Show me the money … Not

I was reading yet another online discussion about the “horrid” status of modern medicine. One after another, various participants (all from the healthcare world) wrote of the impossible stress put upon them. The “system” expects them to fully evaluate every patient in 15 minutes. One of the discussants described multiple scenarios in which patients were presenting for specific problems, but clearly had systemic issues. More so, it became clear very quickly that these patients’ primary care physicians were not doing their jobs. These patients were suffering from a lack of proper medical management of their diabetes, high blood pressure, heart disease and more.

One of the participants noted that her mentor decided to leave general medicine in order to become a practitioner in a boutique service. The patients of this boutique service would tend to be more affluent, younger and with far fewer medical problems. Unquestionably, one can provide excellent care within 15 minutes when the vast majority of patients have simple problems. By the time these patients age into their geriatric version, this boutique doctor will have already retired from practice. So at least from the doctor’s point of view, this is a perfect option.

I like playing the game “let’s imagine”. I like to ask people questions by describing scenarios. Often times, I use this approach in order to force an answer to a specific case, rather than allow the discussion to be more of an overview and nonspecific.

Let’s imagine that every doctor was promised a salary of $200,000 a year. Why specifically this number? I wanted to choose a number that would be considered a significant salary but still not anything close to the top level salaries that many private physicians earn. If someone wants to argue that this should be $300,000 or $400,000, I am open to the change.

One of the reasons doctors “need” to earn more is due to their heavy debt, secondary to their many years of university study. I should point out that there are many people who are carrying heavy debt from their years of study but have absolutely no hope of ever earning anything close to what doctors earn. How do these non-physicians manage? I don’t know. I do know that I rarely read about these non-physicians, especially when you compare their stories to the amount written about the difficulties that physicians face due to student debt.

Let’s continue to build our imagined world, and let’s say that all student debt for physicians is wiped out. Someone, at the moment it doesn’t matter who, pays off every single physician’s $250,000 worth of debt secondary to their extensive education. In return, physicians are asked to see on average 3 to 4 patients an hour, no matter what their specialty. Obviously, the situation would be different for surgeons who may spend many hours with a given patient, all of it in the operating theater. So, let’s imagine we are talking about primary care physicians and non-surgeons.

So, for primary care physicians, they can count on the fact that they will be earning $200,000 a year without the need to pay off any debt whatsoever. Some quick and simple math means that every patient would get 15 to 20 minutes of the doctor’s time per visit. Assuming that a reasonable percentage of the daily patient flow would be made up of patients who truly can be managed in 5 to 10 minutes, it should be possible to devote, in some cases, 30 to even 40 minutes for more complicated patients, without extending the workday.

Someone much smarter than me can find all of the necessary data online and calculate how many physicians would be needed to fill all of the slots necessary for providing all of this care. This smarter person would also do some division and figure out how much it really is practical to pay each physician for this kind of work load. And finally, someone has to factor in the cost of paying off all that debt. When all this is done, I hope/suspect that every doctor will still be able to make a reasonable salary for a reasonable amount of work.

There is no question that in some cases, doctors will still need to stay late or answer phone calls in the middle of the night in order to provide full care. If a person finds such intrusions intolerable, then in my opinion, they had no business studying medicine as a career.

I will now ask my question. Would my scenario work?

I don’t have the answer. I didn’t do a study. I didn’t send out any surveys. I do know that the scenario described is somewhat similar to the situation in Canada, where I studied. I finished medical school after doing a bachelor’s degree, with no debt. That was because my father was able to afford the $1000 to $1500 a year tuition [with books] that McGill University asked for. Despite what is written about Canadian healthcare, it’s pretty good. And in many cases, the entire cost of care is covered.

Clearly, I am a socialist. And I have a fundamental trust in the good nature of people to always do their best and be satisfied with their “lot in life”. Empirically though, I am wrong. My scenario will not work. People tend very quickly to mediocrity and less, if they are not pushed forward. Without incentive, it seems that people will not internalize the concept that if we all participate, we all benefit.

My friends and colleagues who fundamentally believe that competition is the only way to achieve better and better quality of service, have a great deal to back them up. But as a socialist, I also look at the bodies strewn along the roadside that did not “make the cut”. I would argue that neither socialist nor capitalist system is perfect. But at some point, one must choose an approach.

I will say this – I have encountered far too many physicians who simply are not self driven. It seems hard to imagine how this could be, given the personality type necessary to get into medical school and “survive” a residency. But I have seen it. I have met far too many physicians who would never survive in a truly competitive environment. And by the way, this is still true in the US as well.

Until modern technology collects the data and generates the statistics that allow us to compare quality of care amongst doctors, hospitals and HMOs, patients will never really be able to choose what is the most cost-effective treatment. Until doctors are required, by market forces, to provide a certain quality of care, it seems that such care will always evade us. My fantasy of the noble physician riding in and doing what is necessary mostly out of commitment, does seem to be just that – a fantasy.

Does technology offer not just data/analysis, but a solution?

Technology will clearly play a critical role in the future restructuring of the medical system. Firstly, people (using technology) will identify any and all points at which the appropriate software and hardware can assist and even replace human involvement. Even before artificial intelligence makes it possible to diagnose over 90% of cases via the Internet, the same AI will assist healthcare providers to do the proper tests, and to prescribe the right medications and make maximal use of the time allotment with the patient. I imagine that there will be a great many startups that grow out of this need for dramatically enhanced efficiency throughout every step of the delivery of medical care.

In such an environment, where computers are constantly working to keep the load on healthcare providers low, will anything change from the human perspective? Will doctors suddenly enjoy their work more? Will the complaints stop? Certainly, the number of patients will not stop growing. So, is more and more advanced technology the only way to keep everyone happy?

I think yes. I think that computers will be able to compensate for poor physicians so much so that comparative statistics will show high quality of care no matter where you go. Market forces will then push costs down, as the “product” being provided is universally high quality. Every patient will get good care, and doctors will be left to fight out what their salaries should be for non-oppressive work environments.

I like this imagined scenario.

Thanks for listening

My website is at



About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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