Status quo primary care: How did things get this bad?

“Nine of 10 doctors discourage others from joining the profession,” writes Daniela Drake on the Daily Beast.

And stats say that by the end of 2014, about 300 physicians will commit suicide.

What is going on?

A few years back, practicing medicine was named the second-most suicidal occupation. Yet, it hasn’t stopped. The level of sheer unhappiness among physicians is on the rise.

Being a doctor has become a humiliating undertaking. There are those who feel that America has declared war on physicians — and both physicians and patients are the losers.

For one, consider the fact that in certain cases ER docs cannot charge less than what a chargemaster decides, even if that patient is financially burdened. Meaning, if that patient isn’t wrapped up in the red tape, he’s not getting the help he needs. And, if he does carry the proper affiliation (Medicaid, etc.), the doctor will have to work just to receive compensation for the work performed.

Not surprisingly, doctors want out. Seriously, there is a website known as the Drop out Club – which hooks doctors up with jobs at hedge funds and venture capital firms — and it has a legitimate following.

It’s difficult for people outside the profession to understand how ugly the affair has become — ICD codes, and end-of-shift dictations, and — let’s stop for a second. Does anyone really meet with 25 to 40 people in one day? Imagine that, you’re a top notch blogger. You work in the comfort of your living room. Could you imagine 40 different people parking, entering your living room, sitting on your couch, just to have a quick conversation about their enterprise, that you will have to briefly write about later that day, or tomorrow, and that you will have to follow up with next week, just to make sure everything you wrote went where it’s supposed to.

Chances are you don’t follow up because, oh yeah, you have to see 40 people per day just to pay your rent and earn enough money to pay your bills and your student loans (pretend it’s expensive to become this hypothetical blogger) and take home the market salary for a blogger.

Now, to make matters worse, let’s pretend there is a company, called DreamZone. And that this company’s sole role is to be available to pay you to create stuff that helps these clients who come to your house everyday. At the end of each day, you have an additional task, which is to communicate to DreamZone, what you did that day and what you decided on that day to do in the future. From there, DreamZone determines your reimbursement for the work you’ve already done, and, as it sees fit, tells you when it won’t pay you to do something you believe will help your client.

What a scenario, right?

But that’s fee-for-service healthcare.

Author Malcolm Gladwell implied that to fix the health care crisis, the public needs to understand what it’s like to be a physician. Imagine, for things to get better for patients, they need to empathize with physicians — that’s a tall order given the nature of our decidedly un-empathetic times.

After all, the public sees ophthalmologists and radiologists making out like bandits and wonder why they should feel anything but scorn for such doctors — especially when Americans haven’t gotten a raise in decades. But being a primary care physician is not like being, say, a plastic surgeon — a profession that garners both respect and retirement savings. Given that primary care doctors do the work that no one else is willing to do, being a primary care physician is more like being a janitor.

Unfortunately, things are only getting worse for doctors who still accept health insurance. Just processing the insurance forms costs $58 for every patient encounter, according to Dr. Stephen Schimpff, an internist and former CEO of University of Maryland Medical Center who is writing a book about the crisis in primary care. To make ends meet, physicians have had to increase the number of patients they see. The end result is that the average face-to-face clinic visit lasts about 12 minutes.

In fact, difficulty dealing with insurers has caused many physicians to close their practices and become employees. But for patients, seeing an employed doctor doesn’t give them more time with the doctor — since employed physicians also have high patient loads.

“A panel size of 2,000 to 2,500 patients is too many,” says Dr. Schimpff. That’s the number of patients primary care doctors typically are forced to carry — and that means seeing 24 or more patients a day, and often these patients have 10 or more medical problems. As any seasoned physician knows, this is doable, but it’s certainly not optimal.

Most patients have experienced the rushed clinic visit — and that’s where the breakdown in good medical care starts. “Doctors who are in a rush, don’t have the time to listen,” says Dr. Schimpff. “Often, patients get referred to specialists when the problem can be solved in the office visit.”

And that’s why I became a direct care doctor right out of the gate. Under the weight of red tape — all the third parties making money without providing actual care — fee-for-service physicians have to constantly improve their “productivity” just to keep their lights on. And now they have to keep their patient satisfaction scores up or risk losing their jobs. Industry leaders are so fixated on patient satisfaction, despite the fact that high scores are correlated with worse outcomes and higher costs.

Seriously, trying to please whatever patient comes my way destroys the integrity of my work. It’s a fact that doctors acquiesce to patient demands — for narcotics, x-rays, doctor’s notes — despite what survey advocates claim. And now that Medicare payments will be tied to patient satisfaction: This problem will get worse. Doctors need to have the ability to say no. If not, when patients come in for an appointment, they’ll have a hostage, not a doctor.

There’s nothing worse than the terror that accompanies a malpractice suit. Nothing. But what about the paranoia that comes with a doctor, worried about his patient rating, who doles out painkillers. God forbid the patient legitimately has drug-dependency issue and overdoses. Where’s the blame? On the doctor, again.

And of course this is rare, but this is the world of fee-for-service family care that our leaders are envisioning. This catch-22 — the fear of keeping your lights on and the fear of what might happen if you do — is not going to lead to optimal outcomes.

“There’s a media narrative that blames physicians for things the doctor has no control over,” says Kevin Pho, MD, an internist with a popular blog where physicians often vent their frustrations. Indeed, in the popular press recently doctors have been held responsible for everything from the wheelchair-unfriendly furniture to lab fees for pap smears.

No wonder doctors are suicidal. No wonder young doctors are repelled by the idea status quo primary care.

So how did things get this bad?

I’m not sure if I’ll ever be able to answer that. But if enough patients say, “I Want Direct Care,” maybe we won’t have to.

Josh Umbehr is founder, Atlas.md.

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