Ali Binazir

To
become a doctor, you spend so much time in the tunnels of
preparation—head down, trying not to screw up, trying to make it from
one day to the next—that it is a shock to find yourself at the other
end, with someone shaking your hand and asking how much money you want
to make. But the day comes. Two years ago, I was finishing my eighth
and final year as a resident in surgery. I had got a second interview
for a surgical staff position at the Brigham and Women’s Hospital, in
Boston, where I had trained. It was a great job—I’d get to specialize
in surgery for certain tumors that interested me, but I’d also be able
to do some general surgery. On the appointed day, I put on my fancy
suit and took a seat in the wood-panelled office of the chairman of
surgery. He sat down opposite me and then he told me the job was mine.
“Do you want it?” Yes, I said, a little startled. The job, he
explained, came with a guaranteed salary for three years. After that, I
would be on my own: I’d make what I brought in from my patients and
would pay my own expenses. So, he went on, how much should we pay you?

After
all those years of being told how much I would either pay (about forty
thousand dollars a year for medical school) or get paid (about forty
thousand dollars a year in residency), I was stumped. “How much do the
surgeons usually make?” I asked.  He shook his head.
“Look,” he said, “you tell me what you think is an appropriate income
to start with until you’re on your own, and if it’s reasonable that’s
what we’ll pay you.” He gave me a few days to think about it.

Most
people gauge what they should be paid by what others are paid for doing
the same work, so I tried asking various members of the surgical staff.
These turned out to be awkward conversations. I’d pose my little
question, and they’d start mumbling as if their mouths were full of
crackers. I tried all kinds of formulations. Maybe they could tell me
how much take-home pay would be if one did, say, eight major operations
a week? Or how much they thought I should ask for? Nobody would give me
a number.

Most people are squeamish about saying how
much they earn, but in medicine the situation seems especially fraught.
Doctors aren’t supposed to be in it for the money, and the more
concerned a doctor seems to be about making money the more suspicious
people become about the care being provided. (That’s why the good
doctors on TV hospital dramas drive old cars and live in ramshackle
apartments, while the bad doctors wear bespoke suits.) During our
hundred-hour-week, just-over-minimum-wage residencies, we all take a
self-righteous pleasure in hinting to people about how hard we work and
how little we earn. Settled into practice a few years later, doctors
clam up. Since the early nineteen-eighties, public surveys have
indicated that two-thirds of Americans believe that doctors are “too
interested in making money.” Yet the health-care system, as I soon
discovered, requires doctors to give inordinate attention to matters of
payment and expenses.

To get a sense of the numbers
involved, I asked our physician group’s billing office for a copy of
its “master fee schedule,” which lists what various insurers pay staff
doctors for the care they provide. It has twenty-four columns across
the top, one for each of the major insurance plans, and, running down
the side, a row for every service a doctor can bill for. Our current
version goes on for more than six hundred pages. Everything’s in there,
with a dollar amount attached. For those who have Medicare—its payments
are near the middle of the range—an office visit for a new patient with
a “low complexity” problem (service No. 99203) pays $77.29. A visit for
a “high complexity” problem (service No. 99205) pays $151.92. Setting a
dislocated shoulder (service No. 23650) pays $275.70. Removing a
bunion: $492.35. Removing an appendix: $621.31. Removing a lung:
$1,662.34. The best-paid service on the list? Surgical reconstruction
for a baby born without a diaphragm: $5,366.98. The lowest-paying?
Trimming a patient’s nails (“any number”): $10.15. The hospital
collects separately for any costs it incurs.

The notion
of a schedule like this, with services and fees laid out