Can't Find a Doctor? You're Not Alone

Primary doctor shortage

Many of us want to believe the free market is efficient and will allocate resources properly. Thiis belief is deceptive and leads to adverse consequences in many instances, particulary in health care.

Expensive Health Care

I worked for 47 years until I got sick and had to stop working. At 65 years of age I found my self with a horrible flareup from Lupus, an illness I never even heard of. It took me six months to heal from the flareup and tried to go back to work. I was not hired because I was diagnosed with what the corporations and insurance industry consider "a pre-existing illness" and would not insure me. Unfortunately, I could not get anymore insurance due to my "pre-existing illness" and was rejected by several well known health insurance companies. Six month later due to the stress of not finding a job and not being able to purchase insurance--wham I get another flareup and again I am laid up. I went through all my personal savings within a year. It took me almost two years to get disability. Meanwhile, NO doctors or clinics would take me without insurance and many doctors will not take Medicare patients. I lived in Plainfield at the time and had a difficult time finding a doctor willing to treat me. All the years of paying taxes and contributing to social security and I could not find a doctor to treat my Lupus. We all will find ourselves in a difficult situation of being old, sick and poor. Of course, if you are rich or a politician you will not have to worry.

Been there.

Can't Find A Doctor

The last time I actually saw my doctor was 2 years ago. Whenever you go to his office the person who sees you is a Physician's Assisant. Supposedly this person is overseen by the doctor. But who knows?

It is interesting that the same US news and World report that a couple of years ago felt that advanced practice nurses and other mid level providers were an adequate replacement for primary care physicians now sees this as much of an issue.

Ironically there is data recently showing that Physician Assistants as well were shunning primary care.

The bottom line is we need to make Primary care more attractive to medical students vis a vie Specialty care. If that means adjusting or even reversing the pay differential then so be it, additionally pay is not the only factor here. Primary care physicians sense a lack of respect from all concerned. In many ways primary care has become an area where hours are long, gratitude is less, payers look upon lowly, hospital administrators consider an afterthought when planning expansion plans or making community facility plans etc.

Ironically in a capitalist economy, even if you feel money should not be the determining factor, you do have to sort out the pay differential to rectify the other issues plaguing primary care.

We also need to be careful as a society, not to consider mid level providers as an alternative to PCPs. They are physician extenders and as long as that role is kept to that they fill an invaluable void, anytime the issue of more autonomy comes up, it simply means that we are taking yet another step in a direction we will regret in the long term. Likewise when we encourage a higher and higher proportion of our doctors to subspecialize, we are doing the same. Most developed countries have an approximately 50/50 split in their physician between primary care and subspecialties, in the USA we are better than 2/1 in favor of specialty care and that ratio is worsening, is it any wonder it is becoming harder to find Primary care Internists or Family physicians any longer? It will only get worse in years to come, as we have more older, retired baby boomers, with multiple chronic illnesses, insured by a medicare system that continually cuts primary care physician fees as a way to reign in costs, all while ignoring escalating hospital costs, drug costs, medical devise and medical equipment costs, fat insurance company profit margins and administrative costs, and even medical specialty care costs, all while ignoring arguably the most valuable and cost effective services in the system.

So, in conclusion, medical students are no fools. They see the writing on the walls and they are voting with their feet. It is time to put up or shut up.

Can't Find A Doctor?

,,I am a family practitioner with a solo private practice in Prince George's County, Maryland just outside of Washington D.C. I have been praticing in this area for the last 15 years so I have a rather large following of patients. The warning signs of a primary physician shortage have been present for many years but we as a society have not been paying attention. The sacrifices that one makes to become a doctor are expected. It comes with the territory. Lots of studying. Endless test taking. Years of training. (I was almost 30 years old when I got my first real job). But who could have anticipated that some 20 years later I would have to continue to make major sacrifices just to continue as an old fashioned family doctor? Private practice is just about the only venue left in which you can practice the way you were trained. To place patient care & concern first. What makes this increasingly difficult is the reimbersement system. Despite booked schedules, full waitng rooms, and long hours trying to go the extra mile for my patients, I don't generate the kind of revenue that other specialties can with much less effort. I live a modest lifestyle. As a matter of fact, patients of mine who are my neighbors are suprised to discover that the guy in t-shirt and shorts mowing the lawn and washing the car is their doctor. They just assume that I wouldn't be living in their neighborhood. So unless we decide as a nation that primary care medicine is valuable and studies have shown that it is, it is going to be next to impossible to find someone like me to be your family doctor because although I, like most doctors, chose a career in medicine to "help people", it is also how I earn a living and I should be compensated fairly for my years of training and experience. The doctors who have stopped accepting Medicare (I still accept it) have made a business decision because in many instances it costs you more to provide the service than you are paid so you lose money with every visit. The bottom line is that the entire reimbursement system needs to be overhauled to better compensate primary care.

primary care

No mention of nurse practitioners in this article. Typical.

Study after study has shown that primary care nurse practitioners provide the same high quality of care as physicians do. Nursing education is focused on patient teaching and coordination of care - medical schools simply do not teach this. They also don't teach end of life care, and they don't help their students learn how to listen to patients. (They don't even do a good job of teaching their students how to talk to patients.)

Nurses see patients holistically - they look at their health, nutrition, home environment, family influences, cultural influences, income - they treat the whole person. And the cost for a nurse practitioner's education is considerably less than that of a primary care MD.

Until our medical system puts the emphasis on prevention instead of treatment, and allows the preferred place of care to be the home, school, workplace, or church instead of the doctor's office, clinic, or hospital, nothing will change.

Until we put the emphasis on healthy behaviors as a way of life, instead of expensive surgeries and medicines after the fact, nothing will change.

The old fee-for-service system taught us that doctors make lousy businessmen. Managed care has taught us that businessmen make lousy doctors.

Why not let nurses - the ones who spend the most time with patients and their families, the ones who are taught how to listen, how to see the whole patient, and how to coordinate care - run the show for a while?

We'll do it better and cheaper.

exhaustion

I have worked and worked and worked for almost two decades as a primary care physician. I have felt acutely the disrespect of hospital administrators and specialist colleagues. Seven years ago, I gave up on the private sector for good and went into military medicine. Eleven years after finishing my family medicine residency training, my husband and I had nothing in savings at all, just $17,000 of equity in a very old house, and two old cars that were falling apart. As an Army medical officer, I earn perhaps a fourth of what a civilian gastroenterologist earns for the same workweek. I still work 50 to 70 hours per week, and have to be ready to go to war, but at least I only have to see three patients per hour and we have some retirement savings finally. I'm proud of what I do as a patient-centered physician, but without the option of federal service, I would have given up in despair by now.

Prmary Care

C. MacLean RN:

Your diatribe against physicians is also "typical" for the discusssion presented by advance nurse practitioners. I am a physician who was a nurse first, so I have been through both routes and see both sides of this story.

I agree that nurses are taught to focus on patient education and to incorporate the entire bio-psycho-social model in dealing with patient care and management. But nurses simply do not study the same breadth and depth of knowledge of diseases as physicians do, period. I know, I did them both.

I also agree that society needs to focus on prevention and healthy lifestyles. But are you truly suggesting that just because I have the letters "MD" behind my name means that I do not advocate such healty behaviours as smoking cessation, weight control, exercise, etc. to my patients? Hogwash!

I am willing to review independent studies that show that primary care nurses provide the same level of care as physicians. But for someone never trained in medical school to state that medical students aren't taught how to see the entire patient or that they aren't taught to listen or talk to a patient is quite simply incorrect and only reveals self-serving personal bias. As an example, my resident physicians' conferences this month include presentations on the care of a culturally diverse patient population and delivering difficult news. There are rotations for medical students to learn hospice and end-of-life care (I took one as a 4th year medical student).

Also, my opinion as a physician educator is that the skill of communicating is more a part of the student's interpersonal skills he/she brings to the learning process and is not easily taught to any student. Put simply, it depends more upon the personality type of the student, not which discipline they pursue as to how good a communicator that student becomes in the professional setting.

So let me be at the front of the line in saying that nurses are wonderful colleagues in the teaching of patients and coordination of their care, but that does not mean that they have become the doctor. I know, I have been both.

Fixing the system

It's nice to see that the lay press is finally covering what we family physicians have been saying for the three decades I have been in the business: only comprehensive, long term disease management is going to impact the health of the population and save money. However, we have never been paid to do that. Every insurance plan is set up with a 1930's model of paying for illness. Even HMO's failed to fix the problem because in order to sell the plans, they had to tell subscribers they could see any specialist they wanted as long as we, the "gatekeepers," allowed them. The incentives were to do less for people.

The physician and in particular the patients should be incentivized to prevent problems. Why do we pay thousands for angioplasty and coronary bypass but almost nothing to prevent the need for these procedures?

As a family physician and geriatrician, I will commonly manage up to 15 problems in one visit. I get the same reimbursement for that as when I manage 3 problems in a 30 year old, but the complexity is far greater in a 90 year old. It's hard to convince physicians to do this when they can take out cataracts or do invasive cardiology and make 3-4 times more. So, if one day soon all Americans have insurance, there will be no doctors to care for them. It would be like all of us having cars but no gas.

The other issue there is little discussion about is end of life planning. 75% of Medicare dollars are spent in the last ten years of a person's life. We all must decide for ourselves when enough is enough rather than trying to extend another week or month of life when death is inevitable.

I have the utmost respect for nurse practitioners. I work with several daily and have been a nurse practitioner educator so I know what they can do. Our patients will be best served by a team that has an NP and a physician working together. Every day I discuss the management of some of the more difficult patients in our practice with my NP. Her training allows us to work together so I need not always see every patient. Without the physicians in our office, she would have to refer many patients to another specialist. That does not save money in the long run since we are able to manage about 90% of our patients' needs together. We are not in competition; we are a partnership.

If the system will help us in primary care to do what we do best and give us the means to accomplish it, we can fix health care in America.

LOST IN HEALTH CARE

I started my career as a Respiratory Care Practitioner, then applied to both Medical school and Physician Assistant School. Ironically, I got accepted into both.

I start this Summer in PA school in New York. I have choose not to go to Medical School just due to the decrease salaries and the increased cost. It would of cost me around 300k for medical school and taken me 10 years of education to me a Neonatologist to complete my goal. If I continue as a RCP, thats 10 years of an $80k salary minimum, thats $800k lost in salary at minimum plus a lost in regular daily activies.

In end, PA school would cost me $50k, average salary is 100k, and can still provide greatly in the health care system at a decrease expense.