by Craig Klugman, Ph.D.

How your doctor is paid may affect how he or she approaches the work. Steven moved from being a private practice doctor to working in academic medicine about 6 months ago. He has noticed a number of differences in the practice environment. He works far more hours in academia for less pay. He finds academic medicine to be inefficient—what took 20 minutes in private practice takes 2 hours in his new university hospital. If his private practice held a staff meeting, they were provided food and sometimes paid for their time. In a faculty meeting, there is rarely food, they take place before or after a long day, and there is no extra pay. Whereas a substantial staff would take care of much of the governance of the practice, the faculty spend unreimbursed time governing the department.

The difference seems to come down to how one relates the job to compensation. For the private practice physician every action, every note, every behavior is charged to a case. There is a direct link between action and compensation. Cause and effect. You want to make more money, you take on more cases. You want more time off or to take on different tasks, you do fewer cases and make less money.

But in academic medicine, or even some managed care organizations, the compensation is disassociated from the practice. Academic pay structures can be complicated with bonuses for meeting certain standards, but essentially one is given a set salary. That salary is received if one works a 50-hour week, 80-hour, or 100-hour. Whether you see 10 patients or 15 patients, the base salary remains the same. This system allows faculty time to teach residents and students, to be part of the governance of their department, and to do (some) research because time is flexible when it’s not a commodity.

However, this separation, which allows a person to have a dynamic position, is the same one that makes it easy to feel taken advantage of. If one person leaves, the department can save the salary by splitting the job among the remaining people. If there’s a new report that needs to be written, or a new project to be done, you just add that work to someone else because it costs nothing. If you want to make more money, you have to go up in rank, take on additional duties (which usually require a different skill set and more time), or move to another institution.

For Steven, the move to academic medicine has been difficult because he feels that the expectations weighed against the compensation are out of balance. Having recently been at an academic medical center myself, I have seen first-hand the concerns he expresses. Many of the best people left because they realized that they were not treated respectfully, that they were forced to take on additional tasks that required substantially more work time, and that they found themselves wallowing in resentment rather than finding fulfillment in taking care of others.

The way we pay doctors may affect how they think about their work and thus how they approach their colleagues and patients. For some, the flexibility of academia and the ability to do research and teach is worth the reduced income. They think of their work as a mission rather than as something done for pay. The money just appears in the bank account once in a while, separated from the everyday tasks. For the person in private practice, there is a greater sense of control because the work done is directly related to money made. I am not claiming one system is superior to the other or that all doctors should be paid in a certain way. But I am suggesting that people are motivated by different things—some by money and others by flexibility and freedom. And all of these factors are related to how a person feels about his or her work and ultimately, what kind of care patients receive.

If we expect physicians to treat patients with compassion, empathy, and care then we also need to treat them with respect and thinking about the relationship between work and compensation is a good start.