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Cheer up, you could have been a lawyer!

December 2009

Cheer up? Traditionally, prime bragging rights for parents have included daughters or sons who grew up to be doctors, lawyers or engineers. While I suspect your parents will still love you no matter what career you choose, they may love you a little more now if you became a doctor–especially if you became a lawyer and now are living back home.

Lawyers are hurting. Or should I say, on behalf of all of my colleagues who, like me, have been involved in absurd malpractice claims: Lawyers are hurting, hooray! It turns out that many attorneys, even the ones graduating from top-flight law schools like Harvard, Yale and Stanford, can’t find a job. Traditionally, graduates of these schools would be coming out of training staring at offers that would make a resident lightheaded, and perhaps even cause a primary care physician to be envious. On top of that, many established attorneys have been laid off or are underemployed. In fact, the entire industry has been shaken as even their payment standard–the billable hour–has come under pressure.

Cause for celebration? Perhaps, but lawyers’ misery may present a cautionary note for our own profession, especially when we consider how much debt these young lawyers have accumulated. An old college friend, Jonathan Glater at the New York Times, wrote about the curious case of the attorney who paradoxically could not get a license because of his law school debt burden. Jonathan noted that, “New York’s courts have overlooked misconduct like lawyers’ solicitation of minors for sex, efforts to deceive judges and possession of cocaine. Those instances have led merely to temporary suspensions from practice.”

However, the New York state appellate judges decided not to ignore the fact that this lawyer’s student loans were over $400,000. They denied him membership to the state bar because they believed such a level of indebtedness implied that, “Applicant has not presently established the character and general fitness requisite for an attorney and counselor-at-law.”

Could this happen to a doctor? Clearly, medical education debt is out of control, with the average debt currently running $154,607 upon graduation from residency. Given that most doctors need between three and seven years to even start paying back their loans, it appears the average doctor is halfway to our friend the lawyer’s plight when they make their first repayment.

If we are to believe debtdoctor.net, a doctor “cannot be denied your license because of filing [bankruptcy].” I’m not sure if I am more relieved to read this or more terrified to know there is a Web site with that title. And because bankruptcy could be reportable on a medical staff application, it is at least possible that physicians would be denied hospital privileges if they were mired in legal limbo due to financial problems.

Massive school loans have affected the employment landscape of lawyers; the analogy to our own field is the much higher salaries paid to subspecialists. There is a national shortage of public defenders, which reminds me of the scarcity of primary care physicians. Faced with lower salaries, which are under even more pressure due to the fact that the recession has left state budgets in crisis, most lawyers saddled with heavy debt cannot consider working in such a field. This has led directly to decreased access to legal care for the indigent.

Back to the billable hour, which is the only professional reimbursement system under more assault than our fee-for-service model. Both suffer from the perception, warranted I believe, that they create perverse payment incentives summed up as “Paid more for doing more.”

For lawyers at least, the depressed economy is no longer able to pay for such inefficiencies. Cash-strapped companies are looking to more affordable solutions to their legal needs, and lawyers are now being forced to work on a contingency basis or for a set predetermined fee.

Perhaps a bit of a stretch, but set attorney fees may foreshadow the almost certain trend to bundle physicians’ professional fees. (As an aside, I doubt physicians will be practicing in a contingency-based world any time soon but it is still a fun exercise to imagine what that would look like: “If I cure you Mrs. Smith, I will take 40% of your Medicare and Social Security loot; if you die, I get nothing. Fair enough?”)

So what is the upshot? At a minimum, it is at least an interesting observation if not an ominous warning for physicians if they believe the status quo will not change. And no matter what career you choose, assuming you aren’t already a hospitalist, I trust your mom will be proud of you. However, cautionary tales aside, it is clear that if you become a hospitalist, your mom will be apt to love you a bit more than your other siblings, as is the case with my mother. (Full disclosure, my brother is a practicing attorney in Seattle, and I am, needless to say, a hospitalist).