Another Modest Proposal*: Paying for Physician Training

Paul Fischer

One of the main considerations in physician pay under CMS’ relative value system is the training required to complete a task. This is generally thought to be well understood but is, in fact. a quagmire of controversy.

Take for example the specialty of family medicine compared with dermatology, anesthesiology, or ophthalmology. Family physicians make between 1/2 and 1/3 of what these other specialties make, so one would think that there is a huge training difference. The truth is that each of the four require 16 years before medical school, 4 years of medical school, and 3 years of residency.  The 3 highly paid fields require 1 additional year in a transitional internship.  So the family physician education represents 23/24 or 96% of the length of education required for the others.  Since when is a 4% investment worth a 200% to 300% return?

There are, of course, longer training programs.  Internal medicine fellowships are 2 to 3 years on top of a 3-year residency.  There was a time when this made sense, since the idea was to educate competent general clinicians and then for them to specialize in a narrower field.  Given the limited general physician work of, let’s say, cardiology, one could easily argue that the 3 years of internal medicine training are wasted. Should cardiologists, therefore, be credited with 23 or 26 years of training? It would obviously be more efficient to move these physicians directly from medical school into the cath lab.

There are some physicians who keep going on and on in their training, completing one residency and then another. One fellowship and then another.  CMS must come up with a numerical way to appropriately compensate these individuals for their time, yet discount it for any lack of relevance that their training might have for performing a particular procedure.  Take, for example, the resident who completes his general surgery training then goes on to do a fellowship in vascular surgery, then goes into practice and limits his practice to the laser closure of veins, a technique he learned in a weekend CME meeting.  Should this physician’s income reflect 7 years of training or 3 days?

I have always argued that the year you learn the most is the year you first go into practice.  It would certainly seem appropriate, then, to give everyone credit for this 1 year of training.  But what do you do with compensation for training after that, given that almost all physicians are engaged in work that requires lifelong learning?  It would seem a reasonable solution to give credit at .5 of a YOT (year of training) for that first year and for up to 20 consecutive years. After that, you would subtract .25 YOT for each subsequent year, acknowledging that some of what you had learned by that time would be out of date. Passing a mini–mental status exam on an annual basis after age 60 would also be required to know whether any financial advantage at all should be given for previous training.

It would obviously be essential to add training income for CME.  I would personally be opposed to awarding such training time for drinking coffee in the doctor’s lounge while watching FOX news.

So, be very careful when you emphatically state that all of your long education merits more pay.  Someone may want to actually count.

*In an earlier essay, the author proposed collapsing all specialty procedures into 4 CPT codes.

Paul Fischer MD is a family physician at the Center for Primary Care in Augusta, GA. He is lead plaintiff, with five of his primary care colleagues, in a law suit against CMS and HHS, claiming that those agencies’ reliance on the AMA’s RUC has been out of compliance with the Federal Advisory Committee Act, because they have failed to require that committee to adhere to the Act’s management and reporting rules. See Replace the RUC for more information.

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