An aphorism in practice

My boss, who has been a great mentor and friend to me for nearly five years now, once gave me a rather pithy piece of advice that I have always followed: "Never be good at anything you don't want to do." Be good at something, and someone, whether it's your boss, your best friend who wants a favor, or even the U.S. government, is going to want you to do it.

So, when being good at a particular skill requires years of intense training and thousands of dollars in student loans, and the reward is that one can expect nickel-and-diming from insurance companies at best, and outright slave labor at worst, is it any wonder that medical students, while they may not have heard my boss's advice word for word, are refusing to be good at what they don't want to do? The New York Times reports this week that medical students are choosing in droves, not to pursue the "needed" areas of medicine like primary care, but the more lucrative (and, not coincidentally, less regulated) fields of dermatology and plastic surgery. With Medicare and private insurance companies demanding increasing amounts of paperwork for decreasing amounts of remuneration, medical students can see that being a primary care physician isn't the high-paying career it used to be -- and they may quite rightly decide that four years of medical school followed by additional years of working long hours for low pay in a residency, plus taking out hundreds of thousands of dollars in student loans, is too high a price to pay to pursue that field. Why not, instead, spend that time and money learning a different area of medicine -- one with which neither the government nor private insurance concerns itself, and thus one in which a doctor can make more money with fewer headaches?

Worse still is the situation with emergency-room care, as anyone who reads M.D.O.D. will know. "Outright slave labor," as I described the situation for a newly minted doctor, is no exaggeration in the ER, thanks to the Emergency Medical Treatment and Labor Act (EMTALA). EMTALA requires that emergency rooms treat any patient who comes in, regardless of his or her ability to pay. What this means is that ERs are paid for about one-third of the services for which they bill. That means slave labor -- doctors performing services for which they will never be paid, often for bums who treat the ER like their primary care physician because they "can't afford" to see a regular doctor (yet somehow manage to scare up enough money to fuel their cigarette habits). Unsurprisingly, emergency room doctors are following my boss's advice and deciding they won't be good at what they don't want to do -- so they leave the ER, or even leave medicine altogether. Hospitals are doing the same -- they don't want to lose money to patients who won't pay, so they refuse to be good at it, meaning they stop offering emergency-room care.

The result of combining heavy regulations with "never be good at anything you don't want to do" is that care cannot be had by anyone, while availability flourishes in freer markets like dermatology and cosmetic surgery. If Americans want more people who are good at what we need them to do, we must create a free market -- so that that will be what doctors want to do.

Update: Check out this post at M.D.O.D. for a firsthand account from a doctor who knows what it's like to do primary care -- and has chosen to be good at something else because it not only pays better, but offers him an easier workday.