Tuesday, April 29, 2008

New Doctors - New Culture

I attended a hospital retreat this weekend and the subject was how do we recruit new physicians into a medical community when they don't want to do private practice medicine? New young doctors want controlled lifestyle, guaranteed salary, benefits and predictability. The type of practice most primary care doctors have is just the opposite. We have no salary guarantee...you eat what you kill (pardon the awful metaphor). Patients don't get sick during predictable hours and there have been many years when I funded my employees IRA but there was no money left over to fund my own. That is just business "crazy" and the young doctors are smart enough to know that.

Today's article in the Wall Street Journal , "As Doctors Get a Life - Strain Shows" addresses this very issue. U.S. medicine is undergoing a cultural revolution that will change how patients receive care. It has already begun, with the emergence of "hospitalists", doctors who only work in the hospital and take care of patients who are admitted. The days of the family doctor meeting you at the Emergency Department and taking care of you in the hospital are long over. The hospitalist works by shift and when he goes off, another one assumes responsibility for the patient's care.

Young physicians do not want to take call. When they are off they want to be off. If they do cover on weekends, they expect to have weekdays off to be with family and friends. Young physicians do not want to deal with office employees or running a business. They expect a full schedule of patients to be there and an office administrator to deal with other business aspects like contracting with insurers, collecting payments and worrying about Medicare hassles.

The problem is that primary care practice and even some specialty practices have not been set up this way. There are thousands of practices across the U.S. that have aging physicians that want to retire or turn their loyal patients over to a new emerging doctor. The new doctors are choosing dermatology and plastic surgery as career choices (really, how much botox does America really need??). The number of doctors that choose primary care or general surgery as a specialty has plummeted and those few absolutely do not want to take over the old style practice.

Medicine is going to have to adjust really quickly to forgo a major shortage of caregivers over the next few years. Hospitals across the country are having difficulty finding doctors to take Emergency Department call. To counter this trend, hospitals are developing employment models for the new physicians so they can provide salary and benefits and office management.

In California, there is a law that prohibits hospitals and other corporations from employing doctors. Medical groups in Universities, Kaiser-Permanente and community clinics are able to offer real jobs and the new physicians are going for it. But that leaves the aging private practice physician with even more work, more call and no way to transition their patients when they retire.

In the meantime, I have about 15 people a month asking me to recommend a physician because their doctor dropped all insurance or retired. I have no names to offer.


Healthnut said...

I'm not sure if primary care doctors will even exist in the future. If they do, they will most likely work inside a Walmart, Target, CVS, or Costco. And it's not joke but a very likely trend. Already we are seeing the retail sector aggressively getting into outpatient care. By 2010, Walmart is predicted to have over 400 clinics. Walgreens, CVS, Target, and Costco are expected to follow similar suit.

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Anonymous said...

If that turns out to be true in the future to only have Primary Care Doctors in places like
Costco, Target and Walmart it would be not only very sad, but extremely disrespectful and degrading to their education, training, knowledge and profession. I hope it never comes to that!

Linda Cole Leighton said...

That would be so tragic!! We need our good doctors, like Dr. Brayer and my own doctor here in Tucson, Dr. Mariali Garcia.

Jonathan said...

Is part of the problem simply that while we have a growing population in this country, the number of medical schools, graduates, and residency programs are fixed?

Said in economic terms, do we face an increasing demand for physicians while the supply remains constrained?

If this is indeed the case, then I suggest that, generally speaking, the overall quality of medical care can only go down.

Doctor T said...


You are right about this trend, I am living it. I am an internist 3 years out. Joined a very reputable, succesful, IM practice in the town where I trained, and sacrificed two years of my life for next to no pay, no time with my (3) kids, and nearly wound up divorced.
Made the jump to a hospitalist job 30min way about a year ago. Now, 15 scheduled shifts per month, no call, no nights, marriage and family in-tact (even traveled some together this year) and for all of this... a 40% pay hike and BIG signing bonus.
Impossible to argue with.
Dr. T

Cynthia Chiarappa said...

I saw an interesting license plate holder in the physician parking lot this morning. It said something to the effect of "No cash on board. This is a doctor's car." Times sure have changed!

Toni Brayer MD said...

Jonathan: Medical schools are expanding and particularly, osteopathic schools are adding slots so we will be training more doctors overall. There is a disconnect, however because the residency slots are not increasing. Keep in mind it is a 10 year cycle to get more doctors into communities. There is also a maldistribution in specialties, so without incentives, more doctors does not solve the primary care issue. The problem is well described by Doctor T below your comment.

Cynthia C: Yes, times have changed for sure.

winlotto said...

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pcsolotto said...

Thanks to the blog owner. What a blog! nice idea.

Anonymous said...

So, You Want To Be A Doctor…..

Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason believed and speculated by others for this decline of this health care profession specialty that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training, as the annual salary of a PCP is around 130 thousand a year on average, others have concluded may be the national average and factors in payers both of a private and public nature.
Yet considering the additional attention of shortages of students in some medical schools as well, as conceived by others, one could posit hat this professional vocation that has been one viewed in the not so distant past in the U.S. as one with great esteem and respect may not be desired as a vocation by many, that requires commitment and dedication, as reflected in their training regimen in the U.S. that consumes about a third of their lifespan. Such reasons for this paradigm shift may include:
Primary Care Doctors perhaps more than other physician specialties seem to be choosing to practice medicine under the direction and financial security of one of the many and newly created health care systems These regional and nationally created systems are typically composed of numerous hospitals and clinics under combined ownership- frequently of a private nature that is not dependent upon their beliefs as it is perhaps on their profit motives and intentions. Yet their approach and etiology of their views regarding the restoration of the health of others are usually similar with such mergers of multiple medical facilities, which are presently preferred to save costs, it has been said, and therefore these systems have not been protested by a largely uninformed public.
Conversely and in addition, this system of increasing popularity is not necessarily a desired method to practice medicine as a primary care physician, often stated by them as members of their employer that has the power to limit and dictate how they practice medicine. This is because, among other reasons, such doctors have largely unexpected and unanticipated limitations regarding their patients’ heath provided by them. This is further aggravated by possible and unreasonable expectations of their employer, such as mandating that doctors they employ are required to see as many patients as theycan in a day, and there have been cases of physicians being fired by a health care system- along with financial rewards for seeing more patients a day than what is determined as average visits by others. Such requirements likely and potentially affect or alter the clinical judgment determined by physicians employed in what may be viewed as authoritarian employers, which would limit the medical care they provide to their patients, as well as the quality of this care. Also, such health care systems may have their own managed health care system that may be determined by factors not in the best interest of the patients of doctors employed by the health care system.
The primary etiology and stimulus for a doctor to practice medicine in this way is due to their frequent inability to provide and employ ancillary staff, combined with the increasing premiums for their mandatory malpractice insurance, which may make doctors financially unable to work independently.
Malpractice laws and premiums, which is determined in large part on a state level, are an issue with those required to have this adverse aspect of their professions. Also, these premiums become more expensive for doctors, depending on the perceived risk of their chosen specialty. For example, the premiums of an OB/GYN doctor are usually higher than one of a specialty viewed less risky for lawsuits, such as Dermatology, perhaps.
In addition, the issue of medical malpractice is also frequently a catalyst for a doctor to practice what has been called defensive medicine, which basically means that the health care provider is prohibited from relying upon their subjective factors in their assessment of their patients, which in itself raises the question of what the point was of all of their training in the first place. Because if a doctor practices medicine in such a way, it typically involves what may be considered as unnecessary diagnostic testing for their patients to rule out what may be unlikely disease states of their patients’ medical conditions. This waste of medical resources is further validated by the legality reflected in the tone of the notes a doctor usually annotates or dictates with their patients.
Such restrictions and limitations imposed on today’s primary health care provider are usually not fully illustrated during their training for this profession, which is one that has been viewed as one that is quite noble and of great responsibility on a societal level. It seems that this perception and vocation that now is greatly misperceived due possibly to being deformed by others who may have profit as their motive for the health care they may dictate to doctors they may employ in some way, which often and likely is in conflict with their motives as doctors and how they wish to deliver needed health care to others. This may be why this medical profession may no longer be viewed as distinct from other vocations, in large part, as it seems that presently the profession of a doctor has been reduced to one dependent on the financial stability and growth of its employer, which may alter how the doctors perceive what is expected of them as well, which may affect the importance of how they view their profession, as it has been said that overall, doctors are somewhat understandably more cynical and demoralized, which may be replacing the pride they historically have viewed their callings as doctors, as well as the perceptions of patients in the U.S. Health Care System.
Further complicating and vexing to these restrictions is the usual financial state of the individual physician, as theynormally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed, it has been estimated, along with this debt amount presently is about 5 times higher than it was only a few decades ago.
Conversely, there are some who believe that doctors in the U.S. are over-paid and are compared with some corporate monster, who behaves based upon the premise of greed. In spite of how they are judged, physicians are likely not absent of financial concerns- which may be of more of an issue than many other professions, comparatively speaking, in addition of taking on more responsibility that is of greater importance compared with other vocations. Such realistic variables should be factored in when one chooses to judge the profession of a physician. On the other hand, no physician should view their jobs as no different from any other venture capitalist when rationalizing their income and motives related to this exceptional vocation as a physician, as others are more dependent on their judgment.

It has been determined by others, and suggested often and lately, that many of today’s physicians practicing medicine in the United State do not recommend or speak favorably of their professions compared with their typical views of their profession in the not so distant past. While this self-perception physicians may have of a negative nature may be somewhat understandable it is also and potentially unfortunate for the health of the public in the future, and the nature normally associated with the medical profession which could deter ideal medical care for others
There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state perceived by themselves as well as others of their profession as medical doctors.
Then again, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession in relation to how their vocation is viewed by others and based on limited judgment and analysis. Yet citizens overall should determine what sort of health care they desire, and it seems that often they fail to voice this right as a citizen.
For perhaps Primary Care Physicians in particular, the medical profession and those who provide medical care clearly needed by others to some degree appears to be absent as a desired path of today’s careerist. The authentic reasons for what many believe to be a negative perception of possibly the entire health care system may never be known, yet many would agree that most U.S. citizens are understandably concerned with the state of this system of great importance to society. Yet need to be active more in assuring this necessity is more aseptic.
“In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero
Dan Abshear
Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.

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