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T o the Editor: The suggestion by Richard L. Kravitz that physician incomes be tied to the average industrial wage is intriguing, although total health care costs may be related more to the doctor’s pen (or keyboard) than what’s in his or her pocket. Nonetheless, the issue of physician income and how it’s earned has long raised troubling questions. Back in 1904, the Journal of the American Medical Association approvingly quoted a popular magazine’s editorial about the resistance of Bthe reputable physician^ to Bcommercial methods,^while also acknowledging the problem of Bmerchant doctors^ afflicted by Bmoney madness.^ Similarly, the founders in 1913 of the American College of Surgeons (ACS) included a vow by its members to shun the Bdishonest money-seeking and commercialism^ then seen as rampant. Nonetheless, professionalism alone never proved an adequate prophylactic. During the 1950s, a period that some like to call a BGolden Age,^ far too many doctors grasped for the gold. With private health insurance increasingly common, the lay press and medical journals alike were filled with tales of appendectomies for stomach aches, hysterectomies for back pain, Bghost surgeries,^ fee splitting and similar abuses. Leaders of the American Medical Association (AMA) and ACS tried and failed to stop the abuses. A 1955 AMA report found that doctors Bdisplay a consistent preoccupation with their economic insecurity. They think about money a lot—about how to increase their incomes, about the cost of running their offices, about what their colleagues in other specialties make, about what plumbers make for house calls and what a liquor dealer’s net is compared to their own.^ WhenMedicare took effect in 1966, it essentially let doctors set their own Busual, customary and reasonable^ fees. The AMA pleaded again for restraint, but the imperative of banishing financial insecurity won out. Perhaps, as Kravitz suggests, now is the time to move towards a new social contract. Its terms would secure appropriate income and autonomy for physicians in return for a professional embrace of accountability to provide safe, evidence-based and compassionate care.

Physician Incomes in the Twenty-First Century: Time for a New Social Contract