Interviewing a primary care doctor to better understand her professional day

As a young primary care doctor in Kiev, Ukraine (then part of the Soviet Union), Dr. Elena Rogova learned her craft well, working in a hospital that catered to scientists, celebrities, artists, musicians and senior government officials.

As a top medical student, this hospital had sought her services, and she enjoyed her work there. Dr. Rogova had no intention of leaving her native land until a great uncle invited her to visit him in Toronto in 1990, where she met her future husband. She took her medical “boards” in Canada and the US, and after receiving top marks, was off to New York.

In NYC she worked at St. Barnabas Hospital as an intern and then resident. After completing her residency program, she was invited to stay as a faculty member at the hospital. In 2003, she set up her own office, a one-woman practice with no partners. Her walls boast of certificates exemplifying her expertise in cardiovascular diseases, as well as recognition as one of America’s top physicians. She is also an accomplished acupuncturist. This is no garden variety doctor, as she effortlessly navigates in her office on three inch heels, well dressed and with blond hair and a dimpled smile. Her warmth and informality radiates and her patients adore her, even if I do sometimes find it hard to understand her lingering Ukrainian accent!.

She carries a purple stethoscope and refuses to wear that white signature lab coat that might raise the blood pressure of some of her patients. She also carries an extensive, handwritten patient file with her to every appointment, and she is outraged that she would have to spend $50,000 to convert to an electronic filing system. This is the doctor we all wish we could have — a Marcus Welby, MD in a skirt, if you will — but is rarely found, especially in our current healthcare system, with its impersonal provider/consumer delivery model.

There is little time in an office visit to experience a true doctor/patient relationship these days, for time is money as insurers squeeze every nickel they can out of a billing. Consequently, limited minutes can be spent with any patient. This is not true in Dr. Rogova’s office, however. Her patient time allocation is generous to a fault, with some demanding patients tying her up in lengthy discussion of their illnesses. Then she has to do battle with the patient’s insurer to be paid, as payment is evaluated on the basis of the complexity of the office visit.

Ultimately, the insurer downgrades the service, paying a fraction of the deserved fee. This does not include Dr. Rogova’s calls from and to patients that are never compensated for by the insurers, not to mention the hours of paperwork at the end of the day that often stretch well into the night. So many hours in the service of her patients, and yet Dr. Rogova still finds time to see other patients at Montefiore Medical Center. Clearly, this primary care physician is on the front lines of medicine every day, catching and diagnosing potentially deadly illnesses and knowing which specialists her patients should see. Most referrals or extra tests are not to self-protect against malpractice litigation, even though nationally it is an un-addressed and expensive issue.

The tort reform also weighs heavily on her mind, along with all doctors. Yet this doctor – as well as all primary care physicians – is on the low end of the pay scale in medicine, with the big dollars going to those specialists. But aren’t these primary care physicians specialists as well, and with greater knowledge in many more areas of medicine? The doctor briefly mentioned our delivery system is a problem (I wished for more time just on this subject) and the lack of respect primary care physicians receive. She lamented the hostile environment surrounding medicine and how it wears one down spiritually, emotionally and physically.

This is in stark contrast to her years practicing in the Ukraine, where doctors were held in the highest esteem, with no greater calling. We forget that medicine a long time ago was the great calling here as well, in a bygone era of close doctor/patient relationships. Every American parent dreamed of a son or daughter becoming a doctor, lawyer or teacher. Would the good doctor want her teenage son to follow in her foot steps?

I asked Dr. Rogova some questions to better understand what her professional day is like, and what the day of thousands of other doctors are like. Here are my questions and her answers.

Q. Are you familiar with the Affordable Care Act?
A. Not really, I haven’t followed it closely. I stay out of political issues, because doctors’ opinions aren’t sought.

Q. Are you a member of the AMA?
A. I was a member until last year and dropped out. They aren’t doing anything.

Q. Do you have any time to read?
A. I love to read, as I came from a home with a library of 2,000 books that belonged to my parents. Mainly the classics.

Q. What do you read?
A. Various medical publications, fiction, WSJ, The Economist, Time Magazine, National Geographic.

Q. How many patients do you see in a day?
A. From 20-34, each day is different.

Q. How many patients do you have?
A. I am not sure.

Q. How many insurance plans do you accept?
A. All major plans and Medicare, well over 100, but no Medicaid.

Q. How much time a day do you spend on the phone with insurers?
A. About an hour and a half.

Q. Is it about your fee?
A. No, it is mainly about seeing that the patient receives the care needed.

Q. How many code numbers are used for billing in your practice?
A. About 200.

Q. What is the average fee from the insurers?
A. About $25.00-$90.00 if moderate complexity. With some insurers paying as low as $25.00 for moderate complexity of treatment.

Q. What would you change in health care if you could?
A. All healthcare should be affordable with prescription drug prices negotiated by the government so people can afford to have them. Health care is a human right.

Q. I know the tort question and medical malpractice is a hot-button issue. What do you think?
A. Excessive tests and defensive medicine are a direct consequence of proliferation of frivolous malpractice lawsuits. We must stop this, which frustrates all doctors and serves no-one except lawyers. It does not benefit patients and may be harmful and is a terrible waste of resources and creates potential animosity between doctors and patients.

Q. What percentage of your total income is spent yearly on office expenses?
A. Approx 55%.

Q. I know the big-ticket items are rent for your office, salaries and medical malpractice, is that correct?
A. Without a single judgment against me, I pay $25,000 (up from $22,500 last year) for malpractice insurance and the insurer with each increase makes it retroactive to the beginning of the year. And rent for the office is $3,000 per month and parking my car another $3,500 per year. And salaries for two staff members, not disclosed.

So we can assume this doctor does well because she has an incredibly busy and successful practice due in part to her extraordinary competence and personality, and the fact that she works like a horse. The average primary care physician’s income is about $180,000.

Let’s solve the tort issue, and create a fair system of justice for both patients and doctors, as this is an imperative. The fact that “5.4 percent of doctors are responsible for 56.2 percent of medical malpractice pay-outs,” according to a 2004 Public Citizen report, is an issue that is costly in both human and financial terms to our nation, holding us all hostage. The solutions exist, if Washington has the will.

Pearl Korn is an advocate of improved Medicare for All, the United States National Health Care Act (H.R. 676) and contributor to the Huffington Post.

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  • Dan

    So is $180k 45% of her office revenue? Does she pay malpractice premiums using her 45% or is that considered an office expense? I’m always confused by listed doctors salaries.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    This is what bothers me the most:

    “Q. Are you familiar with the Affordable Care Act?
    A. Not really, I haven’t followed it closely. I stay out of political issues, because doctors’ opinions aren’t sought.”

    It’s like fixing the roads and bridges infrastructure with no input from engineers.

  • A Family Doc

    It’s ironic that an advocate of Medicare for all would post about the plight of primary care physicians.

    Medicare, via the AMA’s RUC, has been the primary driver behind the slow collapse of primary care by steadily devaluing cognitive work compared to procedures.

  • http://www.facebook.com/sparkspeds.nv kevin

    You left out the fact that when the good doctor spends “generous” time with one patient, the next patient who is made to wait will then threaten to sue the good doctor for lost time or the patient will flame the good doctor on numerous anonymous doctor rating sites. It doesn’t pay to be “generous” with your scheduling or your time, it only pays to be on time. All you get for your generosity is histility and the haterd of everybody who is made to wait even those who waited will also get “generous” amounts of your time.

  • soloFP

    The current system does not reward the doc who spends 20-30 minutes with a patient. Locally the “best” docs are considered the most productive. The ones with the best salaries see at least 40 patients a day and bill mostly 15 minutes visits. The moderately complex visits often are downcoded, and billing for time spent helping patients is not compensated. The time waisted on the phone for free talking to insurance companies to get MRIs/CTs etc prior authorized is not paid to me, but the doctor to doctor call on the other end is getting paid a salary to hear my patient’s history and reason for the study.
    It is very true that if you spend extra time with one patient, you either stay behind most of the day or have to shortchange another patient. The patient who has to wait too long or who is shortchanged likely will leave your practice. Spending extra time with the patient does not guarantee avoiding a malpractice suit, as the patient with a two page list and mutliple concerns may be difficulty to figure out what the patient really has.

  • http://www.mdwrites.com MD

    Dr. Rogova seems like your typical primary care physician working real hard and perhaps making less than she should. She has the same concerns as all the physicians of this country. Malpractice concerns in a very broken system in my opinion. Declining reimbursements and battles with insurance companies. Hopefully someone who makes decisions will hear the battle cries and make a change.