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17 EW NEWS & OPINION November 2014 tions realistic. This is where Dr. Jauhar goes off the rails. He is disappointed by his choices. Yet, at the conclusion of his book, he acknowledges the joy of medicine in the small social exchanges, the hope in a patient's eyes, gratification that a quotidian job can't provide. Yeats concludes: When all that story's finished, what's the news? In luck or out the toil has left its mark: That old perplexity an empty purse, Or the day's vanity, the night's remorse. Unlike other artists striving for perfection, physicians rarely suffer an empty purse or a night's remorse. I wish Dr. Jauhar well. EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com by J.C. Noreika, MD, MBA small businesses, managing a med- ical practice is difficult. Unless you are a box office or recording star, athletic icon or Wall Street master of the universe, finances matter. William Osler purportedly said "medicine is a jealous mistress." It can also be pleasurable, seductive, and rewarding. Like politicians, many patients don't like "doctors" but love their doctor. Few physicians derive personal gratification by merely making money. Those who do admit that focus, failure, risk- taking, and luck play a role. Medi- cine will always be schizoid about the duality between altruism and commerce. It can't be helped. But it is in society's best interest to keep doctors comfortable. "We trust our health to the physician … their re- ward must be such therefore, as may give them that rank in the society which so important a trust requires." Adam Smith wrote that in 1776. Conversely, it is in physicians' best interest to keep their expecta- ish Medical Center (LIJ). His book rehashes the failings of modern medicine: A remuneration model that encourages too many services, tests, and imaging; intrusive bureau- cracy damaging the doctor-patient relationship; overspecialization causing too many referrals with little coordination of care; decreasing re- imbursement, increasing overhead, diminishing profitability leading to the need to schedule more patients; too little time to think. His expectations of a medi- cal career clearly have not been met. He professes to be underpaid, overworked, and pressured to cut corners. Are these problems of the system or with his choices? Out of training, he opts to live in Man- hattan, has a physician spouse who is a stay-at-home mom, and takes employment as a junior-staff car- diologist at LIJ. To pay the bills, he moonlights and is exposed to an al- leged seamy side of private practice. Prior to 1966's introduction of Medicare, physicians' income tracked the nation's median. By the 1970s, it was closer to 6 times the median. Medicare afforded a deluge of dollars to meet the demand of the elderly even before medical technol- ogy shifted the mortality curve. The so-called Golden Age had dawned. America's physicians remain among the world's most highly compen- sated workers. Why the morale problem? The game changed. Folks writing the checks began calling for increased accountability and over- sight; value was introduced. A better educated, secularized society chal- lenged physicians' infallibility. The electronic medical record happened. According to the U.S. Depart- ment of Commerce, America's median household income 2008– 2012 was $53,046. If a household had income of $388,905 in 2011 (the last year the IRS provided data), it drank the ambrosia of the 1%. The top 2% made $250,000. There are about 115,000,000 households in America, meaning 1,115,000 are in the top 1%. I believe physicians properly represented. Money is always a problem. It is human nature to disregard the other 98% of the population if 2% are doing better than you are. Like all The intellect of man is forced to choose perfection of the life, or of the work, And if it take the second must refuse A heavenly mansion, raging in the dark. T hus, William Butler Yeats, arguably the greatest 20th century poet, unraveled the conundrum of choice. The morale of America's medical doctors is a topic of media focus. A survey by The Physicians Foundation has been cited recently in The Wall Street Journal, the Washington Post, and other newspapers. It reported, "only 6% of physicians described the pro- fessional morale of their colleagues as 'positive.'" This influential survey has problems: It is outdated, having been published in 2008; only 12,000 of 270,000 primary care physicians and 50,000 specialists respond- ed; responders disproportionately represented primary care physicians, solo practitioners or those employed by healthcare systems, older doctors and women; and because it queried the morale of others, it perpetrates what psychologists call the Fundamental Attribution Error. Six percent? Really? Reading Dr. Sandeep Jauhar's "Doctored: The Disillusionment of an American Physician," you'd think the number optimistic. (The subtitle of The New York Times' book review was "In 'Doctored,' Sandeep Jauhar Examines a Broken System.") Dr. Jauhar is a cardiologist who has captured the New York media's attention with 2 inside-baseball books on his profession. "Doctored" fostered interest because it purports to expose the waste, avarice, and dishonesty of the fee-for-service healthcare system. Dr. Jauhar is an intelligent man. Born in 1968 in New Delhi, his family immigrated to the United States in 1977. He earned a PhD in physics at Berkeley before settling on medicine. He heads the Heart Failure Program at Long Island Jew- The doctor doth protest too much J.C. Noreika, MD, MBA Insights