Saturday, December 18, 2010

Talking Dollars and Sense: What Money Says about Physician Value – Monetary roles in social status and value - Torey Lipscomb

Money talks. It has the ability to tell complex stories at face value. It can speak to the apparent value of family names and the homes that come with it. It can show one’s interests through purchases. It can express national wealth and worth when compared with other nations. It can also tell how valued one is. While this statement is on the extreme end of provocation, it also shows how dollars and cents allow humans to convey value. That is, while money is certainly not the entire story, it is a significant portion of it. Money helps describe your supposed status in society through material wealth: housing, cars, clothing, and education for example. And, as a result of this, societies reward work which can be deemed as valued with the almighty dollar. This is certainly the case in medicine and health care in the United States. Currently, around one-third of all practicing physicians are in primary care which places the United States primary care physician per capita below most industrialized nations. What’s worse, only one-fifth of current medical students have the intention of entering primary care (1). Mostly, this is attributed in the large--and growing--income gap between generalists and specialists (1, 2, 3). While efforts have been implemented which successfully increased primary care income, this has come at the price of further increasing that of the specialists in a commensurate fashion. Therefore, the gap is perpetuated. This paper will argue that while money is an extremely important part of solving the primary care shortage policymakers have largely engaged in a retroactive attempt to raise and (somewhat) equalize incomes. The main flaw in such reasoning is that the underlying assumptions ingrained in American lay and medical culture remain unaddressed and unchanged. By addressing the norms and societal-level messaging surrounding primary care physicians in comparison to their specialist counterparts, higher impact and longer lasting changes can be made in addressing the income gap which can result in greater motivation to enter primary care.


Historically, general practitioners were among the most revered in the medical profession. Highly respected for the breadth of knowledge to see, problem solve, and effectively diagnose very diverse patients, successful treatment was seen as a mark of excellence in clinical ability and judgement. In addition, the personal relationships built ensured the physician knew their patients’ histories in and out. This could be said to be the golden age of general and family medicine: autonomy, respect, patient satisfaction, challenging clinical work, and a fair rate of compensation (4). However, largely due to accident, there was a shift in the professional structure of American medicine which created a hierarchy. During the post-World War II era when many Westernized nations adopted more comprehensive and societal-based health care systems, Americans continued operating on the values which made them fundamentally American: hard work and democratic freedoms are the keys to success. Thus, while many of the European nations were in fiscal dire straits, the United States experienced a stable economy and a flurry of new successes (5). Historically, post-war conditions have presented ideal conditions for investments in social policy. Economically distraught nations tend to put substantial emphasis on social policy, as it is seen as key to restoring stability and infrastructure in the nation. This is precisely what allowed medicine to become a social good in Europe and Japan (5). However, those who fare better do not place a similar emphasis on social goods. The latter scenario categorized decisions made in post-war America. While many other nations either had or started national health insurance programs, the United States established national programs for returning servicemen but chose to develop privatized insurance policies for those who could afford them (5). Coupled with hospital insurance policies, the medical profession could for the first time be certain of full compensation from each patient. This led to a flurry of new residencies and private practices. And, as reimbursement methods changed, it became clear who had the most political leverage: specialists (2, 3).

Mass media, professional culture, and social expectation & organization

These increases in reimbursement rates for specialty physicians not only provided enormous economic incentive to enter a specialty, but also created a shift in values surrounding physician type (2, 3, 4, 6). Particularly coupled with technological advances and the American desire for empirical and definitive answers, specialists became more prominent and utilized given their access to diagnostic equipment. These notions became reinforced in the media through hospital advertisements touting trauma center status, availability of MRIs, and in-house specially trained doctors who can meet any range of diagnostic needs. In addition, television shows such as General Hospital; Doogie Howser, MD; ER; Scrubs; Nip/Tuck; and Grey’s Anatomy have reinforced the high value of intervention medicine and excessive technological utilization. This increase in value is reinforced by social expectation theory, stating that individual behavior and choices are shaped by a desire to conform and meet the expectations of others (7). This can occur through experiential learning or through external sources. Particularly true with medical culture, mass media portrayal of medicine’s and physicians’ potential in a specialized sense helped to externally shape America’s view of medicine. Even more pertinent is the role of social organization theory, which gives rise to societal norms, roles, ranking, and sanctions surrounding specific groups and behaviors. Ranking can be seen as very influential when dissecting value shifts in medical culture. As media portrayals of emergency medicine, highly technical medicine, and surgery increase, changes in the hierarchical order of physicians occur. In addition, tying this order to reimbursement rates offers another source by which this shift occurs. Lastly, “sanctions” (such as through the level of reimbursement, lobbying abilities of professional groups and their level of success, and structural characteristics of Medicare and Medicaid payments) are in place that further reinforce this new professional order in medicine. As currently used, social organization and expectation theories indirectly support and further the income gap among physicians.

Retroactive solutions: a flawed methodology

Through policy and legislative attempts, it is clear that Americans feel there is a need for primary care physicians and, currently, an imbalance in how we reward their efforts. Thus, the United States has engaged in retroactive solutions to equalize the playing field as well as incentivize medical students to enter primary care (8). By marginally raising wages for primary care physicians in ways that are asymmetric to specialists’ current rates or subsequent specialist increases, the value of primary care remains unchanged. This, again, is not so much an issue of overall income but income as related to perceived peers (6, 9, 10, 11). The system is currently structured in a way which silos primary care from all other care. As a result, established ranking systems are reinforced and become more deeply ingrained. In addition, by relying on such retroactive methods such as loan repayment through the National Health Service Corps or other incentive-based programs physician retention has been shown to be rather low (8). The small time commitment needed to relieve debt serves as just that: a way to start fresh and enter a higher paying, higher valued specialty field post-service. Physician retention upon completion is around 50% less than that of primary care physicians not participating in such scholarship programs. In addition, retention rate stratified by training (i.e., family medicine versus any other field) shows a similar trend (8). Essentially, these programs elicit the very opposite of their desired outcomes.

In fact, these methods rely on theoretical bases of expectancy, agency, and social-cognitive theories (12). These theories all essentially say that incentives (intrinsic, extrinsic, or both) affect a person’s level of effort and ultimate performance. That is, these theories rely on an individual’s expected utility in predicting performance (12). For physicians, this correlates to relative, as opposed to nominal, income level. Retroactive methods do not adequately address relative income, and it can be argued it is not addressed at all. In fact, generalists and pediatricians suffered an average real income loss of 2.13% while specialists experienced real income increases as high as 9.1% (13). Compensation is certainly an extrinsic predictor of performance, particularly when coupled with intrinsically rewarding work, which can lead to increased effort (12). However, until the value of physicians is addressed by way of equalized incomes monetary incentives will continue to be ineffective in recruiting primary care physicians (4, 12).

Methods of motivation: does money or value talk?

Any approach taken to increase primary care physician supply has relied solely on extrinsic monetary motivation versus other sources of motivation. While this can be attributed to the nature of policy and relative ease by which fiscal solutions can be administered on a large scale, it has not and will not provide the desired results. Particularly true of primary care, medicine is a field of inherent intrinsic motivation and an array of extrinsically motivating factors (4, 6, 9, 10, 11). Studies show medical professionals are among some of the most committed to their occupation and most strongly motivated by their work itself, as opposed to businessmen, who cited time for family and income aspirations as the highest motivating factors (9). These findings contradict former and current policy solutions to increase physician supply. What’s more, physicians are much more likely to indicate highly valuing the “social status or prestige” of their occupation as compared to businessmen or those in general occupations (9). In addition, meeting parental expectations and garnering respect in their professional community were most important for medical professionals as compared to other groups (6, 9). Therefore, norms, hierarchy, and perceived value are much stronger for physicians than for other professions (6, 9). These are largely influenced by personally motivating factors of the medical profession which consist of value and rank versus money made (9). Instead of using the culture of medicine, policymakers and legislators have relied solely on monetary motivation and highly visible, yet unsuccessful and costly, solutions to the primary care shortage.

Further evidence of monetary incentives’ limited success, higher levels of debt upon graduation from medical school were not associated with lower likelihood of choosing primary care or work in community health centers relative to no debt (6). That is, debt was not the most significant factor in deciding to enter primary care. What does seem to be more predictive of primary care practice is exposure to an educational environment which values primary care, such as public medical schools and exposure to Title VII (6). Therefore, primary or specialty choice is not exclusively influenced by income. Rather, it is highly influenced by educational institutions and experiences with primary care, further emphasizing the need to increase perceived value of primary care physicians (4, 6).

An additional proposition to increase access to primary care is through the expansion of nurse practitioner and physician assistant roles and duties. While this may increase the supply somewhat, it will almost certainly further limit the number of medical students who enter primary care. Not only would such primary care expansion largely shift the role of primary care physicians to that of manager, but it would also further devalue primary care within the medical community (4, 6). This would be a short term solution with negative long term implications for survival of primary care physicians.

Summarizing decreased value

In summary, decisions were made at the inception of individual health insurance that created a system of payment which tended to value and empower specialist physicians more so than physicians in primary care. This payment system shifted the public and medical perception of value to give deference to specialists, further incentivizing medical students to pick specialty positions versus general ones. Mass media sources, such as hospital advertisements and television shows, portrayed good and normal care as that with high utilization of technology and specialty care. These factors further increased the income gap for primary and specialty physicians. Policymakers and legislators then resorted to retroactive solutions, such as the National Health Service Corps and commensurate primary and specialty pay rate increases, to incentivize more medical school graduates to enter primary care and give the perception of rising income. Such solutions are fundamentally flawed, as they primarily address extrinsic factors of motivation and reinforce the hierarchical value system among physicians. The second portion of this paper will propose new solutions to this complex issue which work to undo the consequences of failed attempts in the past.

Restructured values: recognizing the role of professional worth

In order to increase the number of primary care physicians, values ingrained within the professional community must be restructured. It is necessary to increase the perception of worth and ability of generalists, while not necessarily adjusting values surrounding specialists. While this is certainly vital within the professional community, this effort must filter to the masses as well. Lay perception of primary care also needs to change with that of physicians. While social expectations and organization theories have been ineffectively used in the past when shaping medical culture, these theories still present a promising and relevant opportunity to shape medical mass media (7). As seen with portrayal of tobacco use in movies, public health campaigns can have influence over media exposure (14, 15). For instance, after introduction of campaigns to reduce tobacco use in blockbusters in 2001 PG-13 rating movies consistently portrayed tobacco use less than 50% of the time (14). In some years, portrayal percentage was as low as 39% (14). The thrust of the Smoke Free Movies campaign is Big Tobacco’s manipulation of youth, which it uses to “de-normalize and de-glamorize tobacco use” (15). Much like the truth campaign, Smoke Free Movies has relied on the theory of psychological reactance to reveal the role of tobacco companies in shaping youth behavior (15, 16, 17). In addition, as this is done on a large scale; addresses societal decisions; and is attempting to shift values, this campaign effectively utilizes theories of social expectations and organization to get desired results (7).

In addition, use of the law of small numbers may add salience to primary care. By highlighting patient profiles which required surgical or acute intervention (read: specialty care) that led to a negative outcome (e.g., injury, hospital acquired infection, or other comorbidity) which could have been avoided through proper primary care, the value of primary care can be further developed. Particularly by citing failed procedures and premature death, the need for primary care physicians becomes readily apparent and may spark more student interest or increased pressure by constituents to fix the problem.

While exposés unveiling widespread manipulation by the medical profession or campaigns reducing faith in medical care are unnecessary, the theories proven successful in fighting big tobacco and generating salient awareness can be effectively used to increase the generalist workforce. By engaging in media campaigns which change the face of primary care physicians to laypeople and the medical community, generalists can be seen as highly regarded medical minds deserving of the same respect as their specialist counterparts (4, 6). In addition, as this movement is built, primary care may gain more lobbying leverage and attention at state and national levels of government. This is vital, as lasting and real change will come most certainly through policy effectively addressing the physician income gap. As was seen with tobacco in Hollywood, a push can be made to diversify medical professions portrayed in television shows and movies (14, 15). While subtle, it can work to shift the perceived value of physicians across many disciplines. This is important when attempting to change established norms and defaults for behavior in society (7). It is important to note that these theories lay a framework by which change can begin and is not, however, a comprehensive approach to the primary care shortage. In addition to mass media, the target audience (particularly timing of audience exposure) and perception of incentives are of paramount importance (7, 8, 19).

Currently, attempts to increase primary care physician supply rely on retroactive attempts post-medical education. However, as seen through Title VII funded and public institutions’ ability to produce more generalists upon graduation , these are not the most effective tactics. Efforts must be made prior to medical school, ideally at the societal level. This is important as it will further help to shift norms and defaults, as well as prime individuals for careers in primary care by making this a more salient profession (19). These are all aspects of the British behavioral economic model MINDSPACE (19). This important model presents policymakers and public health officials with the chance to simultaneously alter the status quo while drafting policies and legislation to reinforce these changes. Consisting of nine elements--Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitment, and Ego--which do not necessarily work in a linear fashion, this model attempts to unite rational and irrational individual behaviors into a societal framework amenable to policy intervention (19). While MINDSET will not be discussed in detail in this paper, a prior paper offers a description of this model and its applicability to the primary care shortage (MINDSPACE paper).

In order to effectively reshape medicine’s professional culture, timing of the message’s delivery is crucial. As discussed, many past and current efforts designed to increase the supply of primary care physicians rely on working backward. That is, by relying entirely on monetary incentives, policymakers have attempted to generate more interest in primary care after students have completed their medical education (8). Since medical education institutions (such as public versus private) seem to influence choosing a career in primary care, new efforts must target prospective students before entering medical school (4, 6). Mass media approaches already discussed will ensure the masses are exposed to this cultural change. In addition, undergraduate campuses, high schools, and community outlets could be targeted to ensure prospective students are exposed to primary care and its value. Current medical student recruitment is predominately targeted towards those in the biological sciences. In addition, scientific and medical research is valued by medical education institutions (4). These qualities are often less predictive of interest in primary care and family medicine, as they do not value the soft skills these physicians require (4, 6). By expanding recruitment efforts and targeting majors which may have students who value the nature of primary care, more incoming medical students could have a desire to practice generally (4).

Also, positive experiences with primary care physicians or community health centers increase likelihood of entering primary care (4, 6). Policymakers could designate funding which would create a shadowing program for students interested in a career in medicine. By seeing the positive impact these practitioners have, students may be more inclined to enter primary care and work to add value to the profession. One of the most important long run impacts of these approaches is increased political leverage. As more physicians enter primary care and show their ability and drive, their lobbying power will increase and help to start closing the generalist-specialist income gap.

In addition to primary care awareness pre-medical school and a broad level of exposure, it is critical for solutions to address other factors of motivation beyond compensation. Particularly for physicians, work motivation extends beyond compensation or bonuses. Physicians are highly motivated by public perception, prestige, social contribution, and esteem of colleagues (9, 10, 11). In addition, academic institutions promoting primary care and requiring more in-depth community health or primary care rotations produce more primary care graduates (4, 6). By increasing community commitment and primary care exposure in all institutions, schools could generate more primary care physicians by way of an intrinsically motivating academic environment instead of reliance on monetary contributions (4, 6). This, again, is an opportunity for policy making and could be dovetailed with MINDSPACE efforts to increase exposure and value of primary care. In requiring medical schools to increase primary care exposure and rotation requirements, students are primed for work in primary care and some of the current need of primary care become more salient. Over time, norms surrounding practice choice and student defaults will begin to reflect this commitment to primary care (4, 6, 19).
In sum, compensation is an important facet of any career. In addition to rewarding an individual’s effort, it conveys worth of the work done and establishes the value of the position within the workplace and society. This is particularly true in medicine. Physicians regard esteem of the community, parental satisfaction, and respect of peers as some of the most important considerations in career choice. That is, physicians tend to place a good deal of weight on their perceived value by others. Currently, American society offers little motivation to enter primary care: primary care physicians are drastically underpaid when compared to the remainder of their professional community and they are not valued within medical culture. By addressing the persistent income gap between generalists and specialists, more medical graduates will have increased incentive to enter primary care. In order to do so, the underlying norms, behavioral defaults, and other considerations must be adequately shifted. This can be done through increased presence of primary care and physicians in the media, targeting students prior to medical school, and acknowledging that not salary alone predicts behavior. Policymakers have the opportunity to increase the value of primary care through regulation of medical school curriculum, such as more exposure to community health centers, rural health, and other facets of primary care. This is a crucial time to do so, as currently there are insufficient primary care physicians. With decreasing levels of interest in primary care among students and increasing patient populations through insurance, this shortage is about to become more real and urgent. While difficult to align the interests of all parties involved, it is essential to solving the primary care crisis.
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