As Physicians’ Jobs Change, So Do Their Politics

They are abandoning their own practices and taking salaried jobs in hospitals, particularly in the North, but increasingly in the South as well. Half of all younger doctors are women, and that share is likely to grow.

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states. {…}

Because so many doctors are no longer in business for themselves, many of the issues that were once priorities for doctors’ groups, like insurance reimbursement, have been displaced by public health and safety concerns, including mandatory seat belt use and chemicals in baby products.

Even the issue of liability, while still important to the A.M.A. and many of its state affiliates, is losing some of its unifying power because malpractice insurance is generally provided when doctors join hospital staffs.

Because doctors are, apparently, completely unaware that the medmal liability insurance that their employer has to pay on their behalf comes at the expense of the value that they add (and therefore the compensation they can demand) to the overall organization. Oh, and the reimbursements they make are completely unrelated to how much of a salary that they can expect. I can buy that these things are not as much on the forefront of their minds as they previously were since they are negotiated or paid by their employer, but there’s something in the air in Maine if doctors up there no longer think medical malpractice doesn’t matter to them. Or more likely, it’s not an issue there because the issue isn’t pressing because Maine has remarkably low malpractice insurance rates despite the lack of traditional tort reform.

It also entirely contradicts my experience. Even in tort-unfriendly states, frivolous lawsuits weigh very heavily on doctors minds. It weighs on my wife’s, despite the fact that her medmal is paid for. It matters above and beyond dollars and cents. It’s partly a matter of pride, wherein a doctor doesn’t want to have to explain to a jury of 12 people who know little of medicine while the baby didn’t have a chance while John Edwards is on the other side talking to the dead baby’s spirit. Maybe this is impossibly arrogant. Maybe this is foolish. But in the years I have been surrounded by doctors – some liberal, some conservative – I have never once heard that it’s not a big deal. If anything, I think that they are too obsessive over it. But then, that’s easy for me to say because it’s not my ass – and career – on the line.

Unfortunately, this “see, they’re coming around!” tone taints my view of the rest of the article. But really, I think that there is something to the article in its totality. Particularly in family medicine, which is disproportionately populated with women and less entrepreneurial men. But I wouldn’t be surprised if it’s happening more generally. Doctors are, I think, caught between two realities. The first is that they have lived in a very Republican world. They worked hard, they were smart, they got ahead. Others that worked hard and were smart got ahead, too. It’s a very meritocratic atmosphere. Then, when they’re out of their education and residencies and/or fellowships, they are thrust into a world where they have mountains of debt but are getting taxed like they’re rich. Further, they’re taking care of people who have often broken their own bodies through ignorance or gross misjudgment and expect someone else to put them back together (almost always having worked in charity hospitals, where the expectation is that you will do so on someone else’s dime). This all lends itself to a more conservative worldview. Even the liberal docs I know have suspicious attitudes towards those below the working class.

But on the other hand, there’s this: they’re educated, high-earning individuals. This group has been trending Democratic for a while now. Regardless of the merits of conservatism and the Republican Party, the peer pressure is leaning against it. The Republican Party has become increasingly embarrassing, on a social level. The party that went from embracing George H. Bush to embracing his son to embracing Sarah Palin. Yes, yes, conservatives can argue that George W. Bush wasn’t actually conservative or was a RINO, but among the friends and colleagues of educated individuals, that is not the perception. Medicine and engineering seem to be the last two strongholds of educated, white collar (or white coat, anyway) Republicanism. So, especially when considering the demographic shifts (women into medicine, foreign imports into engineering), it’s not surprising to see the movement.

Obama, whether by benign policy or crude politics, is making the transition particularly easy for primary care physicians. Regardless of our resistence to his health care plan, there is at least the sense that Obama “has our back” in a way that previous presidents did not. By “has our back” I mean the backside of primary care docs and their families. He named a primary care doc as surgeon general. His reimbursement restructuring favors primary care over specialists. At least rhetorically, he “gets it”. He also defines “rich” as income above what most primary care physicians will make (and those who do make that much are more likely to have been doing it a while and less anxious about it). If it’s all rhetorical or political posturing, it’s really quite shrewd. Driving a wedge between primary care docs and specialists isn’t particularly hard and primary care docs are more likely to be supportive anyway, for a variety of reasons (more likely to be female, less likely to be money-driven).

I don’t know how this would translate to specialists, though, and the extent to which the Democrats may be making gains there. Obama hasn’t been as kind to them, though he might not need to be. Since they earn a lot more than their primary care counterparts, they might feel less stingy when it comes to taxes as they can pay off their student loans and such a lot faster than primary care docs can.

Or it’s possible that the NYT is drawing a trend from nothing but some weirdness in Maine.


Category: Hospital, Statehouse

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19 Responses to Medicine & Politics

  1. Barry says:

    “Because doctors are, apparently, completely unaware that the medmal liability insurance that their employer has to pay on their behalf comes at the expense of the value that they add (and therefore the compensation they can demand) to the overall organization. ”

    In general, large groups negotiate better rates. If you were a small-gropu practice, you’d have to negotiate with professionals; in a large institution you have your own professionals to negotiate with them.

    “The first is that they have lived in a very Republican world. They worked hard, they were smart, they got ahead. Others that worked hard and were smart got ahead, too. It’s a very meritocratic atmosphere. ”

    I’m sorry, but what world are we talking about? The GOP seems to be composed of crony capitalists and grifters. Please note that Silicon Valley isn’t a hotbed of GOP sentiment. Nor Hollywood, despite that being a world capital of extremely successful and profitable US companies which compete on a world-wide basis. Go to hotbeds of actual entrepreneurialism (i.e., ones where the business plans generally don’t involve getting a government contract through a well-bribed Senator) and see what the breakdown is.

    And now we get to the heart of things:

    “But on the other hand, there’s this: they’re educated, high-earning individuals. This group has been trending Democratic for a while now. Regardless of the merits of conservatism and the Republican Party, the peer pressure is leaning against it. The Republican Party has become increasingly embarrassing, on a social level. The party that went from embracing George H. Bush to embracing his son to embracing Sarah Palin.”

    ” Yes, yes, conservatives can argue that George W. Bush wasn’t actually conservative or was a RINO, ”

    Yes they can, but that tended to be a phenomenon which happened *after* it was clear just how much Bush II screwed things up. And even on the way out, he had favorable ratings from (IIRC) 30% or more of the American people, and far better ratings from self-identified conservatives. ‘Bush is a RINO’ is simply a lie; and ‘Bush isn’t a conservative’ really doesn’t mean anything, because actual conservatives are thin on the group. Bush was a right-winger as are most Republicans.

    “but among the friends and colleagues of educated individuals, that is not the perception. Medicine and engineering seem to be the last two strongholds of educated, white collar (or white coat, anyway) Republicanism. ”

    A party which publicly disdains knowledge, education and science does have these problems. BTW, I wouldn’t be so sure about the one for engineers; that could easily be something which hasn’t been true for a couple of decades. Some of the same factors affect this: Republican war on science, Republican right-wing social/religious culture war, more women and foreigners, as well as the fact that engineering doesn’t carry the status that it used to (I did a search, but was unable to find the figures).

    “So, especially when considering the demographic shifts (women into medicine, foreign imports into engineering), it’s not surprising to see the movement.”

    And a party which still has problems with women, foreigners and people of a (how shall I say) less beige hue will continue to have these problems, until a few decades down the road, when the definition of ‘white’ gets rejiggered, and the last reactionary ‘Kinder, Kuche, Kirche’ right-wing leaders have joined history. We just saw the GOP base soundly kick Hispanics off the bus and under the wheels, with people like Karl Rove saying ‘Nooooooo!’. And that base reaction is now solidly entrenched in the state GOP legislatures and governorships in several states (largely ones where ‘War of Northern Aggression’ is a favored term).

    For medicine, there’s, there’s also the status shift over the past 20-30 years. Back in in the day, the (white, male) doctors called the shots, and the insurance companies paid. That put them into a good position. Now, the insurance companies have far more control, which has economically demoted a lot of doctors. This also has effects on entrepreneurialism; any doctor setting up a small-group primary care practice is now effectively a contractor/supplier to the insurance companies; they have to run their practice by others’ rules, and scrounge to get paid. More than in the old days, because it’s no longer a matter of getting patients to pay, but of getting megacorps to pay, when they have professionals incentivized to squeeze the doctors hard. I recall an article about a service which coded doctor’s billings, advising them what to bill, with different protocols for different insurance companies. They boasted that they could get the ‘no-pay’ rate down to 25%. That was what they *bragged* about.

    I’ve seen this in liberal analyses of the situation, as well, where GOP/Democratic support is graphed over 40-50 years for various job goups, with no mention of the fact that many of these saw sharp social changes over this time.

  2. trumwill says:

    Barry, I’m writing this from my phone, so I’ll have to keep it short-ish.

    The “world doctors live in” is the world of their careers. If you do what is expected of you, you will do quite well, financially. See more patients, perform more procedures, get into a more lucrative specialty, you make more money. This is in contrast to, say, Hollywood, where success is (or seems) arbitrary and even if you succeed there, most of the people you started out with are likely still living hand to mouth. Silicon Valley is somewhere between the two. Meritocratic, but also risky. Get a job at the right startup and you will be a millionaire, get a job at the wrong one and you will be starting over and unemployed. With doctors, almost none will ever make millions a year (as doctors) and very few will make less than six-figures unless that’s what they want.

    So when Republicans talk about meritocracy and getting ahead through hard work, talent, and perseverence, it rings more true than with other professions (even if the GOP is being entirely disingenuous).

    My experience with engineers is that they still tilt to the right, by and large. Their world is actually not all that dissimilar to that of doctors. And, of course, they trend male. This is certainly subject to change with more and more Asian-Americans entering the field and with the same peer issues that exists with docs.

    (Also, I have to mention this as I do with conservative commenteers. We like to keep things at Hit Coffee as non-partisan as possible. And we try to avoid demonizing people with which we disagree and groups that we don’t like – this comes up with immigrants quite a bit – with somewhat rare exceptions like the FLDS. This post falls mostly under the cover of analysis and perceptions, not who is necessarily right and who is wrong.)

    (Post modified by author)

  3. Maria says:

    Texas tort reform seems to have worked in reigning in outrageous malpractice suits:

    http://www.ama-assn.org/amednews/2011/06/13/prsd0615.htm

    Texas has also recently implemented a “loser pays court costs” system for lawsuits, similar to what is in place in Britain. I wonder what the impact will be.

  4. Mike Hunt says:

    The first is that they have lived in a very Republican world. They worked hard, they were smart, they got ahead. Others that worked hard and were smart got ahead, too. It’s a very meritocratic atmosphere.

    Ah ha. The Republican propaganda machine makes its appearance on Hit Coffee.

    Or it’s possible that the NYT is drawing a trend from nothing but some weirdness in Maine.

    The NYT is famous for extrapolating trends from anecdotes.

    ===

    Generally speaking in life, the more women and minorities are in a profession, the less respect it gets. Tangentally to that, I was reading an article from the 70s about the importance of heart rate to health. The pronouns in the article made it very clear that the doctor was a man and the nurse was a woman. For example: When you visit the doctor, the first thing his nurse does is take your pulse. She keeps track of this information, along with your height and weight.

  5. web says:

    There’s an old saying about familiarity breeding contempt that I think applies. Doctors who primarily treat lower-income people are likely to see people who are lower intellect, who come up with some pretty stupid ways to injure themselves or engage in bad lifestyle choices.

    On the other hand, it’s much easier to fall into bad lifestyle situations or fail to maintain your body adequately when you don’t have safe public parks/areas to exercise in, safe public streets to go running/jobbing on, your nearest food options are either fast food or grocery stores where the produce section is a joke, and can’t afford personal trainers.

  6. David Alexander says:

    they are thrust into a world where they have mountains of debt but are getting taxed like they’re rich

    I was about to write about how paid student loan interest is tax deductible, but given the immense debt that one faces after medical school, I suspect that one would easily reach limits very easily.

    Of course, all of this makes an argument for the government to fully-fund medical school to avoid to this issue.

  7. David Alexander says:

    Texas has also recently implemented a “loser pays court costs” system for lawsuits

    I would argue that before we magically impose tort reform, we need to determine how many cases of malpractice are questionable at best and how many are valid. Unlike countries with “free healthcare”, if a doctor screws up in the United States, the only recourse to pay for whatever extra treatment one may receive may end up coming from the malpractice lawsuit in the case of some. The question is if marginal malpractice cases will lose the awards that they should be entitled to due to the fear of losing.

  8. trumwill says:

    Ah ha. The Republican propaganda machine makes its appearance on Hit Coffee.

    On the contrary. I submit that the world in which doctors live in is unusually meritocratic. Meant to be implied was that most of us don’t live in such a meritocratic world.

    The NYT is famous for extrapolating trends from anecdotes.

    Well, there is that. At least they did the legwork and talked to some of the state medical industry lobbyists rather than talking to a handful of doctors saying “Sarah Palin was THE LAST STRAW” or somesuch.

  9. trumwill says:

    I was about to write about how paid student loan interest is tax deductible, but given the immense debt that one faces after medical school, I suspect that one would easily reach limits very easily.

    I’ve been meaning to post on this. But there are some rather odd incentives, at least among some docs, not to pay off their student loans in as timely a manner as they could.

    Unlike countries with “free healthcare”, if a doctor screws up in the United States, the only recourse to pay for whatever extra treatment one may receive may end up coming from the malpractice lawsuit in the case of some.

    I would point out that most of the time, the caps are limited to non-economic damages. Pain and suffering and so forth. That’s what gets doctors most anxious. On the other hand, it can strangely leave providers better off if the patient dies than if there is some lingering, costly condition.

  10. trumwill says:

    On the other hand, it’s much easier to fall into bad lifestyle situations or fail to maintain your body adequately when you don’t have safe public parks/areas to exercise in, safe public streets to go running/jobbing on, your nearest food options are either fast food or grocery stores where the produce section is a joke, and can’t afford personal trainers.

    No doubt, being able to afford trainers and club membership can make a difference. With fast food and the like, what you get out of it is what you make of it. I would like to think that better produce would make more of a difference, but I’m skeptical.

  11. web says:

    Will,

    Having been around people actually doing studies on this stuff, all people have a tendency to eat the food they can acquire fairly near to either their workplace or home. The foodstuffs in even mainstream grocery stores are less and less healthy and more and more packed with misleading claims about their healthiness (I laugh, for instance, every time I see the label “a fat free food” on a box of candy).

    Much as I hate to admit it, the less-educated sector of the population takes this kind of crap at face value. The kind of person who actually believes that a Fruit Roll-Up qualifies as one of their daily servings of “fruit” for instance.

  12. ? says:

    I am always suspicious of the NYT’s motives in publishing a story like this as it seems to me that they are lauding the trend. It is no surprise that left-leaning folks applaud physicians becoming slaves, but I still can’t fathom how social wedge issues trump that concern in the minds of doctors themselves.

    Specialist incomes vary widely, by the way. I am not a neurosurgeon or a radiologist, and the reductions in feimbursement will have a lasting unfavorable impact on people in fields like mine. It will not only make it harder to pay off loans, find a spouse, support a family, or save for retirement, but it will also wreak havoc on the job market. Neither hospitals nor private groups are eager to hire specialists when they fear declining revenue. Was this future really worth 10+ years of my time?

  13. Brandon Berg says:

    Grocery stores in poor neighborhoods don’t stock produce because poor Americans don’t buy produce. A trip to Chinatown will confirm that the causality runs in this direction and not the other.

  14. web says:

    Brandon,

    that’s circular logic. I could easily point out that when I go to the grocery store near my house, I buy produce – the produce is fresh and appealing.

    I wouldn’t touch the produce at the grocery store near my workplace, however. I’ve watched it being delivered and unboxed and even before they put it on the shelf it’s already wilted and nasty.

    If I were poor, and that was the only produce at the grocery store? Yeah, the boxed stuff would be a lot more appealing.

    Strangely, canned vegetables are cheaper (and more often on sale!) at my local grocer as well.

  15. Barry says:

    Will, I apologize for the tone of my comment – it was unnecessarily partisan and harsh.

  16. Barry says:

    Will: “The “world doctors live in” is the world of their careers. If you do what is expected of you, you will do quite well, financially. See more patients, perform more procedures, get into a more lucrative specialty, you make more money. This is in contrast to, say, Hollywood, where success is (or seems) arbitrary and even if you succeed there, most of the people you started out with are likely still living hand to mouth. Silicon Valley is somewhere between the two. Meritocratic, but also risky. Get a job at the right startup and you will be a millionaire, get a job at the wrong one and you will be starting over and unemployed. With doctors, almost none will ever make millions a year (as doctors) and very few will make less than six-figures unless that’s what they want.

    So when Republicans talk about meritocracy and getting ahead through hard work, talent, and perseverence, it rings more true than with other professions (even if the GOP is being entirely disingenuous).”

    (sorry for the long quite).

    Will, the main thing about your description medical world is that the applicable word is not, ‘entrepreneurial’, but rather ‘organizational’. Similar to somebody getting a really good education, and being hired by a blue-chip firm.

    The point about success in Hollywood and Silicon Valley riding strongly on luck simply confirms the entrepreneurialness (entrepreneuriality?) of the system. Entrepreneurs take risks; they might make it big, they might go bankrupt, they might make a reasonable amount (which wasn’t worth it, considering the risks). Entrepreneurs take risks; they might come into the market with the right product/service at the right time in the right manner, and find that due to a couple of large contracts, a rival got a jump in the market which allowed them to dominate. Entrepreneurs take risks; they might find out that the market shifts quickly and strongly against them, so that last’s years good bet is now this year’s bet on a lame horse.

    In many ways, entrepreneurialism is not meritocratic, because it relies how huge amounts of luck.

  17. trumwill says:

    Barry, I largely agree. It’s less the risk-reward entrepreneurialism and more the work-reward aspect of it. Financially, there are few risks involved and therefore little luck is required. Do these things, make good money. Work harder, be smarter, be more ambitious and you’ll make more money, though. But it’s quite a different sort of thing than risk-reward entrepreneurialism, where the path to success is less proscribed.

    Another example of work-reward entrepreneurialism is car sales, which also apparently tilts to the right (this came up when someone accused Obama of closing down Republican car dealerships and someone else pointed out that most car dealerships are so). Starting up a car dealership is certainly riskier than starting up a practice, but it’s still a well-beaten path where minding your money and making your sales gets you ahead. I think it’s these environments where one becomes most inclined to believe that you get ahead by working hard and doing what you’re supposed to do, which is something that Republicans emphasize to a greater degree.

    (Regarding your original comment: no problem. Different places invite different sorts of conversations. It’s not uncommon for people new to HC to not immediately see that it’s more a coffeehouse and less a battle arena than other sites. I’ve “misread” sites like that before.)

  18. trumwill says:

    Web, I don’t think it’s a question of “circular logic” but rather of questioning causation. Do people in poorer urban areas buy less produce because it’s not fresh, or is it not fresh because it’s not worth the investment of places that serve these demographics to keep fresh produce stocked?

    I don’t know that there’s a clear answer to this. I think it’s true that people would probably buy more produce if it were fresher. But I also think that the costs of fresh produce exceed what these places would make… which is why they don’t keep the stock fresh. In places where fresh produce does sell, as Brandon points out with Chinatowns, it is more likely to be available.

  19. Mike Hunt says:

    Barry: Will, I apologize for the tone of my comment – it was unnecessarily partisan and harsh.

    Come on now Barry. Posting on the internet means never having to say you’re sorry.

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