I read the recent popular posts from Matthew Moeller (Dear lawmakers: this is what it’s like to be a doctor today) and Nick Rademacher (Lawmakers shouldn’t care about the personal hardships of doctors) with great interest. They reflect perspectives from two interesting turning points for most medical careers- medical student, and established attending physician. I’m a U.K.-based surgeon and though the healthcare systems in the UK and USA are very different, the issues of student legacy debt and pressure on remuneration for doctors are similar. Ruminating on both letters led me to consider what a doctor is worth.

Many doctors in the US and UK will empathize with Moeller’s situation, and feel a degree of unfairness in the way we, as a profession, are portrayed in the media by devious politicians. It’d be easy to dismiss Rademacher’s reply as the enthusiasm of youth that will change with age and experience, but I’m wary of castigating him for expressing views that many shared at his stage of training. I‘m sure they are sincerely held, and are indeed the heart of why most of us ended up in medicine in the first place.

Behind these two opposed views lurks a more significant issue: the influence of medical reimbursement on the future direction and structure of healthcare. Like it or not, doctors are the critical decision makers in the majority of medical interactions. Once the decision is made, certain tasks can be delegated to specialist nurses, but the critical decisions are always made and reviewed by a doctor. It’s the decision-making capacity that makes doctors the indispensable part of health care- the part of the system that actually adds real value to the patient outcome.

There are many aspects to the compensation package for a doctor- the job satisfaction, sense of personal vocation, and other intangibles, do go some way to mitigating downward pressure on financial remuneration. But it’s these personal rewards that are cynically exploited by policy makers to force down the financial rewards of the medical profession.

For the majority of doctors, idealism eventually butts up against the hard reality of economics. If the decision makers, the engine room of healthcare, are put in a position where their financial remuneration does not reflect the personal investment in training, nor allow them to enjoy a reasonable standard of living, then the inevitable consequence will be an exodus from certain specialties and activities into other areas which are better compensated.

The end result may be a stratified system of care. The best and most energetic medics could end up treating the wealthier members of society, who can afford to pay for their services, whilst the less affluent patients are left with a dwindling number of overworked idealistic doctors grinding themselves into the ground in an attempt to prop up a public health service under continual and excessive pressure. Healthcare will become more unequal, which, in curious irony, is the polar opposite of what most policy makers say they intend.

So, what is a doctor worth? In the final analysis this probably rests on what the purchaser of a service is prepared to pay for it. In many other walks of life there is a direct correlation between price and quality — isn’t it possible that this rule may also apply to medicine?

Eddie Chaloner is a vascular surgeon who runs a private practice Radiance Health in London, England. He also works part time for the National Health Service.