Doctors Vanish From View
Harried by the bureaucracy of medicine, physicians are pulling back from patient care
So does the ever ticking clock. Insurers, doctors say, keep reimbursements so low that it's not economically possible for a primary-care doctor to practice with fewer than a few thousand patients on the rolls. That's where the squeeze comes in--the average 17-minute office visit may not be sufficient to get enough information to diagnose the problem and talk about the ever growing list of health issues they're supposed to bring up, from screening for skin cancer to advocating exercise and a healthful diet to being alert to signs of domestic abuse or addiction. That doesn't even count time to answer patients' questions about drug ads they've seen or information they've researched on the Internet. "The average doctor sees 25 people a day," says Rachel Naomi Remen, cofounder of the Commonweal Cancer Help Program and a family and community medicine professor at the University of California-San Francisco (story, page 51). "I don't know how to say hello to 25 people a day."
A matter of time. Worse, those meager 17 minutes may be with a different doctor every few years, because when employers switch insurers, or people change jobs, their old doc often isn't part of the new plan. That's a real loss. When you aren't familiar with a patient's past care, it becomes difficult to track, monitor, and anticipate the medical needs.
Patients in turn feel less connected to doctors whose names they may not even remember; that contributes to eroded respect. "My father had a lot of health problems and was taken care of by a gentleman who was fairly old at the time," recalls Jeffrey Sartin, a 43-year-old infectious disease specialist in La Crosse, Wis. "My dad regarded Dr. Murphy as only slightly below God, and that awe and respect . . . is something I learned at a very early age. That has definitely changed. Not only are doctors not accorded respect, people are waiting to throw brickbats at them."
Sartin hastens to add that he doesn't want to return to the paternalistic days when patients were so in awe of doctors that they accepted their decisions, no questions asked. But some doctors are frustrated that while they have less sway with patients to comply with treatment, they have more expectations heaped on them to produce perfect outcomes and are left holding the bag when something--even something out of their control--goes wrong. Says Stephen Sokolyk, a cardiologist in New Braunfels, Texas: "We have the responsibility but not the authority."
None of these problems are going away, because the dismay of the elders has now trickled down to newly minted healers. "Even young physicians who come out eager and excited at the end of their training program encounter frustrations early on," says Jack Lewin, CEO of the California Medical Association. When Merritt, Hawkins surveyed residents to see if they would still go into medicine if they had it to do over again, those frustrations surfaced. In 2001,95 percent said they'd pick medicine over an alternative career. But in 2003--just two years later--that had dropped to 74 percent. "In my residency, if you had polled, at least half would have said that if they could go back to college they wouldn't choose medicine," says one new physician doing an endocrinology fellowship.
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