What Role, Money?

arm wrestlingI had a heated discussion this afternoon with a MAG buddy of mine – a solo-practice orthopedic surgeon practicing in a rural area of Georgia.  He began with “I’m (fed up) with the bashing of fee-for-service (FFS).  There’s no (alternative) compensation methodology that creates similar levels of physician productivity.” And off we went.

The Definition of Physician Productivity.  I’ll send him the link to one of my previous posts (“The Real Definition of Physician Productivity Might Surprise You“), but we agreed that wRVUs can be a part of measuring “work-done”, particularly when comparing the unequal burden of caring for a patient-population with higher levels of diabetes or kidney disease, or lower levels of medical sophistication.  But fundamentally, he defines physician productivity as “things done to patients today”, rather than “patient problems solved today or avoided tomorrow.”

the one word that could save your life

The Role of Money in Determining Physician Work Ethic (or if you prefer, in Determining Discretionary Effort).  My friend firmly believes that money is the ONE, dominant motivation of physician work ethic – that salaried physicians will “work (only) when they want to.”  He went on to say that higher levels of pay will create higher levels of effort.  But I know my friend gives the same level of high effort in the OR when operating on a Medicaid patient as he does when operating on a commercially insured patient, producing an incongruity in his argument.

in money we trustIf not money, then what?  I spoke of group culture (interdependency among and accountability to one another, ensuring reliably high levels of effort by all), and inherent altruism among physicians, but he would have none of it.  For him, those concepts were somewhere between mythology and ideology.  He offered a (not-so) hypothetical case of a little girl with a newly broken elbow presenting to the orthopedic office at 5:01 pm, ostensibly ushered into the FFS office, but turned away by a salaried orthopod.  He was incredulous at my declaration that a given physician’s behavior in such a circumstance would be (ie, must be) dissociated from the presence or absence of compensation.  I never got to plug Daniel Pink’s work.

daniel pink drive

This conversation unnerved me.  Not because I am unlikely to ever change the mindset of my friend relative to the role of money in physician behavior.  And not because of some ridiculous belief we physicians should work for free; I believe physicians should be highly compensated for the high stakes, high intensity, narrow-tolerances of our privileged craft, just not through a FFS mechanism.


Rather, I believe my friend’s point of view is likely reflective of the majority of FFS colleagues.  Thus, our profession is threatened even more than I once believed.  W.W.O.D?

william osler, ca 1890s



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