Where have all the doctors gone, long time passing,
Where have all the doctors gone, long time ago,
Where have all the doctors gone, driven out of practice every one,
When will they ever learn, when will they ever learn.
A few years ago, I received a phone call from a distraught husband. His wife was having post-menopausal bleeding and he was worried. She had no established physician, was insured by Medicare, and he had called all over looking for someone to take her as a new patient without success.
The top diagnosis to rule out was cancer, and he knew it.
In order to get her seen, I had to call on a personal friend who is a family physician. Unfortunately, the diagnosis did turn out to be sarcoma, an aggressive cancer, but at least she was seen and referred to a specialist the following day. If that couple had not called me, how long it would have taken for them to find a physician?
In a survey cited by US News and World Report, 29 percent of patients with Medicare reported difficulty in finding a physician who would take that insurance in 2007, increased from 24 percent in 2006. Even if one has a physician, only 30 percent of Americans say they can get a same day appointment, which is second to last of all industrialized nations, only ahead of Canada.
There is a shortage of physicians these days, and it has reached crisis proportions in primary care: family medicine, general internal medicine, and pediatrics. Our politicians are speaking a lot these days about universal health care, and whether it should be funded by employers, the federal government, individuals, or some combination of all three, but what good is health insurance if there aren’t physicians to take care of the patients?
The American College of Physicians wrote “primary care is on the verge of collapse”, and the staffing firm of Merritt, Hawkins & Associates published, “Will the Last Physician in America Please Turn off the Lights?”
Why aren’t there more primary care physicians? Let’s first look at economics. The cost of college and medical school continues to rise, with the average debt of medical school graduates over $139,000.
The earnings of primary care physicians is the lowest of all physicians, about one half that of specialists. Where do all the new doctors go? Joseph Martin MD wrote that they are hitting the ROAD: Radiology, Ophthalmology, Anesthesiology, and Dermatology. Why not? They have better pay, better lifestyle.
The federal government through Medicare sets rates of payments for office visits for each type of physician and for procedures, with insurance companies following suit. Procedures are generally reimbursed at higher rates than office visits, and specialist office visits more than primary care, as they have completed additional years of training.
Now for the workload: Primary care physicians perform a lot of tasks that are not reimbursed, such as on-call responsibilities, referrals to specialists, nursing home placements and family meetings. They must address all of the patient’s problems as opposed to one organ system. For example, a cardiologist sees a patient with chest pain, writes a consultation note, orders an EKG (test), blood work, echocardiogram (test), possibly a stress test and maybe a cardiac cath. (procedure). Then the patient is prescribed cardiac medications, and sent back to the primary care physician to manage.
An Internal Medicine physician typically sees patients with multiple medical problems such as high blood pressure and diabetes, taking at least a dozen prescriptions (if elderly), and he is responsible for guiding their total care in a short, 15-minute office visit. No wonder 75 percent of Internal Medicine residents go on to specialize as opposed to practicing as general internists.
The population is aging, creating a need for more comprehensive primary care, but physicians are aging also. About 25 percent of the physician workforce is over age 60.
Physician satisfaction is decreasing due to lower salaries, more regulations and paperwork, insurance company hassles, increasing malpractice cases and high malpractice insurance premiums. Physicians are required to treat patient’s pain, but have been criminally charged for contributing to pain killer addictions.
Physicians are retiring early or transitioning to more satisfying non-clinical careers with better lifestyles. About one half of all new physicians are women, bringing new outlooks to medicine, but many want to raise children and eventually go to part time practice or leave medicine altogether.
Where is all this leading? Please come back next week for “Where Have All the Doctors Gone” Part II where I will look at the effects of the primary care shortage and what needs to be done about it.
Do you have health insurance stories to share? Are you a physician with a similar – or different – take? Email Dr. Decipher at email@example.com.
Disclaimer: This does not take the place of regular medical care, and is not a complete review of any medical conditions. Consult with a physician before any treatment or taking any medications. Seek medical attention immediately for any serious symptoms, or call 911. No current or local patients have been referenced, so any resemblance is purely coincidental.