More on good business vs good medicine

Here’s a cynical letter from an internal medicine physician found on Internal Medicine News:

The headline, “Internal Medicine Seen as Unmanageable Career Choice,” hit home. One of the last sentences, however, demonstrated that someone missed the boat:

“The initial results suggest that students respond to a structured curriculum, which gives them the sense that internal medicine is a manageable career.”

Ouch.

As a solo internist since 1985, I have seen my modest income from the mid-90s drop like a stone at a time when I need to be most productive, as I look to educate my four children. The fact is, internal medicine is not a manageable career choice. We are forced to see too many patients, many adults with chronic diseases, and we get paid too little to do this. In addition, we must either give up hospital care to hospitalists (and see a decline in income) or continue to provide in-hospital care at a time when inpatients are sicker, residency coverage is more limited, paperwork is more burdensome, and risks are much higher.
When on call, because we have so many patients (often around 3,000 for a busy doctor), we are usually peppered with calls, making lifestyle issues a major concern. The result is burnt out internists telling medical students and residents not to choose internal medicine (primary care) as a career.
The solution is very simple: better compensation for internists. Since that will never happen, internal medicine as a career choice will fall right off the chart in the next 5 years. So really, the goal should not be to fool seniors into making silly choices. The reality is, primary care internal medicine is a silly choice for a career.
It is just that simple.

A bleak prediction on the future from someone on the front lines. For someone like me who has only recently been in practice, it isn’t encouraging. The sad thing is, I can’t argue with anything that has been said. I think your outlook depends on how you approach primary care. As I have stated before, you have two spectrums – good business on one end and good medicine on the other. If you think you can practice purely good medicine in today’s environment, you’re sadly mistaken. If you accept a little bit of good business when you practice (granted, that’s a big if for some physicians), then one can thrive and survive.

The key point – it’s impossible to practice purely good business with purely good medicine. The decision is where on the spectrum you choose to fit in.

Comments

Ms. Vickie
As a Nurse who worked for an Insurance Company and left them, I will say you are very correct in your assessment of the future of the Internal Medicine or actually Primary Care Medicine period.
Anonymous
The assumption is that somehow good business and good medicine are at odds. I don’t think this is true. What is true is that practice under terms constrained by and defined by insurance companies is not in the interests of doctors, viability of medical practices, or good patient care. We need to see, and we need to make our patients see, that these are two separate entities. Part of the problem with American medical practice is that we have become bedfellows of insurers, making more and more accommodations to the insurers, while being persuaded, by our patients and their insurers, that these accommodations are necessary to good practice and good care. So we have allowed our practice overhead to become blown up by staffing and claims processing costs that were never part of a practice’s operations in the past. Insurers have passed many of their own point of service administrative costs to the doctors while cutting reimbursement or practicing other payment denial techniques that have further added to their bottom line. And we have been bullied into believing that we must protect our patients from the harshness of medical expenditure by accepting payment from insurers rather than demanding the payment from the user of the services, the patient.
It has been a perfect strategy for the insurers and for Medicare and Medicaid. They are buffered from the patients when they fail to honor their coverage terms and the patients don’t feel as accountable for costs when they leave the doctor to file claims and wait for payment. And the administrative burden on the practice, coding, filing and other paperwork, gives the perfect opportunity for insurers to use clerical discrepancy as a reason to delay payment. (Clean-claims payment laws have not worked as advertised–there are loopholes despite this legislation).
If internal medicine has become unmanagable, doctors have been unwitting participants in making it so.
If we are to participate with insurers, there are ways to even the playing field. One is to demand immediate payment for services, if not from the patient, then from the insurer: electronic funds transfer from the insurer to the doctor at the time of service, not ten, or thirty or sixty days later, and no pay means no play.
Let the insurance companies find some other soure of income besides short-term lending at the expense of the doctors.

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