Primary care doctors face burnout, and how that affects health reform

Not only are primary care physicians in short supply, there more evidence that they are burning out and leaving the field.

According to a study in the Annals of Internal Medicine, “large numbers of physicians claimed a lack of control of their work, a chaotic work pace and time constraints during patient visits,” and, “more than a quarter complained of burnout. More than 30 percent indicated they would leave the field within five years.”

Not good numbers if universal coverage is potentially about to be enacted, and primary care doctors are needed to care for a potential influx of patients.

Indeed, Dr. Wes nicely encapsulates how burnout is affecting the medical profession today:

We expect our doctors to be devoted, available, enthusiastic, meticulous and at the top of their game with perfect “quality” and “perfect performance,” while simultaneously cutting their pay, increasing documentation requirements and oversight, limiting independence, questioning their professional judgment, and extending their working hours.

Not a situation that screams, “sign me up,” is it?

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  • Bill Seitz

    One answer might be to delivery universal healthcare through clinics staffed 80% by PAs and NPs, with MDs as resident-expert floater….

    Of course, like any trade guild, the AMA fights such clinics every chance it gets…

  • Happy Hospitalist

    Perhaps this model would work in specialty and surgical clinics as well. I think you are on to something.

  • family practitioner

    To Bill Seitz:

    PA’s and NP’s are also prone to burnout, causing many of them to find their way over to specialty care where life is easier and more lucrative.

    Replacing MD’s with NP’s and PA’s does not address the problems with primary care that are clearly dilenieated in the article: increased workload and declining reimbursement.

    I am not opposed to a primary care future with significant NP and PA involvement, but please don’t think such a complicated problem (our healthcare system) has such a simple solution.

  • TrenchDoc

    Since I have refused to become a member of the AMA I can speak to the above comment without prejudice. In our 10 provider clinic we have 2 NPs. They do a great job but there are limitations:
    1. most older patients want a “real doctor” that they can see on a regular basis to handle their multiple complex diseases and to answer their 2 pages of questions
    2. in my experience many NPs are quick to refer a patient out to a specialist which will not work well in the “new health care system”
    3. employing NPs is difficult in primary care practices because NPs want autonomy and financial rewards but are adverse to taking on the financial risks of running a practice.
    The current model of primary care practice is dying and in my opinion can not be sustained. Many of us older PCPs are going to leave because we do not have the time, energy or financial incentives to hang in there. Now to the none physicians on this blog this does not mean we are being insensitive, money grubbing, amoral doctors. It just means that many of the primary care docs in this country have realized that when we drop dead from exhaustion many of you patients will step over our cold bodies and ask “who is going to take care of me now?”.

  • SmartDoc

    To the eloquent, insightful TrenchDoc:

    You say: “The current model of primary care practice is dying ..”

    I say: “The current model of primary care practice is being maliciously and with malice and forthought brutally murdered.”

  • Susan H

    SartDoc and TRenchDoc have just distilled the whole mess to its essence with:
    “The current model of primary care practice is being maliciously and with malice and forthought brutally murdered.”
    “…many of the primary care docs in this country have realized that when we drop dead from exhaustion many of you patients will step over our cold bodies and ask “who is going to take care of me now?”.

    How can that message be relayed straight to the public: the customers, voters, insurance purchasers, potential litigants?
    Americans WANT to team up with docs and nurses to get to a workable system, but so many middlemen have lodged themselves between, and fostered antagonistic relationships between doc/pt. (seller/buyer) that the message is lost.

  • Dr. Mary Johnson

    Spot-on, Smart Doc.

    “Not a situation that screams, ‘sign me up,’ is it?”

    Well Kevin, No . . . especially not when the “reformers” and so-called “advocates” don’t care to hear or learn from individual cases.

    That, my friends, is classic AMA: “We don’t do individual advocacy” (but we’ll for sure be at that table . . . supporting legislation that sells out individuals).

    And it’s the reason, Trench Doc, I stopped paying the AMA dues long ago.

  • Bad Medicine, Good Solutions

    Primary care is like an oil change. You pay for out of pocket and when you get into the fender bender because you were texting, eating a big mac, and trying to shift at the same time is when you use your insurance.

    Primary care is cheap and when done right the patient-physician relationship is restored. Look to this organization to see how people are doing just fine without insurance And if you feel these are people are too uppity, look here at this doc who is doing just fine without insurance

    I say good riddens to the current system. It isn’t friendly to primary care, and nor should it be.

  • jsmith

    Bill Seitz, I’ve been a family doc for 20 years. Your floater idea looks good on paper, but I have one question. Who in the hell would want that job? When he or she could be a specialist instead. I backed up NPs for years, at Kaiser and elsewhere, and it was a thankless task. I saw my own pts, plus any of theirs that turn out to be complicated. They would knock on my door while I was doing a physical and ask me to help out, so I got double work for single pay. Moreover, they would take all the easy cases (sore throats, cough), and I got all the diabetics with fever, one train wreck after another all the live long day. What a lousy job! And if you think that the floater doc will just sit with his feet up all day and consult, well, I’ve never seen that, and I’ve seen a lot.

  • Linda

    Our family has gone to the same doctor’s office for five years. There are no docs still there who were with the practice when we started. Last summer was the third time I got a letter asking me to pick a different doctor so my husband and I chose to go to a neighboring town where we hope we will finally have the same MD more than once. Out of the original six doctors, one moved out of state, one to a different city, one is teaching, one moved into administration at the hosp. and one got out of the medical field completely. Not sure where the other ended up.
    My sister goes to a different doctor’s office in the same city. When she called for an appt two weeks ago, she was told that the earliest appt. with a male dr. was end of Sept. If she wanted a woman MD., it was end of Nov.
    Both practices have begun to rely more heavily on NP’s to take up the slack.

  • Alan Plum, Ph.D.

    As a longtime Kaiser member, I’ve gotten to study the ins and outs of internists and other family type pcp’s, and what I’ve found is that the best Kaiser doc is quick, tuned to only the major stuff, cheerfully likes the rhythm of Kaiser, and has the quickest finger in the West. My current PCP is so busy she claims she doesn’t have time to read a two-page proposal I sent months ago. When she related her medical life to me, recently, I was impressed and worried. It sounded like all of her free time, as well as clinic time, was spent on medical research and taking care of pts. I give her five years at this rate. No, three.

  • NY DOC

    I have been looking intensely at what the possible end product will be with the current administration’s health plan.

    I have been listening to Obama and what he wants to accomplish and he is good at oration. I am all for what he says he wants to accomplish.

    Then I see his real plans and I am aghast at what he is creating. I cannot believe he has no impulse to work on tort reform, in my opinion the biggest factor of cost increases in medicine. I cannot believe all the taxes he needs to raise. I cannot believe that no one is talking about teaching the American people that unnecessary/non beneficial treatments should not be given. Everyone wants to control the physician’s pen but no one is looking to protect the physician from the bullying of the patient, lawyer and other regulatory authorities. I have not heard one mention about encouraging the physician from not having to order unnecessary tests by protecting them from lawsuits or protect them from regulatory hassles because they actually said no to someone who didin’t need the treatment. Right now as an example you get patients who want disability paperwork but really did not deserve it. Either you do the paperwork or spend days responding to authorities because the patient comes up with sometype of complaint against you. If you don’t protect the doctor, how the hell is he/she going to say no when a patient, family or lawsuits demands innefectual treatment?

    How about someone teaching the American people (especially those on mediciad, where they can and do demand anything and get most of it) that there is a cost to that automated wheelchair or that they really do not need 20 prescriptions nor do they need to see three specialists a week. Obama and the lawyers are going to say, see the physician authorized these unneeded things without actually thinking it through that they have trained a gun to the physicians head and given the patient the trigger.

    Obama is going to blow up demand and at the same time decimate what is left of primary care. The middle men (insurers and pharma) will continue to pillage with deals that sound great on paper (they will drop 80 Billion in costs while expanding coverage will add net revenue by 200+ billion ). The totallity of cost control will be focused on the physician who is in turn will get pillaged by malpractice, regulations, patient disrespect and paperwork up the wazoo.

    Primary care they say needs help, and they give it a 5% raise. What is a 5% raise going to do when malpractice goes up 20% a year, rent, health insurance, supplie costs go up 10%+ a year?

    They focus on the cost of education as the reason people do not go into primary care.
    Hello what are they smoking? Who would go through 8 tough years of comeptitive,demanding education to make less than the plumber, electectrician, accountant, lawyer …. etc.?

    There is really only one solution for primary care and Obama if he accomplishes what he wants will accidentally accelerate the process. The solution to primary care will be concierge type medicine. Patients will have to pay money directly to their primary care physician and in doing so will have to learn to respect them. Because if the patient does not respect them, there is no incentive for the physician to treat them.

    This is already happening. I have 20 new patients wanting to come to my practice every week. I recently realized that I don’t have to listen to the disrespectful, non-compliant, potential legal risk patient anymore. I can let them go. If I let them go my office is a hectic but non-controversial place. I feel less stress, my staff feels less stress, my other patients feel less stress.

    I let two patients go last week and I let two patients go this week and I feel great. Not just because I don’t have to listen to them cursing and abusing staff but because I feel that I have at least some power left.

    I plan to let more people go over the next couple of months and make my working environment better. I would encourage others that run on the hamster wheel to start looking at doing the same and make their enivonment as pleasant as they can.

    I feel somewhat encouraged and will start looking at what it takes to go to concierge practice. It looks like the only way out left.

    good luck to you all,


  • TrenchDoc

    NY Doc
    Excellent points. It still seems to the patient that their PCP has the power but we are being regulated and sued into nonexistance. I started to develop an age management private pay practice 2 years ago. I work one day a week with one staff in the age management practice and 5 days a week with 3 clinical staff 1 receptionist and an entire billing and collections department. In the age management practice all clinical decisions are made by me and the patient – no hassels. Patients pay 100 percent of my charges BEFORE their evaluations. I see 1 age management patient during that 6 hour work day. In my internal medicine practice I see 40 patients in a 10 hour work day. That 1 patient a week age management patient generates 25 percent of the income that the 200 patients a week generates. Guess where my practice is headed? How did I get to the point where I was seeing 40 patients a day? I had to because:
    1. it takes seeing 40 patients a day to support my office and give me the income I feel that I have earned with my 32 years of clinical experience
    2. there is no other internist in my area that will take up the slack – 60 percent of my practice is Medicare.
    PCPs are like anyone else you make our jobs difficult enough with not enough compensation to justify the pain of practice and we are gone. Dose that mean we are selfish because we will not see you as a patient and be paid at a rate that barely covers the overhead that was created by your insurer’s demands and regulations?

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