Why pediatricians and other primary care doctors leave medicine

There’s little question that the workplace environment for doctors is deteriorating.

Especially in primary care, where physicians are arguably needed the most.

That’s why is so disheartening to read this Newsweek essay from pediatrician Karen Li, explaining why she left the field.

Much of her piece can be attributed to the bad old days of managed care, where doctors were frustrated by the bureaucratic impediments placed before them:

Why would a businessman or, worse yet, the HMO secretary with a treatment algorithm on her desk have any right to tell us what was best for our patients? After all, who had the medical training? Increasingly, more time and effort was devoted to fighting back for our patients, writing rebuttal letters to HMOs, calling secretaries and working up through the system to finally presenting our arguments to the medical directors of each HMO. Trying to justify basic treatment for our patients became a regular and distasteful part of life.

All while physician salaries have not kept up with inflation, which Dr. Li starkly takes: “Hospital nurses questioned why we took on so much responsibility and worked such long hours for paychecks significantly smaller than theirs.”

The reason why Dr. Li stayed on for as long as she did was for the sake of her patients, and the gratitude they expressed when their health issue was addressed. Indeed, that’s a feeling that makes it worth the hassle doctors have to fight through and the burnout most physicians face.

But in the end, it became too much, and the field is now down one less pediatrician.

A similar situation is facing primary care throughout, and it’s becoming sadly inevitable that more passionate doctors will be forced to leave the profession.

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  • http://bittersweetmedicine.com/ Dr Lemmon

    Don’t complain about the hours, the pay or the bureaucratic hassles because, except for other physicians, nobody cares.

    Unless our professional organizations get some teeth behind them or until physicians take some tough action, it will only get worse.

    Remember, at it’s core good health care is about two basic things, good doctors and good nurses. All the bureaucratic stuff is just fluff. We are where the rubber meets the road.

    Good luck to Dr. Li.

  • http://www.drjshousecalls.blogspot.com DrMaryJohnson

    How does this woman get a weepy article in Newsweek, while I’ve been in the blogosphere for five years – fighting tooth & nail to right some wrongs and keep the faith – despite being treated like crap by every government/medical/legal oversight agency under the sun?

    She gave up. Moreover, her story does not come remotely close to what I’ve endured over the last twelve years. But she gets the print love?

    I haven’t thrown in the towel. But I’m ready to. Then the profession will be then down two Pediatricians.

    • Jeremy Smith

      Dr. Johnson -
      The people who frequent this page most do it for the discourse in the comments, including yours. I know your story well. It is a terrible thing that has happened to your career. However your post above does you no favors in trying to persuade those of us with no vested interest in you or your story to your cause, and I think that is one of the reasons you post here frequently. Back off the “my plight is so much worse than hers, but she’s the one who got an article in a failing news glossy!” angle. It’s unbecoming, and you’re better than that.

      • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

        Jeremy, yes I AM better than a lot of the things I’ve had to do in order to stay alive and kicking.

        One of the things I blog about is why the news glossys are failing . . . and that’s because they’ve pandered and sold-out and ignored what’s right under their noses for so long. But the “failing news glossy” STILL reaches an audience/ceiling that I’ve not yet been able to crack. Certainly, if you know my story well – and it’s so “terrible” what was done to me (and what has yet to be fixed because no one has a “vested interest” in what happened to a Pediatrician fired by her hometown hospital for saving a baby’s life) – you understand my frustration.

        Last year, this nation passed healthcare “reform” that did not include medical peer review reform, whistle-blower protection or tort reform. After twelve years of getting pummeled by corrupt lawyers and businessmen – only to be told (by the Congress) that none of that is worth fixing – yet continuing to hang-in/fight, it’s VERY hard to take that Dr. Li can GIVE UP because of “bureaucratic impediments” and get her essay published in a national glossy . . . but I cannot get the time of day.

        I really do want to know. What the hell does it take? It’s an honest question. And I’ve brought it to social media’s “leading physician voice” – someone who obviously has the connections and the clout that I (for whatever reason) don’t rate.

        I don’t care if it’s “unbecoming” to ask. As a Pediatrician who has endured much hardship because I did the right/ethical/medically-correct thing, WHY don’t I rate?

        • http://www.notebookingdiscovery.org/wordpress Alice Robertson

          Hi! Mary I was going to answer you privately, but I am so rushed. I wanted you to know your comments are appreciated, but available on the web. Many in print news get massacred for reprinting what is widely available on the web (readers don’t want to pay for what is free). Their writers try terribly hard to come up with new stories, or angles, that are fresh to their readers. Now I am just surmising many journalists go searching the web for people to interview (my neighbor was an editor of a big newspaper, so I am viewing this through the lens of editors).

          I would suggest you keep telling your story about the bureaucracy, and even other doctors (the peer review information is very important, because doctors tend to promote this as a type of cure……hmmm………..not as long as other doctors who like their jobs very much are involved. Ack! Sorry to the doctors (well the altruistic ones! :) ), but as long as you are helping people stay alive it does sorta come with the territory…….and, personally, I am finding it discouraging to deal with the system. Even if the doctors feel overwhelmed enough to quit, I am thinking if they feel that way it could be best for them and the patients if they took a break (for some a long one). I know I am tired of having to read medical notes in an effort to find something someone else may have missed (I live in terror of this happening again). We would tell a teacher, or a policeman, or others in public service the same.

          Doctors run the bureaucracy, and considering the importance of their jobs, and how one error can change a life/lives forever, it’s just too important an issue for anyone to remain quiet over. The dialogue is vital, so all sides can try to understand the issues before them.

          Most of all I think doctors should take a cue from Dr. Jerome Groopman whose deep love for the patients, and lack of self-pity shines through. I, honestly, can say I fell in love with the guy after reading his book! He is, quite simply, a dream come true :) at least in my world of reading and writing. I just think if more doctors could express themselves, but at the same time express a deep desire to use their education and skills to help mankind we would probably be more inclined to listen if we think they care (who wants to listen to someone who writes in a manner that they don’t like patients?). When it becomes a sheer rant we tune-out, ultimately, it’s because we are paying for that service. I really believe the vast majority of patients are easy to get along with. I tend to think teachers have a much harder job, and when they rant they get tuned out also by parents. I feel certain doctors rant about the carpenters and contractors who don’t do their job well……….and so it is………when money is exchanged for a service.

          Mary…..be encouraged……….your story and all the other stories online are helpful beyond the present. You may feel that your screams are unheard, or that you are worn out…………trust me most people who want to help others feel that way (and it’s not just the doctors………..it’s everyone involved in this drama). I really do believe your experience makes you a better doctor (same with doctors who have been patients………they come out all the better for it……..hopefully! I am sure there are a few the nurses who have thought of some real torture treatments when doctors become patients! :) Grrr…………that sardonic humor of mine just doesn’t quit!!
          Alice

          • Alice

            Meanwhile (as Dr. Li exits the profession due to her frustration with paperwork & reimbursements – and immediately gets an essay published in Newsweek), [end quote]

            Well……considering Newsweek is on the brink of going under, how can one know who will ultimately be read more? Sometimes it’s simply who you know. I know my neighbor (the editor) could move mountains, and I was asked several times to go to the editorial meetings (but like you, at times, I felt my passions were a bit futile……I still consider going).

            Just so you know, I found your story intriguing and sad, as I am sure others do too. Have you wrote to the editorial staff at Newsweek, or a letter to the editor? It may get published in response to the article. Or a google search to write to the author to find out how she was published. I found the author of a book on Facebook and wrote to her to thank her for her input, and she wrote back on this blog to share how to contact her.

            Being victimized is so hard. I wish I could help, but I am just one helpless fish in a big ocean myself. I, too, feel victimized and you were able to help me understand a few aspects of the journey I wish I wasn’t on.

            Maybe there should be a “Doctors Anonymous” considering the pile-up of devastation.

          • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

            Alice, I appreciate your comments (really, I do), but I’ve heard the “you’re on the web” argument before. The reason I’m in the blogosphere is because I was invited by a local journalist. Blogging was going to be the way that stories previously short-shrifted and deserving of attention would make their way to the MSM media.

            But it has not worked out that way. And that’s because my story does not reflect very well on a major (hospital) advertiser. In terms of the MSM (and the kind of exposure that might prompt law enforcement to act as opposed to play dead) I can’t get past the locals – who now sneer and spit and tell me, “Well, you have a blog”. So I am damned if I do and damned if I don’t. Ergo, my screams remain largely unheard in the ECHO chamber that is the web. And I AM worn out.

            Meanwhile (as Dr. Li exits the profession due to her frustration with paperwork & reimbursements – and immediately gets an essay published in Newsweek), this up-coming Monday, in my hometown, the way-over-paid hospital CEO who did me dirty is hosting a “healthcare forum” . . . this when his reign-of-terror is a prime example of the “culture of corruption” in healthcare that needs to be reformed:

            http://drjshousecalls.blogspot.com/2010/06/healthcare-forum-in-asheboro-purpose.html

            OBTW, my Mother taught special-Ed and first grade for over thirty years. She is a saint, and (having spent some time in her classroom observing before she retired), I agree with you – I could not do her job for more than 15 minutes.

            She got to watch her daughter bust her ass to become a Pediatrician, and come back to the town where she had taught for so long, and get CRUCIFIED for doing the right thing by a child.

            No “hooks” there.

  • madoc

    I can’t understand why anybody stays in primary care. I can’t understand why anybody goes into primary care at this time. I feel very sorry for all those doctors that are suffering with those awful problems. I feel helpless right now.

  • max

    When patients start fighting for their pre authorizations instead of physicians maybe some bureaucratic heads will listen. Tell the patient “sorry they aren’t paying for that test/rx.” Patient:” why?” Tell them you’re not sure but if I were you I would call them and yell at them. Have a nice day. Stop the treadmill. Don’t pre authorize anything anymore. Let the patients fight it out.

    • Vox Rusticus

      I think you are right. The patients are paying the insurance premiums. If the companies they were paying had to justify their denials and delays, and explain why pre-authorization by anyone not connected with the care was relevant to anything besides the insurance company’s bottom line, then there would be real pressure on the companies to change behavior. Until then, don’t expect improvement.

    • http://www.notebookingdiscovery.org/wordpress Alice Robertson

      I could be wrong on this, but it would seem if this was followed through to fruition, all those optional treatments would not get filed or paid for, because the patients will usually only follow through on the vital stuff. Doctors pay will go down, or we will need less doctors? But then again maybe less claims, means cheaper insurance? It’s all based on supply and demand, and as much as most people hate them… the insurance companies are part of the flow chain. If patients start to do this a whole lot of jobs will be lost because hospitals have a lot of staff trained to do this, and they usually do it very well. The bureacracy stuff that is driving doctors crazy seems to be part of their job description.

      I guess I am curious why this is such a thorn in their side. My husband has a lot of issues associated with his job he doesn’t like. Nurses used to get writer’s cramp, and do vast amounts of paperwork. Teachers and others have huge student loans (sure some can go to the innercity and get a lot of it wrote-off, but I figure doctors can join the Peace Corps as my neighbor did and get 70% of their loans paid off too). I know so few people who aren’t fed up with their jobs, or want a career change (Forbes Magazine covered this), that I am curious about all this ranting about student debt and paperwork from the medical establishment.

      Why does it feel like we are all in the same boat, but the doctors want the life rafts first lest they bail? Some patients wonder if that’s a threat or a promise, but I am one who wants to improve the relations between patient and doctor. We are all people afterall……:) And we do need each other, if we can stop shouting past each other.

      One other thing, I am finding doctor’s notes of great curiosity these days. There is stuff in them I don’t understand, and it goes beyond patient care. Why the personal stuff about why a patient switched doctors, etc.?

  • Lilly

    ” Let the patients fight it out.”

    Patient care is secondary in today medical system. Whether it’s the insurance companies or the doctors, compassion is gone. While it may seem like a good idea let patients fight it out, patients don’t have any power. Ultimately, the patient would do without.

  • LynnB

    Ok to let them fight out PPI A vs PPI B or ARB 1 vs ARB 2 . Not OK to let them fight the ineffective chemo drug or the CPAP instead of BiPAP .

  • PAULMD

    Dr. Lemmon is right.

    I am, however, continually frustrated by the folks steering my state medical society in their approach of government appeasment and acceptance of the current times. ACOs are coming and anyone with 1/4 of a brain knows that it is just a shiny new fashionable way to mandate care and not pay the provider.

    “Teeth”. I’d settle for gums from some of the other docs I deal with. My gloves came off a long time ago but it seems other than my subspecialty society, nobody wants to fight.

  • David Locke

    Don’t expect patients to fight back. I’d love to, but I’ve found that my employer leaves their responsibilities in the hands of claims processing companies. I’d love to sue my former employer for breach of contract. The did not pay a single claim the year I worked for them. The laws are rigged to ensure that patients have no rights. And, most patients are at will employees, so why would their employers care?

  • Alice

    Mary…….another encouragement. I don’t have time to follow all the threads here…….but in a few I have observed that when women doctors author a thread you have a better chance of a response. Then on a few threads it seems the doctors answer first, then when the other mere mortals come in usually doctors quit responding! :) Wonder why?

    But I know you and Ilene follow it through. That’s a fantastic trait. Other doctors should taken heed, because to the average observer, like me, it seems to be the casual way doctors handle things (maybe the repetition gets to them, and maybe we expect too much). But we scream when pilots, bus and train drivers, or paramedics seem to cavalier………..and so it goes with public service that can seem monotenous, but so necessary. Patients have a need and want to heard. I was so appreciative of your answering of private e-mails. I only know one of our doctors who I can count on to answer my e-mails. Some don’t answer at all, or even call you when you write that your child isn’t well from radiation (I got another doctor involved, so the doctor finally wrote and told me there are no side-effects to radiation. I told my friends I was going to invite this particular doctor out for cocktails……….atomic ones…… at the nuclear medicine bar! If they have no side-effects why are people locked in leaded rooms? He then wrote and asked if our child was experiencing mental problems. I was ready to go mental…..or medieval on him! :) Ack! I did change doctors, and now our notes say I loved the guy, but switched. Go figure!)

    I know, speaking for myself, I don’t want my daughter to be just a face in the crowd………and her doctor was honest….. he has no memory of our earlier meetings. It’s understandable on both sides, but somehow I think they will remember us! Not for being demanding though, but for being persistent and kind………..and, yes, forgiving them for being human at times and doing the wrong thing.

    Anyhoo……..Mary your blog is more effective than you know. Months ago while trying to figure out the peer review process (that just seems so rigged) I found your blog, then you posted here and I appreciated your forthrightness, and most of all your honesty and caring enough to answer a private e-mail. You gave me what an article in Newsweek could not do. You gave me your time and heartfelt response privately.

  • FormerTeach

    As an individual, who is way outside of medicine, I am in the education field. Better organization, i.e. unionization, may seem like a great deal for those medical doctors, however it will hamper any efforts to make medicine the once, honorable profession. In education, unions have increased salary for dome appointed few (dependent upon city and state), decreased time requirements for salaried professionals and increased overall work conditions (i.e. air condition in buildings; personal relationships with administration) however the organization has damaged the context of education, as there is a lack of individual voice within the school system, and given a black-eye to the whole education profession, as there is a greater distrust between educational professionals and the general public. In terms of being able to make decisions, educators still are unable to do so, as school board members (business leaders, attorneys, doctors, etc.) seem to have their hand in what they think is best for the student. In some states, the medical professionals are determining what should be taught in biology and chemistry.

  • fortitude

    good for dr. li, more docs need to leave the profession. The fact is that Dr. Li, while a great doctor, is probably not the greatest business person, and thus probably has rising out of control costs, and because reimbursement DECREASES every year eventually things like this happen. Back in the 80′s you didn’t have to be a penny pincher/bean counter to run a succesful medical practice. you didnt’ have to learn how to run quick books and your lawyer and accountant weren’t a huge part of your practice. In response to “Former Teach” i have never heard of MD’s determining what should be taught in Bio and CHem, anyway it seems that creationists and intelligent design apologists in texas are gaining control in that aspect. i think you need to worry about those guys rather than MD’s(who in general are well versed in bio and chem) about screwing up the educational system.

  • http://www.twitter.com/alicearobertson Alice

    i have never heard of MD’s determining what should be taught in
    Bio and CHem, anyway it seems that creationists and intelligent design apologists in texas are gaining control in that aspect. i think you need to worry about those guys rather than MD’s(who in general are well versed in bio and chem) about screwing up the educational system. [end quote]

    Alice: Why would this information bother you? Evolution is debated hotly, so why not throw out creationism and let the students decide. Are Creationists that scary?

  • fortitude

    Re:alice, i dont’ want people with no training in bio and chem determining how my kids learn, just like i don’t want MBA’s and JD’s telling me how to practice medicine. Koodo’s to Kevin MD for initiating such stimulating debates!

  • http://www.twitter.com/alicearobertson Alice

    Re:alice, i dont’ want people with no training in bio and chem determining how my kids learn, just like i don’t want MBA’s and JD’s telling me how to practice medicine. Koodo’s to Kevin MD for initiating such stimulating debates! [end quote]

    Hmmm……but there are Christians, Jews and Muslims who believe in Creationism and some of them are bio and chems. I don’t view it solely as a theology type of discussion. It seems more like censorship?

    I am all tied up on the measles board with some doctors who think they created the bloomin’ world! :) I sometimes wonder if self-proclaimed intellectuals have the ability to use logic, and why they rely on those credentials so much.

    In Texas it’s the educrats all debating this issue, so even an education doesn’t really mean one has the ability to reason better. It just means you have studied a topic, because I am using the term “expert” with great care these days. I am still perplexed how some of the people I know got a degree. Even they laugh it off.

    Anyhoo……..I believe private schools do a much better job at educating (and homeschoolers), so creationism isn’t hurting their ability to learn or function, or as just being a decent human being (which seems of much more value to me these days).

    Yes, indeed, kudos to Kevin…..but I am feeling pretty lonely out here……….just determined to be a voice in the wilderness.

  • Garitt

    My wife wants OUT of primary care and so I thought I would ask the following question. Are there alternate career avenues that a primary care physician could look into or is she stuck now having to work as PCP?

    Is there a long retraining road ahead, or is she already qualified to be considered for other health care related opportunities?

    Thank you
    Garitt

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