Primary care doctors need 35 hour work weeks

Jeff Goldsmith recently opined on why practice redesign isn’t going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice — having docs see even more patients per day, and grouping them in pods — is unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with “Gen Y physicians with a revealed preference for 35-hour work weeks.” (Guilty as charged.) Goldsmith ends by predicting a “horrendous shortfall” of front-line clinicians in the next decade.

Now, not everyone believes that a shortfall of PCPs is a serious problem.

However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed.

So serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with a 35 hour work week.

I can already hear all clinicians and readers older than myself harrumphing, but bear with me and let’s see if I can make a persuasive case for this.

The crisis we face

First, consider the situation.

The most pressing and urgent health services research problem society must solve is how to restructure healthcare such that we can provide compassionate, effective healthcare to an expanding Medicare population, at a cost the nation can sustain.

This is a problem with very high human stakes at hand. As we know, most older adults end up undergoing considerable health-related suffering at some point, with family caregivers often being affected as well. Much of this is due to the tolls of advancing chronic diseases, such as diabetes, heart disease, COPD, arthritis, dementia. And a fair part of the suffering is inflicted by the healthcare system itself, which remains ironically ill-suited to provide patient-centered care to those medically complex older adults – and their caregivers — who use the system the most.

Needless to say, the financial stakes are high as well, with projected Medicare expenditures usually cited as the number one budget buster threatening the nation’s financial stability over the next 50 years.

A necessary part of the solution

Next, consider an essential component to compassionately and effectively meeting the healthcare needs of the Medicare population:

Medicare beneficiaries – and their family caregivers – must be partnered with good PCPs who can focus on person-centered care, and can collaborate with them as they navigate the many health challenges of late life.

Especially once they are suffering from multiple chronic illnesses and/or disability, seniors – and their families — need a stable relationship with a clinician who can fulfill the role of trusted consultant and advisor as they go through their extended medical journey. Healthcare for older adults almost always becomes complex and stressful for seniors and their families. Even educated and activated patients who are willing and able to direct their own care will need a generalist who can maintain a longitudinal health dialogue with them, and who can help them sort through complicated medical situations as they arise.

Now, much as been made of teams in primary care, and the importance of moving past our historic model of PCP as the person who knows it all, and does it all. This change is long-overdue, and I’m thrilled to see it coming. When properly implemented, I’m quite sure that team-based care will help older adults obtain the comprehensive primary care services they need and want.

But even with excellent team-based care, I believe most older adults will want and need a PCP to function as their high-level medical strategy consultant and collaborator.

Common challenges for PCPs of older adults

For instance, consider the kinds of issues I routinely addressed as a general internist for older adults:

  • Following up on 6+ chronic conditions and 12+ medications, in an integrated whole-person fashion. Good luck outsourcing this to disease management.
  • Following-up on the work of multiple specialists, many of whom hadn’t explained their thinking to the patient and family. Yes these specialists should get better at explaining their thinking. No, they will probably not resolve the conflicts between their recommendations and some other specialist’s recommendations.
  • Resolving the conflicts inherent in attempting to follow clinical practice guidelines in patients with multiple conditions. For a fun read on how elderly patients routinely generate a gazillion conflicting clinical practice guidelines, read this JAMA article.
  • Adjusting care plans as a function of goals and what seems feasible for the patient. It is pointless to recommend chronic disease management per best practices if it doesn’t seem feasible to the patient and family. Also, many disease management approaches must be modified in the face of conditions such as dementia, cancer, advanced COPD, etc. I’ve spent my fair share of time taking diabetics with mild dementia off sliding scale insulin regimens. (Hello endocrinologists, please stop recommending labor-intensive blood sugar management.)
  • Explaining why certain commonly requested interventions – antibiotics, diagnostic tests, specialty consults – might not be helpful. People have questions. Answering questions takes time and attentiveness. It’s obviously much easier to rely on the historic approach of doctors and just tell people what to do, but that’s not good care.
  • Helping patients and families prioritize and identify a few key health issues to work on at any given moment. Many older patients have 15 items on their problem list. Prioritizing is key. (Not losing track of all the issues is hard though.)
  • Helping patients and families evaluate the likely benefits and burdens of possible medical approaches. Should that lung nodule be biopsied? Should knee replacement surgery be considered now, or still deferred? So many of the decisions we face have no clear right answer.
  • Helping patients and families cope with the uncertainties of the future. For instance, it’s impossible to predict how quickly someone with dementia will decline and become unable to live at home, but these issues are of grave concern to families and they need a clinician to talk to.
  • Addressing end of life planning. I’ve found this is often trickier in the outpatient setting than on an inpatient palliative care service.
  • Weighing in on family conflicts. I’ve had to watch patients and spouses squabble in the visit over what the patient is and isn’t able to do. Similarly, adult children worried about a parent will call and ask for me to intervene. (Stop her from driving! Make him take his pills!)

I must say that I love doing the work above. It’s deeply satisfying to help patients make sense of all that is medically happening to them, and to support them as they cope with their health challenges. But it’s also, as you can imagine, difficult work that is cognitively and emotionally demanding. The pressure of 15-20 minute visits makes things harder than they should be, but even if we went to 30-45 minute visits, the work will remain fundamentally intense and somewhat taxing for the provider.

Can anyone seriously argue that we won’t need PCPs to do the work above for Medicare beneficiaries over the next 20 years? (Plus we’ll need them do manage dementia, falls, and all the other geriatric problems too.)

Ok. Then if we agree that the work above is essential to the wellbeing of millions of older adults, and is a crucial component to providing overall cost-effective healthcare to the Medicare population, we must get serious about how we can recruit and keep clinicians as Medicare PCPs.

The benefits of a 35 hour work week

If the work of  Medicare PCP could be organized so that it fit into a 35 hour work week, we’d see the following benefits:

  • More clinicians would be willing to do, or stay, in the job. Let’s face it, we have ample evidence that work-life balance is important to the younger generation of physicians, especially those with young children. As much as this dismays the older generation of physicians, this trend seems to be here to stay, so perhaps we should learn to work with it. Debt relief – the usual hope for attracting people to primary care – is never going to be enough on its own.

Given that we are asking PCPs to actively engage with patients and families, embrace shared-decision making, adapt to technological changes, and make a whole host of behavior changes, making sure that clinicians in this role aren’t burnt out by long working hours just makes sense

Summing it up

The impending shortage of PCPs constitutes a national emergency. In order to provide the growing Medicare population with compassionate, effective healthcare at a sustainable cost, seniors will need stable relationships with PCPs who can function as their strategic medical consultants, collaborate in helping to meet healthcare goals, and provide emotional support.

Doing this type of PCP work can be extremely rewarding, but it’s also cognitively and emotionally demanding.

Structuring the job of Medicare PCPs into a 35 hour work week would probably attract more clinicians to the job. It would also help PCPs maintain the cognitive and emotional resources needed to do the job consistently well, and could reduce burnout in this group of key clinicians.

Leslie Kernisan is an internal medicine physician and geriatrician who blogs at GeriTech.

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

    Nobody is forcing PCPs to work more than 35 hours, or any other number of hours, if they are self-employed. The reason people must work more hours than they can manage, is that 35 hours of nicely paced visits, don’t pay the bills. So what this is saying, is pretty much what every PCP is also saying – primary care payment rates should be doubled.
    Regarding employed PCPs, who don’t get to set their own hours (or visit time), and who are certainly going to be required to work the same hours even if reimbursement rates are improved, perhaps primary care should not be operated by CorpMed.

    • southerndoc1

      It’s hard to figure out what the OP is proposing. For most PCPs, cutting back to 35/week would mean a significant drop in income (in private practice, it would just about cover the overhead, leaving an income of zip), which will make primary care even less attractive than it already is.
      The issue isn’t the number of hours worked, as many PCPs are perfectly comfortable working 60-70 hrs/wk. The problem is the low rate of pay per hour.

      • PCPMD

        I think the OP is suggesting that for many, 60-70 hours per week is no longer acceptable. In my own practice, I’m certainly seeing this. There was a time (even 7 years ago, when I started at my current practice) when it was a given that the newer/younger doctors would work full time, and often moonlight, and then over the years, slowly transition to part-time work (Usually in the last 5-10 years before retirement), when the rigors of a 60 hour work week were just too much to face.
        Now, half of our new hires (male and female) are part time right off the bat. This means a significant pay cut, 40-60 grand per year less than their full time counterparts. However, more time with family, more time to exercise and pursue other interests is a strong motivator for a lot of our new docs. I don’t think extra pay will necessarily incentivize them to work more hours. Also, a 35 hour work week in primary care actually = 40+ hours of real work (assuming you’re VERY efficient and have an established panel).

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

        I agree with PCPMD regarding the OP suggestion, but I believe that the implication is that there shouldn’t be a commensurate drop in compensation, because automation and “care team” “innovations” will more than make up for cutting back physicians hours.
        Unfortunately, if we look at other “industries”, gains in productivity from “labor saving technology” and “expertise saving innovation” are usually translated into more profits to the corporation, not to more leisure for knowledge workers. So I find it hard to imagine that Kaiser or HCA will allow physicians to cut back on hours without reducing their pay.
        In private practice, you could probably do that, if your conscience allows it, but I don’t think it will any time soon.

  • ninguem

    The impending shortage of PCPs constitutes a national emergency.

    Take a deep breath. Maybe a Valium might help. “National emergency”.

  • Anthony D

    I wish more young physicians would be interested in Primary Care then going into a specialty. Its a wonderful field and those who go into P.C . are not govern by money and like to be a doctor to help others.

    Yes we all need money to survive, but I thought primary care doctors were the ones how truly like to be called humanitarians.

    Just my thoughts!

    • Suzi Q 38

      I agree.

    • PCPMD

      Relying on other people’s charity is not a solution to the primary care shortage (some may argue it’s been the cause of it), just like its not a solution to any other societal need.

      When a person chooses a profession as their life-long endeavor, they take many factors into consideration:

      - Lifestyle of the profession (how hard will I work, what unpleasantries will I have to put up with?)

      - Cost and duration of training

      - Prestige associated with the profession

      - Income and the lifestyle it affords

      - Natural talents suitable to that profession

      - The social good that it will do

      - Personal enjoyment of that profession.

      I believe these sets of values represent the decision making for the vast majority of people (including people who go into public service industries). I think all of these are important for most people, with some having a slightly greater bearing on their decision than others.

      However, you can’t expect that the “social good” alone will be sufficient to continue to drive tends of thousands of highly talented people per year into primary care, without the other considerations. Or you can, but you’ll be disappointed.

    • azmd

      There is a significant difference between being “governed by money” and by realizing that you have certain basic needs that you need to be able to meet through your means of employment.

      I think many medical students would like to pursue primary care as a career. However, they must also pay back medical school loans, which are substantial, and most of them would also like to have children. Having children, if you are an educated professional, typically means that you will want to provide them with educational opportunities similar to the ones you were given.

      Personally, I don’t see a problem with people who have spent hundreds of thousands of dollars and decades of their lives to become doctors, expecting that they should be able to afford to send their children to college. Increasingly, the income provided by primary care practice does not enable a physician to be able to do that.

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

        I would agree doctors should be paid a lot (with a child with cancer I remember being mesmerized by our surgeon’s hands. At times I could hear him speaking, but my eyes were on his hands…and the training that went into his skilled use of them. His hands seemed priceless to me:)

        You may have read the WSJ section on healthcare recently? They discussed this problem. I thought the doctor who answered that we need smarter medicine (and, obviously, smarter patients who will quit using up resources for unnecessary care) did the better job of sharing where we need to go with this (he was debating against more residents). The other answer was about more NP’s with back-up teams of specialists who can brainstorm. There were a lot of good ideas, that will, obviously, run into implementation problems.

        That said….many patients have a problem with doctors complaining (because the average doctor makes five times what the average patient does. Yes, he may have five times the amount of student debt). A real stickler is when doctors proclaim they want no student debt and want it wrote off on the taxpayer’s back.

        So yes your sacrifice is appreciated and it should be compensated well and it is. The data shows the top jobs in the US (and they pay very well) are held by doctors or the medical profession and they pay more than a typical CEO).
        April 01, 2013
        The latest data from the Bureau of Labor Statistics (BLS) reveal that nine of the 10 highest-paid positions in the United States require medical training.

        U.S. News & World Report analyzed the latest BLS data,
        which included average annual wages as of May 2012. The data found that
        the 10 highest-paid jobs in the United States were:

        1. Anesthesiologists ($232,830)

        2. Surgeons ($230,540)

        3. Obstetricians and gynecologists ($216,760)

        4. Oral and maxillofacial surgeons ($216,440)

        5. Internists ($191,520)

        6. Orthodontists ($186,320)

        7. Other physicians and surgeons ($184,820)

        8. Family and general practitioners ($180,850)

        9. Psychiatrists ($177,520)

        10. Chief executives ($176, 840)

        • NewMexicoRam

          Something goes wrong and a patient sues for hundreds of thousands.
          A doctor helps a patient live and gets paid $120 per day rounding on the patient for 10 days–$1200.
          Something is wrong with this.
          You think “smarter medicine” is the way to go? Sure. And get rid of the 15 minute office visits, which means each visit needs to have higher fees than now.
          And, I believe this, that the average doctor has 5 times the stress that most other people have. Medical decisions have lives at stake.

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

            No, smarter medicine is not as you shared. You know an ENT (Dr. Ball) at Cleveland Clinic had a whole lot of time with me and still didn’t read my daughter’s lab report (twice. His delay cost us cancer that spread and we are still cleaning it up. It’s in her lymphs now because of his desire to waste time while proclaiming he is overworked when asked how he made such a colossal error). An ultrasound tech saved my daughter’s life when she told me to please get a second opinion. So, it’s much more than time constraints going on with lousy doctors. Maybe smart medicine would mean burned out doctors get to hell away from patients and live up to their do no harm mantra:) Okay, that was a drama alert with much sincerity, but smart medicine would go beyond the GP with a patient file going to a team of specialists with many more eyes on the patient file. Much better than the one set we get now.

          • NewMexicoRam

            Mistakes happen.
            And there ARE jerks out there.
            But there’s also jerks driving drunk everyday, yet alcohol hasn’t been outlawed again.
            What about all the people who don’t drive drunk and are responsible? Why doesn’t anyone cheer them on?
            Relating back to medicine: I think you can see my point. I’m talking about helping those who are honest, conscientious, and care about giving good health care.
            I’m sorry to hear about your daughter.

        • azmd

          I stand by my comments. Remember that this entire discussion is about primary care doctors, and whether it is greedy for them to suggest that they have a 35 hour workweek in order to entice medical school graduates with significant educational debt (more than five times the average educational debt, by the way) into considering a specialty which is high-stress but not well-compensated compared to other specialties.

          Looking at your own data, primary care doctors make $180,000 per year (a salary which is four, not five times the average salary of a new college graduate, by the way). At most top tier colleges and universities, this annual salary means that one’s children qualify for financial aid. That’s assuming that they can get in, since increasingly college admissions decisions are tied to the family’s ability to pay as many colleges retreat from need-blind admissions policies.

          With respect to the charge that physicians complain about how much they make, I really don’t see that. I see us responding with predictable frustration to suggestions that we are “greedy” for expecting to have a typical professional-class lifestyle in exchange for a lifetime of incredibly hard work. It would be great if doctors were saints, or monks, since that seems to be the cultural ideal that we have for the profession. But it’s an unrealistic expectation. There are just not enough saints out there to provide all the physicians that people need. So we’re going to have to settle for human physicians who have human needs to be fairly compensated for doing extremely difficult work that requires years of expensive and arduous training.

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

            Well…I don’t think you are greedy, but the public views many doctors as whiny. And most people don’t qualify for financial aid unless it’s a single income household. Comparing just primary care is fair, but not an average comparison of all doctors because primary care is only a subset. You sacrificed a lot of years in money and training and deserve to make a very good wage. I just think some of the defensive talking points doctors use don’t overall pan out. Because the bottomline is the wage scale I sent through is fair (actually, I thought a few doctors should make more, but it was an average so some do).

            The thing is many doctors will post as if they are in Mensa (we know only 2% of society qualifies for that and Mensa is a eclectic group) So, ultimately while doctors proclaim themselves a part of some group of intellectual types, really the truth is they are extremely well educated not the best and brightest some doctors here tell us they are (one told me doctors are the smartest in the room….okay…I’ll go with that! Ha!). I share that because that smugness hurts all their colleagues.

            So I am at Cleveland Clinic with thousands of doctors who are supposedly the cream of the crop. Hmmm….if we use data we know that again while they trained well, and paid well they are not of superior intelligence, nor the “saints” you shared. There are already so many doctors we know via data again they can’t all be brilliant.

            The truth is for many years the money lured some very smart people into the field, and some real losers. The losers hurt patients and colleagues with their big mouths and greed.

            But the losers will always be around, and when the good doctors are humble enough to be honest and do their jobs really well I think the public (overall…you will always get whiny public too) they see the value of your job. And when they need and receive good service you will overall have an advocate. I think mainly you are dealing with a minority of colleagues who hurt the whole profession with their greed.

            Personally, I think doctors should be paid well. Our doctor has 14 years of school and training, and many years experience. I am extremely grateful, and as I have shared if he makes a million a year…good on him….but then again I worry when they make money off of their own investments or BigPharma (Cleveland Clinic was sued and had to stop the practice of doctors using items they profited from via investments).

          • azmd

            I do not see the argument being made that doctors should be paid more because they are smarter, but maybe I am missing something. I would not agree with that argument, since I think there are other types of workers who are just as smart, or smarter than physicians, and who make less money, research scientists for example.

            However, the fact is that being a doctor means that you spend a minimum of 5 years staying up and working all night every fourth night during your training. In many cases you continue to be awake nights for the rest of your career, performing work that is extremely stressful, since people’s lives depend on your doing it correctly. It is quite simply an exhausting profession to go into, much more so than most other occupations available to intelligent and motivated students.

            It is incomprehensible to me that people would expect that high-quality students would continue to choose this type of career knowing that their lifestyle would involve not only constant fatigue, very high work stress and having limited time with their children but also limited ability to provide them with educational opportunities.

            I think what people hear is not whining, it is simply doctors pointing out that there’s only so much that you can reasonably expect people to sacrifice before you start to see unsustainably high rates of job dissatisfaction and burnout in the profession.

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

            Right…the argument here has not reached the level of IQ or whining. In truth it sometimes seems the doctors with the best hours make more than those with more sacrifice (my friend is an OB and until she became part of a bigger practice she resembled the exhausted doctor you described, yet she made a lot less than a dermatologist. While in private practice she felt like had no life because of the nature of her specialty). My GP friend has a straight 10-5 pm job and enjoys his job very much…but feels that being part of an ACO has made his job much harder but more profitable. And some very good researchers have completely given up….the government has made their jobs nearly impossible.

            Overall I agree with you. I was just summing up past conversations (and, you need to remember a few years ago I was mad as hell at doctors who would defend the doctor who did so much harm to my daughter. A few comments bordered on cruel because some doctors can’t stand any condemnation of their career choice, while a small few really just shined in their comments and knowledge….a conversation with them felt like a separating of the wheat from the chaff:)

          • azmd

            I am sorry you have had conversations with doctors that have left you feeling jaded about our profession. I know that those do happen, and it’s unfortunate. It’s my hope that forums like this can provide a place where doctors and patients can honestly share their experiences from either side and we can start to find some common ground on how our healthcare system can be fixed.

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

            You know this is just wonderful! It’s posts like this that reach out to connect that help heal patients who really do struggle. I was thrust into a medicinal abyss and am still on a type of cancer carousel and I am really grateful when doctors go the second mile. Thank you!

          • rbthe4th2

            Have to agree with this AZMD. I agreed and disagreed with some of your comments, but the fact is, you are sharing more information than at least 2 previous doctors of mine about my own health care ever did. I thank you for that and I will respect your rights to say so. Just wish all docs were like you.
            I probably wouldn’t be so jaded had it not been for 2 attitudes that I got from surgeons. They might have been good but being childish and refusing to let me choose my treatment or even giving me options, that’s just not right.

      • Suzi Q 38

        Yes it does. Anything is possible if you live frugally.
        Some people spend whatever they make, others spend more than they make. There are still others, like myself, that spend less than they make.

        We sent both our kids to Berkeley without student loans.
        Our combined income is less than that of a PCP, but fortunately we did not have the huge student loan bills.
        If I took the salary of a PCP, then minused the SL’s,
        I still might make it, LOL. I am that frugal.

        We live in an average neighborhood, and drive paid off cars. There was a time that we drove a “beater.”

        I shop at discount stores for my clothing.

        We did not go on vacations to exotic places until the kids were in high school and college. If we did, it was a bargain vacation.

        We made our kids share a beat up mini-truck for their car in high school AND college. I felt it was good for them to learn how to negotiate who got to use the car and when. One week our daughter had priority, the next week, our son did.

        Their clothes were purchased from Target.

        • azmd

          The lifestyle you are describing is really not that extreme. I grew up in a much more frugal household than that. I still drive beater cars and buy my clothes at Target and my children have far less than their peers whose fathers are lawyers or real estate developers or Microsoft executives who retired at 45. Most PCPs live the same way I do.

          So trust me when I say that increasingly, when people tell me that I need to stay even later at work to comply with some meaningless documentation or certification requirement that will mean that I miss dinner or someone’s practice yet again, I say to myself, “Wait, why I am doing this? Why would anyone do this?”

          We recently told our son in college that we would not support his being pre-med,since our doubts about its future viability as a profession mean that we’re not comfortable making the investment in medical school for him. It’s a shame, since I come from three previous generations of MDs, all of whom were hard-working public servants. But I see us at the end of the slippery slope that the medical profession got onto by pretending that it’s not important to be fairly paid for highly challenging and stressful work.

          • Suzi Q 38

            AZMD,
            Yes, it has been a very nice and sweet life so far for me, all things considered.

            When our friends were buying McMansions in the pricier cities, we stayed put in a city that was considered lower middle class. We were just in one of the better neighborhoods.

            The local public school was not so good, but our daughter did well by always being enrolled in the honors or AP courses. I was very friendly and knew each and every teacher that she had. I avoided teachers for her that were not good. I kept the teachers well supplied with markers, baby wipes (for the white boards), and packages of photocopy paper.

            Our son transferred to another magnet school in a city 30-40 minutes away. He did well as it specialized in technology and learned how to program a computer before he got to Berkeley.

            Both of them almost went to UC San Diego, but I sold them on giving Berkeley a try, as it was so different from where we lived. It was difficult, but they survived academically and flourished personally. They love living in the Bay area.

            They graduated not too long ago; in 2007 and 2008, respectively. I think that the tuition at the time was about $8K each. the living expenses was about $1K a month each. You are right, college is not cheap.

            Ironically, our son has several friends that are still in or just finishing medical school. They were concerned about me, so they guided me throughout my ordeal once I hit the crisis point of my diagnosis. Most of them are specializing in one area or another. There is only one friend that is choosing to be a PCP out of 6. Our son is a computer engineer, so he does not have the need for further education. He does well with just the BS in Computer Science and Engineering that he graduated with.

            Our daughter struggled more, as she finally decided she wanted to be an NP. She has a year left, but has worked the entire time at a local hospital. The hospital has been more than supportive and paid about 50% of her tuition, and purchased a lap top computer for her.

            I think that she owes about $60K in student loans for her Masters and NP. She has worked while she studied.

            I remember sitting down with them before they started school to try to get them to commit to a major, as this is all daunting to pay for.

            I till can not believe that doctors get paid as little as you all say.

            I have a friend whose husband is a pulmonary specialist, and she buys whatever she wants at Nordstrom. They live in a huge house, and they can put their kids not only through undergrad college but medical schools as well. She does not work outside the home at all.

            My other friend is a PCP and she struggles. She also does not like to work full time because she likes to stay home with her children. Add to that is the fact that they have a huge house payment.

  • Beau Ellenbecker

    Seeing more patients isn’t the answer. Its the problem. I have seen some Family “Doctors” who see 35 patients a day. Problem is that is all they do…see them, not actually care for them.

    On a busy day I can see 18–22 patients. I feel that is to many but I couldn’t pay my staff or myself seeing less. (Incidentally I make less than the average in my position).

    So much of what we do as family doctors is unpaid. All those phone calls, refill requests, insurance paperwork, and results call backs are unpaid for.

    Further the increasing use of EMR’s and legal environment has moved our medical records from being a documentation of care to assist further care into a documentation to prove care to avoid lawsuits. Shameful.

    What we need is better compensation so we can spend more time with patients not make more money.

    • Suzi Q 38

      “Seeing more patients isn’t the answer. Its the problem. I have seen some Family “Doctors” who see 35 patients a day. Problem is that is all they do…see them, not actually care for them.”

      I agree. I would rather pay a bit more and have a less stressed out doctor care for me.

  • James Matthew Crumb

    There is no reasonable way to produce a 35 hour work week for primary care physicians. We don’t have enough physicians to see the current patient load, much less the increased loads objected under Obamacare.

    By allowing physicians to function as individual businesses, our health system has created a large number of very high volume practices. These practices operate with an average on 7 ancillary staff per doctor, with high efficiency and high compensation for the doctor supervising the team.

    The 35 hour work week would only occur under hospital practices, with unionized physicians, as in most European systems. The problem with this is that European countries employ 2 to 4 times as many physicians per capita as we do.

    To cut patient load and doctor pay in half, we don’t just need more primary care physicians, we need more doctors. We would need twice as many doctors as we have now, just to hold the line for the next year.

    We are on track to spend less money on healthcare this year than last year. Since in America health care spending is directly proportional to the number of doctors, that means that we have lost 6 to 8 percent of our practicing doctors in a single year. Even if we doubled the number of medical students next year, it will take 5 years at a minimum to have a workable number of doctors. Likewise for the PA and NP schools.

    And immigrant doctors? Who would want to come next year? Let’s face it. No one knows what will happen next year, but a national call for 35 hour work week for doctors probably isn’t too likely.

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

      Please post some reference links to the following:
      1) The “large number” of primary care physicians practicing in “individual businesses” “with an average on 7 ancillary staff per doctor”
      2) The actual countries where there are “hospital practices, with unionized physicians, as in most European systems”
      3) The numbers showing that “in America health care spending is directly proportional to the number of doctors”

      Thanks….

  • BPtoMD

    Are you kidding me??? All the primary care physicians I konw (myself included) would be happy with a 40 hour week! By the time I’m done with all the garbage of an EMR, useless telehealth reports, pt call backs, refill requests, lab results, diabetic supply requests, looking over consult notes, attending some meeting for whatever committee, reading over the latest prescriber letter 40 hours would be a dream. And after spending years in school, training at 80 hours a week in residency, jumping through every hoop imaginable, and having to make decisions on a daily basis that may cost me my livelihood you better expect that I expect to be paid well. Don’t you dare admonish us to be happy with scraps from the table.

  • T H

    Four thoughts:

    1. The general population needs to get over the ‘Specialists deliver better care’ mentality. It is entirely untrue. Specialists deliver great care for their specialty, but are frequently make recommendations that are antithetical to the patients real problems (witness the endocrinology comment in the article.) Fam Med, Peds, and IM are trained to deliver AND COORDINATE care.

    2. Hospital-based clinics are little more than harvesting machines for Medicare and Medicaid: few people ACTUALLY need a 1-2-3 month follow up yet they are seen like clockwork and it’s “One visit, one problem” because otherwise it’s going to take too long to fit in 40 patients in a day.

    3. There aren’t enough doctors to go around. We needed to expand medical school classes 10 years ago and we’re just now getting to it and PAs/NPs have stolen a march on the physician establishment. They will fill/are filling a vital role for routine medical care, but please do not mistake their excellent care for that of a fully-trained, board certified physician.

    4. Yes, doctors are paid well. We are the ones who bear ALL of the responsibility and risk because the insurance companies and hospitals have gerrymandered the rules to such that their actual risk in case of denied/subpar care is minimized. But, the majority of ‘needless expense’ is related to administrative portions of care which does not aid in patient care. Insurance payments by patients go to things like advertising, stockholder dividends, and Board of Director salaries that could deliver immunizations to every man/woman/child in the US for 5 years.

    and finally, 35? PLease. Most docs would love to work less than 60 and be happy at the chance.

  • J Stevens

    I work at an urgent care center and we’ve been getting pounded by Medicare patients for over a year. Local PCP offices just don’t have the space on their books anymore and a couple of them will be closing at the end of the year. As a result, many of my peers have gone to part-time or full-time limited (less than 32 hours a week). Enjoyed the article but this situation cannot and will not get better.

  • jere14

    Good post.

  • Kristen

    Also, Medicare needs to acknowledge Naturopathic Physicians as PCPs as that is how we are trained. Sadly, right now it depends on the state licensure laws and in mine, I cannot prescribe enough meds in our limited formulary to be able to call myself a PCP, whereas in the state next to mine, I could. Also in my state, nurse practitioners are considered PCPs, yet I, a doctor, am not. This is the same dilemma DOs went through a mere 15-20 yrs ago and they are now filling much of the PCP void as they’ve proven to be just as much of a “doctor” as an MD. NDs provide screening exams, school physicals, gyn/procto exams, run appropriate labs/imaging, manage chronic illnesses, perform minor surgery, always provide patient-centered care and prescribe medications when needed just as any PCP. We focus on prevention and integrative medicine whenever possible, which allopathic medicine is heading towards anyway. We are the only docs trained in pharmaceutical-herb-supplement interactions as part of our core education. There are thousands of licensed NDs in the US and the government needs to let us help.

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