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.
Follow Stephan A. Schwartz on Twitter: www.twitter.com/saschwartz905
Dr. Cindy Haines: Are Primary Care Physicians Going Extinct?
Because, as I've put it, Why join labor when you can join management - insurance companies and hospital corporations. They'll make more money, and so be able to repay school loans that sometimes go as high as $400K. And they'll have more regular hours., etc.
So who will take care of the sick? Easy. Foreign trained doctors, who'll earn more here than in, say, India. And many of these guys are very, very good.
Why should American doctors sell themselves short? After all, they don't earn their first paycheck until they're at least 30-31 yrs old - if they go straight through (and in some specialties, such as colo-rectal surgery or neurosurgery, till they're 36).
$100K/yr, net, seems like good compensation and I'm not saying it's bad. But if the ideal in this country is the "free market," young doctors should consider offering their services to the highest bidder, and patient care isn't it.
Many avenues are available to them that would allow them to make what decent lawyers, MBAs and accountants earn in recognized firms - $250,000.oo to $500,000.oo, or more. Should the "free market" that determines the much higher dollar value of MBAs', accountants' and lawyers' work not also allow doctors to search for a 'competitive' income?
1. Malpractice is high because doctors kill and harm tens of thousands of patients per year. Up to 225,000 according to one study. Could it be that the overuse of drugs and surgery are the wrong way to practice medicine? Studies showing that people who get less medical care are healthier and those that live in areas with lots of access to state of the art medical care do worse. In addition, lifestyle medicine performs better than drugs with all the major killers: heart disease, diabetes, etc.
So, doctors are making a ton of money doing a lot of harm to people and and then...
2. Complain about making six figure incomes and refuse to accept medicare/medicaid. Could it be that they are really saying something else? Perhaps that they are profoundly unhappy with the work they chose to do because it is often little more than being a pitch-person for the drug industry. Eight minute visits that culminate in the signing of a prescription is not exactly good use of smart people.
We can do better. First, patients need to be directed to preventive care (not early diagnosis) first, then to therapies that correct imbalances. Specialist, drugs and surgery should be the last, not the first, stop in addressing health concerns.
In my case, whenever I see a medical patient (California's medicaid), I'm paid about 50% of my fixed costs. I lose money, in other words. And so do most doctors.
If I could just convince my staff to forgo salaries, and my landlord to forgo his rent, my malpractice carrier to forgo payment, and if I didn't have kids in college, why I'd happily swing wide my doors.
But the solution you're suggesting is to replace physicians with "lifestyle and dietary" advisers/managers, and so obviate the diseases before they cost us.
One of my colleagues, a retired med school dean, has a couple of simple solution:
1) We are one of the few developed countries that makes it's medical providers fund their own education. Spend five years in primary care and the feds will pay off your loans. Clean and simple.
2) Want to fix Medicare primary care issues? For every Medicare patient you take in primary care, you get 1000 bucks a year. Pittance to the system, but in 10 years the 70/30% split of specialists vs primary care would be fixed.
The current health care reform is about access, not reforming the broken system. You get what you incent, folks. DrCrankyMD
The MBAs, accountants, lawyers and myriad managers have earned their money managing health care. And so they richly deserve the 33% overhead we pay for their precious services, which is cut of the health care dollar they get before a penny goes to care givers.
After all, why should the CEO's of insurance companies and hospital chains not be entitled to the $50 million/year bonuses their counterparts in the financial industry get? I mean, think about it: many of them have earned their MBAs! If we could just get doctors and nurses and hospital technicians to take, say, a 10% pay cut, why health care CEO's might be able to earn what hedge fund managers make, and so prove the value and superiority of the "Free Market."
I want SINGLE PAYER MEDICARE FOR ALL! HR4789 OR HR676
I'm getting kind of tired of all these excuses that claim that the wealthy need to keep getting away with not paying back to the very society that made them wealthy. The excuses are nearly identical to the ones used by the Nobles and Monarchy in France in the 1790's... and we all know what happened then, don't we.
Current physician fees under Medicare are barely enough to cover expenses, and they are under constant threat of absurdly large cuts because of a deeply flawed rule called the sustained growth formula (SGR). Congress has postponed cuts nearly on a monthly basis, because allowing them to proceed will cause physicians to become insolvent under Medicare, therefore leaving them no choice but to refuse to see Medicare patients, and leaving many "insured" Americans essentially without insurance. Yet Congress has failed to definitively act on this issue by allowing the SGR to continue, as opposed to eliminating it entirely.
A couple of days after talking to my doctor I saw yet another article about doctors supposedly refusing to take medicare patients because of rates of reimbursement. So I took out the local phone book and called eight different doctor's offices and explained that I would be on medicare soon and was looking for a primary care doctor. Every one of the offices said that they were accepting new medicare patients.
Maybe this denial of doctors for new medicare patients in occurring in some locations. But really, I think it is just a lobbying ploy by the medical associations to put pressure on congress to maintain current rates.
When a professional has a quasi monopoly a service/product whch means life and death to a lot of peope, he/she can be very choosy. Why would Dr. X, choose PRIMARY med care med practice making about $150 dollars per hour when its possible to make around 7--800 dollars per hour as a specialist?
It might help this quasi monopoly problem if we do with the med profession like we do the military. Cadets or midshipman, after graduation, are obligated by law to serve, what is it, at least 2 years in the military of the USA. The problem in med profession is the enormous cost of the education as compared with most other professions. My view is that the public could get a return of $10 on every one dollar invested in sponsering medical education with a stipulation somewhat like our military acadamies. These med grad's would be obligated to pratice at least 2 years in primary care with preference give to sparsely populated areas of the US..This would not be a "loan" program but a scholership.
Result: you would have medical doc's actually COMPETING with on another for patients like other typ professions compete tirelessly for clients which keeps fees DOWN for most. And keep in mind that the core of the US health care crisis is the preposterous difference between how US doctors are paid compared to other wealthy nations where medical care is not so scarce.
That said, our sad economy, in which health care will be one of few growth areas, might spur an uptick in med school admissions, and there's been talk of incentivizing primary care....
Why then do doctors continue to almost automatically perform unnecessary procedures, such as male genital mutilation (also known under the euphemistic term "circumcision"). Is it because the procedure usually takes only minutes, pays well, and can be shunted off on interns, and even nurses?
No doctor can possibly acquire and update in his head all the data needed to treat literally any person who decides to appear. This has never been possible, but we all pretend because it's nice to see one person.
Memory and process are the problems; memory, as in all other endeavors in the modern world, is handled by computerization of needed data, organized to allow instant and accurate retrieval night or day.
Process in medicine should be a caring, thorough, reliable, straight-thinking person sitting next to a patient and the computer that allows all 20 feet of textbook knowledge to be accessed instantly, including updates from all the latest publications.
We don't need more "family doctors". We need access to medical information in the hands of people adept at listening and then following protocols developed by leading authorities in every field. THESE PEOPLE NEEDN'T ALL BE DOCTORS. And there's the savings.
And all that information must also be in the hands of patients.
We must face the fact that we delude ourselves that any one physician can know enough to be a "family doctor". We need a whole new paradigm. This one will never work.