Where are all the nurses and doctors going?

Have you had trouble getting an office appointment with your doctor? When you finally get an appointment, how often do you actually get to see your doctor? And when you do, does your doctor seem increasingly stressed?

Last month, my physician friend said he was shutting down his office practice and taking a job as a hospitalist. He’s a great, caring doctor who also volunteers his time each week to provide free care on the Indian reservation. I asked why he was making this difficult decision, but already knew the answer before he confirmed it: He’d had it with the avalanche of bureaucratic paperwork and reporting regulations that requires several full-time office employees to deal with, insurers who all had different ideas on how he should practice medicine that weren’t always in the best interests of his patients, ‘quality’ measures that weren’t about quality, third-party payers who were reducing reimbursements and requiring more of his staff to continually fight just to get paid, and he couldn’t afford the 10.1% pay cut that goes into effect next month. Practicing family medicine no longer offered a viable future.

Lots of Americans probably don’t realize that doctors are getting their pay cut 10% by the largest single payer in the country — Medicare — reimbursements that are already often lower than the costs of providing the patient care. Nor do they know about the lobbying interests shaping the evolving healthcare system and the practice of medicine, as well as making these cost-containment reimbursement decisions. Many doctors know this is just the opening salvo into what it will be like for them to become employees under a single-payer plan taking shape. Nurses learned similar lessons years ago, hence, the severe nursing shortages. But patients don’t know what it will be like to be patients. As babyboomers face years when they most need healthcare, these issues will affect them more than ever.

This isn’t about doctors and nurses simply whining and wanting more money, this is about the ability to give quality care for patients and have rewarding careers in a viable, uncorrupted healthcare system. Special interests profiting off the current system aren’t about to complain. Hardest hit in this current controversy (besides patients and all of us) are the primary care doctors who provide the daily care to millions of us, say doctors. Medical students are going into better-paying specialties and family practice doctors are leaving the profession. Why? Brian Klepper at Healthcare blog offers a lengthy, but valuable explanation as to what’s going on from doctors’ perspectives.

Bad Medicine: How The AMA Undermined Primary Care in America

On Tuesday’s Wall Street Journal website, Dr. Benjamin Brewer describes physicians’ reactions to the 10.1% cut in Medicare physician payments that will take effect January 1. He argues that the onus will fall, once again, disproportionately on primary care physicians, who are already losing the struggle to keep their heads above water. He is right, of course. There is no question that Medicare must rein in cost. But…

American primary care is a shambles, and it is now clear that it will not be viable in the future unless significant changes occur in our national attitude about its value and in the way we pay for it. While, in other developed nations, 70-80 percent of all physicians are generalists and 20-30 percent are specialists, in America the ratio is reversed, the result of a payment system… evolved to reward expensive care… Medicare’s payment system, which is the basis for most commercial payment as well, favors specialists …

The career-choice implications of these financial dynamics are not lost on medical students, who have been diverted in droves away from what many apparently see as an unrewarding primary care office existence. Between 2000 and 20005, the percentage of medical school graduates choosing Family Medicine dropped from a low 14% to an abysmal 8%. Among Internal Medicine residents, an astonishing 75% now end up as hospitalists or sub-specialists rather than office-based general internists.

Of course these numbers beg several questions. Who will oversee care as the boomers enter their most medically intensive years? Who will keep up with the knowledge explosion and manage our individual patients and the nation’s health?... How did we get here and who bears responsibility for it? The short answers:

The issues and controversies are reviewed in his article, including a reference bibliography for more details. Addressing these issues, he writes, will be difficult in our “special interest-driven system,” but the American public needs to at least be made aware of what’s going on and what it means for them. As he writes:

But our Congressional representatives and the American people almost certainly don’t know these details. Most Americans and, for that matter, most health care professionals, are utterly unaware of the roles of the AMA and MedPAC in shaping the primary care crisis and our larger health system problems. Most believe the AMA speaks for all physicians… The most influential lobbyists – the AMA is one of Congress’ largest contributors, as are the drug and device organizations who sell to specialist physicians – appear to have the ear of Congress.

He goes on to examine some of the solutions being proposed and discussed among medical professionals that are unlikely to be reported in mainstream media. The comments from doctors are also enlightening. It offers interesting perspectives we seldom hear. He concludes:

One last observation. The background reading for this post reminded me of Jared Diamond’s great, cautionary book, Collapse. Diamond describes society after society in which leaders knowingly made decisions that undermined their survival. But they couldn’t course correct because the decision-makers were benefiting from the current circumstances. I wonder whether we’ll be able to avoid that fate.