Doctors are burned out and they don’t enjoy their job as much as they used to.  But looking broadly, physicians are still spared the economic difficulties and loss of autonomy that are present in most other sectors where people are still lucky enough to be employed.  There are issues that doctors rarely face: unemployment, inability to pay their rent and food with their paycheck, and lack of health insurance.

These benefits are noticed by patients, who see their insurance premiums going up and up, even as they can ill afford their current medications.  ”I spend $1,200 a month on my medications,” a patient told me this week, and that’s a lot by anyone’s budget. They wonder if doctors “would accept more reasonable fees,” but the truth is physician compensation is almost as variable as the compensation of actors.

Sometimes patients call in about the astronomical bills they’ve received from the hospital where I work.  But when I get bills from our pediatrician, I wonder the opposite:  how does he stay in business?  How does his practice pay for rent, equipment, housekeeping, the army of nurses and schedulers and medical assistants who take calls, how do they have someone who can call me back or answer a question without a visit, someone who can call to reschedule or call in a prescription, and someone who can do the billing.  The visit fee isn’t enough to cover all that.  It is the childhood vaccinations, it seems, where a few painful minutes make up for the uncompensated time spent talking to the anxious parents about their child.

I’ve heard doctors themselves argue that some of us should be paid significantly more than others.  I hear this typically from the doctors whose job does not involve, as mine does, staying in a hospital overnight.  And yes, it is true, if you work overnight or on weekends, it is more stressful, more tiring, more disruptive to family life, and you should be paid more.  But while the surgeons and other doctors who have particularly stressful jobs may be, on average, paid more, the highest paid physician is not the general surgeon who comes in the middle of the night to do appendectomies and save lives.

At UCSF, as in many other Universities, for example, the highest paid employee is the football coach.  Next? No, not the guy staying up all night to operate, it’s the dermatopathologist.  Never heard of him? He’s a pathologist who looks at slides of skin biopsies.  Probably during regular business hours.  Definitely with no one dying in front of him.  In our system, it is the procedures that are paid for, not the talking to patients, and a dermatopathologist can review a lot of slides, which, like reading x-rays, are paid for as a procedure.

Physician compensation does not necessarily correlate with stress or difficulty, and the harried primary care doctor you see is not the reason we’re spending 18% of GDP on healthcare.

The average medical student graduates with $150K of debt.  But on the other hand, the average medical student, unlike the average chiropractic student, dental student, or virtually any other student, is able to pay this debt off.  It might take until they start paying for their own children’s college education, but the fact remains that they are able to find employment where they will ultimately be able to pay their educational debt off.

On the flip side, medical student debt, coupled with the income inequality among physicians, helps to explain why the most competitive specialties in medicine are dermatology and radiology, why anesthesiology has become increasingly sought after, and why the most difficult surgical specialties to get into are ophthalmology, plastic surgery, and orthopedic surgery.    Think regular business hours, small, scheduled, elective surgeries, and cash-only practices.

“Our dean had a meeting with all the medical students because no one is going into internal medicine, and everyone is doing anesthesia instead,” a resident said.  But the forces at work are not something a meeting can solve.  What can the dean say to a graduating medical student owing $150k that would counter the salary and lifestyle discrepancy between a graduating anesthesiologist and internist?

The counter-intuitive weighting of what we value as a society is reflected within medicine.  Changes to the structure of how and why physicians are paid are underway.  But in the meantime, when patients are angry over their medical bills, they would do well to remember that chances are, the Porsche in the physician parking lot does not belong to their primary care doctor.  And doctors would do well to remember that, chances are, their professional struggles are likely far less Darwinian than those of their patients.

Denitza Blagev is a pulmonary physician who blogs at mybetterdoctor.