The economic divide between specialists and general practitioners is real, but physicians don't take out their financial angst on each other. Insurance plans and government payers get the blame for ratcheting down reimbursement. Still, salary considerations are changing who practices what, as medical students move away from primary care.

Despite the essential value of both specialists and generalists in healthcare delivery, specialist salaries are undeniably higher and probably always will be. But antagonism between the have-nots and the haves has waned lately, as changes in the economic structure of healthcare have hammered all doctors' incomes.

Indeed, the ill will these days is more unified--and more directly aimed at the insurance companies and government payers that use ratcheting down physician reimbursement as a key way to contain costs.

Kristin Santangelo, MD, is a urologist in Oxnard--and she's a good example of the sort of income detente that seems to exist between those near the top of the wage scale and those closer to the bottom. "Obviously, income depends a lot on overhead," she explains. "Being a specialist, I have a lot of equipment in my office and I do a lot of procedures there. But the general practitioners and primary care physicians spend a lot of time with patients, looking over a lot of stuff and managing a lot of medical problems. If you do things that are more specialized, like taking patients to the operating room, you need to be compensated for that. On the other hand, are PCPs making enough money? Probably not."

Lytton Smith, MD, a family practitioner in Yorba Linda, remembers when income-based hostility was much more of an issue than it is now. "In my community 10 years ago," he reports, "there was a cardiovascular surgeon making multiple millions a year, compared with PCPs, who were making in the $140,000-to-$150,000 range. Certainly, we respected the capability, tenacity and the work ethic of that particular surgeon, but we could never understand that degree of income difference. The extreme differential could never be justified in the minds of PCPs."

Day to day, however, interspecialty relations are pretty good, Dr. Smith says. "Most PCPs have good working relationships in their communities with surgeons and other doctors they refer to," he says. "In the aggregate, there may be some PCP angst about other doctors making too much money. But in our individual communities, we generally don't worry about the details."

That's right, Dr. Santangelo concurs. "I don't hear a lot of griping about the differences in pay," she reports. "I hear a generalized gripe about more work for less pay."

Physicians are somewhat resigned to the fiscal realities of modern medicine. "How we feel about reimbursement doesn't make a bit of difference," says Tim Pietro, MD, a urologist in Riverside. "We can argue until we're blue in the face. So most of us commiserate on the fact that it's not so much how big our piece of the pie is, it's the size of the pie--and it's shrinking. That's the problem.

"My income--not in inflation-adjusted dollars, just straight dollars--is less than it was in 1992," Dr. Pietro continues. "I know how the older doctors respond to that. We just work harder to keep our income up. Most of the younger doctors say, 'We don't want to do that.' Their whole philosophical approach is different. Maybe they go in with lower economic expectations."

Will Economic Expectations Drive the Future?
Economic expectations have begun to reshape medicine, as new entrants into the field are keenly aware of doctors' differing salaries and choosing their paths accordingly.

It certainly wasn't always that way. "Thinking back to when my fellow students and I were making specialty decisions, future income was not the major driving force behind them. Most people decided what they wanted to do based on what they liked doing," Dr. Santangelo says.

Dr. Pietro recalls that when he made his specialty decision some 20 years ago, he did it based on what would make him the happiest, what he was most interested in and what he felt he was best at. "I had no clue what paid the most," he says. "And at the time, I believe most folks were like me. We felt that medicine would provide a good living--and it didn't matter whether it was on the lower end of a good-paying job or the higher end."

Is that the case now? "I suspect not," Dr. Pietro says. "There is more knowledge by some of the younger doctors of the economics." Indeed, he adds, "if I were to advise someone younger trying to make a decision, I'd tell him or her to pay attention to that."

It seems medical students are already paying attention. "There is a trend of fewer and fewer medical students going into primary care," says Clayton Patchett, MD, an orthopedic surgeon in Pasadena and president of the Los Angeles County Medical Association.

Students are making the simple choice of enduring more schooling so they can make more in practice, Dr. Patchett says. "PCPs can make $150,000 or take a specialty course in gastroenterology for just two more years and make $250,000 to $300,000. Everyone's going to want to do that. In fact, studies show that the primary care programs are not getting filled and 60 percent of the people in them don't intend to practice it."

Dr. Smith says the prognosis for PCPs isn't good. "An emerging critical issue in medical training is young physicians' awareness of the economic disparity," he says. "And unless it's addressed, the sickest patients, those requiring the most analysis of medical therapies on an outpatient basis, will be treated by the least-qualified physicians. The high-profile, high-income specialties provide a small portion of the medical care given to patients, but economic factors are driving the top students into those fields. The fields where the medical care rubber meets the road--geriatric and internal medicine--will get only the lower-rated physicians. We'll have an upside-down medical care system."

Dr. Patchett puts the primary-care predicament another way. "I advise my colleagues to shake PCPs' hands and pat them on the back because they may not be around very much longer," he says. "The main reason is that the primary care model doesn't work economically. On top of that, the PCPs I know aren't having a good time." Part of the problem, he says, is all the extra work PCPs have to do--the cholesterol checks and the blood pressure tests and the phone calls--to get the lowest reimbursement.

Perhaps one solution would be to change the medical education system, Dr. Patchett suggests. He says there is an abundance of specialists. "We should cut back on the number of specialty care physicians," he says. "If somebody falls down on the sidewalk, there's an orthopedic surgeon there right away, presenting a business card."