On Medscape Physician Connect (MPC) an online "physicians only" website, one primary care doctor wrote recently, "I laugh every time they discuss healthcare policy, the real issue should be how to save primary care."
I have a friend, Henry (I have changed his name for his privacy) who, after years as a master carpenter, decided to live out his dream and become a family physician. Almost two decades of study and clinical work followed as his children grew, too much on the periphery of his vision to suit him, and debt piled up. Finally, he became a doctor. One HMO dominated the city in which he lived and newly launched he was thrilled to be asked to join one of its family clinics -- with seven other physicians, physician's assistants, and nurse practitioners. Both Henry and his clinic are iconic representatives of a modern family medicine practice. Notably, the clinic has more insurance clerks than nurses.
Now, seven years into his practice, Henry is successful, oppressed, and unsatisfied. After the years of training that left him $250,000 in debt, he is paid just under $150,000 gross -- about the national average for a primary care doc. It seems like pretty good money in these parlous times, although it is a pittance when compared with, say, the average income of a colo-rectal surgeon which is more than half a million, and can go twice that.
Henry tells me he has to pay about $2,000 a month for malpractice insurance, and another $2,000 to service his student loans. This leaves him pre-tax with about $100,000. To get this money, Henry sees an average of 460 patients a month -- it works out to be about 15 minutes per patient. He hates the constant schedule pressure. Think about that for a moment: You spend your day making decisions that may change a person's life, but may also harm them irreparably if you are wrong. And you do it in little chunks of time. Day after day after day. He admits it is sometimes hard to keep his patients straight, and this really bothers him. He could see fewer patients, but there would have to be a downward adjustment to his income, and his employers would not be happy. Equally as irritating to him is that the company gives him less and less discretion as to how he can practice medicine. In the illness profit system in which Henry is embedded, in his own mind, he is slowly being turned into a kind of uber-technician. It causes him anguish, and he is representative of many in modern family medicine.
In 2010, the United States has 352,908 primary care doctors. The Association of American Medical Colleges estimates that 45,000 more will be needed by 2020.
Will they be there? Most who examine this issue come away with the sense they will not. Our healthcare model is precariously balanced because it is so unnaturally structured to favor profit. As we are about to discover, even the small changes made in the recent health reform legislation -- if they survive this next round -- are going to further stress this unstable system dramatically, and in ways that the overheated rhetoric that marked the debate hardly considered. The act of extending coverage to 30 million people is wonderful at one level; much has been made of that. Less was said about the fact that with the over-65 population doubling, as American Association of Medical Colleges Chief Advocacy Officer Atul Grover, MD, PhD, observes, "it will be difficult to meet care needs, and more people coming into Medicaid rolls and insurance exchanges will exacerbate that." Grover explains, "We currently train about 25,000 doctors a year, and will need another 5,000 or so per year if we are going to meet the needs of the next decades."
Yet we face an already active decline in the number of primary care physicians. "The number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007."
One of the biggest reasons family physicians give for their dissatisfaction is the ever growing paperwork and micromanagement imposed on them. Henry works from 7:30 am to 7:30 pm, and electronic records mean he is also his own clerk; each patient visit means he has a data entry task to complete. Because he is a truly conscientious man this takes a lot of time, and he stays late to keep it current and works over the weekend to catch anything he missed. Henry is far from alone in his unhappiness over the seemingly endless record keeping he is required to do. On Medscape Physician Connect one finds these sort of messages:
"The intrusion into medicine by third-party payers (better known as the insurance industry, Medicare, and Medicaid) has been coming since the '60s, but this effort to control costs has really become burdensome over the last 15 years, and it has not controlled costs and has not improved quality."
Another contributor remarks, "Every visit has its own catch-22, whether that's a prior authorization, a formulary, a HIPAA rule -- it never ends."
Yet another posting: "The only ones of us left in family medicine are those that are too young to retire and too old to retrain into another specialty."
At the front end of medicine, the family doctor seems close to overload-- living a world of 15-minute patient visits, interminable paperwork, a night sweat debt burden amounting to a second mortgage and, if the physician is in private practice, the malpractice costs. The model of medicine American primary care physicians are forced to practice conspires to create an unsatisfying career, which is why fewer and fewer young doctors are taking it on.
This confluence of a diminishing supply and a society with increasing needs almost inevitably is going to mean longer delays, more difficulties getting appointments, and more stress on everyone. It will take at least a decade and could take longer to get through this. And it is a crisis that should not be happening. It is the wholly predictable outcome of the health care system it represents. Moreover, the lack of available professionals encourages the development of adjunctive professionals, not as well trained, and usually at a lower pay level, who take up the slack, and this has its own unintended consequences for both doctors and patients. Sociologist Andrew Abbott in his University of Chicago Press book, The system of professions: An essay on the division of expert labor describes the process, writes: "a profession whose jurisdiction is excessive must increase its productivity or expand its numbers."
The present system has reached a productivity threshold that can hardly be raised. Thus, as Abbott points out, "when a powerful profession ignores a potential clientele, paraprofessionals appear to provide the needed services." In Henry's family practice, the lack of MDs has resulted in an increase in the number of physician's assistants and nurse practitioners. He admires and respects them but secretly asks himself whether their rise isn't another sign that the trend of primary care medicine is make it little more than a pharmaceutical dispensary. From the insurance perspective, a mixed clinic such as Henry's, and thousands like it, is a better financial deal because part of the client load is carried by personnel who do much of what physicians do, but for a lower cost.
It is interesting to consider the dysfunctional reality of family medicine with the pharmaceutical success at creating medications for hither to unknown conditions those family physicians and their paraprofessional colleagues can be encouraged to dispense, all driven by the enormous drug advertising on television. Medical writer Martha Rosenberg makes the point: "When The Medication Is Ready, The Disease (and Patients) Will Appear."
As whatever healthcare reforms survive the new Congress kick in over the next four years, this family physician crisis will be but the first of several arising from our failure to address the real issue: If pouring over a trillion dollars into Iraq and Afghanistan is in the national interest, is a healthy population in the national interest? Is it, in fact, a factor in our national security? If the answer to those questions is yes, how can it not be essential for America's success in the 21st century that we create a real healthcare system that makes citizen health, and not profit, the first priority.
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