Monday, April 10, 2017

A Theory of Relativity, Part III

When doctors' work can't easily be compared, and how the government fits into the picture.

In the last post, I went over what could be thought of as the first principles of addressing doctor pay relativity. I'd like to thank readers of this website and the Medical Post for some thought-provoking questions and counter-arguments. The only way these issues can ever get hashed out is through open and vigorous debate, which can't be done in tweets, and certainly can't be done when there's a negotiated offer on the table, or when a medical the association is being sued by its own membership.

Apart from the "technical problem" of doctor pay, i.e. translating what a doctor's typical income should be into a fee-for-service schedule, there are three (really two, as I'll explain) unresolved issues: 

1. How can we compare the work of unrelated medical specialties?
2. How do we leave room for incentives and disincentives in such a scheme?
3. Where does the government, and by extension, the taxpayer footing the bill, fit into the picture?

As I noted last time, the work that translates a doctor's time and effort into a comparable unit has to already been done, or at the very least provides a solid starting point to work from.

The formula is by no means perfect, and given the number of years passed, the profession probably needs to re-survey members. But the logic is sound. What was missing was a check against the actual work the doctor does: the basic scheme - (TIME x INTENSITY) + OVERHEAD - mapped onto that specialty's average workload. 

That's fine for comparing one Family Doctor to another, or a Thoracic Surgeon to a Colo-rectal Surgeon, but what about comparing a Family Doctor to an Ophthalmologist? Or a Psychiatrist to a Radiologist?

If doctors are forthright about the relative intensity of their jobs, there shouldn't really be a problem. A Forensic Pathologist's hour of moderately challenging casework should pay the same after expenses as a Plastic Surgeon's. The respective hours worked and volume of cases will account for the differences in net pay. If the difference is still excessive, one of them is underpaid relative to the other.

Things naturally get tricky when we deal with doctors who have trained for different lengths of time, the obvious example being Family Doctors (2-3 years of residency) as compared with Royal College specialists (at least 5 years, plus 1-2 years of fellowship training). There might never be a satisfactory solution here, and in some jurisdictions it's led to the medical associations breaking up along GP/specialist lines. At the risk of great personal harm, I propose a starting point for long-term negotiated solution:

When comparing specialties to arrive at an equitable per-"time x intensity" net pay, start with years of post-secondary education and training as a multiplier.

A typical Family Doctor (traditionally) has a four-year Bachelor's degree, four years of med school, plus two years of residency, for a total of 10 years. With a five year residency, a typical community specialist will have 13 years of post-secondary education and training, yielding a multiplier of 1.3. Which means that if a Family Doctor earns, say, a net pay of $100,000, a specialist working the same hours, at the same intensity, should net $130,000. Again, this is net pay, with overhead, liability insurance, and professional expenses factored in. And again, this takes difficulty and intensity of work into account. 

Is this "fair"? You can't know until you work through the math and compare the result with what doctors are currently earning relative to one another. While it seems at first glance like a Family Doctor's work is being discounted significantly, maybe even excessively, a doctor's long-term financial plan can't be disregarded. A three year head start on consultant-level earnings can make a major long-term difference in terms of paying down student debt and getting an earlier start on retirement savings. Does that make a GP's lifelong earnings a wash with a specialist's? Likely not. Then again, specialty residencies can be far more intense than Family Medicine training, particularly after internship. The Royal College exams also take an enormous toll on a doctor and his or her family, bordering on traumatic depending on the specialty. Family Doctors have a challenging road to full certification, but it's not as awful as the one taken by specialists. In any case, I only proposed a 1.3 x multiplier as a logical starting point. Doctors negotiating in good faith should be able to reach consensus from there.

Finally, we come to the issues of incentives/disincentives, and the proper place in the relativity discussion for government. I consider these to be connected, based on another "fundamental principle" for the relativity discussion:

Doctors should decide among themselves what their time is worth relative to one another. The price of that time is to be negotiated with government.

Right now, the divide-and-conquer strategy of governments (not only in Ontario, but in jurisdictions anywhere) is to say, "We will only pay $a for cataract surgery, but will be willing to hike the pay of a Geriatrician consult from $to $c. Talk among yourselves whether to take it or leave it." 

Under a relativity agreement, the response is, "No. A doctor's time is a doctor's time, once costs, training, and stress are factored in. The profession is united and stands behind the work put into arriving at this formula. You don't want Family Doctors making an easy buck, seeing nothing but runny noses all day? Go ahead and de-list the service, but expect to pay more for what the doctor sees in its place. You want more opioid counseling? Let's talk about a new service code. More rural doctors? We'll help you develop cash incentives."

The aim of a relativity agreement isn't necessarily to win more money for doctors. It's certainly not to impose a communist-style single wage level for all doctors. Rather, it's to do away with money as a crass motivator for doctors to choose one specialty over another or alter their practice patterns inappropriately. What I've raised in this series isn't intended as a be-all-and-end-all solution, but rather a way to prompt doctors - that have been badly divided and maligned for some time - to seek solutions in good faith, for the sake of professional harmony, and the stability of the broader health care system as well.


  1. I commend you for stimulating thoughtful dialogue in our profession. It is unlikely that any single relativity formula will please everyone. However it the interest of equity and collegiality in our profession, we simply can't accept arguments that distorted relativity that has persisted for years is some kind of "market norm". We also have to deal more effectively with our infatuation with procedural medicine as opposed to relationship medicine and our inclination to value the former more than the latter.

    1. Thanks Dennis! I think what I'd most like to see is doctors reaching this (admittedly uncomfortable) consensus as an entire profession. Failure to take the lead will almost certainly lead to a more blunt, and decidedly less satisfactory scheme imposed by the government.

      It's unrealistic to expect that the different fields of medicine will be equally *prestigious*. Surgery will always be seen as more glamorous than Pathology or Psychiatry, but an inescapable difference in prestige should not in and of itself lead to a difference in remuneration. Any attempt to place a greater importance on one doctor's time over another is something the profession should not accept.

  2. Thanks for these series of blogs. The second in the series was the best supporting case for relativity adjustment I have read to date. Question: Any reason why you focused on RBRVS instead of CANDI?

    1. Thanks! No reason apart from familiarity with the RBRVS document that I read for a post from about a year ago. If CANDI is a more straightforward and acceptable starting point, so much the better.