When I was in college, there was an infamous course known as Chem 20. Organic Chemistry was the sieve into which was poured every pre-medical student in the university. But only those who came through it with an A or B could reasonably expect to get into medical school.
Chem 20, therefore, became a psychological laboratory of pre-med anxiety. Every class was a combat mission. Each grade was a life or death matter. It reeked of Olympian anguish and Olympic competitiveness. It taught people whose goal in life was the relief of pain and suffering that only the fittest, the most single-minded, would survive.
I remember Chem 20 whenever I read about President Carter's outrage at the medical establishement, or when someone sardonically points out yet another M.D. plate on yet another Mercedes Benz, or when the National Council on Wage and Price Stability points out that the median income of doctors - $63,000 in 1976 - has risen faster than any other group. In short, at times when others talk about the M.D. as a license to make money, I think of the Chem 20 factor.
I know that we regard doctors as altruistic when they are treating us and avaricious when they are billing us. But I don't think we can understand the end result - high fees - unless we understand the process of selection and even self-selection by which people actually do become doctors.
On the whole, doctors made a commitment to go into medicine when they were 18 or 19 years old, with the full knowledge that they wouldn't be "practicing" until they were 30 or older. In a "Now Society," they would hold the record among their peers for delayed gratification. The sort of laid-back, non-competitive person who wants to "live in The Moment" would drop out of Chem 20 with an acute case of culture shock in a week.
It is the dedicated or the narrow minded (choose one from Column A) who go through college competing for medical school and go through medical school cempeting for a good internship and through internship competing for a good residency.
Today, residency is not the financial hardship it was when most practicing doctors in this country were young. Hospital Physician magazine says that the average doctor in training earns $12,500 to $15,000. But it is still basically an emotionalized physical endurance contest.
It is normal for a young doctor to work an 80-hour week. It is normal to work every other night and every other weekend. It is normal to be cut off for10 years from anything approaching a rich personal life. It is normal to come to regard the world as a hierarchy and a ladder to be climbed.
While there are thousands of others who work long hours just to keep a toe-hold in solvency, there is no other professional training that is comparable in terms of sheer stress. So, many of the doctors are sustained through this training by one vision: The Big Payoff. In this society, the Big Payoff is traditionally translated into dollars.
The end result of the training process is doctors who are often as addicted to work as patients to morphine. And doctors who have come to genuinely believe that they are "worth" whatever fees they can charge because they "worked for it." I suspect that they are searching - sometimes desperately, and often futilely - for a return on the real investment they made their 20s.
So, the government may be right when it says medical fees are spiraling because there is no free-market economy in doctors. The law of supply and demand doesn't work well in medicine.
But that is only half of the story. If they want to see the psychological side, they have to go deeper, further, back to where the system begins - back as far as Chem 20.
The course is still being given. ONly these days, I hear, there are pre-med students who won't even share their notes.