This short Post was placed on Sermo. This online Physician community has 110,000 physicians as members and the AMA does NOT speak for us. I ask you to take the time and have the courage to read this post and the comments of the 130 physicians who took the time to add their brief comments. This Post was chosen as the Sermo Pick from over 500 other posts. This is a MUST read if you hope to understand the REAL Health Care Crisis looming over us.
The Demise of Primary CareFewer and fewer medical students are choosing primary care. Health policy experts agree that any reform in our health care system must include a well-educated, caring primary care doctor who is able to manage the health of their patients with an eye on using resources optimally to keep costs down.
That's a tall order and it seems that few policy makers realize the value of primary care physicians. People are making a huge assumption in this reform effort. They assume that as we provide coverage for millions who don’t currently have health insurance, that there will be enough doctors to actually provide health care to these additional people. That is a huge assumption to make given current trends and policies. Let me share with you why we are losing so many primary care doctors. What follows are a few examples I experience each week.
How many dozens of chest pain patients have I seen in the last month where I didn't order an EKG, get a consult, set up nuclear imaging or send for a catheterization? Only I have the advantage of knowing how anxious some are and that they have had similar symptoms over the last 20 years. After a history and exam, I am willing to make the call that this is not heart disease. In doing so, I save the system tens of thousands of dollars. Most of these patients are worked into a busy day, pushing me even deeper into that mire of tardiness for which I will be chastised by at least 6 patients before the end of the day. My reward for working these people in and making the call is at most $75
How many times has an anxious patient come in, demanding an endoscopy, who I examined and then decided to treat for 3-4 weeks first? Few of these patients are happy no matter how many times I explain that it is reasonable to treat their reflux symptoms for several weeks before endoscopy. This delay in referral has lead to many tense moments in the last 20 years. Cost savings to the system is thousands of dollars each and every time. I am willing to make the call and go with the treatment. My reward is about $55 from Medicare and the Big Blues.
How many low back pain patients have come to the office in agony knowing that there has to be something serious to cause this kind of pain? A good history and exam allows me to reassure the patient that there is nothing we need to operate on and that the risk of missing anything is low. This takes a lot of time to explain as I teach them why they don't need an MRI. If someone else ordered the MRI, guess who gets to explain the significance of bulging disks to an alarmed patient? Setting realistic expectations on recovery and avoiding needless imaging helps saves the system thousands of dollars. My reward is another $55.
How many diabetics do I struggle with, trying to get them to take better care of themselves? How many hours have I spent with teenage diabetics who will not check their blood sugars and forget half of their insulin doses? Hundreds of hours seem wasted until one day they open their eyes and want to take care of themselves. My reward for years of struggle is a few hundred dollars at best. The savings to society for my hard work and never give up attitude is in the tens of thousands of dollars.
I am in my 22nd year caring for 3600 patients. Having me in the system has resulted in savings in the hundreds of thousands of dollars each and every year. My financial incentive to hang in there and work harder is that I now make less than half of what I did 20 years ago. This year I will make even less.
These are the reasons so many physicians have left medicine entirely and most of us left wonder how long we can continue to work like this. I have always served my fellowman out of a sense of love and compassion. That’s why I went into medicine. I have been richly rewarded by my patients over the decades as they appreciate my judgment and skills. Isn't it a shame that after all this time and with skills honed by decades of experience, many of us can no longer afford to work as a physician?
No one is talking about this on the national level. If they don’t address these issues then good luck having Physician Assistants provide the safety net with 2 years of training. Good luck getting newly trained physicians once they see our salaries. Good luck having Internists in your community with only 1% of medical students going into Internal Medicine. Good luck recruiting primary care specialists when we are short 70,000 and 1/3 plan on retirement within 3 years.
If there is any irony in this, it is that I will find myself in the same. Now that is ironic. Anyone know who is taking new patients in California?
Vance Harris, MD
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Comments by Physicians
Family Medicine
Posted Aug 11, 2009 at 6:18 AM
I'm there, too.
Family Medicine
Posted Aug 11, 2009 at 7:04 AM
Thank you for posting your thoughts.
Family Medicine
Posted Aug 11, 2009 at 7:27 AM
I feel the same way.
Floridoc.....I have read your thoughts and appreciate them.
What are we to do??
Family Medicine
Posted Aug 11, 2009 at 7:47 AM
Interesting that the narrative ends with fears that Dr Harris won't be able to find an English speaking doctor to take care of himself and his wife in his retirement years. I worry about the same thing. Likewise my patients. The day I have to lock the doors to my practice for the last time, I too will have nothing to say to the thousands of people who depend on me other than Good luck! You're on your own.
Like much of the deterioration of our society during our lifetimes, this sad state of affairs comes as a result of high level managers without morality or common sense pushing the agendas, and creating our priorities. That's why hope is about to be extinguished in the emotional rantings of politicians and "angry mobs" alike, all ignoramuses, all clueless, all devoid of solutions as they set the course of our futures.
Dr Harris, I might suggest bypassing California and retiring to Mexico. A more hopeful society.
Internal Medicine
Posted Aug 11, 2009 at 8:14 AM
Dr. Harris- Can I suggest that you send this wonderful narrative to the NY Times "Well" blog (by Tara Parker-Pope)? It is typically a horrible doctor-bashing blog, with clueless commentators who think all doctors are stupid, money-grubbing jerks. Maybe this could help just a few of them see the light.
Family Medicine
Posted Aug 11, 2009 at 8:42 AM
A truly insightful commentary on our future. Please send it on to the media.
Family Medicine
Posted Aug 11, 2009 at 9:12 AM
Si'
Both to the initial post and follow up.
Family Medicine
Posted Aug 11, 2009 at 9:36 AM
Abandon hope all ye who enter here .......
Family Medicine
Posted Aug 11, 2009 at 9:52 AM
5 stars, only because 6 is not available
Orthopaedics
Posted Aug 11, 2009 at 9:53 AM
Primary docs like you will be missed. I know when I see certain MD/PA on referrals that the patient will be on 10 meds ( always several anti-depressants and usually chronic pain meds) and think they need immediate surgery for a minor MRI finding.
Surgery, General
Edited Aug 11, 2009 at 10:57 AM
How truly sad our current state of affairs is. We only have ourselves to blame. Once we throw in the towel our opposition automatically wins.
We are our own worst enemy by having allowed our lack of collegial trust and unity to rule the day. Instead we have allowed our socialization into medicine to be a barrier rather than launching board to change, innovation and creativity.
Is there the collective energy to lift ourselves up by our boot straps. Afterall, it's never about how many times you are knocked down, but about how many times you get back up again.
I am not ready to give up. The road and journey along with the rewards have been to valuable to allow the enemy to win.
All the is necessary for evil to win is the good men and women chose to do nothing.
Family Medicine
Posted Aug 11, 2009 at 11:04 AM
Bravo! I agree with sending this to the media. Reflects the way I felt before i retired. So glad I did it.
Neurology
Edited Aug 11, 2009 at 11:19 AM
Please do send this out to as many newspapers and TV stations as possible, it may not make their "standard of care" because it reveals the true nature of what is happening to physicians instead of bashing us, but it is better than saying nothing. More physicians need to be aggressively sending out notice to these media, they really have no clue what is happening or the impact of so many leaving. God Bless you for your dedication, your caring and may you find something that will keep you at peace and harmony with yourself.
Family Medicine
Posted Aug 11, 2009 at 11:32 AM
I'm only 35 and have been looking at different businesses/alternative forms of income for the last year. Kind of sad that my income has peaked in only 5 short years. As overhead goes up, and reimbursements don't keep up, I'll be going home with less each year. I agree that this fact of life is going to discourage any med student from going into primary care.
Family Medicine
Posted Aug 11, 2009 at 11:40 AM
Well written. I couldn't agree more.
Please forward this to the media and our brainless Congressmen and Senators.
Family Medicine
Edited Aug 11, 2009 at 12:37 PM
Reality check, my dear colleagues- so long as our legislators have thier own kind of medical insurance benefits not similar to anybody else's in this country, things will not improve for Medicine.
So long as there are about 20 or so full time docs that cater to Capitol Hill, (I'd call it Capitol Hill urgent care for the lawmakers (CHUCFL)), such that they do not have to have pre-auths, and can be admitted to Bethesda or Malcolm Gray or Georgetown "fast track", we're shirts-out-of-luck. (intentionally modified)
In no other specialty group in Medicine is the lament more significant than in Primary Care- for a whole lot of reasons we already know. "We are our own worst enemy" is right- in that most of us would rather see patients than attend seemingly useless meetings- versus a lawyer/lawmaker whose actual profession is meeting with people, and maneuvering within a system that was specifically designed by and for them. Now, they are trying to control the medical system so that theirs would be absolute control. I believe there is still free will. It should still work, so long as there are enough docs that stand by the profession and uphold its virtues.
What you wrote- Absolute truth, webdoc!
Internal Medicine
Posted Aug 11, 2009 at 12:37 PM
Well said.
Sadly.
Reflects the reality of us in the trenches.
Internal Medicine
Posted Aug 11, 2009 at 1:06 PM
You sound like you are a kind, honest, reasonable physician - which is what I strive to be. However, you need to stop and take a deep breath. Here is why, our society needs you and your kind. For you to stop caring for people out your current frustation would be a real tragedy.
Get Real! Save yourself and your ideology! Start charging and demanding payment from patients that you deserve for your time. Just do it! Yes, you will lose some patients for whatever reason. However, people are smart enough to know when someone really cares and that is worth alot to some people(like yourselves).
The thing that you need to resolve to is that the SYSTEM is driving you mad and they are aware of this and they don't care!
Set your fees, do your work, forget the system and see what happens!!
I would love to talk to you about this.
Family Medicine
Posted Aug 11, 2009 at 2:03 PM
All I can say is "me, too."
And then sometimes we get nasty letters from patients like the one I got today for discussing diet, food diary , nutrition and ways to work in bits of physical activity - she said that I make her blood pressure high by discussing these things with her.
You don't know me, but I am gentle in my approach and spend sooooo much time.
Internal Medicine
Posted Aug 11, 2009 at 2:53 PM
Dr. Harris, thank you for sharing your insight. Primary Care is very undervalued in many ways. Sadly, most people will never appreciate the value of primary care doctors until they are gone, which I believe will happen soon. When the government forces universal health care upon everyone I anticipate reimbursement to drop like a rock. No one in his/her right mind will invest the years of training and cost to study medicine, much less specialize in primary care, when the pay is no better than one can earn by working in other occupations requiring far less sacrifice.
Family Medicine
Posted Aug 11, 2009 at 5:48 PM
Shocking to see so many primary care docs in the same situation as me. The demise of primary care is only the beginning. This downward spiral has begun to affect some specialities and will eventually drag them all down too to a mediocre socialized healthcare system for all.
The only way to prevent this and other government attacks on our own rights is to have a true revolution, or in the case of Texas...secede.
OBGYN
Posted Aug 11, 2009 at 6:04 PM
It sounds like you are the kind of doc I want taking care of me and my family. We all need to seceed from the insurance garbage and go back to patients paying for their routine care so they understand what they are "buying" and let them deal with their insurance companies.
Hang in there.
Family Medicine
Posted Aug 11, 2009 at 8:21 PM
I am glad I am not alone in my thoughts. I often feel when I get on health care blogs "Am I the only one out there wondering what has happened to my career this profession I was so excited to enter. I have been practicing only 5 years but I feel I have been beaten by a stick for 30. What I don't understand is why do many physicians use PA and NP's . I understand many take them on the help with the burden but how can we support those that devalue our training?
Family Medicine
Posted Aug 11, 2009 at 10:19 PM
I feel your pain. I love what I do but cannot make a living doing it. I could not have said it better myself!
Orthopaedics, Sports Medicine
Posted Aug 12, 2009 at 12:23 AM
Thank you for sharing. It truly pains me to see how poorly rewarded primary care physicians are for their dedication and effort.
Unfortunately, our healthcare system rewards "doing" instead of "thinking".
Neurology
Posted Aug 12, 2009 at 2:41 AM
well, the NP/PA brigade will be able to take our places when they practice according to the protocols and guidelines provided to them by their new EHRs.
*snort*
Internal Medicine
Posted Aug 12, 2009 at 8:05 AM
migrainemaven, I think you are correct about protocols and practice guidelines. I think there has been a movement afoot for a long time now to establish a cookbook approach to practicing medicine. There seems to be this belief that if you write the cookbook that anyone with little or no training can practice medicine. And that is why there is this trend toward NPs and PAs. They are invading not only primary care but specialized areas as well. There are NPs practicing independently as Pulmonologists, Gastroenterologists, and even Hematologists [gasp] in my town right now. That is really scary.
Family Medicine
Posted Aug 12, 2009 at 9:00 AM
We all used to know our skill level, and worked comfortably there. PCP's skill level deteriorated in the eyes of many patients, who have a built-in Mayo Clinic Is Best gene. Any midlevel can make the referral, or patients can self refer.
Current "reform" doesn't even get a whiff of this problem.
Otolaryngology
Posted Aug 12, 2009 at 12:47 PM
This posting is one of the only things I have read on sermo in the past several weeks which has seemed honest. It gets to the point of one of the major problems with our system. The experienced, thoughtful primary care physician is struggling. The incentives in the system are to provide good customer service. What does that mean to the patient? Ordering the MRI, consultation with a specialist, prescribing cialis. On a busy day when you are being lectured to by your medicare patients for being tardy, why not send all those patients that call with acute problems directly to the emergency room?
OBGYN
Posted Aug 12, 2009 at 10:38 PM
Went to a meeting tonight and spoke to a NP who recently "hired a doctor". How about that! Will start a new post for comments, but thought I'd put it here first. Wow!
Family Medicine
Posted Aug 13, 2009 at 9:35 AM
After 30 yrs in practice, I feel your pain.
I hope that this does get sent to the media as you have so eloquently expressed the feelings of many PCPs. If it weren't for the appreciation of the patients, many of us would (and have ) doubt our own worth as physicians.
Internal Medicine
Posted Aug 13, 2009 at 1:35 PM
...and they wonder why no one wants to do primary care....
Internal Medicine
Posted Aug 13, 2009 at 2:16 PM
I agree - and with canuckmd
These kinds of perspectives need to make it to the general public - or at least the Congress and White House - combined with the comment from the ED med mal concern thread -
Do we do what we know is right (or sufficient) or what we need to protect our a$$ from that next potential law suit (what is necessary)? (As for the comments that they cant see any difference in medical care patterns in tort reform states, the response if related to the length of tort reform and when the doctors learned to practice. It's a bit like say that an abused spouse will not continue with the same behaviors as soon as the abuser is out of line of sight.)
As long as patients are free to self refer and do not need the primary care blessing, then if they really thinks something is wrong, they will pursue it. The question is how often is the high powered work up necessary? It will depend upon the history - which changes with each telling - something else/different leaks out that may be crucial. That's the one aspect that is not adequately addressed in most medmal - how good of a historian is the patient, or how good of an interviewer is the physician?
OBGYN
Posted Aug 13, 2009 at 2:53 PM
Thanks for posting. Very well said.
Family Medicine
Posted Aug 13, 2009 at 3:29 PM
You know how if feels when you warn a person of their consequences, and they continue to do destructive behavior, and when it happens there is a tempation to say "I told you so."
That's the way I feel about primary care. The people in charge have had a chance to change it and nothing has been done. Now, I almost hope for the collapse of primary care just to see the mayhem it will cause. People flocking to the ER for minor problems, costs spiraling out of control. There will be some satisfaction seeing people say "what happened? what could we have done?"
Family Medicine
Posted Aug 13, 2009 at 4:15 PM
Great post. Sad, but great. Sad because it is true.
Family Medicine
Posted Aug 13, 2009 at 4:19 PM
I agree with all y0uo've pointed out and all true having similar experiences. I just wonder why the 'leadership' in teh AAFP seem to be ecstatic at the thought of OBama Care --all because someone somewhere will get a paying pt out of the present nonpayers. Who's taking medicaid NOW so how is another govt insurance going to be an improvement. But the real corker is we in FP are going to be replaced by NP's and PA's because regradless of what 'they' say--they DON'T value us and try any way possible not to pay us or pay us less and less--if you cannot se the writing on the wall you AIN'T looking.
Family Medicine
Posted Aug 13, 2009 at 4:30 PM
Thanks for eloquently putting into words what I have tried to convey to my friends and colleagues. Someone just asked me this week to donate $10,000 to a worthy local charity. I guess they think I am rich beyond measure just because I have M.D. after my name. They didn't understand that I can barely keep up with my bills ( I have had to borrow money for the last 2 years to pay taxes). I strive to avoid ordering expensive tests and medicines for my patients. Where is my reward?
Internal Medicine
Posted Aug 13, 2009 at 4:31 PM
Dr Harris, thank you for sharing. it gave us who are planning to venture out there on our own a big chill. What can we do from here on?
Family Medicine
Posted Aug 13, 2009 at 4:31 PM
We can all sympathize with Dr. Harris. And I wish him the best of luck in his future endeavors.
However, all of this is mental masturbation unless we as individuals decide to take our future in our own hands. To wait for the physician community to organize, speak, and fight for us is like waiting for the sun to rise in the west. It isn't going to happen. However, you as an individual can decide to take actions that disencumber you from insurance reimbursement. The road may be difficult, but the law of supply and demand will win out. The journey of 1000 miles begins with the first step.
Family Medicine
Posted Aug 13, 2009 at 4:37 PM
Great post and very well written! I believe that if the general public were to better understand our side / situation from a Primary Care viewpoint that it would help gain more of their support. This is very written post and speaks very well how Family Practice works so hard to practice medicine and save money and in return we are the "bottom of the food chain."
Internal Medicine
Posted Aug 13, 2009 at 4:41 PM
I was in a similar predicament. After 8 years of declining income, I quit primary care. Now I am employed as a hospitalist. I enjoy the work and I make a comfortable living. I lose count of the number of inpatients looking for a PCP. They ask me if I have an office to see them, but unfortunately my office is now the hospital. The private practice PCP is an endangered species. Primary care will evolve into big medical groups (like university run groups or large private groups) that will have the clout to negotiate with payers. And more and more physician extenders will be used which we are now seeing in the hospital setting as well.
Internal Medicine
Posted Aug 13, 2009 at 4:45 PM
Very well written. You need to get this to the media!
Family Medicine
Posted Aug 13, 2009 at 4:52 PM
Unfortunately, most of us try to protect ourselves from litigation and try to order tests. Also, if patients are unhappy with you because you refuse to order any tests (because those tests are probably unnecessary), they switch to another physician who will...which sounds good in theory until you lose enough patients to lower your income. Just like antibiotics. It took me 3+ years to train my patients that antibiotics are unnessary in URI because most physicians in my area give out antibiotics as soon as patients come in for cough/sorethroat/ fever.
Most of us physicians use up so much time and energy to take care of our patients that we run out of steam to fight the politicians/lawyers/insurance companies.
It's very sad. I don't think anyone will appreciate the physicians again nor will physicians have decent compensation until there are more and more empty positions and inadequate medical care.
Family Medicine
Posted Aug 13, 2009 at 4:54 PM
I flounder in the same boat!!! So do my partners. Only our income is less than half of yours. This is a story that MUST be told, or our health care crisis cannot fail to degenerate into utter disaster. Who killed Marcus Welby?
Family Medicine
Posted Aug 13, 2009 at 5:04 PM
Nicely written -- a great read.....I hope you find a way to continue in medicine
Family Medicine
Posted Aug 13, 2009 at 5:05 PM
Too true.
A friend once told me, "we argue over the length of our chain and the size of our prison cell." I say we take reimbursements into our own hands, even if it means ridding ourselves of third parties.
I can't wait to get started!
Family Medicine
Posted Aug 13, 2009 at 5:06 PM
Brilliantly put.
Maybe Sermo can send this to NBC Nightly News?
Perhaps hearing our side of the debate might clue folks in.
Family Medicine
Posted Aug 13, 2009 at 5:12 PM
Ditto that.
Family Medicine
Edited Aug 13, 2009 at 5:21 PM
My partner and I run an urgent care/family practice and charge up front. We are open 7 days a week and mostly do drop ins. Each of us has a half day a week for physicals by appointment. What wonderful peace of mind. We are not rich but feel good about the practice. We can (heaven forbid) spend time with patients. People who see us really want to see us. They are not there just because we are on their plan. We get special rates for the uninsured for lab and Xrays, CT's etc. We submit the insurance forms for the patients and they get to wait to be reimbursed what ever their insurance will give them! Because we don't take Medicare we give them a 20% discount.
I feel like an old fashioned doctor and I love it.
Internal Medicine
Posted Aug 13, 2009 at 5:22 PM
Is there an association of physicians who have just opted out of all insurance (public and commercial) payments? I've been wondering about how to actually just do it....I'm tired of all the sad talk.
Family Medicine
Posted Aug 13, 2009 at 5:24 PM
Eloquently written. Thank you for this.
BusiMD--I agree--I wish we all could just say "Enough" and just go to cash pay like dentists. Forget about government and insurance companies...
Family Medicine
Posted Aug 13, 2009 at 5:25 PM
Dear Dr. Harris,
When you decide to organize the primary physicians march on Washington let me know. I'll be there with you! (No joke) God speed, Dr. Harris.
Family Medicine
Posted Aug 13, 2009 at 5:26 PM
Dr. Harris: I am also a Family Physician, now retired, who used to be at UCLA where I see you went to med school. Among other things, I write a health column for an online "paper"
and I'd love to post your wonderful letter with your permission of course. My e-mail is dshlian@earthlink.net
Family Medicine
Posted Aug 13, 2009 at 5:28 PM
In find this very depressing, yet very true and cuts to the core of what is going on in American Health care. The decline in incomes (despite steady or increasing productivity) is worse when inflation is considered. The 220,000 20 years ago translates to 360,000 today. So Dr. Harris' real income has been slashed by 66% in 20 years.
And President Obama and Ms. Pelosi have promised they will find the money for universal care by "putting the squeeze" on physicians (not my words, President Obama's).
I am even more depressed, in that this battle is lost already. We have been sold out by the liberal AMA, AAFP, and MMS. Retire if you can, find something else to do if you can't.
I've been saying the same thing for the last decade. We will get universal health care. But very few are going to like it.
Family Medicine
Posted Aug 13, 2009 at 5:29 PM
You need to have a sit down, heart-to-heart with Obama. The really sad thing to me is that I see more and more of my FP brethern selling out to the system, or burning out. Please send this to every newspaer you can and every media site!
Family Medicine
Posted Aug 13, 2009 at 5:30 PM
Vance I agree with your comments 100%.
Unfortunately, I don't think we as "doctors" get much sympathy from the public and if we do get pity, it won't do anything to improve primary care. If you tell some people you make 120 thousands they will think you are rich, they don't understand the dedication it takes.
It is also clear to me the government will never do enough to improve primary care the way it should. We really need to turn medicine upside down.
Internal Medicine
Posted Aug 13, 2009 at 5:32 PM
Dr. Harris:
I am a PCP in the same boat as you. Your words were so eloquently stated that I contacted a friend of mine who works with the NY Times. She is very interested in getting in touch with you for the possibility of doing a piece on you. Can you email me directly with your contact information?
Family Medicine
Posted Aug 13, 2009 at 5:38 PM
physicianwade, a march to Washington by primary care? Count me in.
Family Medicine
Posted Aug 13, 2009 at 5:47 PM
Agree 100%.
I have done rural primary care for 35 years. Still at it after CABG. I treat about 30 patients a day, do office surgeries, even put in permanant pacemakers since 1978. News media said Medicare pays 80% of what the Physicians charge, lol. I am reimbursed 42 cents on the dollar and have not raised fees in 15 years.
Insurance CEO's getting 12 million dollar bonuses, from the premiums paid to their companies for health care, then denying that payment when needed, is obscene and criminal. No one speaks of them as greedy.
The health care system is not broken, but health care financing is, and we are broken by the same system. Count me in when you march.
Family Medicine
Edited Aug 13, 2009 at 6:05 PM
The ONLY way to stop the relentless tide of ever increasing control and declining payment for all doctors is to stop accepting insurance as payment.
The only way to do this is for doctors to form risk pools of patients who will pay into a third party managed fund that pays doctors directly. This fund can not be an insurance company bent on profits. It must be a non-profit pool of funds administered by an accounting firm for a reasonable fee and accessed by doctors for payment of services.
All the money would be directed toward paying those who care for patients.
Any surplus would go to each individual patients account and gain interest.
Those that had a deficit because of medical expenses would have coverage from the fund based on a predetermined formula. Doctors and patients would decide if they wanted to spend resources. If they are not there, then some treatment and interventions would be withheld.
At least, control of the money would bring control of medicine where it belongs.
In the hands of doctors and the people they care for.
Until we organize and stop accepting payment from third parties ( like Mayo clinic did with Medicare), then there is NO HOPE for any of us to take control of medicine again and practice the way that is best for everyone.
Family Medicine
Posted Aug 13, 2009 at 6:08 PM
Very well written.
Unfortunately, the compassion that makes us good physicians, also makes us more susceptible to pressure from the patient to "do the MRI". If we don't care what patients think or aren't trying to please them in the first place, they probably wouldn't be coming to us anyway. So many of us more tender-hearted physicians start off ordering a few too many tests and consults. I think most of you know what I mean.
So when, after years of seasoning, we have reached that point of confidence and can hold off on the CT head for every concussion, and EKG for every chest pain -- because we know the patient and they trust us and will let us know if they get worse -- when we reach that point, THAT is where we should be rewarded for our judgment.
I can sympathize. I've been in practice 15 years and just this week have fielded the unexpected evening phone call from a patient/friend with a 15 y.o. daughter who had a concussion 2 days ago: "should I worry if she's still dizzy?" I know her. I know the family. They're reliable and they trust me. "Hold off for another couple days if she's otherwise ok & let me know if she starts acting weird or is getting sleepy", etc. etc. "Ok, doc." Boom. Instant $1500 saved.
And today I saw a patient with "bad" low back pain that doesn't radiate. She has bipolar disorder and she gets nervous thinking what it might be. I'm giving her exercises and asking to see her back in a few weeks. No MRI. She knows to call if it gets worse. She was fine with that.
I couldn't have done that my first few years of practice very easily. My patients trust me now. You can't easily put a price on that, but I can tell you I hope without being bombastic; that is the way I want to be treated, and the way I hope to continue to treat all my patients.
Doesn't everyone want a doctor they can trust and ask questions of? Does anyone really want the kind of IF-A-THEN-B provider America is churning out? Can medical care be robotic? I always tell my med students "you might be taught something else in your classes, but I'm going to tell you, patients want a part of you. They don't want just your opinion. They want to know what you would do in their shoes, and in return, they'll trust you if you treat them right. Don't keep yourself so at a distance that they could look up the same information you're giving them in a textbook. Take relational risks and care for them."
Family Medicine
Posted Aug 13, 2009 at 6:11 PM
An eloquent and powerful description of our situation. Dr. Harris needs to sit in the Rose Garden with Mr. Obama, have a beer, and tell him like it really is. I would prefer that he speak for me rather than any other professional organization. Tell them, "We are not the enemy, we are the solution, if you would only listen."
Family Medicine
Posted Aug 13, 2009 at 6:13 PM
WHO IS ORGANIZING US !!!!!
Will my colleagues join me in saying I DO NOT ACCEPT ANY INSURANCE !!!
If we did this at the county level we could start a revolution.
And don't think it won't be a bloodbath.
That's what it will take.
ARE YOU READY ?!
Family Medicine
Posted Aug 13, 2009 at 6:16 PM
I predict eventual single payer system; the patients who want MRI's endoscopies, antibiotics, etc. that aren't indicated will not be happy. The IOM or other body will publish algorithmic guidelines on diagnosis and treatment of all illness. If a certain procedure or medication is not immediately indicated, and the patient insists on it, he/she will have to pay for it him/herself! Note that CARE will not be denied, only COVERAGE!
The PCP will then be exhorted by the patient to embellish the complaint (aka fraud) in order to get what he/she wants...or the patient will simply exaggerate the complaint.
So glad I have more years behind me than ahead!
Family Medicine
Posted Aug 13, 2009 at 6:17 PM
Having worked on both sides of this fence, as a provider and for a third-party payer, I definitely agree that health care financing is a broken system in need of complete rebuilding. Funny though, in all my years, I've never heard anyone declare that all lawyers should be on salary.
Internal Medicine
Posted Aug 13, 2009 at 6:24 PM
This piece reflects/mirrors exactly what I had been going through during my time with primary care. The only part that is missing was the fact that, not only was I 'getting it' from my patients, but I was also constantly 'getting it' from the administration/clinic director (I worked for a 'non-profit' hospital clinic that was anything but)--with incessant, almost belligerent demands for increasing productivity/RVU's.
I got out of primary care ~1.5 years ago, and am now much happier doing hospitalist work in a suburban hospital. I truly feel sorry for my counterparts doing primary care...
Primary Care has got to be the only profession/commodity-if-you-will whose supply and demand curve does NOT mirror the salary-curve. But, there I go again, another 'overpaid professional' complaining about the pay, huh?
Internal Medicine
Posted Aug 13, 2009 at 6:44 PM
Vance, I feel your pain. I have been a general internist for 13 years and have watched my income sag, have been unable to vacation and see my family less and less. I too am giving this up. I will be leaving practice to become a medical director for an IPA this November. The only positive thing I can say about being a doctor is that at least I will have a good fund of knowledge when my primary nurse provider sees me. I feel sorry for all of the patients that won't be able to advocate for themselves.
Internal Medicine
Posted Aug 13, 2009 at 6:56 PM
Well put!! I'm seeing the same in my practice daily for the last 30 years. I will continue since I enjoy medicine too much to stop. I have to stop now and then and remember the difference between humility and humilitation.
Family Medicine
Posted Aug 13, 2009 at 7:30 PM
Thank you for a very well written post. It's a career summary that reflects my own experience. Best wishes for the future.
Med/Peds
Posted Aug 13, 2009 at 7:48 PM
Primary Care Medicine has gone from being a Profession to being a Very Expensive Hobby. Those who can afford to "Practice" without having to worry about paying the bills will be the only ones left.
Family Medicine
Posted Aug 13, 2009 at 7:52 PM
Please send this to our President. I now make the same I did seven years ago out of residency. I had to put my student loans on forbearance. Where is my kickback from the government? I'll spend the rest of my career paying off my career. There is no value nor respect for our clinical decision making anymore. Why go to med school when we could just order tests and google any info we need? Most of the time I still love what I do, but it's sad when I deter people from going into medicine.
Family Medicine
Posted Aug 13, 2009 at 8:06 PM
Hello from me, too.....
I, too, was totally fed up with
1. insurance co. formulary dictating treating
2. asking "permission" to order an MRI
3. etc. etc. etc.
And I gave it up, 22 years of FP incl. attachment to an Ivy League hospital teaching program. And, I found funding and started a full-time, non-profit Clinic for persons without health insurance. TOTALLY rewarding. Decent income. No insurance companies. NO formularies. Just good people who need help. 90% of the help is volunteer, and since everyone likes his/her job, the working situation is cheerful and loving. Absolutely necessary, actually LOVE going to work.....and no matter what happens in DC, there will always be a need for clinics such as ours.
(theclinicpa.org). There are options.
DON'T give up your talent, education and love for people !!!!
Family Medicine
Posted Aug 13, 2009 at 8:19 PM
We've got to understand, and the public needs to understand: Physicians can care and ask for payment simultaneusly. Expecting to get paid doesn't mean we don't care. My practice style is the same as Dr. Harris. This is how my father practices. This is how my wife practices.
Doctors feel guilty asking for money, and the public plays on that.
We need to value our own services before we can expect anybody else to do so.
Don't change your style - keep being a good and compassionate doctor.
But don't do it for free.
Family Medicine
Posted Aug 13, 2009 at 8:22 PM
Agree completely . . . just yesterday I got ER notes for a patient with a sore throat and poorly controlled BP (she doesn't take her meds, big surprise) . . . CXR, lateral neck film, EKG, CMP, CBC, cardiac enzymes, PT/INR, rapid strep (negative), strep culture (later negative), treated with IV fluids, IV clindamycin, IV Rocephin, IV vancomycin (I know, hard to believe, that's what the chart says), po clindamycin, and they doubled the dose of the antihypertensive drug she doesn't take . . . comes in to see me next day with diarrhea . . . like you I would have treated her for $55, not the probable $5500 the ER visit cost, and I would not have caused any iatrogenic problems either. Yes, I guess I am underpaid, and I did make more 10 years ago, but then how many people do make $120k and can pretty much go and live anywhere they want and find a job that will pay them that much? But how to incentivize the system and the players not to waste money without making it look like we are being rewarded for denying care or by having legions of case managers tell us what we can and cannot do? The answer of course of simple professionalism, but nobody will trust us with that any more.
Internal Medicine
Posted Aug 13, 2009 at 8:33 PM
Well written - I think you should become a writer! I am serious - you speak for all of us. Please don't stop writing and keep getting the word out there - - I hope one of the major newspapers does pick up this piece. I was at a birthday party last week that I took my 10 year old son to and overheard a PA (she works for a local dermatologist) complaining that she "only" makes $140,000/yr and I about fell out of my chair.
Endocrinology
Posted Aug 13, 2009 at 8:42 PM
Well written, but why take it out on foreign-trained docs? Unfortunate comment, since these docs (like myself) are providing equally valuable care to millions of people. Wish you had not made that comment....
Family Medicine
Posted Aug 13, 2009 at 9:00 PM
It's not a coincidence that, among the industrialized world, the health care systems that are rated with the highest quality of care and the lowest per capita costs also have the highest percentage or primary care doctors. I hate to say the obvious, but RBRVS - as created, promoted and preserved by the AMA - has been the single greatest destroyer of primary care and the American health system since its inception in the early 1990's. When a single 30-day event monitor - mounted by a tech, dismounted by a tech and interpreted by a computer chip - is reimbursed at 5 times the rate for examining, evaluating and managing a sick patient then there is something seriously wrong with the value system. There is a reason why there are more MRI machines within ten miles of my office than there are in the entire country of Finland and we all know that the reason is not because of good patient care. Primary care is hurtling toward extinction at breakneck speed (look at the average age of your primary care colleagues) and one can only wonder where our patients will go for care in ten years and where our specialty colleagues will look for referrals. Perhaps they will all converge on the PA at the local Wal-Mart.
Family Medicine
Posted Aug 13, 2009 at 9:07 PM
Excellent. Yet sad to think this is reality. I work in a rural areas and have never made more than 90,000 and that was only once. Rest of the time about half that. My patients tell me that I will get rewarded in the next life. My school loans don't care nor my other bills. I haven't had a vacation since 1996. I work practically every day. I also resent that I have to compete with PA/NP who abosolutely do not have the qualifications.
A copy of Dr. Harris' letter should be sent to every member of the congress, both houses to read. Although I fear it is too late. Nothing will stop them. Even if every doctor did unite, we still do not have a big enough number. We can stand forever, but no one will notice. They will only notice when there are no more Dr. Harris's caring for the patients.
Internal Medicine
Edited Aug 13, 2009 at 9:54 PM
Here are my 2 cents: the root of all evil is health insurance -- this is an oxymoron in and of itself -- one can never insure health for it is uninsurable. At best, one can insure cost of certain medical procedures at certain time points. Further, once health is damaged, no type of insurance, and, for that matter, nothing at all, can restore the health to the previous level. Finally, health is a function of aging and, again, there is no way to insure against aging. Therefore, the ONLY solution, in my opninion, is outlawing any and all insurance. Medical care should be ONLY fee-for-service -- this will ensure accountability, quality, timeliness, and fairness -- to both the patient and the doctor.
Internal Medicine
Edited Aug 13, 2009 at 10:16 PM
As all have indicated, well said.. you just described my life for 6 years... I saw the writing on the wall and mostly gave up primary care for the last 4 years... I have been a hospitalist and nursing home director/provider... I still work 7 days a week, but I take home a lot more money as I have NO overhead.
When I was running an office, with a PA, NP, a second MD, we typically grossed $60,000 a month (the NP was 1 day a week, the PA and MD were full time, as was I... we took lots of medical... and that was a big part of my financial undoing).
The non-calif docs will not understand the overhead we have here.. Workmans comp, utilities, rent, medical waste disposal, property and liablility insurance.. they just eat you alive... I rarely had less than 70% overhead, and I only had 2 support staff per FTE. Running a private practice in Calif is close to impossible, unless you are willing to take a net income of 80K for all your efforts!
When you read in the papers about who are the major players in health care reform today.. you see listed the parasitic Health insurance companies, the drug companies, the hospital associations and of course, politicians... Physicians, nurses etc are singularly UNrepresented in the main negotiations it seems. We now should very clearly know where we rank the the schema of things... My advice is to be working on developing a second career!
And no, I do not know any really good docs taking new patients in Calif... I do know some good private and group docs, but they are just overwhelmed with patients, and I do not know how they are keeping their sanity!
Good luck to you and very nice, accurate description of my life as well for those 6 years!
Family Medicine
Posted Aug 13, 2009 at 10:17 PM
totally agree with you...and I'm 35yo!
Family Medicine
Posted Aug 13, 2009 at 10:18 PM
I am 61 years old and have cut back to "part time." I work for a hospital on salary, making less than my daughter, who is a master's-level teacher in a large urban area. I leave for work every day at 6:30 in the morning and return home at 10:30 pm and am on call every sixth weekend. I don't do hospital work any more, though. (My patients hate the hospitalist approach, but it helps me somewhat.)
I love primary care. I especially love my older patients. I love it when they tell me about their grandchildren and great-grandchildren, and where they went on their last vacation.
I hate the fact that I am ALWAYS behind, always facing stacks and stacks of paperwork, always facing hundreds of unanswered phone calls and tests that need to be reviewed, always feeling as if I am letting someone down. If it's not my patients, it's my nurse or my fellow physicians; if it's not them, it's the practice administrator or the compliance officer; if not them, my wife or other family members. And I leave the house every day thinking, "Hmmmm....I wonder who's going to try to sue me today?"
I keep hearing that the answer is electronic records and responding to patients via e-mail. When will I have time to e-mail people? And who reimburses for that?
And so-called "outcome-oriented" medicine: I'd like to know where my responsibility as a physician ends and where the responsibility of the patient begins. As I review patient records for my recertification this year, I'm looking at diabetes. I had to select five records for diabetes patients whom I have treated. None of the five followed my instructions. NONE. I looked at my notes and discovered that I gave them guidelines that would have helped them to improve and manage their diabetes in positive ways. However, all five of them continued to eat harmful things, not exercise, and four out of the five were non-compliant with medicine. Then they cannot understand why their blood sugar is off the charts! I advised all of them about the repercussions of not complying with the treatment plans, and they all replied the same way: "But doc..."
So, if I were to be judged on the outcomes of these patients, particularly vis-a-vis reimbursement, I would be penalized because they are non-compliant, right? And how many e-mails would I have to send to them to ensure that they were checking their blood sugars and eating right?
I'm not sure what the answers are. I do know, however, that I'm getting tired, and I'm certainly not getting rich. (My salary is about $85,000, and I do get health insurance benefits from my employer.)
When baseball players and football stars are making millions of dollars every year, and when Wall Street's "best and brightest--you know, the ones who were responsible for the tanked economy--get multi-million-dollar bonuses--and when our health care system is in the disarray that it's in, no one needs to be a rocket scientist to realize that we need change. But what's happening at these town hall meetings is going to make it almost impossible for anything to happen.
Status quo, anyone?
Family Medicine
Posted Aug 13, 2009 at 10:39 PM
It all makes me sad.... :(
Family medicine is a hugely depressing field to be in these days.
Thanks for your posting.
Internal Medicine
Posted Aug 13, 2009 at 10:39 PM
You've stated eloquently what I think about on a daily basis. I can't help but feel burned by our specialty colleagues who can tell a patient "There's nothing more I can do, follow up with your PCP", collect the big bucks, and leave us comforting and doing no harm, innovating something to keep the patient going but leaving us with no time to lobby or be involved in politics and no money to pay someone to push our value to the system.
Family Medicine
Posted Aug 13, 2009 at 11:12 PM
Good luck to you. I hope you find some enjoyment in whatever you do next.
For myself, in some ways I feel fortunate to have work in difficult economic times.
BUT, if I did find something other than clinical medicine with comparable compensation, I wouldn't regret hanging up the stethoscope.
Hospitalist
Posted Aug 13, 2009 at 11:29 PM
Could not agree MORE with all you've said. I CLOSED my I.M. Primary Care Practice in November 2007 after 20 yrs as a PMD in favor of Hospitalist work. I thought about a Radiology residency but could not bring myself to leave my wife for 3 or 4 years.
Is is not just the money, it's the "hassle factor" of CPT coding, ICD-10 coding, Pharmacy Benefit Managers & Insurers questioning every medical decision we make and 145,000 pages of Medicare regulations that have put the final nail in our coffin.
No one will follow me or my generation into Primary Care as it currently stands
due to ruinous discounting by Medicare, Blue (double) Cross and the rest
of the 4 letter words; HMO's, PPO's.
To improve our lot, not only fair payment must be made, but they must remove the shackles of excess paperwork, oversight, regulation & insurance bulls**t & "allow" us to actually PRACTICE MEDICINE and find some joy in it. If "they" did that, current docs will stay in it & future docs will go into it.
Though I for one will NEVER climb back onto that treadmill - I will never return to the living hell that Primary Care I.M. has become.
Hear any of THAT in ANY of the "Health Care Reform" legislation?
Family Medicine
Posted Aug 13, 2009 at 11:34 PM
I believe that Family Medicine is almost dead. In fifteen to twenty years it won't exist. There might be Med-Peds. But Nobody will be able to do full practice FP with OB and inpatient care anymore in the regular U.S. It's already a rarity in most parts of the country. Family Practice residencies are being forced to shut down by Medicare regulations and fines, and new ones can't afford to open because of the risk of retroactive penalties that can be levied up to 4 years later. One residency was just charged 11 million dollars by Medicare and forced to close. Meanwhile, NP's are being positioned as the primary care medicine providers of the future. Maybe they can do just as good a job with less than half the training. It is a conspiracy by the new Socialist Regime to put primary care MD's, especially private practice, out of business so socialized medicine is the only game in town. And NP's will be the foot soldiers. There may be room for a while for enterprising doctors to practice in a cash-based model, outside the Gov't system, but they may be regulated out of existence once the new Socialst System has full power over U.S. Healthcare. I agree with Dr, Harris who wonders, what doctor will he go to, since so many are leaving the profession.
Internal Medicine
Posted Aug 13, 2009 at 11:38 PM
My wife is internist. She has closed her practice .... BEFORE even starting .
She flat out refused to work as primary care practice. She will take a Hospitalist job or go back to India.
Family Medicine
Posted Aug 13, 2009 at 11:38 PM
Vance says it all. I just retired after 45 1/2 years. The time was right. I started before medicare and have seen the evolution from when medicine was a dignified profession to the AMA selling us out.My years were good and I am fulfilled. Only the last few years has the tragedy of medicine surfaced. We have lost our dignity and have taken on the role of laborer at the behest of Medicare and Managed care.Patients are guided by the falsehoods of managed care and we are the whipping boys(and girls) for their frustrations. My admiration goes out to those of you who have the fortitude to percivere. My heart is broken and my soul is ravaged at the thought of what is to come if the present is any indicator.
Roy J Hotz Jr MD (Retired)
Internal Medicine
Posted Aug 13, 2009 at 11:39 PM
Thirty years ago, we had a shortage of Primary Care Physicians and I answered the calling. After 5 years of search for the "right" Internist, my practice finally found one. I believe "history is repeating its self" again! Reasons for the declining interest in Primary Care were well outlined in your article. This country and the third party payors better start waking up because our patients are not going to get the quality care that they deserve. In a few years, I also plan to retire. Who will be my Internist...or NP ? Scary thought....indeed!
Anyway, Good luck! Enjoy your retirement!
Family Medicine
Posted Aug 13, 2009 at 11:40 PM
I came out in 1994 when fam med was making sense. I thought I would be the WalMart of docs... 90% of what you need will be on my shelf for half the price. True that when you have a third party paying for a service that another party is receiving, the is no free market competition (the only true mechanism to improve both quality and access). We should have came out on top... not so. I wouldn't demonize the insurance... I see it save more butts then it dodges, in the end.
I'm solo private rural... the last NON-saleried in SW Pennsylvania that I know of. Everyone else is owned, saleried, and, well, you know.
I've become a bottom-feeder living off the cast-offs that the saleried choose not to do. Yeah... working twice as hard for a fraction of the pay... but after the nuclear war only us cockroches know how to survive.
O-Bomb-a Shelter for rent.
Family Medicine
Posted Aug 13, 2009 at 11:40 PM
Dr Harris,
I congratulate you on fighting the "Good Fight"! I unfortunately share your pessimism, it just took me 24 years to get there! I offer:
1. Family medicine as a specialty is DEAD (unless residencies accept NP/PAs); why complete a 3year residency to make minimum wage? Both the AMA and AAFP have betrayed us in order to be part of Obamacare.
2. Like OTC meds, the hundreds of thousands of dollars you saved were never really accounted for and so are ignored by HMOs and Medicare.
3. The public views healthcare as a right (not in the Constitution!) and feel they (or their hairdresser) know exactly what will help (Botox?). Except for Medicare-aged patients, respect is GONE.
4. Our specialty collegues are REALLY sympathetic, but do nothing (they'll be in our position in a few years).
5. The ONLY satisfaction left for outgoing FPs (other than a job well done) is that Fedicare will probably fail financially in less than a decade (about the time we need it).
Congratulations on leaving medicine.
Gary Kiefer MD
Family Medicine
Posted Aug 13, 2009 at 11:50 PM
Well written. Only been out of residency for 4 years and income peaked in 2nd year. Continues to decline along with the amount of time I am taking off and the vacations I take. The student loans??? not declining quick enough. Love where I practice but I have to have a part time job (I work shifts in the local ER) in order to be able to stay working in my current office. Partner close to retirement. Anyone want to work in small town Kansas? As FPs here we can do OB....any takers???
Internal Medicine
Posted Aug 14, 2009 at 1:04 AM
Nice article. All of us in primary care can identify with you. The only answer is to drop out of all insurance and managed care plans, and medicare, and medicaid programs. Take advantage of your hard earned reputation with your patients and develop a direct medical practice. You can survive in private practice if you can convince a couple of hundred of your current panel of a couple of thousand patients to pay you directly on a monthly or annual basis for medical care. The retainer type medical practice is the only current viable business plan for the survival of primary care. You can lower your overhead dramatically with this type practice. You only need minimal space and one employee. Check out the website: www.simpd.org for details about physicians involved in this type practice. Also read the book "Concierge Physician" by Dr. Steven Knope. Good Luck.
Family Medicine
Posted Aug 14, 2009 at 1:45 AM
Thanks for your honest and insightful posting. After 30 years in Family Practice I couldn't agree more! I'd love to join you in retirement but can't afford to pay my health insurance premiums if I retire even though I have a $2500. deductible! (But then who needs health insurance when there are no doctors left?) At least you had some good years at the beginning---I have practiced in a town of less than 5000 all my life and didn't make over $80,000./year for my first 15 years in practice (yet somehow sent three children through 17 years of private education---surprise, surprise, none of them were interested in following in my footsteps). Now hospitalists are providing "better" care for my hospital patients and ordering thousands of dollars of negative tests because they have no time to read my histories which would explain what has already been done in the almighty electronic medical record which is supposed to be such a cost savings according to our President. After three years of mandated usage, I still can only see 80% of my former patient load because I have to type in all my orders and can't find any old information which was at my fingertips with my efficient, self-designed paper chart., not to mention all the life-threatening medication errors that occur at the hospital daily because of it. And for being transformed into a data entry clerk after all my graduate education and 30 years' experience I take a 40% pay cut and am working two extra (non-patient care) hours/day! Now I just got severely reprimanded by my hospital for pointing out that the EMR had the wrong medications listed and asked to alter the medical record---but no one thanked me for saving the patient's life. Do you think all of us primary care docs will get invited to the Whitte House to share a beer with the President?
P.S. How do you get $25. for reading an EKG? I get paid $6.42 to do that even if I find an acute MI
Family Medicine
Posted Aug 14, 2009 at 2:40 AM
I am the future of Obamacare. I have been out of residency for a mere 5 years now, working for the "man" under the NHSC so I can remove the crushing burden of debt that medical school left me with. I work in a rural health clinic in northern CA, and every day, I get to say the words: "I'm sorry, that isn't covered, " or even better: "Yes, that would be covered, but there's no doctor of that specialty in this county that takes county medicaid. You will have to wait until it becomes an emergency, and then show up at the ER to force them to treat you." Once I have my debt removed, I am seriously considering leaving this already quasi-socialized medicine system and opening a fee-for-service clinic. I just can't take the unfairness any more.
Family Medicine
Edited Aug 14, 2009 at 7:35 AM
Dr Harris, are you free in 2012? There is a position called the US Presidency that you are qualified for. I think it pays a helluva lots more than 120K. Thanks for your thoughts.
Osteopathy
Posted Aug 14, 2009 at 8:38 AM
Dr. Harris-you have hit the nail on the head.
A few interesting things I have seen over the last two weeks, that are not even discussed. Last year we spent on six different things ver 1 Trillion Dollars-over utilization, rebilling, over prescribing antibiotics that are not indicated etc, etc, etc. (WHY?)
Also in 2008 the top five health insurance companies, Pharmaceutical companies (Pfizer et al), Pharmacy companies such as Care Mark and Medco, the devise manfucatures of things like joint replacments and pace makers, and the for profit hosptial systems made well over 58 Billion dollars in profit. (WHY?)
Each hospital that has a Residency training program gets paid well over 100,000 per resident in direct and indirect monies but yet they pay fuill time faculty well over the national averages of private doctors. (WHY?)
Hospitals because of financial greed buy out doctors, give them a salary and at the end of the month grade them and see if they are following the rules.
We are our own worst enemy, but I do not see an end to this in the future.
According to one study-nearly 50% of specialty vists are for things like HTN and Hyperlipidemia, some thing a well trained PCP can handle. I have seen locally in our FP residency that the patients are referred out for everything from Post nasal drip to a toe nail avulsion. It seems that the only thing that is being taught byt he full time faculty who see at best 20 patients in a week is how to fill out that referral form.
Although I am only 38 and in practice for nearly 10 years, I remember when it was an honor to be asked to teach, for no pay, it was an honor to be appointend the Department chair. Now the "requirements" tell the hospitals how many faculty they need per resident, and you apply for Department Head positions.
We have a society that has become one of entitlement-I had the right to health insurance and it should pay for everything.
Just one other thought, those doctors that have 10,000 capitated lives from HMO's...what an easy life...I wish I had that many-at 10 dollars per month-$100,000 per month for 12 months-1.2 Million and I'd sit at home with my feet up and answer emails all day-referring them out to specialits and have my wife do the computer based referrals...I would also get a big bonus for being such a good doctor by sending them to the specialist for care (and oh by the way they seen a PA or NP anyway).
Not a bad way to practice medicine-too bad I like to see patients and put my hands on as a D.O.!
Just my two cents
Family Medicine
Posted Aug 14, 2009 at 9:03 AM
Maybe I am not to old yet to move to Australia or England or maybe train in another specialty.
Internal Medicine
Posted Aug 14, 2009 at 9:36 AM
Dr. Harris---That was straight from the heart, well said. Sad to lose you from the ranks yet happy that you're able to get out of the trenches. These are challenging times indeed. . .
klinsman55---Even New Zealand is hiring, I keep getting these brochures (permanent positions or locum tenens).
Internal Medicine
Posted Aug 14, 2009 at 9:47 AM
Power commentary. I wanted to be a physician my whole life but life got in the way so I've only been practicing for 10 years at 63 yrs old. I too have already begun plans for an alternative profession. I will however make myself available to care for other physicians - only.
Emergency Medicine
Posted Aug 14, 2009 at 10:38 AM
We know they can't do it without us - but they're going to try "IT."
I think the best plan for those who still want to be a "doctor" as we move into the next decade is a same-day walk-in clinic, not taking MA or Medicare or Obamacare, or any insurance for that matter, and charging $40-$75 per visit based on level of service, cash or Visa card (with a 3% surcharge).
Do minimal studies on-site (plain film XR, EKG, CBC, Chem 7, UA, rapid strep/TC, HCG) for cash.
No EMR (if your handwriting is legible, a srawled sentence would probably take care of most encounters - like we used to) - most charting is for billing . . .
A scheduler that can answer the phone, take a BP, draw blood, room a patient and clean a room . . . and used to be an XR tech . . .
Consider "going bare" with no malpractice insurance to limit overhead - sequestering the business in an LLC and the involved docs as "independent contractors" with their own LLC and sheltered assets.
At 3 days a week, 40 wks/yr. 25-30 pts/day, avg. $50 / pt before ancillaries, and assuming ancillaries will cover overhead, your looking at $150K to $180K per year with a lot less headaches. Let alone the fact that you will only need to maintain your state license and whatever credentials and re-certs YOU decide, not some billing clerk.
Hell, you can sell shampoo and vitamins and whatever else you want in the waiting room, too - just like the vet and the chiropractor. . .
Why we ever quit doing that in the first place is beyond me, now.
Family Medicine
Posted Aug 14, 2009 at 10:45 AM
Well said, and felt. And yet, I need something different. I've practiced for 20 years, missed the "golden years" of medicine. But I do make a difference, and I don't measure it by how many dollars I save.
I can't and won't allow myself pity. Almost every profession has it hard right now. Bailouts and lawyers piss me off. But I'm not them.
We are in a sacred profession. Let's recommit to it.
Family Medicine
Edited Aug 14, 2009 at 11:10 AM
Thoughtful words JV1.
Family Medicine
Posted Aug 14, 2009 at 11:27 AM
Eloquent, insightful, true.
Pathology
Edited Aug 14, 2009 at 11:40 AM
Thanks for the great letter. I was well burned out in my practice but stuck it out for 45 years. My young ideals of taking care of patients was long gone and I wished I'd gone into Veterinary Medicine instead. Now, in my "Golden Years", I'm fighting Obamacare to try and provide a better future for us all, esp. for the younger generations. We can't give up and let Government take over all our liberties!
Good luck to us all.
Psychiatry
Posted Aug 14, 2009 at 11:58 AM
Beautifully written, terribly sad, and totally true. Please consider submitting your essay to the media for publication if you have not done so already.
Family Medicine
Posted Aug 14, 2009 at 12:13 PM
perfect story: Any thing goes around comes around
Family Medicine
Posted Aug 14, 2009 at 4:42 PM
I would love to share this posting on Facebook, as many non-physicians just don't understand why many in the physician community don't support nationalized health care, public "option", etc. Many people wrongly feel it's because we're greedy and just want to make more money. Would that be okay, to post this? I think if we can get perspectives like this out there, the smoke that the government is putting up would clear for many voters.
Pediatrics
Posted Aug 14, 2009 at 5:05 PM
So eloquent and poignant.
The sad truth of the current state of affairs in primary care.
There is some hope out there. I think we can still do a lot of good and change the course.
There is a national group of doctors working on this very thing.
Take a look at the work of L. Gordon Moore and the IMP project.
www.impcenter.org/
Perhaps if we all joined together to speak as one, if we 'vote with our feet', we can effect real change that will benefit everyone.
Heck we could opt out of the third party payer merry go round, if we want.
But we will have to band together. Traditionally we're not accustomed organizing. We'll have to get over that.
Internal Medicine
Posted Aug 14, 2009 at 5:11 PM
You must be my twin as I finish my 23rd year of practice, I'm ready to retire mentally and with 5 stints physically.
But I would probably keel over dead the first day of retirement and hell who am I gonna get insurance from Obama....I don't think so.
I'll see you on that sweet by and by.
good post
Family Medicine
Posted Aug 14, 2009 at 5:28 PM
Excellent and poignant post! I agree with others who urge publication in other venues. I would be honored to post it to my blog: www.idealmedicalpractices.typepad.com
The sorry state of primary care in the US continues to generate gut-wrenching tales of woe all the more poignant due to the value we bring when we have the capacity to engage in the full scope of our work.
A group of like minded physicians passionate about taking our profession back (noted above b Bostondoctor) is creating a community of common interest.
We won't wait for politicians, insurers or some 'other' to come save us. We don't need anyone's permission. We'll change what we can in our own practices now.
Family Medicine
Posted Aug 14, 2009 at 6:02 PM
As a third year FM resident about to enter the work force it is frightening to hear your story. Should I start looking for a new career?
Emergency Medicine
Posted Aug 14, 2009 at 6:06 PM
You know, you can absolutely feel the pain and the immense frustration in this post. This should be required reading for anyone going into primary care or even contemplating taking insurance, medicare or medicaid in the future.
Vance, you can be my doctor any day and I'll pay cash....
come to think of it....do you realize that labor costs for a new set of brakes on one of the new Government Motors cars is more than you get paid for the care you provide....you should not provide any level of care for anything less than what it would cost for a new set of brakes and rotors.....
Emergency Medicine
Posted Aug 14, 2009 at 6:07 PM
no Calatea, you should just not accept insurance
Pediatrics
Posted Aug 14, 2009 at 6:28 PM
This should be submitted to the NYT!!
The insurance companies are the middle man. They charge people $500/hr and we only get $75. Time to go back to fee for service. or at least charge for our time.
I see the silicon valley types making $500k/yr or Wall street people or lawyers, we have far more education and at least as much stress. we deserve to get paid.
Emergency Medicine
Edited Aug 14, 2009 at 6:35 PM
louermed- absolutely right! we *need* FPs. and FPs (like all the rest of us) need to be paid appropriately. which means no third parties.
physicianwade, abelmunoz, leibeauxmd- there is a venue and it's called million med march, at the smithsoniam on oct 1.
author2- don't know this for a fact, but i bet Dr. Harris wouldn't mind you using his letter without his name. go for it. send it to congresspeople, interested blogs, newspapers and mags.
jhaislip- thank you for being there for us in the future. at some point i too will "retire" only to assist my family, friends and colleagues. hopefully not too soon, but it depends on how obamacare shakes out.
dr harris- you sound like a decent, hardworking, caring physician. someone i'd like to have taking care of me and mine. perhaps you can reach out to some of your colleagues that have successfully transitioned to cash practices, regain some sanity/satisfaction/fun in your professional life, and still do what sounds like a calling? whatever you decide, god bless man, you deserve it!
ps- can i use your (signed) letter as an attachment to my letter to obama and congress?
Pediatrics
Posted Aug 14, 2009 at 7:02 PM
alternative1, I just sent the link and text to Dr Alice Chen of Doctors for America. Perhaps others should do this as well.
ideas@drsforamerica.org!
Dr. Moore, Good to hear from you!
Family Medicine
Posted Aug 14, 2009 at 7:28 PM
I am overwhelmed with frustration when a patient complains about my very reasonable charge when I think that I have never yet been charged so little by my dentist or my veterinarian...
Internal Medicine
Posted Aug 14, 2009 at 8:56 PM
I closed my office in 2006 after <1yr, when i realized I'd have to see 8 patients/hr and I would make <$40K/yr. Yes, the major insurance was paying me $35 for a level 3 visit. I didn't find hospitalist better, except for the paycheck. Now, instead of not getting paid, i have an administrator up my a** asking me why the "self pay" patient is her so long...why the medicare patient can't go on hospice, because they didn't go home the day after they were extubated.... I'm getting tired of telling them "It's because they're sick".
I'm going locums (?loco), to pay off the last bit of debt I still have from the office and get enough money up to change careers. I just don't have the stomach for it anymore.
Psychiatry
Posted Aug 14, 2009 at 9:29 PM
dr harris please dont give up! We need people like you. I come from a culture which values experience and integrity. Just think when the plane goes down, you need people like capt.sullenbuger in charge to land it safely in the water!!!
I am sure, the majority of patients you have treated are grateful. Dont deprive the patients. Fight the non -MD assholes who despite less education want to package us as "providers of care" for the customers
Emergency Medicine
Edited Aug 14, 2009 at 9:39 PM
For all you frustrated Primary physicians, just hire a Nurse Practitioner. He will refer every stomach pain for an endoscopy and CT scan, every back pain for a MRI and neurosurgery consult, every headache for a ... you guessed it ... MRI, every groin strain to a surgeon to rule out a Hernia, every knee pain to an orthopedist.....
Soon you will have so many gastro-enterologist, radiologist, orthopedist, surgeon, and administrator friends, that you will be eating out at restaurants everyday. Then your low salary will only be needed to increase your retirement fund. You will have no more financial worries.
Psychiatry
Posted Aug 14, 2009 at 10:39 PM
Profoundly sad that we, yes we, have allowed our noble profession to come to this.
