Times are tough, economically speaking, and the forecast for 2009 does not sound good. This brings to mind some thoughts on money, the business of medicine and the implications for PAs.

Society expects physicians-and dare I say PAs-to put aside their personal interests and to place their patients' interests above their own. This is the essence of a professional and has been the centerpiece of the medical profession since Hippocrates.

People throughout history have believed that medicine is a calling that is higher than other occupational pursuits. Not that businesspeople are free from ethical obligations; they are supposed to provide value in the products they offer and are not expected to cheat customers. But the customer knows that the businessperson primarily is interested in making a profit.

For clinicians, the profit motive is not preeminent. The public places great trust in professionals like physicians, and in return they are expected to operate with duty to patients first and to subordinate monetary interests. Medicine also trumps businesses in the humanitarian sense: It is a noble calling to selflessly help the sick.

Money-Motivated Medicine

More than 100 years ago, Irish playwright and social critic George Bernard Shaw offered a telling quote concerning the economics of medicine. In the preface to his play, "The Doctor's Dilemma," Shaw explored the prevailing financial arrangements for those who provided medical services and explored what he considered to be the inherent conflict of interest presented to physicians.¹

Shaw wrote: "That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity." The dilemma Shaw so colorfully describes is the desire of the doctor on one hand to cure disease and relieve suffering and on the other to collect a fee for providing such services.

We also know that some health care professionals abuse their positions by tilting practice activities to maximize income. Economists call this "supplier-induced demand," where, for example, a physician can order that extra lab test or schedule that additional office visit, reflecting more concern for income than clinical necessity.

Some fear that modern medical practice already is increasingly focusing on monetary aspects and that this trend is accelerating. One pair of physicians in a recent paper note that "Although money has always been part of medicine, it has never been so prominent, and it has not been the primary motivator of most doctors' practices. Today's medical students are being inducted into a culture in which their profession is seen increasingly in financial terms. Add in such pressures as the need to pay off enormous debts, and it is not surprising that students' choices (of practice specialty) are dictated by the desire to maximize income and minimize work time."²

PAs, Specialties and Debt

With the reduction of federal subsidies for PA education over the past two decades, PA education has become a tuition-driven business, with most students turning to loans in order to finance their education. This leaves them with the same kind of staggering debt that medical students possess. Given these influences, is it any wonder that fully 65% of all PAs are in specialty practices?

The fear is that financial pressures not only will drive the specialty choices of graduating PAs but also will permeate their professional activities and motivations. We need to remind ourselves of the obligations of the professional and recognize that PAs do fairly well in the area of income. The average practicing PA's salary from his or her primary job in 2008 was $89,987,³ a handsome figure by most standards. Physicians always have been among the most well rewarded members of American society, and appropriately so, given their substantial investment in training and responsibilities. PAs share in those responsibilities and benefit in many ways (including financially) from close association with physicians.

Medicine in America increasingly seems to be taking on a market-focused complexion. Hartzband and Groopman say it well: "Caregivers should be appropriately reimbursed but should not be constantly primed by money. (This) will require collegiality, cooperation, and teamwork-precisely the behaviors that are predictably eroded by a marketplace environment."² And, I would add, precisely the behaviors that PAs are known for.

James F. Cawley is professor and director of the PA/MPH program at the School of Medicine and Health Sciences at The George Washington University in Washington.

References

1. Shaw GB. Preface on doctors. In: The Doctor's Dilemma. New York, NY: Brentano's; 1911: v.
2. Hartzband P, Groopman J. Money and the changing culture of medicine. N Engl J Med. 2009;360(2):101-103.
3. 2008 AAPA Physician Assistant Census Report. American Academy of Physician Assistants. http://www.aapa.org/research/Highlights08/2008AAPACensusNationalReport.pdf. Published September 25, 2008. Accessed January 9, 2009.