Health care economics and the relationship between doctor and patient

I used to practice pediatrics. It has been several years since I decided to leave medicine, but people still ask me about it, and I find myself offering neat explanations between gulps of coffee. Of course, the full truth is much more complicated. The full truth has as much to do with our health care system and our culture as it does with me.

My journey in pediatrics was not entirely typical. I went through Georgetown University’s medical school on a Navy scholarship, which meant that, unlike most of my peers, I spent my formative years as a pediatrician practicing under a system of universal health coverage in the U.S. military. All patients — admirals’ sons as well as the stepchild of a seaman apprentice — received excellent care. Doctors were well paid, and the standards and quality of care were as high as I have observed anywhere. No money exchanged hands: Just show your card and you were in.

Fast forward 10 years and I was in a thriving private practice in suburban Rhode Island, along with several other dedicated, highly trained pediatricians, and an army of nurses. I quickly learned how methods of reimbursement shape the way doctors practice. Private insurance companies decide who gets paid for what, so pediatricians treat serious mental illness with little psychiatric training, use nebulous tools to diagnose attention deficit disorders, and valiantly tilt at the windmill of childhood obesity, not because we can do this most effectively, but because we are the only professionals who can get paid to do so.

At the other end of the treatment spectrum, free market forces often urge us to over-intervene with minor illness, where less really would be more. For example as baby spit up acquired more syllables, expensive medications to treat infant gastroesophageal reflux earned full page glossy ads in parenting magazines, pharmaceutical industries poured tons of money into self-serving clinical studies, and prescriptions flew off our pads.

The economics of health care trickled down into my exam room, into the conversation between doctor and patient, distorting the relationship. Most of my patients, children of the “worried well,” had self-limited illnesses that would get better without any intervention from me. I had to explain again and again to frustrated parents, who had just shelled out a $25 copay, why their child didn’t need antibiotics — or any other medicine — for a cold. I met skepticism, even hostility, as I explained for the hundredth time why a 3 a.m. earache wouldn’t improve with a visit to the emergency room. “Do you know how much I pay in health premiums?” parents would ask. Our system of paying for health care and the stresses on today’s families were pitting my best medical judgment for the child against all the other worries and desires of the parents.

Important things have been happening to keep kids healthy — things like vaccines, nutritional advice and safety education — and these have been provided most effectively by nursing staff, expertly doing what they were trained to do. If a mom was hanging on to her crummy job just to keep health benefits, then it was not too surprising when she insisted on potty training advice from no one less than a board certified pediatrician, thank you very much. I loved chatting with families, but I was spending too much time as Dr. Mary Poppins, pulling an endless supply of fuzzy child care advice out of a carpet bag as I burned up $60 office visits weighing the benefits of naps vs. no naps. (If there were any lectures on naps in my residency training, I must have slept through them.)

I, like most of my colleagues, valiantly stepped up to the plate and kept on swinging, even as I was being pulled farther and farther from the doctor I was trained to be. I did my part to put a scientific spin on our highly subjective approach to learning disorders. I patiently played along with obsessive discussions on toilet training without acknowledging the toll such indulgence took on precious health care dollars, as I tried to meet the ever-expanding expectations of the “worried well.” I taught myself as much as I could about mood-altering drugs so that my depressed patients, denied appropriate access to psychiatrists, would have some one to turn to. In short, I helped put the “dys” in dysfunctional.

In the end I just got tired. Literally. At 46-years-old, being up all night and working the next day left me physically ill. Meanwhile, my own two teenage daughters were spending too many nights at home alone while both their parents tended to patients. So when I was unexpectedly presented with a way out — the chance to teach chemistry at an all-girls’ high school — I took it. It was a painful, difficult choice, but it was the best decision for me and my family.

I have hope for my profession. I believe our society will eventually see the economic sense and moral imperative of universal health care coverage, paving the way for health care to be designed by health professionals, and to be viewed as a right and a responsibility, rather than a commodity to be purchased. I believe that pediatrics can evolve, too, in a way that will truly meet our society’s health needs. We will always need pediatricians to understand and cope with complex or dangerous illness. We will also need trained health care providers, like pediatric nurse practitioners, to deliver competent, less expensive care for health maintenance and minor illness. Pediatricians in turn will need to be trained in how to support those practitioners.

Finally, in an age when public health issues like obesity are what pose the greatest threats to our children, pediatricians will need to move out of the confines of the fee-for-service exam room to advocate for effective health care policy in the wider community. This shift in how we focus and pay for pediatric expertise will be challenging, but I know there is a whole new generation of young students out there who will be up for the task, and a new generation of children counting on us.

Maggie Kozel is the author of The Color of Atmosphere: One Doctor’s Journey In and Out of Medicine, forthcoming from Chelsea Green Publishing, and blogs at Barkingdoc’s Blog.

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  • sh

    Great post. I backed out of medicine myself: many similar reasons…Everyone’s experience is different, but in the end I felt primary care was a dead end job, and I was just a drone trying to grind through as many pts. as possible.

    However, I am not as optimistic as you. Unless there is individual responsibility from the patient we are just a way for them to vent and take out their anger on us.

    • http://barkingdoc.com maggie kozel, MD

      I agree with you on patient responsibility and I think it goes much deeper that the doctor-patient relationship. Our society needs to develop a mature attitude about what it means to be healthy, and needs to raise the bar for what kind of health care delivery we expect and deserve.

  • http://lsminsurance.ca/ Lorne Marr

    As far as universal health care coverage is concerned I think the problem here is that too many people in the US find it difficult to support a system into which everyone contributes but not everyone will benefit from it. If we want to win this fight that has lasted for so many years we will have to overcome this selfish feeling.

  • ninguem

    In the long run economically, especially with the opportunity cost of training and military payback, probably would have been better off teaching high school chemistry in the first place.

    • http://barkingdoc.com maggie kozel, MD

      Teaching has been a fabulous second career for me, but for quite a while I had an opportunity to be everything a doctor could be, and I wouldn’t give that up for anything.

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

        Is teaching teens more rewarding than patients? I think Maggie is right and gained immeasurably from her experience as a doctor. We attend part time private school where the best teacher is a retired pharmacist. He brings so much experience to the classroom.

        Some of the more empathetic and wise doctors post here….which makes the Internet their classroom. It seems to me our own doctors are great teachers. They draw us pictures of organs they will remove, teach us about the consequences. With a kindness of heart…a few are exceptional because they extend mutiple gifts as their talents. Yet…they are the exception…not the rule. When they retire I hope they take sthis gift to share with young minds.

  • Primary Care Internist

    What a disappointing post in so many ways.

    I can so easily empathize with your decision, as my wife and mother are pediatricians, and my wife left practice rather quickly due to burnout and the clear financial disincentive. My mother still practices in her mid-70′s but definitely not because it makes financial sense – she probably loses money. So your decision isn’t surprising at all. What’s surprising is why ANYONE goes into pediatrics, and furthermore once in practice, why anyone stays? Pay is so little, respect is so little, entitled parents calling at 3am for the sniffles are so plentiful because “do you know how much my premiums are?”.

    But then you go into this political diatribe about universal coverage and nurse practitioners.

    There are many many groups taking up the cause of universal coverage – the AMA, ACP, ASIM, AAP, etc. And all have done so at the expense of advocating for DOCTORS! That’s why they’ve lost membership, and have essentially no say in health policy in washington anymore. I think practicing docs should just be doctors, and it’s growing ever-more annoying to hear more and more of us spewing politics, especially when you couldn’t hack practice. Did you ever think that, with so-called universal access, who is gonna treat everyone? Ah yes, NPs, of course.

    NO, WE DON’T NEED MORE MID-LEVELS WITH A SHIFT-WORKER MENTALITY. WE NEED MORE DOCTORS, more “captains of the ship” who are respected and whose opinions are essentially the final word, without second guessing by families, lawyers, etc. If the pediatrician who has been treating all the kids in the family for 15yrs says you don’t need antibiotics, then that’s it! No doctor shopping, lawyer shopping, google-diagnosing allowed. And NPs and PAs.

    Do you really think NPs are cheaper than pediatricians? how is that possible? only pediatricians are altruistic enough to basically work 24-7 for a teacher’s salary – NPs are not stupid enough or altruistic enough to do that.

    You, and my wife, prove that the economics of being a teacher are much more favorable, even after putting in 7+years (after college) in training. Instead of pushing the NP thing, you should be advocating for those MDs who are still trying to hack it, still waking up at 3am tellings parents not to bring their kid with a cold to the ER, and to use some judgment in calling you by first doing some self-triage, to respect your role as their pediatrician, and to respect your limited family time. THIS is what we should be advocating, but you are straying in the same direction of the AMA, and turning your back on your former peers in practice.

    No wonder pediatrics is dead.

    And if you think NPs are cheaper, here’s an example of a recent patient i had – elderly nursing home resident with SOB and an ecchymosis of the arm – NP orders pulmonary and derm consults (???) when all she really needed was a neb, cxr, shot of lasix, and the ecchymosis just needs to be observed for resolution, ie. SHE NEEDED A DOCTOR!

    • johnsonjay

      I can attest to the NP thing. Just yesterday our son was seen by a NP for a cold with a bad cough. The NP ordered a chest x-ray, but then said she was unqualified to read it so we wouldn’t know the results until tomorrow. However, in her opinion, it “looked bad”. She also said he had an ear infection. She sent us to a pediatric ER with us worrying something was seriously wrong with our child. Long story short: no ear infection whatsoever and the chest x-rays weren’t bad at all. They gave my son a nebulizer treatment and sent him home.

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

        My experience at Minute Clinic with NP’s has been fantastic…but universal coverage for the masses isn’t the answer…and I wonder if someone knows about survey’s done with military families? I have heard some horror stories…so I am unsure if we would agree with the excellent coverage. The media had to get involved to up the care for many of the post war victims…and if the VA is the model of universal coverage…yikes….but again they are trying to improve. I just can’t handle the reality of universal coverage the romantics like.

    • http://barkingdoc.com maggie kozel, MD

      Wow. “Diatribe” may a bit strong, don’t you think? I am not sure what you consider to be advocating for doctors. In my mind, it is working towards more rational division of labor and effective use of resources, so that we – doctors – can actually use our expertise the way we were trained to, and our patients can receive quality care at the appropriate skill level. I am sorry to hear of your negative interaction with an NP. I have had many gratifying ones, but it requires a productive relationship.

      • Primary Care Internist

        I have, and continue to have, several productive gratifying relationships with NPs. But I continue to emphasize that they are not doctors, and their usefulness is in:

        1- maintaining good relationships with patients and their families, ie. continuity;
        2- keeping track of specialty consults and test results, and reviewing those with the attending MD
        3- taking care of logistical things

        They can be quite valuable, but more as a “scut monkey” than in actual medical decision-making. And there’s nothing wrong with that – we need those services. But again, they are not doctors, and I don’t understand why our major medical representative groups and many doctors (most non-practicing) want to push their agenda of independent medical decision-making. After all, do we see THEIR professional organizations endorsing the independent practice of lesser-trained nurses eg. RNs and LPNs? Of course not.

        • mary mancuso

          I wish you would stop all the NP bashing. My two kids saw the same two pediatric NPs their entire childhoods and they were far from incompetent shift workers. I sometimes think some MDs on this site are kinda whiney.

          • Primary Care Internist

            did you even read my post? it’s not a matter of NP-bashing, it’s a response to the exponentially-increasing myth that NPs can and should take over the independent practice of primary care.

            Some can make that argument in peds, i guess, because the vast majority of kids seen as outpatients will get better whether you give them antitussives, antibiotics, voodoo, or anything else, or nothing at all. But in geriatrics and in many other fields where you really do see a lot of sick people, their usefulness is as i’ve outlined above. That’s not bashing, just reality. Do you think the airline stewardesses should be able to fly the plane after taking a few flights watching the pilot, and passing an 18-month course taken online?

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

          They are great at diagnosing too! Do you have research that shows they are not able to diagnose as well as a doctor? I haven’t seen any, so a forum like this is educational.

          They send hard cases to doctors, and are a bit limited…which I tend to think means they are not spread thin and are very good within their realm of boundaries.

  • pcp

    “Pediatricians in turn will need to be trained in how to support those practitioners”

    Undergrad, med school, internship, residency so you can support NPs (and take full liability for their actions)? That’s going to sell like hot cakes.

    • http://barkingdoc.com maggie kozel, MD

      I reject the notion that physicians are too special to be part of a health care team. I have seen first hand how effectively physicians can work with nonphysicians in a health care delivery. But it requires training to do it well – and a broader mindset. A quick look at some of the comments to this post reveals that many of us don’t even know where to begin. The irony is that such division of labor would free us up to do what we do best – doctoring.

  • Stalwart Hospitalist

    I would be interested in hearing how overuse by the worried well is more prevalent in a private insurance system (yes, the parents pay premiums, but they certainly have co-pays for each visit) versus a universal system where there is no additional cost to the patient for requesting 30 clinic visits per year as opposed to 4.

    Did the military system in which you worked previously provide for some kind of external limits on use of the system by patients?

    • http://barkingdoc.com maggie kozel, MD

      Thanks for pushing for clarification. I think the phenomena of the ‘worried well” is more cultural than a result of the system we use to pay for health care. The problem is that under our fee-for-service system, there are tremendous financial disincentives for triage. So bedwetting starts at the top of the health care pyramid. A rational approach to dealing with the common travails of child-rearing requires a team approach, and a system that will pay for that – saving money, I would argue, in the long run. As far as overutilization goes, if copays really do help cut down on this, then I don’t see why a system of universal health coverage would have to forego them.

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

        Also, dealing with kids who cannot go to daycare sick, moms who can’t take a day off means highly frustrated parents…add that parents have managed to raise what research shows as the most narcissistic generation ever…actually, with YouTube Narcissist’s can just watch themselves all day, and do ridiculous antics to make sure they go viral!:). Somehow dealing with the actual illness would seem easier than the parents who often think the earth stopped spinning the moment they gave birth.

        But, then again, they have a point, they are paying you for information and help. What they do with that is their business…not much a doctor can do. They used to say pediatrician’s would tell moms to give the child Tylenol. It was to soothe the mom, not the child. Sometimes moms just need to know the doctor did something…anything.

  • jsmith

    I have been practicing family medicine for 21 years and I have no plans to quit. A lot of my patients don’t listen to me; they do what they want when they want. I spend a lot of my time wasting my time, tilting at the windmill of obesity, counseling people for the nth time to do what is right, fighting with insurance companies.
    Why am i still doing this? Because I always expected to have a difficult, crappy job, and I have one. I always expected not to be able to do much, to tilt and windmills. So I’m not disappointed (except with EHRs, I didn’t see them coming). Also I get paid a good amount of money, I will never be laid off, and every once in a while I get to save someone’s life.
    Re-adjust your attitude. Push through the BS. And don’t forget that doctoring is a noble profession.

    • Harry

      My personal career expectations were very dissimilar to those described by jsmith. i expected Fam Med to be both challenging and rewarding. Unfortunately, the challenges continue to mount on all fronts and the rewards continue to dissipate rather quickly.

      With many med students facing in excess of $200K in student loan debt alone upon graduation, it’s easy to see why so many of them are drawn to more lucrative specialties. Until physician payment models are changed, most Primary Care specialties will continue to experience declining numbers at an alarming rate.

      It’s gotten to the point where I can understand the reasons why physicians choose to leave medicine altogether. Listening to my grandfather (retired GP with over 35 yrs of service) speak of how medicine used to be, it becomes even more disheartening now to see the direction our profession has gone. He mentioned to me over Christmas how when docs gathered in his time, they would usually discuss interesting and intriguing medical cases. Now most of my colleagues discuss how difficult it is to continue to function under ever-increasing administrative pressures; increasing documentation, larger and larger volumes of uncompensated care, defensive practices, etc. Combine these issues with a volume-driven payment system, and patients wonder why some physicians operate their practices along the lines of a McDonald’s Drive Thru. All of this simply creates indifference, both by physicians and patients alike. Physicians have simply become a basic means to an end. This once noble profession has been degraded to just merely some other customer service industry where ‘the customer is always right’.

      And when you realize all of the sacrifices (both in time and financial investments) you’ve made to become a physician, dedicating yourself to your patients (often times at your and your family’s expense), you can’t help but to become somewhat indifferent when it seems like everytime you turn around, someone else is stacking the cards against you.

      I am forturnate to have a great population of patients who i feel truly value my services. Now if we can just get Congress and insurance companies to recongnize that same value. I am a patient advocate and will fight for them with every ounce of my being, but i also have to advocate for myself and my family who depends on me to provide for them.

      Unfortunately, unlike most other industries, physicians have little control as to valuing their services. Insurance companies have price-fixed us into a corner and we’ve allowed this to happen. Unlike other industries, when overhead or the cost of goods sold increases, physicians do not have a way to readily pass those costs along to the consumer. As a result, we then have to work harder, see more patients in less time, work longer hours, etc., all at the expense of, to some degree, distancing ourselves further from our patients. The relationship suffers. Our careers suffer. Our personal lives suffer. Our personal finances suffer, even though we still have the burden of that extensive med school debt hanging over us. Physicians deserve better. I think we’ve certainly earned it.

      • jsmith

        Harry, it is tough out there, no doubt about it. A while back I read a great book, The Greatest Benefit to Mankind: A Medical History of Humanity, by Roy Porter, an English historian. It connects what we do to what our predecessors have done for thousands of years. Very inspiring.

    • http://barkingdoc.com maggie kozel, MD

      And many wonderful doctors, my husband being one of them, do just that. More power to you!

  • http://dlmcblog.com meghmala

    Every doctor should practice the primary health care.

  • Max

    I’m not sure how universal coverage would change the authors experience. It seems you were burnt out due to a number of different factors, not just copays. You will still be working long hours. You will still get 3am calls. You will still get potty training visits, perhaps moreso do to removing the copay disincentive for the patient. No reason not to see you if I don’t have to pay, right? That NP is triple booked by the way so you’re the first opening. You will still be Dr. Mary Poppins. Your hours will be just as long and you will miss just as much time with your children only you won’t be taking home as much. But you will be honorable by defending the ‘right of healthcare’. I applaud your sense of duty. Perhaps working for free for your former colleagues in the evenings and weekends would remove economics from your equation and let you enjoy medicine again.

    • http://barkingdoc.com maggie kozel, MD

      You sound a little angry there, doc. If I don’t like the system I should go work for free?
      There are a lot of overlapping issues here aren’t there? I agree that we could have just as crappy a system with universal coverage. My point was that if we can move out from under the misguided financial incentives and disincentives that our private, fee-for service system sets up for us, that we can decide what kind of health care we want – like one based on evidenced-based medicine and clinical efficacy rather than corporate profit. One that offers all the benefits of team work. Call me crazy.

      • Max

        My my…it was merely a suggestion. Don’t bite my head off. You are the one who is angry at the system (and your ‘needy’ patients, by your own admission no less) and was fortunate enough to marry another physician and be able to leave your job (and degree, in my opinion) behind. I have always wondered how physicians end up marrying each other and I finally figured it out..twice the money. It’s not by accident you see opthy’s married to OB’s etc. That double $$ is mighty tempting. It’s a nice gig if you can get it and I applaud your choice that many other women unfortunately do not have.

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

        Maggie help me to understand….don’t hold back…I teach debate and literature…I like thoughtful counterpoints that are not emotionally charged…but factual. And I lived in the UK and I have seen universal care kill a few relatives. I am completely unobjective because of my own experience there. The vast majority of my relatives are still there telling us horror stories…yet, proclaiming they are a part of the world’s best care. I have to left and gag! :)

        Can you share your personal thoughts or answers! It makes great discussion starter points. Are you saying you want public option? A system of universal care similar to the UK…or VA?

  • http://bizsavvytherapist.com Susan Giurleo

    Maggie, I like your idea in the comments of having a system that supports parents with child rearing concerns and skills. That would certainly cost less than having worried parents use their health care dollars for issues of discipline and parenting skills.

    And teamwork is a must. People who are highly trained need to be focusing on complex health issues, while the more minor complaints can be attended to by others. There needs to be less turf protection and more collaboration among all health care professionals who are mature enough to make room for others in the health care process. We know there are more than enough patients to go around!

    In the long run, I believe people have to take more responsibility for their care and how it’s paid for. This could be as straightforward as the patient being responsible for managing their own insurance paperwork. I know people get all up and arms about this idea because they feel they may not get paid, but the auto,life, and property insurance industries have figured this out – why not health care?

    And providers need to empower themselves to explore new business models that are not solely based on managed care reimbursement. This could be as basic as offering a child development/parenting program like you describe.

    Times are tough in health care…but with creativity at the ground level, things can be better.

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

      Why don’t doctors have sheets with websites they like on particular topics? Give it to the parent with the offer to discuss it after they have had time to research it. Just this type of sheet would keep certain parents from coming back (like the supposed ignorant non immunizers doctors here claim they will not treat…or spankers……or homebirthers….I love them on both sides of the aisle…particularly the teachable ones who like to listen and learn…..I love discussing with women with open minds and backbone to tell a doctor they appreciate their input and medical care…but feel compelled to understand what is in that shot in your hand…..blind faith in any doctor is simply foolish….they are there to inform and teach…not act like a type of Svengali).

  • http://www.indianainsurancehealth.com Healthy Person

    Taking more responsibility is the key. Good health care becomes a lot less expensive if we all take care of ourselves!

  • Marc Gorayeb, MD

    In many cases, burn-out occurs because one’s work does not match one’s skills.
    Universal or government-sponsored health care is not insurance; it’s taxpayer-funded care (with or without co-pays). Health benefits for many large-company or union employees is not insurance; it’s nearly first dollar coverage for services that have no business being covered, such as routine or minor visits. The current mandates under Obamacare are going in exactly the wrong direction, requiring “insurance” coverage for routine and preventive services, or for services that many people can afford. This is not what insurance is meant to be, and the system will collapse under this method of financing non-catastrophic problems. And, by the way, you will be under-challenged by many of the patients you see, and you may end up resenting it.

    Insurance should be to cover services whose costs exceed one’s wilingness or ability to pay. If that were the model, I can assure you that most people would not have populated your office with unecessary visits, because most people behave rationally when it comes to personally being liable for the goods and services they receive. If that were the case, price competition would keep medical inflation under better control, more patients who truly need the insurance coverage would have it, your overhead costs and ‘administrative’ time would be reduced, your actual work would be more commensurate with your training and skills, and you might not have burned out so quickly.

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

      I like my insurance and jump for joy to pay a copayment. Do you realize your proposal will be harmful? With two kids who have had cancer (one still does) the bills would have cost us much more. The insurance company keeps prices down, which helps others. And doctors still make a great living….sure it is harder…but other arms of the insurance debacle do not scream like doctors. Mechanics and home improvement businesses know their salaries lean heavily on insurance company payments. It makes it look like doctors have a type of entitlement mindset.

      But you are right catastrophic insurance keeps people home….your income goes down…and you end up dealing with collectors for all the non payments. It also keeps sick people home.

  • imdoc

    I am curious what the author’s opinion is of teacher pay having now changed professions. I read opinions of some people stating there is little difference in demands of teaching vs medicine and, as such, doctors are ‘overpaid’ professionals. From the article it would seem teaching (and chemistry no less) is an easier road.

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

      One difference is teachers do not bring up student debt in every other breath. My son will soon be a teacher. I took on $20,000 in debt for his first year. Soon he will have $47,000 in student debt of his own, plus graduate school and it will be about $100,000 in two more years. He will make about a third or less what a doctor makes, and put up with persnickety parents and kids. Why do doctors whine more than any profession I have witnessed. Honestly, I have read hostage stories where they were in chains with no food and they complained less than many doctors.

  • Sandra

    I’m an IM/Peds doc who has also left Pediatrics after many years and have recently left primary care IM as well, am now doing skilled nursing unit rounding instead as the hours are way better for the same pay so why not? Agree with you, Maggie, the worried well are a HUGE problem in the US, created by fee-for-service medicine and the paternalistic attitude pervading medicine requiring everyone to come in for a face-to-face visit with the doc rather than getting simple RN
    advice over the phone. About HALF of primary care outpt medicine does not require the MD skillset and is easily delivered by RNs, physical therapists, NPs, and PAs. That is a fact, folks — yet i hear over and over to a point where I am sick of it, mostly from male MDs, that NPs and PAs “are not doctors” and shouldn’t be playing doctors. No one says they are doctors. It’s just that the truth is, half of all medical advice ane medical visits do not require the MD skillset. I for one did not go through the years of brutal training, only to find myself sitting in an exam room time and time again over year after year seeing a patient who says “I have a sore throat, started yesterday” or “doc I hurt my knee yesterday” or all the other things that non-MDs can handle. I’m an internist, and I amtrained to care for the quite ill, not minor ailments, and I want my NP, PA, RN, and PT brethren to take on the minor stuff and leave me with the “big league” stuff that I’m getting paid the big bucks to do.

    • johnsonjay

      I think the argument that “HALF of primary care outpt medicine does not require the MD skillset” might be true, but doesn’t necessarily support the more widespread use of NPs/PAs. Sure, the PAs or NPs will make the right diagnosis nearly all the time in the settings in which they are placed, but I think they will still misdiagnose at a higher rate than a MD would. At large volumes of patients, this could become quite a significant problem. Conversely, what about the missed or wrong diagnoses that unnecessarily send patients to the ER or for further testing (and also scare patients because they think something is seriously wrong, but isn’t – see my post above). Perhaps the unnecessary referrals/test ordered by NPs/PAs would counteract any benefits in time-saving we would hope to gain by their mass-use. Is it possible medicine could become even more costly?

      I don’t pretend to be an expert in this area and I’m not saying you’re wrong… this is just what popped into my mind as I read this post.

      • Sandra

        I’m just saying that there is a huge need for properly deployed NPs/PAs and that we MDs don’t need to feel threatened by that (which most esp older esp male MDs seem to be). There is plenty for MDs today. This is part of any solution to solving the primary care horrible worklife issue. The question is PROPER deployment, which has not been done often, with negative results. But, seeing initial visits if needed for some basic/simple things like colds/coughs, the sniffles, sinus issues, i hurt my back/knee/hip/ankle etc — there is a fairly well circumscribed group of issues in primary care that may require occasional MD peripheral involvement but could be mainly handled by RNs, NPs, PAs, and PTs. I have worked with some great NPs and PAs over the years and have lived this. Have not witnessed ANY bad outcomes in the past 5 years of doing this intensively solely in an outpatient primary care setting.

      • Sandra

        Above, i meant plenty for MDs to do.

        And, my view is that incompetence needs to be weeded out/eliminated, be it MD, NP, or PA. For any clinician to say “I’m not sure about the xray” is unacceptable/not competent. That NP should’ve said something like “the xray looks fine to me, i’m sending it for an official read though, and rarely but sometimes they see something I
        don’t and I’ll call you if so.”

      • jsmith

        NPs benefit greatly from physician supervision, although the young, inexperienced overconfident ones hate to hear it. I work with an NP, and she sees the colds, sore throats, scraped knees, etc. It takes a big load off me and I and the pts are darn lucky to have her. I see the chest pains, diabetics with fevers, etc.
        A couple times per day she consults with me about a pt she is unsure about. These are mostly easy cases for me, but if I weren’t there, the patients would wind up with an unnecessary specialist consult or ER visit. That’s OK, no shame in that. She knows her limits.
        There are simply not enough primary care docs to handle the volume. We need mid-levels, but they should be given jobs they can handle. Better for the pts and for them.

  • imdoc

    I think the article is not idle complaining. It profiles an individual who took action. This doctor left the profession and entered a different one and indicates happiness with the choice. This puts her in a unique position to comment on both professions. Chiding such a decision is not useful to the discussion. Some very fine teachers I know have quit to take jobs in other fields ( and yes, they will openly complain about conditions experienced in public schools). These people are missed as fine teachers, but I don’t think it calls into question anyone’s integrity nor does it make such individuals ‘whiners’. What it does call into question is the motivating factors. If society were to witness wholesale exodus of teachers from public schools, or see such individuals bankrupted by excessive school debt, it is a problem to be addressed and improved.

  • JoAnne

    I find Primary Care Internist’s post interesting. Here’s what he wrote:

    “There are many many groups taking up the cause of universal coverage – the AMA, ACP, ASIM, AAP, etc. And all have done so at the expense of advocating for DOCTORS!”

    Universal coverage isn’t about YOU. It’s about patients… who need access to care. Not everything is about you. Healthcare is supposed to be about PATIENTS. When it’s not, it’s simply “medical consulting” because “care” is patient-focused. You know… patients… the ones you are supposed to help… the ones whose bills pay for your house and your kid’s college tuition. You may want to consider thinking about them every once in awhile, Primary Care Internist, because it’s not clear from your post that patients are even on your radar screen.

  • elmo

    “Universal coverage isn’t about YOU. It’s about patients… who need access to care. Not everything is about you”

    JoAnne the organizations he was referenced are actually organizations that among other things are run by and should advocate FOR doctors. You have shown little knowledge in the issues at hand. The fact is MD’s have not had a real raise in 13 years since the SGR went into effect. I can personally attest that expenses have gone up significantly in 13 years without a significant increase in revenue, outside of seeing more patients. Have you had a raise in the last 13 years JoAnne? Let’d talk about universal care. Mass. enacted universal care recently. It is a mess becasue there simply are not enough primary MD’s to see all the new patients. Did the Mass legistature think this one through?…no. Do they really seem to care? Not that I can tell. They just pulled yet another government mandate without actually looking at the results and the ability to carry though on the mandate (ie adequate primary MD’s) Kind of like Obama’s plan. You want universal care joAnn? Fine, then be prepared to pay for it, not some additional meaningless government mandates without addressing well known shortages.

  • healthcare prof.

    I wholeheartedly agree with JoAnne’s post. While I really appreciate the many great articles and opinions of this blog, I am so tired of the whining, self-importance and patient- bashing that goes on. Why don’t a few Doctors out there just post a copy of your W2 forms on the blog and settle the underpaid argument already. You CHOSE this profession. If you are unhappy about the duties of your job, you won’t be the first person on the planet to have a career change. Move along. Someone else will gladly take your place and feel priveleged to have the opportunity to work as a Doctor. There are MANY great Doctors out there who work very hard to give the best care possible for all patients. They are too busy to be whining about it. Kudos to them.

    • pcp

      I’m turning away patients daily. There are NO doctors, PAs, or NPs waiting to take my place. But, there are dermatologists and plastic surgeons on every corner.

      • healthcare prof.

        How many people in the U.S. alone ( never mind international students) are vying to get into Med. School
        or NP/PA programs? Why are they tring so hard to get into these programs? Why is it so hard to get in?

        • johnsonjay

          Producing more docs is not as simple as just accepting more students into medical school programs. Programs cannot accept more students than they are accredited to handle. To expand, they have to get approval from the accrediting agency, and then they need to spend money to hire more faculty, expand classroom and lab sizes, find more rotations for the students (probably the most limiting factor in producing more medical students), etc. I teach at a medical school (on the basic sciences side) and we recently expanded by 100 students and it was a 10 year process that cost the school many millions of dollars. Perhaps a better short term approach would be to convince currently enrolled students to go into primary care… assuming there are enough residencies available to do this.

        • pcp

          “Why are they tring so hard to get into these programs?”

          So they can become radiologists and anestheiologists. Not so they can (like myself and many of the docs here) care for Medicaid patients with 10 chronic conditions and get called “whiners.”

  • elmo

    Ok “Healthcare prof” how about answering a few questions
    1: Given the Mass expereince (hundreds of thousands of new patients without any new PCP’s). How would YOU answer the issue of millions of new patients seeing PCP’s without any provisions to increase PCP numbers as per Obama. Real ideas are wanted not government platitudes that this issue will be addressed (like it was in Mass….not)
    2: You have asked docs to place their W2 forms here. How about YOU tell us specifically what type of “healthcare prof” you are. Are you a private practice PCP who deals with this issue daily or are you an academic doc who has EVERYTHING provided to you by nanny academic hospital. As a private practitioner since the SGR went into effect, I have had to: lay off employees, minimize expenses, hold off on important practices purchases (including EMR), increase my patient load per day, increase my call schedule when a partner gave up and left medicine, take multiple pay cuts, and stop taking new medicaid patients. All in the name of keeping my practice afloat. If you are a private practictioner please tell me how you do it as I (and everybody else on this website) are all ears. If you are an academic doc or not a doc, I am less interested as you don’t know what you are talking about. Presently, I am considering dropping medicare if/when the cuts finally go into effect. My medicare patients are my favorite patients, but following your reasoning I should continue seeing medicare patients at a loss (which would happen if the cuts go into effect), let my practice go under, and damage all my other patients care. Oh and keep my mouth shut because I will otherwise be a whiner. Very simply if you want REAL universal care either be prepared to pay for it and train/hire new PCP’s. The Mass idea of dumping on primaries is not an answer, just yet another government mandate with no basis on reality. My conclusion is you have either worked out a very good deal as a private practice doc or you really don’t know the issues at hand.

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

    Elmo…..I wouldn’t get so worked up when you are both anonymous posters. I am sorry, but anonymous posters can be just about anyone. I could post as a doctor under an assumed name, but I feel it’s a credibility issue (although, I have been accused of lying by anonymous posters……it amuses me….I am easily found as well as any of my doctors if they want to e-mail them and ask. I send them the URL where I post…..they are amused:).

    I should say I did challenge a doctor once with the W2 analogy because he was talking a load of tripe. Claiming he would have retired on less than a union worker. Union workers would right now retire on about $3000 a month and their social security is usually deducted from that amount (in my father’s case it isn’t). That’s just above poverty level……are doctors really retiring on that little? If so, what percent? Although, as I have stated if my doctors made a million last year they earned it. I choose my doctors wisely….and would defend them ad nauseam. Many unions (like the UAW) guarantee an amount per month, then when SS kicks in they deduct it. I know the media would have people believe union workers are living on the French Riviera.

    I don’t think doctor’s wages would be such an issue if some of the doctors here would stop posting about how much they hate their job and want gratitude. It’s quite hard for the average patient to view you as sympathetic when they make about three to five times less than you, and often have student debt in the same neighborhood (I know our son will and will make about 1/3 of an internist…and I have been paying back the meager $20,000 for what seems like the Dark Ages…and we are a one income family with medical bills. He will have a shipload of debt of his own and worked two jobs this summer to pay back $1000 a month. He, literally, never complains and is grateful he can attend college. I share this as a comparison of the average patient who views doctors as those who are privileged, yet make more than them and as I have said before (tongue-in-cheek) I have read hostage stories where the hostage was deprived of food, and chained up for months and even years complain less than *some* doctors:) Again……you are fighting the PR battle of your colleagues who whine so loud while their patients are horrified to read how they really feel…..and, ultimately, some doctors forget that they are paid……we are not usually charity cases.

    If the complaints are about management and insurance companies most patients jump right on it. It’s where you agree. But when it involves patients on a personal or expectation of gratitude I wouldn’t hold your breath. Let’s face it waitresses work as hard as you do for little pay. They don’t pull hissy fits over wages. They are in a service type of job too. And I imagine some waitresses read this board when they aren’t too busy trying to survive.

    All this to say patients completely understand college debt, insurance woes, and working very hard for little appreciation.

    Yep, the times they are a changing……patients are a rough crowd to please…..and they should be when it comes to life and death.

  • Frank

    Madam, are you aware that DoD Secretary Gates is worried about the costs of TriCare and VA may bankrupt the USA? That today’s soldier/sailor needs to diet?

    http://www.nytimes.com/2010/11/29/us/29tricare.html

    Please be careful about seeing Utopia in the past. It is not there.

    If Americans focused on NOT smoking, over-eating, dope, booze and “extreme living” as they do about attacking the careful and frugal — they’d be 50% healthier.

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