An excerpt from So Long, Marcus Welby, M.D.: How Today’s Health Care Is Suffocating Independent Physicians – and How Some Changed to Thrive.
Ripley Hollister has been president of his county’s medical society in Colorado Springs, Colo., and a director of the Colorado Medical Society. He has been a unit commander of the Medical Reserve Corps of El Paso County. His practice has a world-class view of the Rocky Mountains from its floor-to-ceiling windows.
Hollister also does the laundry for his medical practice each weeknight. “Is that the way it should be?” he asks.
Being a launderer has nothing to do with providing high-quality patient care. It has everything to do with economic survival. It is also emblematic of the menial nonclinical tasks, so common now, that erode physician autonomy.
Hollister has practiced cradle-to-grave primary care his entire career. He literally built a practice in a two-acre cornfield in Ramer, Tenn., to satisfy his National Health Service Corps commitment and wipe out what would have been a $300,000 medical-school debt. The town, population 354, is in McNairy County, where Sheriff Buford Pusser, the subject of the Walking Tall movie series, fought moonshining, prostitution and gambling near the Mississippi state line in the late 1960s.
Hollister has had his solo practice for 16 years. Two mid-level providers help him care for 4,700 patients. He has trimmed his workweek to about 50 hours and no longer does obstetrics.
Hollister said falling reimbursement rates and rising practice expenses inevitably mean he must shrink his practice. Marginal clinical services cease. He stopped doing colonoscopies because revenue from them barely covered his expenses. When equipment broke down or needed to be upgraded, he simply stopped providing the service because he could not justify the expense. Lab tests, once done on site, are now outsourced. Results are slow to return. Patients are inconvenienced.
Hollister has stopped doing immunizations. “I discovered I lost $40 on every vaccination. I can’t do that. People can’t understand why they can’t get vaccinated at the doctor’s office. I send them to Wal-Mart or Walgreens. They buy in volume. I can’t. So I send them elsewhere. ”
Hollister is well aware that he is part of a vanishing breed of physician: the solo practitioner who is working hard to serve a larger purpose.
Doctors “are tight-lipped,” he said. “They won’t tell you they are going under. They just vanish. They get taken over by a larger entity: hospitals, health plans, government. You see a wave of doctors who see this as a safe harbor. But hospitals are still finding they can’t manage doctors and make money. So they cut back doctors’ salaries or tell them to see more patients.
“The older ones are being pushed out (of the system). Many are pissed off and leaving. They have a different view of medicine than the new ones. Being a doctor defined who they were. It was their purpose in life. Younger doctors work maybe 40 hours a week. They see it more as employment than a profession. They have a different view about quality of life. They won’t be quite the workforce (in quantity of hours),” he said.
Despite his profession’s head winds, Hollister has no plans to retire. “I want to be practicing as long as I am mentally crisp. I’m never retiring, but I could be forced (by administrative or practice burdens). I just need a support staff and a place to work.”
Physicians have to fight for every dollar. Plumbers and attorneys do not have to call a third party to verify that they will be paid when they fix leaky faucets or draw up wills. Primary-care physicians’ share of the U.S. health care dollar is only 7 cents. If payers cut reimbursement for physician services by 25 percent, the average annual rate of medical inflation would only decrease to 5.7 percent from 6.2 percent. However, primary-care doctors control 80 cents of the health care dollar by sending their patients to hospitals, referring them to specialists and handing out prescriptions.
This outsize influence extends to patient perceptions. Nurses, pharmacists and physicians annually occupy the top three spots in the annual Gallup survey of how Americans gauge honesty and ethics among professions. Gallup has polled on public trust in professionals since 1976. In its 2012 survey, nurses scored the highest, at 85 percent on “honesty and ethical standards,” followed by pharmacists at 80 percent and physicians at 70 percent.
More than 3 out of 4 Americans say their physicians put patients’ interests ahead of their own, according to a Kaiser Family Foundation poll.
About 4 out of 10 Americans say they are confident in the U.S. health care system, but more than 8 out of 10 say the health care they receive personally is good or excellent. Physicians are seen as heroes who help people when they are sick, not as cogs in an impersonal economic sector.
Cardiologist Rick Snyder, former president of the Dallas County Medical Society, quotes Republican pollster Frank Luntz who once said, ‘You doctors are God and the law.’ ”
Stanford University professors Victor Fuchs and Arnold Milstein agree. They wrote in the New England Journal of Medicine, “… physicians are the most influential element in health care. The public’s trust in them makes physicians the only plausible catalyst of policies to accelerate diffusion of cost-effective care.”
Only 15 percent of U.S. primary-care physicians believe the nation’s health care system works well. More than half are frustrated by the difficulty many of their patients face in paying for care.
It is troubling that the nation’s health is in the hands of a profession that displays such pervasive signs of disaffection, disenfranchisement and hopelessness.
Even young physicians exhibit a high degree of pessimism. An April 2012 Physicians Foundation survey of physicians under 40 found that more than half were pessimistic about the future of the U.S. health care system, while 22 percent were optimistic.
Those physicians who are satisfied with their profession tend to display an evangelist’s zeal for practicing medicine, and enjoy addressing conditions such as obesity and nicotine or alcohol dependence. Their empathy also translates into better patient outcomes. Academic Medicine researchers used a Jefferson Scale of Empathy (JSE), designed in 2001 to measure empathy in a medical setting. They found a direct association between a positive physician JSE score and better control of patients’ hemoglobin A1c and cholesterol levels.
Pure and simple, physician satisfaction translates into better patient health.
A survey of hospital executives and practice managers by physician recruiting firm Merritt Hawkins underscores the sharp contrast in the outlook of health care executives compared with that of physicians. Merritt Hawkins surveyed U.S. physicians for the Physicians Foundation in 2012.
- More than 9 out of 10 executives say they feel positive about being in health care management, compared with 1 out of 3 physicians who say they feel positive about being in medicine.
- Nearly 9 out of 10 executives say their morale is positive and they would recommend health care management as a career, compared with about 4 out of 10 physicians who would make such a recommendation.
Travis Singleton, a Merritt Hawkins’ senior vice president, said in a statement,“For health care facility managers, the glass appears to be half full. For physicians, it appears to be half empty.”
Steve Jacob is a health care journalist and author of So Long, Marcus Welby, M.D.: How Today’s Health Care Is Suffocating Independent Physicians – and How Some Changed to Thrive.