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the preventative care—scheduling mammograms, arranging screening colonoscopies, and so on—that is currently recommended for an average-size panel of adult patients (this on top of the regular workday managing acute problems and emergencies). “The amount of time required is overwhelming,” the authors wrote. If anything, the problem has worsened since then.
    However, the dissatisfaction probably would not have reached such a fever pitch if salaries under managed care had kept pace with doctors’ expectations. But they have not. In 1970 the average inflation-adjusted income of general practitioners was $185,000. In 2010 it was $161,000, despite a near doubling of the number of patients that doctors see per day. While patients today are undoubtedly paying more for medical care, less and less of that money is actually going to the people who provide the care. According to an article in the journal Academic Medicine, the return on educational investment for primary care physicians, adjusted for differences in number of hours worked, is just under $6 per hour, as compared with $11 for lawyers. As in the rest of America, there is serious income inequality in the medical profession. Some doctors, especially procedure-based specialists, are probably paid too much. Others, such as primary care physicians, are not paid enough. (Yet almost every doctor feels the world owes them more for what they’ve been through.) Doctors today are working harder and faster to maintain income, even as staff salaries and cost-of-living expenses continue to rise and medical school debt approaches $200,000. Some have resorted to selling herbal supplements and vitamins out of their offices to make up for decreasing revenues. Others are limiting their practices to patients who can pay out of pocket without insurance company discounting. Private practices today are like cars on a hill with the parking brakes on. When you look at them, you don’t realize how much force is being applied just to maintain stasis.
    â€œI am very dissatisfied,” a doctor wrote online. “My father was a family physician … We discussed how maybe the practice of medicine should be reserved for the independently wealthy or a religious order. Seriously, I fear that these pressures will drive suicide and mental disease sky-high within our group of colleagues, who for the most part went into medicine due to the size of their hearts with minimal consideration on the impact of the size of their wallets. We all thought we would be comfortable and be able to pay our bills. All I have to say is, thank God my wife works.”
    The time crunch and reimbursement cuts are only a small part of doctors’ woes, however. Other factors include a labyrinthine payer bureaucracy (American doctors spend almost an hour on average each day, and $83,000 per year—four times their Canadian counterparts—dealing with the paperwork of insurance companies); fear of lawsuits; runaway malpractice liability premiums; and finally, the loss of professional autonomy that has led many physicians to view themselves as pawns in a battle between insurers and the government. A doctor lamented on medscape.com : “The public policy forces acting upon us are pushing us into being technicians on an assembly line with less and less time to relate to our patients as people and sometimes hindering us from even giving the best technical care. But we can only work so hard and so long, and if our patients aren’t willing to pay for better time and attention, then we have to change with the times.”
    The growing discontent has serious consequences for patients. One is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners. Try getting a timely appointment with your family doctor. In some parts of the country today, it is next to impossible. A