Map of life expectancy at birth from Global Education Project.

Tuesday, November 18, 2008

The doctor is out?

You may have come across this report that says half of U.S. primary care physicians want to leave the profession. Actually, I would pay approximately zero attention to this survey -- the response rate was less than 10%, and it's likely that the docs who were motivated to answer are the ones who are the most angry and unhappy. I don't think half of all primary care docs are about to quit.

Nevertheless, primary care in the U.S. is in crisis. We have a shortage of primary care physicians, with long waits for appointments, visits that are too short, and docs feeling hassled, overworked, underpaid compared to their specialist colleagues, and unable to give sufficient attention to their patients. In some parts of the country, it's difficult for people to find doctors at all, especially if they depend on Medicaid, which pays less than private insurance. The situation looks poised to get worse before it gets better, as too few graduating medical students go into primary care residencies, while a lot of primary care docs are nearing retirement.

NEJM recently hosted a round table discussion of this issue and they once again did the right thing by making it open access. Here Barbara Starfield, a physician who is also a highly regarded investigator into effective medical practice, lays out some of the issues. The entire suite of essays is on the NEJM front page right now, although unfortunately they haven't given us a permalink. (This Intertube thing is fairly new to them, evidently.) In my view, there are five major areas where we can look for solutions. The last three are not high on the panelists' agenda, so consider this a contribution to the discussion.

  1. Pay more for primary care services: Right now, doctors are paid a lot for doing tests and procedures, but not paid enough for office visit time and not really paid at all for all the paperwork they have to do and informal consultations with colleagues and patients (as by phone and e-mail). By undervaluing time spent with patients, we make it very difficult for primary care physicians to sustain effective healing relationships and truly understand and meet their patients' needs. We also discourage young physicians from going into the field. Yes, as Starfield says, if we pay more many doctors will choose to see fewer patients rather than increase their incomes. That's good, as far as I'm concerned.

  2. Develop new models of primary care in which M.D.s don't do everything: The idea is to have R.N.s, physician assistants, and counselors of various kinds spend time with patients on health education, support for medication and diet adherence, routine physical exams, etc., and have the expensive and scarce M.D. time reserved for services where it's really needed. I'm only partly into this. I think the physician-patient relationship benefits from having physicians involved with all aspects of patient care, but maybe there's a decent compromise position.

  3. Use information technology to streamline paperwork: This mostly means electronic medical records, linked to Electronic Order Entry and billing systems. If we can really get this to work, it will make Marcus Welby's life considerably easier, but there are obstacles, including cost-effectiveness for small practices (not there, subsidy needed); the need for standardization so all the systems can talk to each other; and cutting down the hassles a lot of physicians experience with pop-up warnings, elaborate paths to get to what they need, etc.

  4. An equivalent of the U.K.'s NICE, with real power: Evidence based guidelines that are respected by insurers, patients and the courts can cut down on unnecessary tests and procedures and make decision making easier. That's a long discussion which I'm not going to get into here.

  5. Improve doctors' communication and time-management skills for patient encounters: I've listened to hundreds of hours of tapes and read thousands of pages of transcripts of physician-patient encounters. Sadly, few physicians are skilled at communicating effectively and efficiently with their patients. While I don't think 12 minutes is enough for most visits, doctors could get a lot more out of the time they do have -- and hopefully, some day, it will be enough. Medical training is barely beginning to address this, and the evidence base is inadequate. (Dear NIH: Give me lots of money. Thank you.)

  6. Universal, comprehensive, single payer national health care: Right now, primary care physicians spend a whole lot of time figuring out what is and is not paid for by their various patients' various insurance schemes, managing complicated businesses that require infrastructure to bill multiple payers, and negotiating with their patients over what expenses they can and cannot pay out of pocket. If everybody has the same insurance, and everything is covered, all of that goes away. And oh yeah, we all save money.

So, whatever reforms we get in the coming year, these need to be in there. Let's make it happen.


kathy a. said...

i'm right with you on 1, 2, 5, and 6. i want doctors to be able to answer questions, to have relationships with patients, to know better how to communicate [and communication goes both ways].

our own family practice uses nurse practicioners to great advantage, and that has worked out great for us: they are well-trained, can afford to spend more time, and are supervised by the medical staff; and they are not afraid to say they need to get more information, or to check in on progress, etc.

universal single-payer coverage will eliminate a lot of waste, cost, beaurocracy, and frustration, in my opinion. companies, individuals, and governmental agencies are currently paying more than enough to finance basic health care for all. the losers would be insurance company investors, who are after the profits to which they have become accustomed.

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Discover What You Think said...

So, You Want To Be A Doctor…..

In recent times, others have appeared to express concern about the apparent shortage of primary care doctors in particular in the United States. Both presently as well as in the years to come, others speculate that the shortage of doctors will continue to progress to even greater absence of PCPs that what exists now. Less than 20 percent of medical school graduates go for primary care as a specialty as a residency program today. Typically, the main reason believed by many is lack of pay compared with other medical specialties. Some anticipate a shortage of 60 thousand or so primary care doctors in the future within the United States. The PCP doctors who practice right now would not recommend their specialty, or their profession, it has been reported.
It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. Ironically, PCPs have been determined to be the backbone of the U.S. Health care system, which I believe them to be. For example, PCPs manage the many chronically ill patients, who benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly half of the U.S. population has at least one chronic illness- with many of those having more than one of these types of these illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget, who are largely cared and treated by PCPs.
The shortage of primary care physicians is possibly due to other variables as well- such as administrative hassles that are quite vexing for the physician vocation overall- along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients due to decreasing reimbursements from various organizations the doctors receive for the services they provide. For reasons such as this, it is believed that some PCPs are retiring early, or simply seeking an alternative career path. As mentioned earlier, the PCP specialty is not desirable for a late stage medical student, so this is quite concerning to the public health in the United States. The number of medical school graduates entering family practice residencies has decreased by about half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers with decreased pay, comparatively speaking.
Despite the shortage of these doctors, primary care physicians do in fact care for the populations they serve and are dedicated to their welfare, as difficult as it may be for them at times. Studies have shown that mortality rates would decrease due to increased patient outcomes if there were more PCPs to serve those in need of treatment. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if numbered correctly to serve a given population of citizens. In addition, PCP care has proven to improve the quality of care given to patients, as well as the outcomes for these patients as a result are more favorable. Most importantly, the overall quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase mildly if at all in the years to come. The American College of Physicians believes that a patient- centered national health care workforce policy is needed to address these issues that would ideally be of most benefit for the public health. Policymakers should take this into serious consideration.
“In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero
Dan Abshear (ex-military medic and physician assistant for nearly 20 years)
Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.