Let’s reframe the question of physician frustration

Next in a series.

There has been a lot of interest in the Daily Beast article written by Dr. Daniela Drake, about very frustrated primary care physicians (PCPs). She quoted both Dr. Kevin Pho and myself from posts here at KevinMD.com. Dr. Drake noted that nine of 10 doctors would not recommend medicine to their children as a career and that 300 physicians commit suicide each year: “Simply put, being a doctor has become a miserable and humiliating undertaking.”

Dr. Pho offered his own commentary pointing out that “it is important to have the discussion on physician dissatisfaction … demoralized doctors are in no position to care for patients … to be sure many people with good intentions are working toward solving the health care crisis. But the answers they’ve come up with are driving up costs and driving out doctors.”

Yes, it is definitely true that PCPs are very frustrated. In a series of in-depth interviews, almost all tell me that their major frustration is not enough time with each patient. No time to listen, no time to think, no time to do critical activities. Why? Because they have to see too many patients per day in order to cover overheads. A few of those that I interviewed have left clinical practice because of these frustrations; others felt that they needed to do “something, soon,” to improve their situation.

But patients are frustrated as well. They find they have to wait a long time for an appointment, sit in the apt named waiting room and then get just a few minutes with the PCP. They observe that the doctor interrupts them within just a few moments, never lets them tell their full story, isn’t really listening and shuttles them off to a specialist or gives them a prescription while never really explaining in their terms what is going on. And they know that they pay a lot for their insurance with premiums rising every year along with lots of co-pays and deductibles. So they are in no mood to feel sorry for the PCP who earns, according the latest Medscape survey, about $170,000-180,000 per year.

The usual response of the medical community is to point out the years of education and training, the high debt loads, the hours of work and the calls at night. That others earn more. That there is an ever growing burden of paperwork, of wasted calls to the insurers and nonfunctioning EHRs. That the responsibilities are high and what could be more important than your health. All true — but it falls on deaf ears for the family with an income of $51,000 (median US household income in 2011, per census).

One major problem is that the average person just does not know what really good primary care could do for them and their health over time. Nor do they appreciate that primary care is or at least can be relatively inexpensive. We (the collective medical community) have not done a good job explaining the value of outstanding primary care.

So let’s reframe the frustration question.

How can patients get superior care from excellent energized and satisfied practitioners at a reasonable cost all leading to not only care of disease but prevention of illness and preservation of well-being? And if this can be achieved, can it lead to more students choosing primary care as a rewarding career?

Government is not unlikely to solve the problem nor will most insurers. It will be up to PCPs and their patients to create a new primary care delivery paradigm. And doctors need to take the initiative to educate the public and lobby for useful change.

There are many options. One is direct primary care (DPC) in its many formats such as pay per visit, a monthly membership fee or retainer-based (concierge) models. The latter two with their limited patient panels are often thought of as only for the elite or the rich but membership or retainer based practices need not be expensive. Several have been written up as “blue collar” plans  with low fees yet limited numbers of patients, same day and lengthy appointments, 24/7 cell phone availability and even free or reduced cost medications and lab testing.

I live in Maryland where I looked up the Blue Cross (nonprofit) premiums in the local exchange. A bronze plan for a 55-year-old costs $3,660 per year with a $6,000 deductible, essentially a “catastrophic” plan. A platinum plan costs $7,728 per year with no deductible but up to $2,000 in co-pays. If the individual requires major medical care, the total out of pocket costs for premium and deductibles/copays in either plan is therefore about $9,700. Buy the bronze plan, create a health savings account and then pay the premium and membership/retainer with tax advantaged dollars. The individual gets high quality health care in a setting where it is to the physician’s advantage to keep the patient well. Alternatively, stay with the platinum plan and get a 12-minute visit.

As to the PCP shortage and patient education issues, Primary Care Progress is one of a number of new organizations sprouting up to bring current and potential PCPs together. To educate patients, they have produced a useful 2-minute animation.

Looking ahead, insurers might one day decide it is logical to buy the membership or retainer for their insureds. The cost would be rapidly repaid may times over. Likewise, employers could do the same leading to a healthier, more satisfied workforce with higher productivity and reduced total health care premium costs. Sounds radical but it is actually logical. Patients would get great care and maintain good health. Providers get to be the true healers they always aspired to be. The total costs of care would come way down. Maybe even more students would choose primary care as a career. Win-win-win-win.

Lets reframe the question of physician frustrationStephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.

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

    I don’t think it sounds radical at all. It sounds like capitation.
    The moment someone else confiscates your money and uses it to buy something that is aimed at benefiting them (e.g. “higher productivity and reduced total health care premium costs”), the individual patient becomes irrelevant and the “provider” works for whoever is paying him/her.

    There are only so many ways we can pay for services. Primary care will never see better days until all secondary motives are kicked out of the exam room, whether by true “direct pay” (i.e. no intermediaries of any type), or by regulations prohibiting interference with doctor-patient decisions.

    • rtpinfla

      I couldn’t agree more. I am anxiously awaiting the day when “insurance” once again means “hospitalization” but have a feeling that the insurance companies actually like the way things are. Why shouldn’t they? They can continue to charge higher premiums while covering less and less. And they justify it in the name of “protecting the consumer from rising health costs”.
      I look forward to the day when “insurance” actually means “hospitalization/catastrophic” but don’t think we’ll ever see it as long as the insurance companies are the ones driving policy.

  • futuredoc

    Good comments. Insurance should be insurance as both of you suggest. Instead it has become “prepaid medical care.” It is interesting that the ACA actually encourages direct primary care in that it has four levels in the exchanges. The Bronze level is essentially a catastrophic policy with a very high deductible (about $6000). At the other extreme is the Platinum plan with no deductible but a much much higher premium. So take the Bronze plan and use a small portion of the savings to buy the membership/retainer. Better care at a lower cost.
    Stephen Schimpff

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

      The ACA is encouraging direct primary care for healthy people who will most likely never reach their astronomic deductibles in any given year. However most of those healthy and younger people are not going to see any particular value in paying retainers for something they don’t expect to need. Even a modest $80 per month retainer far exceeds the two or three visits per year for incidental little things. Most of these people will take the retail clinic/urgent care route, or go without.
      People with chronic disease are not going to use direct primary care until someone forces insurers to count it towards deductibles, and I don’t see that happening anytime soon. Particularly since the commercial ACO lookalike constructs require full control over the PCP in order to turn profit, and HMOs by definition cannot allow direct primary care.
      Which leaves us with the relatively rich and eclectic in both groups, a fast declining segment of the American population.

      • Patient Kit

        I totally agree again, Margalit. I’ve said this before but I’ll say it again. Your comments and posts are what first caught my eye on KMD and inspired me to jump into the discussions here. Thank you for that because I have quickly come to love the many interesting discussions — and discussers — here. I’ve learned a lot in the short few months I’ve been participating here.

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

          Thank you Kit. I have been reading your comments with great interest since you started posting here, and I have learned a tremendous amount from your unique and very compelling perspective. I also really like your writing style… :-)

          • Patient Kit

            Thank you very much, Margalit. That means a lot to me, especially coming from such a good, intelligent writer like you.

  • buzzkillersmith

    The animation: primary care health team plus information technology to cadillacize all the Cadillacs. I’m pumped up, ready to join the team and come in for big win. Aren’t you other docs?

    I was talking with a guy yesterday whose pediatrician wife is doing her charts from home at midnight. I know another CorpMed pediatron who took her laptop on vacation and was charting on a cruise.

    I was talking with another PCP at the Spokane primary care conference a few days ago and made the mistake of bringing up the EHR. CorpMed doc in Kennewick WA . Kadlec or some such foolishness. He was either going to start crying or punch me in the chops. And he was a big guy.

    Give it up, Dr. S. There is no forthcoming solution. Direct care will remain miniscule in the scheme of things.

    I advise investing in lottery tickets.

    • futuredoc

      Buzzkillersmith – I do buy lottery tickets even though I know the chances of wining are infinitesimal. But I still believe that primary care can be fixed. Government won’t do it. Insurers unlikely but possible. It will take PCPs and their patients to force the issue. Naive maybe but better odds than with the lottery.

      SS

      • buzzkillersmith

        Re lottery tickets: I don’t really buy them. That probability class in college ruined me. But if you can play you can’t win. Plus you can pick up some Pabst Blue Ribbon and some smokes while you’re in Circle K. Heck, I’ve just convinced myself.

        Re: fixing primary care. I admire your enthusiasm.

        • Patient Kit

          Are you recommending cigarettes, Dr Buzz?

          • buzzkillerjsmith

            No more than 2.5 packs per day. You gotta draw the line somewhere.

          • Patient Kit

            At $14 a pack here in NYC, that’s a $35 a day, $280 a week, $980 a month, $11,760 a year habit. Ouch. I could probably get a direct pay primary care doc for that!. ;-p

          • Docsicle

            You could probably get a DPC doc, chiropractor, monthly gym membership, personal trainer and a yoga instructor for that! :)

          • Patient Kit

            “Unfortunately”, I don’t smoke. So, I can’t give it up to redirect that money. I do have a gym membership (YMCA) and even here in NYC that only costs about $60 a month. Way cheaper than cigarettes. That is one of my most important expenses since I swim laps 5 or 6x a week and hit the weight room a few times a week. Yoga classes come free with membership. My gym is an essential staple to me. (I don’t have cable TV.) Thankfully, in these lean times post-layoff, broke and dealing with ovarian cancer, a good friend has been paying my gym membership until I get back to work because she knows it’s a lifeline for me, both physically and emotionally. Shhhhh! Don’t tell Medicaid about my gym gift.

          • buzzkillerjsmith

            That’s a lot of money. I’d better cut down a little I guess.

          • Dr. Cap

            YES KIT!! Imagine the power all that blood money could have in an interest bearing account (like an HSA for instance)! See why we get so annoyed that people prioritize bass ackwards??

          • Patient Kit

            At $14 a pack here in NYC, that’s a $35 a day/$245 a week/$980 a month/$11,760 a year habit. Ouch. I could probably get a direct pay primary care doc for that! ;-p

    • Lisa

      My husband is a software engineer and frequently works late and on the weekends. I remember times when came home at dinner, then headed back to the office. Now he has a DSL line and can work from home. Many people work on ‘vacation.’ Long hours are the norm, not just for doctors.

      • buzzkillersmith

        My nephew is a computerguy. No comparison to what I do. Not even in the same league.

        Physicians have the highest rate of burnout of any profession and, incidentally, the highest average IQ.

        • Lisa

          I suspect your nephew has never worked for a startup, although I won’t argue with you about rates of burnout and IQs. I have no idea about rates and professions.

          • buzzkillersmith

            Startup. OK I guess unless he works on EHRs.

            The IQ data is from a Univ. of Wisconsin study a while back. You can google this if interested.

          • Lisa

            The closest my husband ever got to working on an EHR was a computerized spirometer and a visual field analyzer. But that was years ago. Now I don’t understand what the heck he does; he tries to explain it, but I don’t really understand anything beyond the most basic of explanations.

          • buzzkillerjsmith

            As long as he doesn’t work on medical stuff, he’s OK in my book.

      • FEDUP MD

        Not even close. I am married to a hardware designer who has worked for startups when I was a resident and fellow and who now works for an industry leader. Both he and I would agree it is not even close as far as work hours and stress, even when he has a customer waiting for a chip. No one will die if he screws up.

        • Lisa

          I was adressing the work hours issue buzzkillersmith brought up. My husband worked killer hours, had bosses who yelled at him because he wasn’t producing the impossible and generally suffered in the name of earning a pay check. And he never made as much money as most doctors do, not even as much as primary care doctor. Yeah, no one will die if my husband screws up, but I’ve seen doctors screw up and no one died either.

          As was mentioned in the article above, patients won’t feel too sorry for pcps who make a lot more money than they do. If a model DPC and insurnace for specialist/catastrophic care is to be viable, you have to address the advantage to both parties (at the same time you loosen the grip of the insurance companies).

          • FEDUP MD

            I make less money than my husband. He once worked at a company so toxic that he made a spreadsheet that he presented at a meeting indicating that if all the engineers worked 24 hours a day for the months leading up to the deadline, without eating, sleeping, or going to the bathroom, they would still be months behind. Guess what? He and his whole team fled that company and are now working for one that has high but attainable goals. Still not comparable level of work or stress, and he would agree, having been with me since college.

            Of note, comparing an average person’s salary to a PCP’s is not comparable. The average American has some college, not even necessarily a bachelor’s, while a PCP has 11 years minimum of schooling. I have 14 years of schooling and make less than my husband with a master’s, as well as our friends with MBAs, law degrees, and engineering degrees, all 7 years or less. I have 1/5 the retirement savings that my husband does and he paid off his student debt years ago. If patients want to be upset, see how much the administrators at their insurance company with a bachelor’s degree or MBA are making off their premiums they are paying- much more than a PCP, and to no direct benefit to the patient. The whole doctor pay issue is a diversion from where the money is really going and who is really deserving of high salaries- just the way insurance companies and hospitals like it.

    • SteveCaley

      We have a medical system that is inexorably progressing – perhaps even accelerating – in a direction that the DOCTORS hate, and the PATIENTS hate.
      One might assume that these individuals are being ignored. That’s a reasonable assumption, no?
      So, who’s driving this bus?

  • Patient Kit

    For patients with chronic conditions, I think that depends on how much of your care comes from primary care and how much from specialists. As a cancer patient who has to be monitored for recurrence every 3 mos for 2 years and then every 6 months for 3 years and then annually, I currently see my GYN oncologist far more often than my primary care doc. And I would not want my primary care doc to be doing this surveillance. Likewise when I had serious orthopedic injuries. I saw my orthopedist far more often than primary care. I think a lot of patients with chronic and serious medical conditions see specialists far more often than primary care. So, a monthly membership fee isn’t very appealing on top of all of our other expensives, especially for a doctor that we don’t see that much.

    • Dr. Neu

      Sorry to hear about your illness.

      I’m a bit biased here, but good primary care, including coordination of care, is especially important for someone with multiple specialists. Having weekly visits with 15 sub-specialists is not providing you “primary care”. Some of the worst medical errors result from poor communication between various doctors treating the same patient.

      Sadly, the scope of primary care has been greatly reduced in recent decades. The medical community sees more value in PCPs making referrals than actually treating patients. The reality is that many PCPs make more referrals than needed just because they don’t have the time.

      • Patient Kit

        Thank you. All things considered, I’m one of the luckier ovarian cancer patients around. Caught at an early stage, good prognosis, wonderful doc, good emotional support from family and friends. Still, getting a cancer dx was a scary shock and it’s been a challenge learning to navigate the system.

        I adore my specialists, especially my GYN ONC. I wish I could say that I’ve ever experienced the kind of primary care that you and others here at KMD describe. The discussions here have made me realize that I don’t think I’ve ever had that kind of relationship with a primary care doc. Not in my adult life anyway. Primary care, for me, has been pretty fragmented. As a child, we had the same family doc for many years. That may be my last (only?) experience of the kind of primary care you describe. Hopefully, for both primary care docs and patients, my experience with primary care isn’t the norm.

        • Teresa Brown

          I know where you’re coming from, Kit. I see my gyn/onc frequently (OC Stage 3C). I also had some major orthopedic issues and go to an ortho for that. That leaves few reasons right now to see a primary care doctor.

    • Lisa

      The year I had my first hip replacement and was diagnosed with breast cancer, I saw my primary care doctor 3 times, for pre-op physicals. I saw surgeons (breast and ortho) and oncologist many more times.

      • Patient Kit

        Same here. I have very good relationships with several specialists but I feel like my primary care doc barely knows me and I barely know him. Yet, everytime I need surgery, my primary care doc is asked to take the responsibility of clearing me for surgery.

        • Lisa

          The first time I saw my pcp was for a pre-op physical. Since then I’ve seen him for five more pre-op physicals, so I would have gotten to know him pretty well even if I hadn’t seen him for a few minor issues between those physicals.

          • Patient Kit

            I’ve had a number of primary care docs over the years for a variety of reasons like insurance changes on either the patient or doctor end or moves on either end. No bad doc or bad patient scenarios. Just logistics. I’ve just never gotten very attached to any of my primary docs the way I have with my specialists. If my GYN ONC moved to another hospital, neighborhood or borough of the city, I would go with him. I don’t feel the same about my primary doc. I wish I did.

          • Lisa

            sigh….

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

    First let me say that I like your model a lot, and this is in no way to criticize that. The reality is that most people are relatively healthy, so there is a sizable population that may be able to benefit from direct primary care. And there is nothing wrong with completely or partially (hybrid models) catering to this very large group of people.
    As Kit explains very well, for those with more serious conditions, DPC may be a very nice thing to have, but an extra expense nevertheless.
    And there are all the people on Medicare and all the people on Medicaid that are automatically excluded from direct pay arrangements.

    So to go back to the original point raised by Dr. S, I am not too sure that the ACA, and all its trimmings, are actually encouraging DPC. I think the origins of the problem predate the ACA and sadly the ACA has done nothing to alleviate them.

  • Docsicle

    DPC sounds like a great idea in principle, but how do patients pay for expensive specialist visits in this construct? My goal is to establish a micro DPC clinic in the future, minimally staffed and with low overhead. I don’t want patients left out in the cold with regards to specialist care, however.

    • futuredoc

      Docsicle

      There are a lot of examples but take a ook at DrNeu at http://neucare.net/about/ And look at the links in my post above about “blue collar” DPC.

  • Patient Kit

    So, are you saying that DPC is a model that works best for patients who are basically healthy? If so, would direct pay primary care docs only treat relatively healthy people? Or would docs have some kind of hybrid model in which their healthiest patients direct pay and their sicker patients pay via insurance? I fall into the category of managing cancer so I’m not a good candidate for DPC. But I still want to understand it.

    • Docsicle

      I believe that the DPC
      model works as well for many chronically ill patients as it does for healthy patients. It may even prevent chronic illness by giving patients and doctors enough time to discuss lifestyle/environmental risk factors leading to chronic illness before the illness ever develops (i.e diabetes, cardiovascular disease, etc.) I just don’t want, as a doc, to be limited in regards to specialist referrals because patients can’t afford to pay for them…

      • Patient Kit

        I can certainly see how DPC could be good for preventing chronic disease. But I remain unconvinced that it’s a good model for patients who already have serious/chronic illness. I share your concern about making sure the DPC model does not limit access to specialists for patients.

        • Docsicle

          Actually, the reason that DPC is good for preventing chronic disease is the same reason it would be good for treating chronic disease. Imagine a type 2 diabetic having a full hour to discuss their current status with their doc? Many common meds for common chronic illnesses are generic and affordable, and the expensive ones could be bought with the savings from not paying high insurance premiums! Then, there’s the hassle of finding an open appointment to see your PCP for exacerbations of your condition. Finally, because the doc doesn’t have such a heavy load, more time can be spent getting to know the patient and their struggles. It sounds ideal for treating chronic illness.

          • Patient Kit

            As a patient, I, of course, love the idea of my doctors spending more time with me and getting to know me better. But I have lots of red flags and questions and doubts about DPC. Here are a couple of them;

            (1) As long as we still need or may need specialists, lab, imaging, hospitals, surgery, expensive drugs like chemotherapy, etc., I really do not see insurance getting any less expensive for patients as a result of going to DPC. I have a really good imagination but I’m having a hard time seeing insurance getting cheaper. I just do not trust that happening. So, I see DPC as an additional expense on top of the cost that still-needed insurance. Affordable to some but unaffordable to many.

            (2). If docs are going to spend an hour with each patient, won’t their days and calendars fill up fast? Why would it be easier to get an appointment fast with docs who see fewer patients for longer times? How many patients a day could a doc see if he spends an hour with each?

  • Karen Ronk

    I think one of the best points of this piece refers to the current plans available from the ACA. Many people just don’t realize – or acknowledge- how much money you have to pay in BEFORE you actually get any health care paid for. And I cannot see paying for the bronze plan and then also starting an HSA being an affordable reality for many people. I do think that it is going to take a concerted effort by physicians and patients to forge ahead with a better way and the powerful forces against that will be challenging to overcome.

  • Dr. Cap

    But I could see yearly follow up long term cancer survivors, which is the PCP part of my practice. The operative patients could be separate. This is interesting. Now, if only I could clone myself…

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