Are doctors paid well?

Are doctors paid well? 

Or are they normalised to the lack of a major motivator?

Young Bankers

A person known to me did an internship with a bank/financial services firm during the summer break at the end of the first year of a three year degree course. For those two months this bank intern was paid including allowances which works out pro-rata to about £21000 per annum. The hours were very long, typically from about 8.30 am to 10.30 pm the work was very demanding including working on live projects. The output was measured and critical developmental feedback was provided very frequently with no tick box exercises or euphemistic language. The allowances included dinner and taxi back home if the intern worked after 8 pm. On the first day the Managing Director of the firm set aside time to meet the intern before the start of the internship. Just before leaving the team gave the intern a farewell lunch at a Michelin starred restaurant.

All this for an intern with one year university education doing a summer job for eight weeks.

I know reliably that internships in banks after the second year in university is much more common and those youngsters are paid a little bit more.

The starting salary for investment banking and other higher profile areas in banking after a bachelors degree are $100000 to $150000 after bonuses. Starting salaries with an MBA ranges between $120000 to $220000. In the UK for a first year analyst in investment banking is £60000 without bonus (I learn that a few first year analysts make more than £100000 after bonuses). For other areas of banking the first year pay ranges from £40000 to £60000.

Young doctors

I looked at my junior doctors, house surgeons (now called Foundation Year One trainees) in the UK. After five to 6 years in medical school they are first responders to many critical situations that could involve risks to life and limb - their pay is £22636. They get no food from their hospitals even if they worked through their lunch/dinner breaks which many often do. They do not get any allowances. I am informed by quite a few house surgeons from many hospitals that they had not seen their consultants for up to five days and not seen their clinical directors for longer. When these house surgeons leave after four months of work (it used to be six months) it is not always they get a send off dinner and never in a Michelin star restaurant.

Hull York Medical School has recently required their senior medical students to do night duties which involves more than simply shadowing, possibly actual work such as clerking etc; these medical students are not paid for it. I am sure HYMS are not alone in this. I know of no medical student who worked in a hospital or GP practice doing supervised clinical work for which they got paid.

Some/Many India private medical college house surgeons see and treat patients without pay after having paid lakhs of rupees as capitation fees to enter medical school and then lakhs of rupees as course fees for 5 years.

Young doctors and young bankers, both need to have consistent excellent academic record and great CVs. They need to perform under high pressure situations within very narrow time constraints. The number of newly qualified doctors more or less matches the number of young graduates who enter the banking industry. Doctors work shorter hours, banking analysts do 100 hour weeks; however I have many years ago as a young doctor before the EWTR worked 80 hour weeks for many years and the pay was not equivalent to young graduate analysts in banking. Surely someone is bound to come up with the emotional argument of public money, please give it a rest for at least two reasons, junior doctors working with private healthcare providers do not get any higher pay and we constantly hear from the BBC and other public sector bosses about the need to pay themselves competitive rates when compared to private sector.

There is no question that doctors especially young doctors are not paid well. Add to that the longer very demanding education, the stress of dealing directly with individual members of the public's health in often resource constrained circumstances and the very restrictive regulatory atmosphere - the mix is quite a downer for most doctors. Having made a choice to do medicine most people switch to serving the public, relieving pain, noble profession type of thinking to validate their thinking and keep their sanity.

Any doctors in the rich lists?

Four out of 400 in the Forbes USA rich list have medical qualifications. Of these four only Gary Michelson ranked at 328 seems to have made his money from his practice as a doctor - he is an orthopaedic surgeon with 250 patents. Thomas Frist Jr is a medical doctor who made his money by running hospitals. Two other doctors made their billions by their involvement in pharma.

In the Forbes world rich list there is only one person who has made his billions through healthcare. Thomas Frist Jr of HCA  comes in at 262 in the world rich list, as already said he owns hospitals.

In the UK's list of billionaires there is no one who made their cash through healthcare (unless you include Branson who owns Virgin Health but I am not sure he made his billions from it).

Considering the fact that the need for healthcare is universal and eternal (as opposed to cola drinks or branded retailing being a non-essential option) it is very unnatural, strange that there are no doctors in the rich list.

Financial motivation is normal. Are doctors normalised to the abnormal?

Being a hands on doctor treating patients does not pay great.

So, not only a junior doctor is paid a fraction of what their banking colleagues are paid, they do not have a hope of every making it rich by treating patients as a clinician. Our reward systems do not seem to rate the direct saving of life, direct relief of pain and other direct clinical forms of patient contact very highly. There is no financial case for young highly intelligent, hard working high achievers to be doctors. Further, there are no future financial opportunities for doctors.

We may or may not want to or be able to remedy it. However when we look at the big picture and recognise that doctors are also normal human beings with normal emotions but have adjusted to the low finance reality there may be a certain element of hidden, difficult to explore, difficult to understand, motivational deficit which may be impossible to resolve. After all doctors may not be paid as much as bankers but they are paid much more than the rest of the working people; so any doctor who argues about not being paid well could be seen as greedy, unethical and unprofessional - so it is not the done thing. 

One major motivation in life, a normal wish that rewards are linked to effort, especially for the young does not exist for doctors. The medical profession will have this permanent cloud, this eternal chain to its feet in the form of direct financial or motivational levers which are unavailable. That will have its impact on society. The profession is now normalised to it hence unable to argue forcefully or think of innovative means to break through.

The medical profession is fighting the phenomenon of normalisation of the abnormal by confronting a large number of bad practices to improve patient safety (hand washing, routine catheterisation for surgery and many others come to mind). Will they be able to do the same for generally superior financial rewards for the whole of the profession?

©M HEMADRI

Follow me on Twitter @HemadriTweets

Selected sources:

http://www.businessinsider.com/10-richest-people-in-medicine-2012-9?op=1&IR=T

http://www.forbes.com/sites/edwindurgy/2013/03/04/the-worlds-richest-billionaires-full-list-of-the-top-500/3/ http://www.forbes.com/billionaires/list/#page:1_sort:0_direction:asc_search:_filter:All%20industries_filter:United%20Kingdom_filter:All%20states

http://www.careers-in-finance.com/ibsal.htm

Whose job is it in the NHS to reduce deaths and complications?

Recently there is an increasing concern about mortality and morbidity in the NHS. Let us for simplicity say that people are asking whether the death rates and complication rates can be reduced. People are asking if there are any avoidable components in relation to deaths and complications and whether those avoidable problems can be eliminated or at least reduced to minimum. People are also want to know who is responsible or accountable for ensuring lower death and complication rates.

NHS Directors

NHS trusts are in the business of delivering healthcare to their populations – that is the essential purpose of their existence. So it may be reasonable to assume that the directors, who are the top bosses of these trusts  and their bosses (SHA equivalent, NHS England directors) will be assessed and rewarded against clinical quality parameters of which deaths and complications are core.

Apparently not. The contract for the managers especially when it comes to pay uplifts and bonuses are very specific. I quote:

''It is an essential criterion of the performance bonus scheme that the organisation achieves its financial control target as agreed with its grand parent organisation (see paragraphs 64 and 65 below).

Where an organisation fails to do this, all its very senior managers will be treated as Category D performers and so no awards (either annual uplift or performance bonus payment) will be paid to them

The annual uplift will be applied to the basic pay being paid to the post holder (which would include any long-term RRP payment), provided that:

the organisation achieves its financial control target; and

the individual concerned is judged as performing at Category A, B or C.

Those in Categories A, B and C will receive this annual uplift to their basic pay, which will be pensionable

Those in Categories A and B will receive, in addition to the annual uplift, a non-consolidated bonus payment, provided the essential criterion is met –

i.e. that the organisation achieves its financial control target. Bonus payments will be non-pensionable, non-consolidated one-off payments

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/126865/pay-framework-vsm-strategic-and-special-has-pcts-amb-trusts-updated-july-2012.pdf.pdf ''

So it is seems the only officially contracted criteria to be eligible for a pay uplift and bonus is meeting the financial target (and something woolly about being classed as A, B or C. In any case if you don't meet the financial target it is an automatic D which means no pay uplift or bonus irrespective of how much quality is improved and mortality/morbidity is low

What do you think might be happening in a manager's mind when priority setting? Which director will be prepared to have a very low mortality and morbidity and yet be classed as a failure and given a D. If ever a CEO was prepared to do that what do you think that their directors's mind would think given the fact that various director's pay are set as a percentage of their CEO's pay. What does it tell Jo public when the Finance Director's pay is linked to and set at 75% of the CEO pay and all other directors get a lesser percentage? One lovely chain where there is clear financial incentive to reach financial targets and ensure the CEO gets a higher pay. I am sure my understanding is not perfect but it looks like a conflict of interest built into a contract - you could not make it up if you were writing fiction. Where do you think the emphasis will lie? No guess work – it is explicit – financial control target it is and nothing else.

Now do I think for a minute that any CEO or director gets to work and says 'kill patients but save money', heck no. But we have all heard about subliminals, motivation, contractual obligations playing a part in how we perform. It does not sound sweet.

REGULATORS

We then have regulators to oversee that trust bosses who are contractually only obliged to serve the financial agenda are still meeting some sort of standards that matter to a publicly funded healthcare system – i.e. clinical quality with death and complications at its core.

Lets look at some of the regulators purposes:

Monitor: Our main duty is to protect and promote the interests of patients. We do this by promoting the provision of health care services which is effective, efficient and economic, and maintains or improves the quality of services.

CQC: We make sure hospitals, care homes, dental and GP surgeries, and all other care services in England provide people with safe, effective, compassionate and high-quality care, and we encourage them to make improvements.

GMC: Our purpose is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.

But let us look at how it actually works out

CQC

The CQC talks about safety and quality but when you look into what they actually say there is no specific mention that organisations will be assessed against their death and/or complication rates

http://www.cqc.org.uk/public/what-are-standards/national-standards

For God's sake how else do you assess care quality if you do not start with death and complications.

MONITOR

It is the government's aim to provide independence to NHS trusts by allowing them foundation trust status. Clinical quality especially reducing mortality and morbidity is not a criteria for affording independence (though there is assessment on whether the trust is governed properly)

http://www.monitor-nhsft.gov.uk/sites/default/files/publications/An%20introduction%20to%20Monitor%27s%20role%201%20April%202013_0.pdf

With 10 out the 14 trusts under Keogh review being Foundation trusts, it is reasonable to wonder what actually the question 'well governed' means for Monitor.

BOSS' BOSS – The Grandparent Organisation is DoH

It looks like the department of health may have the overall responsibility for mortality and morbidity reduction though those are not explicitly spelt out in their website

https://www.gov.uk/government/organisations/department-of-health/about

It has taken nearly a decade and half after HSMR was introduced that DoH is making some moves to look into this. Perhaps better late than never. But as the grandparent organisation DoH is responsible for setting the contractual framework like it is in the first place.

What about doctors and nurses?

Doctors 

Doctors bonuses in the form of CEAs are based on quality of service and hopefully given to excellence. There is no requirement to demonstrate reduction of mortality or morbidity but the hope is that those two essential measures of quality will be considered explicitly when these awards are made. That is sometimes the case, sometimes that is not the case. In theory it is possible for even the highest award holders to hold the awards without ever demonstrating a decrease in mortality or morbidity.

https://www.gov.uk/government/publications/clinical-excellence-awards-2012-application-forms-and-guidance

Then of course there is the GMC who will come down on doctors who are caught out mainly due to significant single incidents which are reported. More recently the GMC due to its revalidation format demands 'quality improvement' though does not explicitly demand reduction of deaths and complications. 

Nurses

Agenda for change does not speak explicitly about improving clinical quality or reducing mortality/morbidity.

http://www.nhsemployers.org/PayAndContracts/AgendaForChange/Pages/Afc-Homepage.aspx

So who is responsible for deaths and complications in the NHS?

It is everyone's job but no one is required to do it and nobody is responsible or accountable for it.

It does not say in anyone's job description or contractual terms that 'it is your contractual duty to seek and achieve a reduction in mortality and morbidity of your patients and when it is not achieved to provide a reasonable explanation of why they have not been achieved and what you will do to achieve them'. Nobody's pay scale is linked to a reduction of mortality and morbidity. Therefore no one is responsible or accountable for deaths and complications. People do it as an optional extra, as a gesture of goodwill, from the goodness of their hearts, as a side effect of their day jobs. There are so many organisations all claiming to be working for patients' protection, quality and so on but all they do is announce diktats on what others should do; they do not hold themselves accountable on behalf of or as representatives of their members by measured reductions in avoidable deaths or complications. It is always everybody's job, somebody else's job, each one of us wants to hold somebody else to account but never us.

That is why it is so very impossible to deal with and so very difficult to get meaningful sustainable improvements. The contractual requirements, recognition and reward structures are all wrong in the sense they are not geared to look for quality improvement. Looks like this is a case where the structure and process results in just the expected poor outcome.

There are solutions – it is to use healthcare management methods to manage healthcare and not to use as we do now - business, financial, manufacturing, service industry or other management methods for healthcare. Whether there is enough interest, knowledge or expertise to do so is highly questionable.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Further Info: I am informed by an NHS FT Board Director that the NHS Board director's contract that is referred to in this blog does not apply to NHS FT Chief Exec or Board Directors.
It will be interesting to find out who it applies to.
Hemadri
15 August 2013