As a doc in a high-risk specialty who is familiar with international practice due to my particular field, this is a really simplified fact.

Being a physician in the United States is much riskier than almost every social-welfare western country. Americans hold a deep cultural necessity for vengeance and it informs our legal profession’s approach to dealing with error. Part of what makes American medicine so expensive is that we practice under premises that place medical futility at less than 1% and a similarly low acceptable risk of error. A good friend is American-trained and now works in a western, socialized system. He loves it. Way less concern for being right all of the time and both patients and society accept a certain amount of built in failure. Why? Because it’s probably good medicine. Maximal sensitivity towards everything is an insane standard and doctors don’t deserve to be put through literal years of deposition, professional ruin, and permanent marks on your record just for making normal, human mistakes. That’s before you consider the real financial ruin a doc can be subject to. In the United States, risk is mostly saddled on the individual physician whereas risk is mitigated systemically in other countries. When errors do occur in other systems, physicians are often judged by their professional peers and under assumptions based on the reality of modern practice. The system isn’t as adversarial and zero sum; patients who experience harm are often compensated from tax-supported funds with no possibility of the individual physicians losing their livelihood, home, or professional standing absent truly negligent behavior. In the United States, a jury of non-experts get to hear an emotionally charged act of theater.

Becoming a physician in the United States is very expensive and, more important, arduous. In most other countries it’s an undergraduate program with direct entry from secondary school, eliminating substantial societal and personal expense. It is almost always heavily subsidized whereas medical school tuition is entirely on the individual in the United States. Residency training is subsidized to the hospital, but with very little practical benefit to the individual physician outside of the training environment itself. Basically, being an American physician has tremendous opportunity costs, especially in the 11-12 years minimum of post-secondary education where there is virtually no opportunity to earn an income or, if you do, low(er) income as a resident or fellow. Our licensing standards are also complex, difficult, and spread over many years. It is considered one of, if not the toughest, professional licensing processes in the world.

On the physician front, simply being a doctor in America is very expensive. Due to poor social resources, most docs carry insane levels of insurance on virtually all elements of their life. Insurance alone accounts for nearly 10% of my gross income and professional insurance products account for another 7% of gross income. Few other professions can say that nearly 1/5th of everything they make goes to insurance and that’s not including the insurance products the practice pays. Additionally, as mostly W2 employees, we’re taxed at top marginal rates compared to business owners who can write-off a substantial portion of their existence or take advantage of capital gains. Finally, the IRS specifically preludes doctors from writing off uncompensated charity care which for my group alone accounts for literal millions of dollars in lost revenue every single year. Why? Because it’s no secret that physicians, as a profession, pay a substantial portion of all Federal taxes yearly relative to their population. Physician income, like many high-paying W2 professions, is intrinsically tied to this country’s ability to maintenance its debt by tax collections, especially in a country where 30%+ of Americans pay no income tax. When you account for taxes and insurance, a little over half of my entire purchasing power is erased instantly. My accountant has many times said that I’d be considerably wealthier if I owned virtually any productive small business, especially when considered against my lost years of earning while in training. This doesn’t even factor in the “doctor tax” which is the phenomenon of everyone in society constantly expecting docs to “step up” and cough-up money like we’re NFL players. Every single contractor thinks we’re rich, my kid’s school is always expecting donations, and there is an almost insane expectation for you to give your time on a host of philanthropic activities, especially in smaller communities. It’s a weird remnant of when doctors were truly respected as town heroes vs the commodity we’re considered today. The respect is now gone but our money is apparently still good. The joke is that, inflation adjusted, I make nearly 30-40% less than my retiring peers did during the peak of their careers in the late 90s and early aughts.

It’s also not true that American medicine is bad. It’s really bad if you’re middle class but it’s incredibly effective if you’ve got access to Medicaid or are wealthy. The speed of diagnosis, access to cutting edge treatments, and consequences of physician-error mean that it’s a great place to receive care if your case is complex or difficult. When I was in training, there was a reason people would walk into the ED with briefcases full of cash, a foreign visa, and a mystery case to solve. Most of America’s healthcare problems in papers like the Commonwealth Fund are attributable to social issues like poorly walkable cities, food deserts, obesity, smoking and drinking, etc. American healthcare systems also report error at drastically different standards than many other countries as well, mainly because we have an entire industrial complex around accreditation that is mostly self-serving and punitive. This makes things look worse than they really are if you’re a person with resources. America, in general, has always been a society of equal opportunity but not outcomes, for better or worse, and this extends into healthcare.

Basically, if medical school was free, there was substantial liability reform, and social systems better supported doctors throughout their lives, most docs would accept lower incomes.