The Issue of Salary
Salary vs. fee-for-service. There can be much debate as to why one vs. the other. I have seen the debate get quite passionate, usually by those suspiscious of institutions and those that believe in free enterprise.
Prior to completing my residency in Cardiac Surgery, I took some time off and was in private practice in General Thoracic Surgery (St. Joseph's Hospital, Hamilton, Ontario, Canada) for 9 months. My views on the subject are quite coloured by this experience. What I am seeing at the Mayo also influences my opinions on the subject.
I believe that a fee-for-service system has a negative influence on the practice of surgery. The pressures of volume based remuneration lead surgeons to see more patients and do more procedures. In this model of practice, the patient is the one who suffers. Less time is spent with patients and families, whether on rounds or in the office, due to the time pressures inherent in such a system. I believe that part of the reason our profession has been devalued in the eyes of the public is that we do not spend enough time with our patients. When I was in practice, the cynicism of some made me cringe. I would book one hour for all new consultations for lung cancer. Some of my colleagues could not believe that I would spend so much time. They told me not to worry, that I would get faster! To me, this was not an issue of speed!!!
I am not suggesting that procedures are performed unnecessarily or hastily. This would be unethical. However, I do believe that procedural indications and performance are modified in such a way as to benefit the surgeon's purse. Two examples: During a CABG the intra-op TEE reveals a small PFO. Closure of the PFO is not unsafe for the patient and is easy to do. One can argue you are already there so why not? There is a theoretical benefit. However, PFO is a normal finding in an otherwise healthy part of the adult population, so you could leave it alone. If you were paid extra for the closure, what would you do if you were not placing the patient in any danger.
The second example is a drainage of an empyema as an add-on case. There is a premium for cases starting after 6 pm in Ontario. Your case is ready to go at 5:30 pm. Do you and your anesthetist drag your feet to start at 6 pm? It does not place the patient in any danger and it is easily done. I have lived this situation, and I can tell you that when you are starting out in practice and there are bills to pay....This is reality in a fee-for-service system.
There are numerous examples that can be given: some I have experienced first-hand; others I have seen and others I have been told (sometimes as words of friendly advice to a junior staff from those who know the system better). This goes on to a greater or lesser degree on a daily basis.
The other issue is that of dignity. I have seen so many surgeons 'nickel and diming'. They would chase after every cent they believed the system owed them for their sevices. I found this to be a pathetic spectacle. However, the system was set up to reward them if they did this. I have nothing but contempt for this behaviour and for the system that allows and encourages it to occur.
What about a salary-based system? I believe that surgeons would spend more time with their patients and families. It would encourage the performance of procedures for purely medical reasons, without the corrupting effect of volume-based remuneration. However, I think this system must come with a commitment from the surgeon to provide the best possible care, whatever the circumstances.
The danger of this system is the apathy that can develop when income is assured. For example, delays in surgery because there is no pressure to perform operations, which increases waiting lists. Surgeons need to provide a good service to society, and therefore must increase their volume of work as the need arises, even if their income is the same. Another potential issue is the performance of operations during "off-hours". There is no incentive to do this with a salary. Surgery needs to be done when it is needed by the patient, and not at the convenience of the surgeon.
In a salary-based system, the surgeon must rely more on his/her desire to treat patients well. The intrinsic value of excellence in patient care is paramount. Take the example of some cardiac surgeons at Mayo Clinic. What drives them to do the number of complex and difficult cases the do? However many, and however difficult, patients they see, they will be paid the same. I believe that they is internally driven by the need for excellence.
I awknowledge that this system is not perfect. However, I am convinced that it is the most beneficial to our patients. In the long-term, it will select out young doctors that will become surgeons who's drive is less about money and more about excellence in patient care.