Tale of Two Docs: Why Dentists Are Earning More
Randy Bryson and his brother-in-law Larry Fazioli are both medical professionals in their 40s who practice in Pennsylvania. The similarity ends there.
At Dr. Bryson's office here in suburban Philadelphia, a fountain softly burbles in the airy reception area, and patients are offered cappuccino or paraffin-wax hand treatments while they wait. Dr. Bryson works four days a week, drives a Mercedes, and lives in a 4,000-square-foot house with a pool. He and his wife, who works part-time in the same practice, together take home more than $500,000 a year.
At Dr. Fazioli's busy practice near Pittsburgh, patients crowd a utilitarian waiting room, and his cramped office is piled high with records awaiting dictation. Dr. Fazioli says he works between 55 and 80 hours a week, and his annual income of less than $180,000 has been stagnant or down the past few years. He drives a Chevrolet.
The key to their different lives: Dr. Bryson is a dentist, and Dr. Fazioli is a family-practice physician.
Once the poor relations in the medical field, dentists in the past few years have started making more money than many types of physicians, including internal-medicine doctors, pediatricians, psychiatrists, and those in family practice, according to survey data from the American Dental Association and American Medical Association.
On average, general dentists in 2000, the most recent year for which comparative data are available, earned $166,460 -- compared with $164,100 for general internal-medicine doctors, $145,700 for psychiatrists, $144,700 for family-practice physicians, and $137,800 for pediatricians. All indications are that dentists have at least kept pace with physicians since then.
Those figures are a sharp contrast to 1988, when the average general dentist made $78,000, two-thirds the level of the average internal-medicine doctor, and behind every other type of physician. From 1988 to 2000, dentists' incomes more than doubled, while the average physician's income grew 42%. The rate of inflation during that same period was 46%.
Factor in hours worked -- dentists tend to put in 40-hour weeks, the ADA says, while the AMA says physicians generally work 50 to 55 hours -- and the discrepancy is even greater.
"I feel so bad for Larry," says Dr. Bryson of his brother-in-law the doctor. "Especially when he's on call, he puts in some pretty long hours. Physically, it's really taking a toll on him."
Dr. Fazioli says he still gets a lot of satisfaction out of being a doctor and earns a comfortable living. But he admits he'd steer his children away from primary-care medicine as a career. Of his three sons, he adds, two might be interested in dentistry instead. "They see that Randy is doing OK," he says.
Many specialist physicians, such as cardiologists and radiologists, continue to rake in large incomes, generally exceeding those of specialist dentists such as oral surgeons and periodontists. But specialist dentists, too, have seen their paychecks increase at a much faster rate than their physician counterparts.
Healthier Teeth
Dentists have grown richer even as cavities, once the main cause for visiting them, have declined, largely because of fluoridation of drinking water and improved preventive care. According to a study published in the Journal of the American Dental Association in 1999, cavities in 6-to-18-year-olds dropped by three-fifths from the early 1970s to the early 1990s -- even though many children in lower socioeconomic groups still lack adequate dental care.
As people born in the 1960s and later have grown into adulthood, they tend to need fewer fillings than their parents did and are keeping their teeth longer. Painful disease-related procedures such as root canals are declining, too.
So why are dentists so handily outpacing doctors? In part, it's because dentists have avoided being flattened by the managed-care steamroller, and instead many have turned into upscale marketers. Dental care makes up less than 5% of the overall U.S. health bill, and hasn't been a major focus of cost-cutting.
Although some dental insurers have tightened up on reimbursements, most private dental insurance is still paid on a fee-for-service basis. Many optional procedures aren't covered by insurance, leaving dentists free to charge whatever the market will bear. About 44% of all dental care is paid by patients out of their own pockets, according to federal statistics for 2002, compared with just 10% for all physician and clinical costs.
While dentists may be able to focus more on marketing costly optional treatments, many physicians can't make the same kind of switch in their practices.
In competing for patients' own dollars, dentists have become more entrepreneurial, tapping into today's image-conscious zeitgeist. Many dental offices are festooned with pitches for everything from $400 teeth-whitening treatments to $1,200-per-tooth veneer jobs.
There are even $30,000-plus full "smile makeovers" offered by a growing coterie of dentists who specialize in high-end cosmetic procedures. Public awareness of such techniques has been heightened by reality-TV shows such as ABC's "Extreme Makeover" and Fox Broadcasting's "The Swan."
L. Jackson Brown, an economist who is associate executive director at the ADA, says cosmetic procedures account for about 10% of the nation's $80 billion annual dental bill, and are rising fast.
Sally McKenzie, a dental-practice consultant in La Jolla, Calif., who has been in business for 25 years, calls it a "golden era for dentistry." The most common call she gets, Ms. McKenzie says, is to help dentists manage "uncontrolled growth."
The situation is a sharp turnaround from the 1980s, when dentistry seemed to be in decline. Falling rates of tooth decay and a glut of dentists produced much soul-searching in the profession. Several dental schools closed, while others slashed enrollment. Dentists wrung their hands over their inability to get more insurance coverage -- a failure that now looks heaven-sent.
Dentists also have taken advantage of new technology, some of it controversial even within the profession. One major advance was the invention of porcelain veneers, which are wafer-thin shells of material that are bonded to the fronts of teeth to repair chips or misalignment. Unlike older surfacing materials, porcelain resists staining and looks like a natural tooth surface. Some dentists claim the procedure, which involves an irreversible filing down of natural teeth, can create problems. But proponents say that, done right, such veneers can stay in place for years.
"Today, you can create a smile" from materials that people "can't tell are not real teeth," says Joe Barton, a Jacksonville, Fla., dentist who specializes in cosmetic procedures. He says he typically charges from $12,000 to $14,000 to put veneers on 10 front teeth, requiring about 3? hours of his time. "We are competing with cars and vacations and jet skis and new homes, in terms of what people are spending their disposable income on," he says.
Some dentists use sophisticated software-imaging programs to show patients virtual before-and-after photos of what their teeth could look like with cosmetic help. Others have installed $100,000 computer-assisted design devices to make crowns in their own offices.
Intra-oral video cameras, tiny pen-shaped devices that can be used to display images of the inside of a patient's mouth, have become de rigueur. The cameras, which typically cost $2,000 or more, have little clinical purpose -- but there's nothing like seeing an up-close video of unsightly teeth on an overhead TV to persuade a patient that something needs to be done.
The turnabout in fortunes has made some dentists pity their physician colleagues. Robert H. Gregg, a dentist in Cerritos, Calif., says he had an operation for a snapped Achilles tendon a few years ago, which required him to go under general anesthesia for more than an hour. He was amazed his insurer paid just $2,000 to his orthopedic surgeon for the procedure. "I get about $3,000 for a three-unit bridge," Dr. Gregg says. "He's getting pennies on the dollar to what his skill level was."
Dr. Gregg says he offered to pay more out of his own pocket. The surgeon's office manager, he adds, "told me I was the first person" to ever make such a request.
The dentist and physician who are brothers-in-law, Drs. Bryson and Fazioli, both grew up in western Pennsylvania. They are related through Dr. Fazioli's wife, Robin, who is Dr. Bryson's younger sister. She sardonically refers to her brother and husband as "the prince and the pauper." She says she "definitely" doesn't want her sons to follow her husband into medicine. "I see how hard he works," she says. "I tell them, 'maybe you should go into dentistry. See how well Uncle Randy is doing.' "
Dr. Bryson, 44 years old, wanted to be a dentist from the time he was 5, his sister recalls. "We called him Rockefeller Bryson," she says. "He always liked the finer things in life."
While attending dental school in Philadelphia, Dr. Bryson met his wife, Toni Margio, a fellow student. They soon opened a joint practice in affluent Yardley, about a half-hour north of the city.
By the late 1990s, their practice was booming. But Dr. Margio says they both felt like they were "always on roller skates." They worked 10-to-12-hour days, and had to rely on Dr. Margio's mother to care for their son, now 8 years old. Dental insurers were forcing them to discount fees.
Five years ago, after attending classes at the Las Vegas Institute for Advanced Dental Studies, a school known for an aggressive brand of cosmetic dentistry, they dramatically changed their practice. They stopped accepting insurance -- patients are billed directly and can wrestle with insurers on their own -- and started plugging veneers, whitening and other elective procedures.
"We shifted from needs-based dentistry to wants-based dentistry," says the youthful-looking Dr. Bryson, who has a dazzling smile. "It has totally transformed our practice and our personal lives. We see a much smaller number of patients, at a slower pace. I can't wait to get in in the morning."
At their open, two-story office, large photos of patients with gleaming smiles adorn walls painted light blue. Classical music plays in the background, and the air is filled with a pleasant smell. "Aromatherapy," says Dr. Margio, a petite, dark-haired woman with a perfect-looking set of teeth.
On a recent afternoon, a patient is sitting in one of Dr. Bryson's exam rooms with small electrodes attached to her face. The nerve-stimulating device feeds data about the patient's jaw muscles to a computer system.
"Move your lower jaw forward," Dr. Bryson instructs, peering at the computer screen. "Perfect."
The patient, who complains of jaw pain from grinding her teeth, is being fitted for a night mouth guard, or orthotic. Although many dentists charge from $200 to $500 for guards, Dr. Bryson sells one he says is designed to keep the patient's jaw more relaxed. The price: $2,200, little or none of which is likely to be covered by insurance.
'Smile Makeover'
To help patients afford such treatments -- or the $12,000 to $15,000 they charge for a partial "smile makeover" of eight to 10 teeth -- Drs. Bryson and Margio offer financing plans that allow patients to borrow from a bank and pay their bills over as long as five years.
The couple say their practice's gross revenues are up about 60% to about $1.6 million a year since they shifted their focus five years ago. Costs have also risen, to close to 65% of revenue in some years, mainly because of outlays for computers and continuing dental education.
Since changing their practice, Dr. Bryson says he has cut back from 60-hour weeks to 32 clinical hours a week, plus some paperwork time. Dr. Margio now works 18 clinical hours, giving her more time with their son. Both take every Wednesday off. "I coach my son's soccer team," Dr. Bryson says. "I don't miss a practice."
The work, he says, is also more satisfying. "I get patient letters, I get hugs. People cry when they see their teeth. I never got that before."
Across the state in New Castle, at 2 p.m. on a recent Wednesday, Dr. Fazioli was scheduled to have left his office an hour earlier. "This is supposed to be my half day," says Dr. Fazioli, a compact man with a mustache, graying temples and a self-deprecating manner. "But I'm lucky if I get home at 3 or 4."
An overflow of patients has left him behind schedule, and his desk is piled high with records to dictate. "Patient canceled colonoscopy," Dr. Fazioli says into his tape recorder, recounting his exam of an elderly woman. "Says she didn't feel comfortable with the procedure. She's still smoking cigarettes. Had a discussion with her about the need for total cigarette cessation."
He groans as a nurse brings in another armful of charts. "No more. I gotta get out of here."
Becoming a doctor once seemed like a dream job for Dr. Fazioli, who grew up in a mill town about 10 miles from New Castle. His father had operated machinery for a U.S. Steel mill until it closed in the 1970s. After working as a pharmacist, Dr. Fazioli attended medical school, and in 1990 hung out his own shingle as a family practitioner.
At first, the practice grew quickly. His income early on was more than $130,000 a year, and he added a couple of partners. Being a doctor in a small city, he says, means "you get a lot of respect. It's nice when you help people. They're grateful."
The trouble started with the managed-care reforms of the mid-1990s, Dr. Fazioli says. Signing managed-care contracts provided him with easy access to new patients. But more patients meant more office visits at the cut-rate fees demanded by insurers. The federal government's Medicare program has been another headache. Medicare patients make up at least a third of his practice.
"Our reimbursements have stayed flat, but our overhead is up," says Dr. Fazioli, 47. "My take-home pay has definitely gone down." He says he had hoped to slow down a bit as he neared 50, "But I definitely can't do that right now. I've got to keep seeing patients."
Although his typical work week is about 50 to 55 hours, every third week he's on call, pushing the work load closer to 80 hours and often requiring him to go to the hospital in the wee hours.
Dr. Fazioli and his family live in a colonial-style house in a wooded area outside of New Castle. He won't give his exact income, but says it's between $150,000 and $180,000 a year. If he had to do it all over again, he says, he'd still consider being a primary-care doctor, but "I'd look hard at other areas, other states."
As for his brother-in-law the dentist, Dr. Fazioli says, "Randy certainly did his homework. People who come to him want his service. He can charge as much as he can."
Dr. Fazioli recently went to a local dentist to get a bridge put in. The procedure, he says, took about 1? hours over two visits. The bill: $1,200, all of which he had to pay from his own pocket. "I was thinking, 'How many people do I have to see to get that?' " Dr. Fazioli says. "If I made $200 in that amount of time, I'd be lucky."
Write to Mark Maremont at
mark.maremont@wsj.comCorrections & Amplifications:
The total number of root canal procedures performed in the U.S. rose 13% from 1990 to 1999, according to the American Association of Endodontists, a trade group of specialist dentists who focus on that treatment. But the rate among people 45 years and younger is declining. This article incorrectly said the total number of root canals is falling.
为什么牙科医生能赚那么多
兰迪?布赖森(Randy Bryson)和他的妹夫拉里?法奇奥利(Larry Fazioli)均在宾夕法尼亚州行医，且年纪相当，都是四十多岁的中年人。然而，他们的相似之处仅限于此。
布赖森的诊所位于费城郊区，宽敞的接待区里喷泉汨汨流淌，就诊者在等待时可以品尝卡普奇诺咖啡或是享受石蜡手部护理。布赖森每周工作4天，他开著一辆奔驰，住在4,000平方英尺的带游泳池的房子里。他的妻子是兼职医生，夫妇俩的年收入超过了50万美元。
法奇奥利的诊所则位于匹兹堡近郊，这里一派繁忙景象：病人们挤在一间公共候诊室内，法奇奥利狭窄的办公室里则堆满了等待处理的病历。他每周要工作55至80个小时，年收入在过去几年一直停滞不前，并有下降趋势，目前还不到18万美元。他开著一辆雪佛兰。
造成两人境遇不同的关键在于：布赖森是名牙科医生，而法奇奥利是名家庭医生。
美国牙医师协会(American Dental Association)和美国医学会(American Medical Association)的调查显示，虽然牙科医生在医学界曾一度备受冷落，但在最近几年里他们的收入已逐步超过了许多专科医生，如内科医生、儿科医生、精神病医生以及家庭医生等。
根据目前所能得到的最新比较资料，普通牙科医生在2000年的平均年收入为166,460美元，而普通内科医生的平均年收入为164,100美元、精神病医生为145,700美元、家庭医生为144,700美元、儿科医生为137,800美元。事实表明，牙科医生的收入从2000年以来至少与内科医生持平。
这些资料与1988年的资料形成鲜明对比，当时普通牙科医生的平均年收入为78,000美元，只有内科医生年收入的三分之二，且低于其他各科医生的收入。从1988年至2000年，牙科医生的收入翻了一倍多，但其他专科医生的收入仅增长了42%，同期的通货膨胀率高达46%。
工作时间也要加以考虑。美国牙医师协会称牙科医生一般每周工作40小时，而美国医学会称其他各科医生通常每周通常工作50至55小时，而且两者之间的差别越来越大。
“我也为拉里感到不平”，布赖森说。“特别是他总是随叫随到，工作时间很长。这样的工作很伤他的身体”。
法奇奥利表示，他对医生这个职业依然感到很自豪，生活也很舒适。但他同时承认，他会告诉孩子们将来别当家庭医生。法奇奥利补充说，在他的三个儿子当中，有两个对牙医业比较感兴趣。“他们看到兰迪干得不错”，他说。
包括心脏病医生和放射科医生在内的许多医疗专家收入依然不菲，通常超过了口腔外科医生和牙周病医生等牙科专家，但后者的薪水上涨幅度远远高于前者。
出现齿洞曾是人们造访牙医的主要原因，如今齿洞的发病率已逐步下降，这在很大程度上是由于饮水中添加了氟化物，同时牙病预防措施更加先进。即便如此，牙医们依然越来越富有。根据美国牙医协会杂志(Journal of American Dental Association)于1999年公布的一项调查显示，从上世纪70年代早期至80年代早期，6-18岁人群的齿洞发病率下降了五分之三，尽管许多家庭经济条件不好的儿童依然缺乏足够的牙齿护理。
目前上世纪60年代以来出生的人群步入成年，与父辈相比，他们需要修补的齿洞减少了，牙齿也更坚固了。因此，进行痛苦不堪的牙科手术的几率也下降了。
那么，为什么牙医的地位得以迅速提高呢？部分原因在于牙医们避开了美国医疗保健体制的冲击，他们中的许多人转向高消费阶层。目前牙齿护理占美国医疗费用的5%以下，还没有被列为削减成本的重点对象。
虽然一些提供牙科保险的保险公司对医疗费用报销更加严格，但大多数牙科保险服务还是实报实销的。保险公司对许多非强制的牙科护理服务不进行承保，因此牙医们可以自行开价，只要市场承受得起。美国联邦政府2002年的统计显示，约44%的牙科护理费用是由病人自己掏腰包的，相比之下，其他专科和门诊只有10%的费用是病人自付。
牙科医生们可以积极推销那些要价高贵的非强制牙科护理服务，而其他专科医生们可就不能加以效仿了。
牙医们争让病人们自己掏钱，并越来越富于创意，大胆地利用了如今注重个人形象的思潮。许多牙科诊所充斥了五花八门的各色宣传广告，从400美元的牙齿漂白护理到1,200美元一颗的镶牙服务，令人眼花缭乱。
一些针对高端客户的整形牙医还推出了收费超过3万美元的“微笑美容”服务，而且提供此项服务的医生数量在不断上升。美国广播公司(ABC)的直播节目“超级美容”(Extreme Makeover)和福克斯广播公司(Fox Broadcasting)的直播节目“天鹅”(The Swan)进一步提高了公众对这项技术的认知程度。
美国牙医师协会的副执行主任杰克逊?布朗(Jackson Brown)表示，整形服务占全美每年800亿美元牙科医疗费的10%左右。
萨利?麦肯利(Sally McKenzie)是加利福尼亚州的牙科业顾问，拥有25年的从业经验。她称现在是“牙医业的黄金时代”。她接到的最常见的电话就是帮助牙医们处理“难以控制的业务增长”。
此情此景与80年代形成鲜明对比，那时这个行业似乎萎靡不振。龋齿发病率的下降以及牙医供应过剩的局面引起了人们的反省。几所牙科学校被关闭了，另一些也大幅度地削减了招生人数。牙医们为无法争取到更多的牙科医疗保险而扼腕叹息，可如今看来这一失败好似天赐良机。
牙医们还利用了新技术，其中有些即使在业内也颇有争议。陶瓷镶牙就是主要的技术进步之一，它把非常薄的一层物质贴在牙齿正面，掩饰残缺不齐的牙齿。与传统的贴面材料不同，陶瓷不会失去光泽，看上去非常自然。一些牙医指出陶瓷贴面不能剥离，因此可能会出问题。但支持者们称如果操作正确，陶瓷贴面能维持好些年。
“如今，你可以创造一口让人分辨不出真假牙齿的微笑”，佛罗里达州的整形牙科医生乔?巴顿(Joe Barton)说。他说，镶口腔正面10个牙齿通常的收费是1.2万至1.4万美元，大约需要三个半小时。“人们通常把余钱花在汽车、度假和滑雪和新房上，我们就要力争分得一杯羹。”
一些牙医还利用先进的软件成像程序向病人展示虚拟照片，比较牙齿整形前后的效果。还有些医生安装了价值10万美元的电脑辅助设计设备，在自己的诊所里设计齿冠。
用来展示病人口腔内部状况的微型口腔摄像机已成为必备品。这种摄像机的价格通常为2,000美元或更高，临床价值微乎其微，但没有什么比让病人观看电视机里被放大的难看的牙齿更能说服他们接受治疗了。
不知不觉地时来运转禁不住让一些牙医开始怜悯其他同行了。加利福尼亚州的牙医罗伯特?格莱格(Robert H. Gregg)说，几年前他进行了跟腱手术，需要麻醉一个多小时。他吃惊地发现保险公司只向动手术的整形外科医生支付了2,000美元。“我做一个小小的搭桥手术就能得到3,000美元左右”，格莱格说。“与他的技能相比，那医生赚得太少了。”
格莱格说他后来主动提出自己再掏些钱，而那位外科医生所在的诊所经理对他说，“我是第一个主动提出这种请求的人”。
上文提到的布赖森和法奇奥利都是在宾夕法尼亚州西部长大的。法奇奥利的妻子罗宾是布赖森的妹妹。罗宾用嘲讽的口吻称自己的哥哥和丈夫分别是“王子和乞丐”。她表示自己“绝不希望儿子走他父亲的老路”。“我知道他工作很勤奋，就对孩子们说“也许你们应当学牙科，看看兰迪叔叔过得多好”。
布赖森现年44岁，他的妹妹回忆说，他从5岁起就想当一名牙科医生。“我们都称他为洛克菲勒?布赖森”，她说。“他总是喜欢精致的事物”。
布赖森在费城读牙科学校的时候认识了自己的妻子托尼?麦吉(Toni Margio)，他们俩是同学。两人很快就在费城以北的富人区Yardley合开了一家诊所，距市区约半个小时的车程。
到了90年代后期，他们的诊所开始兴旺起来。但麦吉说当时他们俩都感到整天处于“连轴转”的状态。夫妇俩有时一天工作10到12个小时，只能把儿子交给麦吉的母亲照料，他们的儿子现在已经8岁了。提供牙科保险的保险公司还敦促他们降低收费。
5年前，他们在拉斯维加斯高级牙科进修学院(Las Vegas Institute for Advanced Dental Studies)进修，这所学校的整形牙科很知名。之后，两人戏剧性地转变了工作方式和内容。他们停止接受保险公司付费，而是让病人直接付款，病人则可以自己与保险公司讨价还价。他们还开展牙齿美容、漂白以及其他非强制性的牙科服务。
“我们从基本牙科医疗服务转向自愿牙科医疗服务”，朝气蓬勃的的布赖森说，他灿烂地一笑。“这彻底改变了我们的工作内容和个人生活。我们接待的病人少多了，就诊速度也慢下来了。我早上总是迫不及待地开始工作。”
在他们那宽敞的两层楼的诊所里，病人面带微笑的大幅照片挂在淡蓝色的墙壁上，古典音乐萦绕在屋内，空气中洋溢著愉快的气息。“芳香疗法”，麦吉说，她身材娇小，头发乌黑，一口牙齿完美无暇。
前不久的一个下午，一位病人坐在布赖森的检查室里，脸上连接著小小的电极。这种刺激神经的设备把病人颚部肌肉的资料传输到电脑系统中。
“下颌向前抬”，布赖森一边进行指导，一边盯著电脑萤幕。“很好”。
这位抱怨牙齿咀嚼引起下巴疼痛的病人正在进行牙齿矫正。许多牙医为牙齿矫正收取200至500美元的费用，而布赖森的收费标准为2,200美元，几乎百分之百不属于医疗保险的范围。布赖森表示他采用的矫正方法会使病人的下巴更为放松。
布赖森夫妇对8到10颗牙齿进行“微笑美容”的收费从1.2万至1.5万美元不等。为了帮助病人支付如此高昂的医疗费用，他们向病人提供资助方案，允许后者从银行借款，并可在长达5年的时间里还清全部费用。
夫妇俩表示，自从在5年前转变服务内容以来，他们的总收入增长了60%，目前约为每年160万美元。当然成本也在上升，有些年份接近收入的65%，主要源于电脑添置费以及牙科持续教育费。
布赖森称，自从改变业务内容以来，他每周的工作时间已从60小时缩减至32小时，另加一些文书工作。麦吉目前每周工作18个小时，因此有更多的时间来陪儿子。两人每周三休息。“我是我儿子所在的足球队的教练”，布赖森说。“我从没漏过一场训练”。
他说，工作的品质也更令人满意了。“病人写来了感谢信，还与我拥抱。他们看到自己的牙齿后会惊叫起来。以前我从来没有这样的经历”。
同在宾夕法尼亚州，不久前一个周三的下午，法奇奥利原定提前一小时离开办公室。“下午本来是我自己的时间，不过要是能在3点或4点到家就算幸运了”，法奇奥利说。他身体结实，留著小胡子，鬓角灰白，一副无奈的样子。
太多的病人使法奇奥利无法按时下班，他的办公桌前堆满了要处理的病历。“病人决定取消结肠镜检查”，他对一台答录机描述著对一位老年妇女的诊断结论。“她说她对这种检查感到不适。她目前仍继续抽烟。早就告诉她需要戒烟了”。
当护士又拿给他一叠卡片时，法奇奥利叫了起来。“别再给我了。我要下班了。”
法奇奥利曾梦想成为一名医生，他在距New Castle大约10英里的一个工业城镇长大。他的父亲在一家钢铁厂管理机器，直到这家厂于70年代倒闭。法奇奥利起先做药剂师，然后上医学院，并于1990年挂起了招牌，当起来了家庭医生。
起初，法奇奥利的业务发展很快，他的年收入很早就突破了13万美元。后来他增加了几个合伙人。法奇奥利说，在小城市当医生“意味著你备受尊敬。能帮助他人真好。大家都对你充满感激”。
美国医疗保健体系于90年代中期开始进行改革，麻烦也接踵而至，法奇奥利说。签定医疗保健合同能使他很容易揽到更多的业务，但病人的数量越多，他们低价就诊次数也就越多，这是保险公司要求的。美国联邦政府的医疗保险制度Medicare也令人头痛。Medicare的病人数量至少占到了法奇奥利业务量的三分之一。
“我们的收入停滞不前，但管理费用却往上升”，47岁的法奇奥利说。“我的薪水毫无疑问地减少了”。他表示他原先曾希望随著年龄的增长少干一点，”可我现在肯定不能这么做。我得不停地给病人看病”。
虽然法奇奥利每周通常工作50至55个小时，每隔两周他都要出去巡访，因此实际工作量接近80个小时，而且还得常常在□晨前往医院。
法奇奥利和家人住在New Castle郊外一座具有殖民时代风格的房子里，四周树木繁茂。他没有透露具体年收入，但表示在15万至18万美元之间。他表示，如果让他重新做选择，他依然会选择做基础专科医生，不过“我会努力在其他州和其他地区发掘机会”。
至于大舅子布赖森，法奇奥利说，“兰迪无疑工作很尽职。病人愿意接受他的治疗。他可以开高价”。
法奇奥利最近去本地一名牙科医生那接受搭桥手术，共两次，大约需要一个半小时。全部费用为1,200美元，完全自费。“我在想，得看多少病人才能赚到这些钱？”法奇奥利说。“花同样多的时间能赚到200美元的话，我就很幸运了。”
