Why this pediatrician quit medicine

There are an awful lot of reasons that led up to my eventual resignation from a career in primary care medicine.  I don’t know that any one of them is more important than the other (it really just depends on which day you ask me).  One that stands out for me though as a universal problem shared by millions is Managed Health Care, and the imposition it has posed on physicians and patients alike is enormous.

A (mercifully) brief history of managed care: The origins of the first managed care efforts in this country date back to the early 1900′s, when prepaid physician services started showing up in a few select industries and health care organizations.  In 1947, the American Medical Association was walloped with an anti-trust violation for their efforts to limit physician involvement with group health plans.  The movement gained momentum and really got some teeth when President Nixon signed the HMO Act of 1973 into law (way to go, Dick).  This provided a legal avenue for using federal funds to promote the growth of Health Maintenance Organizations.  The backlash really caught up in the late 90′s, when US per capita spending started to rise again, despite the mission of managed care to reduce heath care costs.  US healthcare expenses continue to eclipse the national income, and have been increasing approximately 2.4 percentage points faster than the annual GDP for the past forty years.

Ironically, while the whole point of managed care was to reduce healthcare expenses in this country, insurance company executives have continued to earn grossly exorbitant salaries.  The top executives working at the country’s five biggest for-profit health insurance companies earned compensation of almost $200 million in 2009.  Cigna insurance company paid its outgoing and incoming chief executives a combined $136.3 million that year.  And for all this, we still have the worst health care outcomes compared with six other leading industrialized nations.

Now you have to layer on top of this healthcare cost crisis the fact that doctors have really had to change the way they practice medicine.  Managed care means less time spent directly with patients, and more time spent on non-clinical activities (i.e. paperwork).  The  2011 Medscape Physicians Compensation Report generated survey results from almost 16,000 physicians across 22 specialty areas regarding income and practice parameters.  Primary care physicians have the shortest access time per patient, with a median visit time of 13-16 minutes per patient.  (For the record, pediatricians averaged more patient visits per week than any other specialty.)  17% of primary care docs spent more than 20 hours a week on paperwork and other non-patient activities, and less than half of primary care physicians would choose to go into primary care again if they had the chance to do it all over again.

Quite honestly, this turns my stomach.  And I already got out of clinical practice.

I remember my own horror stories perfectly.  Like the day I spent six hours on the phone with an insurance company trying to get one of my patients a badly needed MRI.  I also had one insurance company deny authorizing my patient an EpiPen.  As medical professionals know, EpiPens are automatically-injecting syringes pre-filled with epinephrine that patients carry with them who have life-threatening allergies to things like bee stings, peanuts, etc.  They keep people from dying.  I could not imagine on what planet and in what solar system an insurance company would have a sane reason for denying a severely allergic patient one of these.  And the worst part was they absolutely had to talk directly to me about it.  They couldn’t discuss it with one of our residents, our nurses, or our nurse practitioners.  I had to take time out of my excruciating schedule to have a lively chat on the phone about why it was important for my patient not to croak.

This is a crime.  I did not pay a small fortune and spend four years in medical school to be trained on how to deal with the insanity of managed care.  And I don’t think my patients would have wanted me spending precious time learning how to appropriately fill out an authorization form, when I could be learning about medical disease processes.  Yes, people are specifically trained to deal with managed care, but often enough the insurance companies demand explanations from us that they simply won’t accept from other staff.  And if we don’t comply, our patients are the ones that pay the price.  If I put my foot down and say it’s inappropriate for an insurance company to require I give a pharmacy my DEA number just for tracking purposes, my patients simply won’t get the medication they need.

Having recently retired myself from clinical practice, I will be the first to admit I miss my colleagues.  I desperately miss my patients (well, most of them anyway).  But I don’t miss this.  Not for one solitary moment.  My heart goes out to my colleagues who are still trying to practice actual medicine in the face of mounting adversity.  Keep fighting the good fight.

Lumi St. Claire is a pediatrician who blogs at My White Coat Is On Fire.

Submit a guest post and be heard on social media’s leading physician voice.

Comments are moderated before they are published. Please read the comment policy.

  • Sarah Wells

    HSAs/spending accounts  and (real) consumer driven pricing  would be a big improvement.  Cutting out all that red tape would be heavily resisted  and I’m sure there would be attempts to replace “deductible monitoring” but perhaps that could be smacked down by regulation.

    I’m very curious…on what pretext did they deny your patient an epi-pen?  Had they exceeded some (arbitrary)  monthly limit? Was the insurer demanding a larger supply than needed? (90 day vs single use)?
    Did they have strange rules about requiring at a previous episode of anaphylaxis that met certain criteria – such as an ER visit?

    • Lumi St. Claire

      Hi Sarah-
        
      I definitely appreciate your comments.  I fear that with medicine being such a lucrative business in this country, major change in the way we do things is always going to be heavily resisted.  

      I STILL can’t figure out the craziness with the EpiPen.  Ironically, it was a patient who was not the most compliant with care and didn’t always keep up with her refills.  Which was why it was so frustrating that when she DID finally recognize the importance of filling it, she was turned down for coverage.  Nothing had changed with her insurance, and the prescription was the same one she had filled successfully in the past.  Her child had landed in the ER several times with angioedema and wheezing, and had been fully tested by an allergist.  Kind of makes you throw up a little in your mouth, doesn’t it?

      Thanks for reading!
      ~lumi

  • sj0

    I agree with Sarah that HSAs would help.  They could help even more if the government would liberalize the rules a little (get rid of the use-it-or-lose-it rule at the end of each year to encourage saving for the big treatments later in life).  HSAs would also improve transparency and competition which would reduce prices for things like MRIs.  There is a great chapter in Tim Harford’s book “The Undercover Economist” on this concept.

     Lumi, I clicked on the link and read sections of your blog, but couldn’t find out what your workday is like now that you are a consultant.  I would love it if you would write a post (either here or on mywhitecoatisonfire.com about what your work is like nowadays.  I am also someone who has become disillusioned and am trying to figure out where to go from here.  (Over the past 15 years, I gradually reduced my internal medicine practice and built up an aesthetic medicine practice.)

  • Anonymous

    The solution is quite simple.  All physicians should join a union, then you would be exempt from anti-trust law.  But, to be sure you would be exempt, you would have to make sure you donate 95% of you political contributions to the Democratic party.  If you think that physicians dealing with an insurance company is bad (which I am sure it is) it is not much better for the patient.  Less you think that more government involvement is the answer, I have just two words for you, Veterans Administration.  At my last visit at the VA  my doctor spent more time on the computer doing the necessary documentation for my visit than she spent on my physical.  I was quit pleased that after my physical, I was told that my ears were clean, I must admit that as a 69 year old man I was quite concerned that I had dirty ears and was greatly relieved to find out they were clean.

    • Lumi St. Claire

      Your points are excellent.  From my perspective though, there is philosophically an enormous difference between “government involvement” and “government financing”.  The people who actually trained to make clinical decisions should be the ones making them, not the government.  A FUNCTIONAL single payer plan should not necessarily look like Medicare or the VA system.  But I too live in the real world along with you and everyone else, and while I’m always hopeful for real change, I’m not holding my breath that this will happen anytime soon.  Thanks for reading!  

  • Anonymous

    Your frustrations are shared by others I am sure. I feel like we are doing secretarial work for everybody. I love outpatient medicine but the day to day tasks far exceeded the rewards of being a good doctor for my patients. The EMR albeit keeps things organise like s big filing cabinet has decreased my encounter time with my patients. Sadly I probably spend only 2-3 minutes of face to face in each 15 minute slot just to be able to finish in time.

  • Lumi St. Claire

    Hi sj0,
       Will definitely plan on a “day in the worklife” blog in the future!  Basically, I took my knowledge and experience and funneled them into more public policy, advocacy, and peer education work.  I’m still very grounded in my field, just not functioning as a primary care practitioner.  Thanks for the blog idea and for reading!

    ~lumi

  • Brian

     I think that HSAs have yet to live up to their potential (and have thus gotten a bad rap) because those that pay for their own care generally have to buy services from practices that carry the financially burden so nicely described here by Dr. St. Claire.  sj0, have you considered transitioning into a direct-pay model?  I have worked with some of the innovators in this field and am really excited about the prospects (I’m an MS2 and plan to go into family medicine—as long as I’m confident that I can find a way to practice independent of the predominant model).

    • Anonymous

      Brian, I applaud your optimism and hope you will be successful in your practice model.  I took a more passive approach – as insurance contracts came up for renewal, I just notified them I wasn’t going to renew; this was easier than giving notice.  I finally dropped Medicare last April.  In this process, I have found that many patients do not value the time I spent explaining their disease process to them or answering their questions, so to save money, they have moved on to other physicians still in their network.  This is why internal medicine is only 5% of my practice now.

      HSAs will not reach their potential until they are more widely used so that they have the power to induce competition.  Certain things have to happen before HSAs can be successful (these are big tasks that will have a lot of resistance, but if we can do this, we will really be able to improve our country’s health at a lower cost):

      1. Eliminate the pre-paid health care system we curently have; use insurance only for what it was intended: the catastrophic or unpredictable events.  Everyone should have a high-deductible, low-premium insurance for car accidents, cancer, or bypass surgery.  As much as people hate mandates, they are the only way to spread risk and keep premiums low.  If we are being extra progressive about things, we might even make this a single-payer item funded by taxes.

      2. Take the money that would have been used for a typical “insurance” policy to fund HSAs instead.  To encourage saving, don’t have the funds expire at the end of the year, and allow people to bequeath funds to heirs (for their HSAs, of course).  These are our own contributions, after all, even if they are pre-tax.  Everyone would be strongly encouraged to fund their HSAs above the deductible (whatever we determine that should be) and keep them funded as money is used.  I’ll let others argue over whether employers should be allowed to use this as a hiring incentive the way they currently use group “insurance policies”.  Again, if we want to be extra progresive, we can minimally fund the HSAs of the poor.

      3. Use HSAs for everything else – annual well visits, blood pressure meds, diabetes meds, mammograms, colonoscopies.  If patients once again become used to paying for things, this new transparency will spur competition.  MRIs and CTs should cost a few hundred rather than a few thousand dollars.  Although it is unpopular to mention this, these funds can also be used for end-of-life care deemed “futile” or for experimental treatments.

      I know these suggestions are highly unpopular, so let the flaming begin!

  • Anonymous

    I only have a question. Those insurance companies that abuse doctor’s time (that is professional education) do they also hire detectives to follow up patients that declare they quit smoking (due to a COPD for example)  but in fact smoke “the toilet way”? And if yes, what do tehy do? Do those insurance companies raise 500% the insurance taxes? I think this would be a good point to start with.

  • Anonymous

    HSA and any other “Market Based” and consumer oriented reforms will not work well if at all, if and until we finally properly lable and enforce with the full force of the law, that “In-Network” really is just another form of organized crime, intimidation, market manipulation, Anti-Trust, Collusion that it really is. Why does almost each and every doctor kiss-up to and join these “Networks” (and how great can any network be if the majority of all docs in any area are part of all of those major networks, Its just another scam joke, falsehood put upon the general population) in the first place? Because it is the only way to gain access to their own “Customers” of their end services that’s why.  As stated so well by the doctor here, a majority of patients do not value their doctor’s training, business, practice expenses or needs, demands and as most experiences have shown, expect for the worst of plans that most docs have opted-out of, patients simply jump ship to the next poor “Slave to their Corporate Masters” who is still in network.

    And when it comes to primary care, the number of docs strong armed into these slave ships is way over 90% last I knew. And the few who attempt to break free and return to a private direct pay relationship with their are labled as Calluse and Greedy, Snooty, too good for the rest of us, elitests. Even many of them actually accept a lower standard of living, provide great long personal office visit slots, with real honest personal relationships with their much smaller, better managed, actually personally known and aware of patients. Who do you think benefits most from such nasty underhanded mislabling of some of our best and most caring doctors attempting to break free for the betterment of both themselves and the patients the care for??? Right, the insurance carriers, the real greedy SOB, 800 lbs gorilla in the room.

    If and until people accept that they pay for Wiskers and Fido directly, and that direct, immediate payment is one of the best and most honest accessment of who and what we care about and who we value, whose skills and services are really “Worth it” to any one of us, Nothing is going to change. No offense the wonderful, hardworking, compassionate, intelligent doctor who care for pets and other animals each and every day. Vet school is just as nasty and haul with many more specics to learn all the differences for and about as opposed to only treating one specific “Breed”, Human Beings Homo Spanians. But I know when I pop my cat in his carrier to see the Vet because he’s got another bout of his digestive issues which we have yet to really get to the bottom of in 3 years now (suddenly he looses his appetite and won’t ear or drink and yet tests and X-rays all normal and a single strong shot of steroids and some IV fluids and he’s as good as new within 24-48 hours as though Nothing every happened…) I better have my Check Book or my Credit Card handy and ready to go or else, I’m not even getting my cat back!!! No less being allowed to walk out the door unharrassed. Payment in Full at Time of Service, end of story.

    Imagine your average family doc never doing another prior auth, filing a claim, having it be denied, having to resubmit it, having the time period for that claim expire even though they really saw the patient and did the work and consumed the supplies too that went with that visit (yes this is all real stuff that happens in Modern American Insurance Based medicine) be it table paper and wipes or expensive vaccines or time consuming tests with modern expensive devices like USB, Computer based, EMR intigrated EKG’s and other similar tests. Oh and the “Price” all insurance carriers and the Feds will pay for that EKG has gone down in half just about in only 7 or 8 years since my wife and I opened her solo practice from about $30-$35 dollars per 12 lead test down to about $19-$16 dollars. I didn’t know our EMR software vendors annual support contract, anti-virus programs, sticky leads, gas and electric, malpractice insurance, or anything else worth measuring as cost of doing business have went “DOWN” 50% in the last 7 years now, did you? So why should we bother to do the right, best thing and purchase the best, intigrated with our computers and software vendors EKG unit if I can’t even pay the darn thing off for so many years, no less actually reach a point of being compensted for providing an extra time consuming test that then has to be reviewed and then discussed with the patient as to what it does or does not tell us, and what if anything might need to be done if something is noticable and significant on that test?

    Primary Care doctors are literally going under and being forced to close shop with mountains of debt from student loans and SBA loans neither of which are dischargeable in bankrupcy, even if one is modestly sick or even mentally ill. If you can at least still flip hamburgers and bring home minimum wage, you are still going to be required to pay what someone else determines you can still afford to pay… This is the supposed American Parents Dream??? My Son or Daughter the Doctor???? And it all starts and ends with the strangle hold and anti-trust collusionary enviornment created by our backwards, written for big business and not for small business (which most modest medical practices and doctors are or would prefer to be in a normal and health viable market place) or individual citizens who depend upon good primary care for the large majority of their health management needs. And it is in Top Quality, “Old Fashioned Personal Care Primary Care Combined with Best of Modern Medicine” (Our Practice’s Main Sales Pitch Slogan, Copyright Feb, 2003) where the best and Most savings could actually be realized for all of us, doctors and patients alike.

    But until this noose is untied from around our necks, that threatens our very financial stability (most of our working class, Middle Class patients drive better, newer cars than we do…. 215K miles on a rust out Jeep for my Daily Driver) and means of supporting our families, paying down our debts, forget saving for our kids college or our own retirement…. We’ll be scrubbing Toilets until the stick us in our graves (Jib Jab, Big Box Mart) we can never break free from our enslavement properly. If restraining both the consumers’ and the service providers’ completely free and unfettered access to one another is not collusion and anti-free trade, then tell me what the heck is??? All while there are a thousand rules and laws imposed upon us based upon bad rules on those very same anti-trust laws (that is why doctors can NOT act Collectively, EVEN when inside the boundaries and cover of a Union). My wife should have attend Cornell just south of here and trained to treat animals instead of attending SUNY Upstate training to treat people, Human Beings. Then she could have a direct financial relationship with her patient customers (well almost… :-) and be treated with the face to face dignity and respect she and all of her fellow primary care doctors deserve.

    Break the Medical Industrial Complex down and all of the collusionary business behavior, or one day we will have no real healthcare left to speak of…..

  • Anonymous

    In my opinion, big mistake! This PCP should look into joining an ACO. They are forming ACOs all across America. They have not been sanctioned to operate yet and HHS is still awaiting trial results, but hospital groups and insurance groups are going great guns in the process to be ahead of the game on opening day. I live in a suburban setting of one of the largest cities in America. There are four competing hospital groups in my region. None of them has less than five hospitals in their group. All of them are forming ACOs as we speak. They all apparently like the idea. They all have a few things in common. They all see a huge change coming in the way health care will be delivered in the future. They all want a piece of the action. Once these massive WalMart style delivery systems are up and running, health care delivery will never be the same. My suggestion for any frustrated PCP that is thinking about quitting? Go check out what hospitals have in store for the future of health care delivery.

  • Anonymous

    “And if we don’t comply, our patients are the ones that pay the price.”

    So, you quit.  Does that have no price to your patients?

    If the majority of caring physicians would just get OUT of third party payer schemes, the dust would eventually settle. 

    I have insurance (not the same thing as access go good healthcare!), simply because my husband’s employer gives it to us.  I wouldn’t pay a cent for it, and don’t use it.  Instead I pay out of pocket to what some, mistakenly, call a “boutique” medical practice.  I get all the good, old-fashioned, caring medical care I my family needs, at a very affordable price.  The doctors are satisfied with their income and don’t have to spend their valuable time fighting insurance.

    It was the acquiescence of physicians to the abomination of 3rd party directed of healthcare that resulted in the mess we are now in, including the escalating cost of ever-diminishing quality care.

    • Lumi St. Claire

      Of course leaving my practice had a price for my patients.  I never claimed otherwise.  As I mentioned at the beginning of my post, there were a number of reasons that lead to my separation from clinical practice, some of them much more about personal traits and goodness-of-fit.  Managed care was simply one piece of the puzzle.

      I agree with the baseline premise that other avenues, fee-for-service being one, may provide a better solution than we have now.  To be fair, the younger generation of physicians came into an era of 3rd party directed healthcare that existed before they arrived.  They never acquiesced to anything – it was the existing system as they exited their training programs and entered the workforce.  It is quite one thing to say we should “just” get out of third party payer schemes.  It is quite another to make it happen when the environment doesn’t’ support it.  I’m not saying it SHOULDN’T happen. But to point the finger at physicians and lay the entire burden of healthcare reform on them is unrealistic in my opinion.  

  • Anonymous

    Well, if I complied at the price the employer or any insurer was offering, I wouldn’t be able to pay back the monster med school loans I took out to do this work.  It is the factor that no one is factoring into their formulas–not even Uwe Rheinhardt–perhaps because he is European and can’t viscerally factor into his brilliant calculations the student loan debt we Americans bring with us into our medical careers.
    A thinker in their late fifties can say blah blah blah but if they do not factor in student loan debt of all providers under 45 who went to  a private school etc  Because that is exactly where the bifurcation happened in medical school loan debt 1996 .
    Until this problem is solved in medicine and in American education in general there will be no peace in American culture.  It is breeding a generational war which makes the current “culture war” look like a joke. The Hunger Games have just begun.   

    • Anonymous

      Good post! I glad you included the words “American education in general…”.

      So I assume that we’ll be seeing you at our next Occupy event?  

      • Anonymous

        I was there with my children on some weekend afternoons in the fall until the Seattle Police Department got psycho as they did with me as a protester long before WTO. Hopefully. the spring will be better as they are under federal investigation.

  • http://www.thehappymd.com/ Dike Drummond MD

    Doctors always say that they, “Just want to be left alone to see patients.” That’s because clinical care is the skill set we are trained to deliver. This is the CONTENT of a medical encounter.

    Then there is the CONTEXT in which the patient visit takes place … the so called “healthcare system”.
    The system often makes no sense … it is a whole crowd of emperors, each in control of their own kingdom of subscribers … and none of them have any clothes on !

    Just like Emergency Rooms have learned to take non-clinical activities away from the docs by using Scribes … we can mitigate and compensate for the System’s shortcomings … and it still takes away from intelligent patient care.

    Worst of all … these stresses burnout and trash our providers. Careers end in shambles, marriages shatter and docs commit suicide because they don’t know how to cope. Lumi got out … too bad … sounds like a really good doc to me. And the “system” chews up good docs like a wood chipper.

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

     

    • http://www.mywhitecoatisonfire.com/ Lumi St. Claire

      Thanks for the props Dike, even though we have yet to meet in person!  It is a huge point to reconcile when we are educated in a content model, and are ruled by a context model in our practice.  While there were many things, both personal and professional, that led to my departure from clinical medicine, the toxic environment in which I was expected to practice was definitely one of them.  

  • davemills555

    Sorry Dike, the “CONTENT” simply costs too much for a growing number of Americans. Each day, more and more Americans join the ranks of the uninsured because we simply can’t afford all the expensive “CONTEXT” just to get a lousy wart removed. What good is “CONTENT” and “CONTEXT” if you are one of the 50 million uninsured? We need a system that is more inclusive. So, if quality suffers so we can get more people covered, so be it. I think most Americans are beginning to see it that way. 

    • http://www.mywhitecoatisonfire.com/ Lumi St. Claire

      I hope, but don’t hold my breath, that Americans changing their view is going to affect the way medicine is regulated in this country.  Until the top 1% who hold the reins of the third-party payer lobby change their minds or are in some way forced to do things differently, I don’t know that we will see a tremendous amount of change.

      • davemills555

        Meanwhile, the ranks of the uninsured and the underinsured keep growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing…

        • http://www.mywhitecoatisonfire.com/ Lumi St. Claire

          Yes they do.  Which unfortunately has not affected decision-making regarding medicine in this country.  I personally am all for a single payer plan that puts clinical decisions back in the hands of doctors, but I would be shocked if this culture of medicine as a business would acquiesce to such a system.  Or any system that changed the current profit system for insurance companies.  The fact that it’s an absolute crime that we have 50 million uninsured, spend more money on health care administration than any other country in the free world, and have some of the worst healthcare outcomes among industrialized nations has apparently not factored in to whether these folks sleep at night or not.  

          • davemills555

            You’d think, with all of the advanced high end education that exists in the medical industry and in health care in general, you’d think with all of the experience that these so-called “experts” have to solve complex problems, they’d have come up with some innovative ideas by now regarding how to make America’s health care system a resounding success for 100 percent of the American people. NOT! Meanwhile, we have over 50 million Americans with absolutely no access to medical care except the hospital emergency room and we have another estimated 25 million more that are underinsured and the ranks of the uninsured and the underinsured keep growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing, and growing. 

            With all of their vast amounts of knowledge, education and experience, you’d think they would be ashamed of what they have created. I guess they are too smart to be ashamed, huh?