Medicine & the pursuit of wealth.

Why become a physician? I recently spoke with two premedical students who offered remarkably diverse responses to this question. The first student, echoing the professed sentiments of many of her peers, responded reflexively that she had chosen medicine because she wanted "to help people." This response has been served up so often in medical school admissions interviews that I greeted it with the relish one would accord a stale loaf of bread. In medicine, we have often tended to take for granted altruistic motivation, with the result that the intention "to help people" has come to seem rather insipid. My lack of enthusiasm was reinforced when, upon further questioning, the student was unable to articulate any compelling vision of the special opportunities or challenges physicians face in attempting to help their patients. The second student, responding with a degree of candor uncharacteristic of premedical students, leaned forward and in a somewhat conspiratorial tone confessed that he wanted to become a doctor to get rich. He knew, he said, that the typical physician is far from wealthy, garnering an annual income only six times that of the average full-time wage earner. Yet he also knew that some subspecialists can earn considerably more, and he planned to parlay his relatively small investment in medical training into a fortune, by setting up a cosmetic surgery practice in a well-to-do area of his hometown. In contrast to the response of the first student, this answer immediately aroused my full attention. My interest stemmed in part from the fact that such candor is so infrequently met with, and in part from the fact that the motivation itself is so intriguing, especially today. Ours is an era in which the jargon of the business schools plays a growing role in the discourse of medicine. Health care is increasingly regarded as a business, the physician as a businessman, and the coin of commerce serves increasingly as the common currency of medical discourse. Patients have become "health care consumers," "clients," or even "customers." In these economically dominated times, it is Curiously engaging that tomorrows physicians should so forth-rightly express an entrepreneurial calling to medicine. Some would argue that the infiltration of sound business principles into the organization and finance of health care should be welcomed with open arms. For too long, physicians and patients--the vendors and consumers of health care--have acted in blissful ignorance of harsh economic realities, shielded from economic exigencies by insurance intermediaries with deep pockets and no immediate incentive to contain costs. Over the course of three decades, however, this arrangement permitted health care costs to balloon from 6 to 14 percent of the U.S. gross domestic product. As health insurance premiums and the costs of government programs such as Medicare and Medicaid continued to rise, payers began to grumble, first quietly, and then ever more insistently, about the renegade cost of health care. Through such devices as diagnosis-related groups (DRGs) and managed care, payers are now attempting to halt the gravy train, by ceasing to reward physicians and patients for spending more money. Managed care represents a shift in health care paradigms, from one in which the physician starts the day with an empty pail into which additional money is placed with every test or procedure ordered (fee for service), to one in which the physician starts the day with a pail of money from which withdrawals are made for each intervention (capitation). In the former paradigm, the more tests I perform, the more money I have at the end of the day; in the latter, the more tests I perform, the less left for me. As a result, physicians have begun to order fewer tests, and the rate increase in health care costs has showed signs of decline. Yet the infusion of entrepreneurial ethos into medicine is not altogether a hopeful sign, and while the second student's lust for riches may have seemed intriguing, it also gave me pause. …