop taking it personally."
It's not just insurance companies that now oversee -- and subtly undermine -- doctors. At one time, most physicians were their own bosses, entrepreneurs who set up their own small businesses. That was part of the fun. "Now," says Fox, who is just such an entrepreneur, "I'm a dinosaur." There has been a vast, largely unnoticed change in the organization of the medical labor force. The solo practitioner, the one most of us grew up trusting, is nearly out of business. From now on, doctors will be employees like everyone else. Just 4 percent of new doctors in New York say they plan to open their own practices. As an employee, the doctor has a fixed retirement age and a set lunch hour -- not that physicians ever take expense-account lunches. (This isn't the business world!) As employees, a lot of physicians won't have secretaries anymore, not their own anyhow. At Mount Sinai, specialists who once had assistants now have answering machines. Yes, there's a receptionist, a billing department. But they work for the administration, just like the doctor. "I can't hire or fire secretaries," explained one specialist at Montefiore. "I have no control over staff." Sure, you can always write up a secretary for misbehavior, but then a receptionist can write you up, too. "If we say one wrong thing, they go to the compliance office," said one doctor who was reported for raising her voice. "Apparently, I have to be on perfect behavior."
The world has changed on the middle-aged doctor. And, to add insult to injury, the younger generation doesn't seem quite as upset. "We're less insane with it," says Stracher, 37 years old. "Our expectations are different. We didn't know a different way."
Making sure patients actually get better is still the responsibility of physicians, as malpractice insurers remind them. (And despite complaints, there's scant evidence that quality of care has decreased in recent years.) Still, these days, other values besides quality guide doctors through their day. Efficiency, productivity: That's what physicians hear. And just like factory workers at the beginning of the century, doctoring has been rationalized to increase productivity. In many practices, the system, even the building, has been redesigned to push the pace. Doctoring has been broken down into its component parts. Assistants take blood pressure. Nurse practitioners take histories. Physicians show up for the flourish, to review the treatment plan, as one puts it.
"This does not signify inferior care or second-class citizenship!" doctors Bruce Yaffe and Ronald Ruden felt obliged to alert their patients in a handout. The current system conserves the doctor's time. And time -- this is the point -- is limited. Increasingly, salaried doctors get paid based on how many patients they see. Even at academic institutions, the elite centers where research and teaching have thrived, docs now have monthly quotas of patients. If they don't make their numbers, they're called in to explain why. "We are the new factory workers," says one gynecologist. She may be right. "I have the feeling of being squeezed to see more patients to gain the same income," echoes a colleague. Extraneous activities -- that is, non-income-producing -- are less possible these days. Those, for instance, who'd like to devote more time to research increasingly look to drug companies. "You can't do that on the academic side anymore," says Dr. Rajiv Patni, who recently took a job at Pfizer. Teaching, too, is valued less. "The Department of Medicine must reduce its budget," explained a blunt letter to one Montefiore doctor, whose teaching salary was cut by a significant amount.
Maybe doctors once felt like kings of the hill. These days, a lot feel "like interchangeable parts," as one physician-employee put it. "A businessman looks at you and sees a medical license that he is going to plug into a slot in his organization," complained one physician. Of course, one reason employers can treat doctors this way is simple: There are too many of them. Doctors traditionally gained power by controlling supply and demand. No longer. In the past ten years, the number of docs has increased by 30 percent. (That doesn't even include physician assistants or nurse practitioners, who sometimes run independent medical offices. "In the future your doctor may be a nurse" is the warning issued by the American Nurses Association.) And as far as demand goes, doctors have never been overly worried about bringing in new groups of patients (like the 40 million uninsured Americans).