txfp

Wow. I love your schedule of charges. My practice next!

I believe that one lets people treat the way they treat you. I am so happy to hear other physicians take control of the situation rather than working grumpy, being someone else's slaves, and complaining all the time. Charging for your professional time is the way to go. Which other profession requires you to sleep with a pager and talk to strangers at night with no reimbursement for it?

Well, regarding the original topic. Thank you for "pledging" $500. If 500 doctors (FP, internists, psychiatrists, pediatricians) pledge $500, we would have $250000 for the lawsuit. I have no idea how much something like this would cost. But I've looked at the website started by the residents who were sueing over the NMRP system, and they had over 10 lawfirms across the country representing them. So it sounds awfully expensive. It's too bad that they lost the lawsuit, but it did give way to the 80 hour work week. Hospitals around the country are employing more PAs and RNs to do the scut work that residents traditionally did when they were on call. So there has been progress. I am going to at least try to get in touch with the 3 plaintiffs who brought up the lawsuits and learn a bit more about their experience. Obviously I am doing all this on my free time so it might take a while, but I am determined to at least talk to these people to see if this is a viable idea.

At the end, our "lawsuit" may or may not happen. CaliMD is right--the ultimate culprit is the government. The issue, however, remains: why are primary care physicians unhappy, why are many people getting poor care, and how can we change it? All pathyways that I can think of that created the problem comes down to the principle of supply and demand. I think by far, the easiest thing we can do, is to control supply and demand of physicians. An corollary is that when people made a decision to become primary care physicians, they really had no idea about the reality, but were asked to commit the time and money it required to take on the task.

If it's the problem with supply and demand, and career education, well, we can't do much about demand, but we can control supply, and we can educate. In fact, we can do these VERY WELL.

Think about it. If we can organize as a legitimate and credible organizations of working physicians, who are adults, with or without children, leading real lives after med school and residency, we have a tremendous power in persuading future applicants to or against from our specialty. More then the Dean of Medical School, glossy brochures, academic faculty members, or anyone else with an ulterior motives to persuade people to go into primary care, we have the single-handed advantage to tell people what our lives are like, after medical school and residency, after having accumulated debt, after becoming fathers and mothers to little children, after passing our youth. This is our reality, and we are ready to tell our stories to those people who are in need to hear.

The concept would be the same as the FICO credit rating system. We will gather a bunch of benchmarks, and do Gallop Poll surveys of working generalists, and summarize these results for the lay public to see, on a real-time basis.
This information would be made available for the lay public to see. We can in addition form tasks groups to individually talk with med students, premeds, and residents, letting them see what our reality is really like. When people learn of our working condition, they will not want to join. The fewer primary care physicians, they more we have in terms have leverage within the system. The more leverage we have, the more we can advocate for patients and for ourselves. They can't just fire us and get the next warm body on the street called Stafford. Of course the government can loosen immigration and get foreign doctors on J1 visa, but that might create a public backlash in this country if the public realize that it is going on.

Without controlling supply and demand, we will always be at the mercy of others.

Yes, we have the AAFP, the ACP, the APA, etc, but these organizations are too removed from reality and from patients. They are in fact doing the opposite to what they should be doing. In order to increase membership, they recruit medical students and tell them what wonderful professions these are. These organizations have lots of jargons that most people don't have the time for. They also don't do direct consumer media marketing, which I believe is so critical in getting the message across to the public. If I ran the organization of consumer and physician advocacy, I would make sure that there is a significant percentage of our budget that goes into mass media marketing. Why do you think the pharmaceutical companies and the "1800-med-hurt" lawyers advertise on TV day and night? Because it works!

We need to educate our patients about what really goes behind medicine especially primary care. The most frustrating aspect of my practice is that patients have absolutely NO idea why they get only 15 minutes per visit. They have no idea why records are not available. They are clueless to know which are the good vs the bad doctors. They don't know that hospitals are awarding hospitalists groups that promise the shortest length of stay and the cheapest care per case. Of course patients have no idea how insurance companies play games such that the burden of payment is on the physician. Or, that EMRs are not subsidized and hence medical records are scattered all over the place between doctors, clinics, labs, and hospitals. These issues I feel, the patients must be educated. As a woman, I hate patching up problems with a bandaid, or brushing the dust bunnies under the bed, and I hate disorganization and inefficency even more. I think as women physicians, we can unpeel to the origin of the problem and clean HOUSE.

Great post, Doctorhope! You brought up some truly critical points. The perception of us by the public has certainly been tarnished over the past 15 years in parallel with the explosion of managed care. I think that we need to convince the U.S. population that we are on THEIR side. I found that I constantly had to remind my patients that I was sympathetic to many of their "gripes" about our healthcare system

You seem to suggest in your last post that by encouraging medical students to stay out of primary care that things will improve. One issue that you did not address in that equation, however, has been the ever increasing "substitution" of primary care provided by midlevels over the past decade or so. Some of the health plans on the east coast, I believe, have groups of NP's listed as primary care providers. When I was in group practice, management would often replace a departing FP with a PA or NP. Likely, then, the more MD's stay out of primary care, the more mid-levels will comprise the majority providers of primary care. For the most part, patients are generally pretty comfortable with the midlevels in primary care. In fact, many NP's are viewed as spending more time with patients and having superior "listening" skills. Management likes them, too. What I am getting at here is that I am suspect that a "boycott" of primary care by MD's will lead to significant change in that midlevels will be eager and ready to "step in". What are your feelings in this regard?

Anyway, great post as usual! I am truly thrilled to see these discussions here on MomMD -

CaliMD

Yes. This is a really big problem. I'm glad that we are being critical of our own logic and testing it.

Columbia University is offering a RN PhD track, precisely to produce nurse practioners who are one level above the regular NP status. When a student finish this program, she will have a PhD after her name. You can bet that she will be addressed as a Doctor. And if you think patients are confused about PA, RN, CRNP, or these physician extenders as it is, wait until you throw the PhD and the doctor title into the mix. If you think primary care doctors are miserable now, wait until when there are more people who are willing and ready to do our job.

I am not sure how this is going to work. The only thing that I can think is, saying to these folks, "well, welcome to our world." If RN-PhD, PA, CRNP start to practice independently, they may be forced to deal with the same issues that PCPs are struggling with now. Let patients sue them, let them carry the same amount of malpractice liability (although plaintiff and lawyer may be less inclined to sue a nurse with lower income earning potential than a doctor), let them carry overnight-holiday-weekend beepers, and let them see 15 minutes/patient and deal with the real-life consequence of substandard care. Pretty soon, these folks will realize that this is no bargain.

But there is one catch. I am sure the system will work it in so that MDs will still have to "supervise" these extenders. You know, get our signatures on everything, so that at the end of the day, we are still responsible for the outcomes of a system that we had no saying in creating. To me, that is the worst case scenario.

What can we do? Again, I think we can educate and alert future medical students and residents about this--yet another hazard of primary care medicine.

Despite of what we think of ourselves, primary care providers are seen as people who are the least specialized, but who are willing to do the dirty work of organizing messy medical problems for little money. I am afraid this is the way specialists see us, and this is how the medical industry/government see us. This is why people feel that a PA, RN, CRNP, or the future RN-PhD can replace us easily. In their mindset, how hard is it to treat asthma, obesity, depression, arthritis, GERD, colds, etc? It's not brain surgery.

What non-generalists fail to understand is that in medicine, individual problems are easy to manage, but once you've got multiple problems, the picture become complex and the total picture is not the sum of its parts. Specialists tend to deal with discrete/isolate problems, but generalists tend to deal with multilple problems that requlre multilple medications. Generalists need to figure out how to balance the whole picture. Not only that, many times the patients' symptoms are vague and not clear cut. You can't MRI or CT every symptom, and yet, you have to make sure that you don't miss a migh a catastrophic etiology. You need time, tact, and experience to realize the 5% of cases that are not straight forward. As if that's not enough, so many patients have psychosomatic symptoms or symptoms that present as an atypical syndrome that no one has every taught you in medical school. It's up to you to figure out whether the patient psychosomatic, or the patient has a rare genetic disease that every specialist has missed. As a primary care physican, at least a good one, you need to know a lot--about the advance of many different specialties so you can make some informed recommendations to your patients. I personally think it's harder to keep up with the literature as a generalist than a specialist. For all those reasons above, I think primary care is truly a specialty in itself.

The situation where patients praising RNs are more caring and listening is a familiar one.
I am frustrated by the patient's lack of understanding why that is.

The only thing that I can think of doing is going back to the drawing board and think how we can stop this trend: Educate the public. If we can get a main-stream massive public campaign going, explaining the necessary virtue of having board certified physicians being one's only primary care provider, we may be able to sway the public so that they make informed decision in picking a PCP, and hence, pursuade their insurance companies to provide PCPs. Not only that, we may be able to get patients to understand that you cannot talk about depression, or fatigue, or malaise, in 15 minutes. Patients will need to understand how their health care dollars are being spent, and why PCPs can only spend a limited amount of time to talk.

At the same time, while we are educating the public, we need to educate our perspective medical students and residents the threat of the emerging extender replacement and competition of our livelihood. Let them think thrice before joining this competition of low-cost care.

If we leave this alone to the wills of others, we let things slip right under our nose, and before you know it, we are dispensable, not only from our own competitors who are within our profession, but from other professions who should not be doing the business in the first place.

I disagree with those physicians who say, "Don't they know who we are? We are doctors! We deserve power and respect, damn it." I think the more realistic approach is to say, well, if the pharmaceutical industry, the health insurance industry, the legal industry, the automobile industry, and even the real estate broker industry actively seek consumer support, and government favors, then we need to do the same, and make sure people understand why health care is the way it is, and how it can be better.

By the way, I respect nurses tremendously. I just don't think PA or nurses are equipped to do what we do which requires a very specific type of training and length of experience.

The nursing shortage a few years ago has led way to improved working condition for nurses, and now the nurses are back in force slowly. The cycle kind of just went on its own, with the help of very vocal outcry from the nursing profession. Imagine if we can control the supply and demand of workers in our profession, how much more we get to say how people treat us.

I know I'm not supposed to post here as a premed (sorry) - just wanted to let you know that us premeds are listening - I've known for awhile to stay away from primary care - I've been warned from all angles - I've even had someone tell me to lie to get into medical school - to say I want to do primary care even if I have no intention to do so. I won't lie. Still I was surprised that this person felt so strongly... I guess that he felt that the schools were playing a game and he was just playing along. I would say that we premeds don't dare question the state of primary care - otherwise we are seen as not wanting to "work for the greater good of humankind". Maybe we'd be seen as money grubbing - not willing to be be truly giving. On a side note... physicians seem to be getting less and less respect - I don't usually go around advertising that I am applying to medical school.. but when someone does ask, and I tell them - I feel as though there is a distance created between us. Almost as if they are thinking - "isn't nursing good enough for you? If you really CARED about people, you'd be a nurse. You must be another greedy doc" - ok, so no one has actually said that to me... but I swear I'm picking up weird vibes. Ok - sorry for hijacking the thread.

doctorhope:

Great post, great topic, interesting insight. Have never considered many of the points you, and others, brought up regarding the lies we're told to get us to be PCPs. Have to say, I WAS warned by the physicians I shadowed while a pre-med; 90% said "Don't go into medicine, whatever you do" and this was the early 90s before managed care, pay for performance, etc really took hold in this part of the country. I remember thinking "Well I can do it, they might not be happy but I will be" because that's the competitive spirit, the drive that got us all into and through med school and keeps us going when it seems impossible to put up with more and more and more. Now, $100K in loans later, it's too late. I think I had chosen to put up with the status quo, but maybe not if this post generates more interest and really starts moving somewhere.

Thanks for the food for thought!

GracieThree said,
I remember thinking "Well I can do it, they might not be happy but I will be" because that's the competitive spirit, the drive that got us all into and through med school and keeps us going when it seems impossible to put up with more and more and more. Now, $100K in loans later, it's too late.


Graciethree,
You and I both.
When I was in highschool, I was told by a resident not to go into medicine. Then when I was in college I remember I was told by an older PhD biochemist, not to go into medicine. But guess what, I went into medicine. Somewhere along the line I got the idea that going into medicine is like climbing the Everest. You go for the burn and glory. You prove that you can beat out all the other premeds who are dying to be at the same spot. Boy, if you got into medical shool, you'd be someone. Your parents, friends, relatives would be so proud. You will be important and no one can say that you have not accomplished anything in your life. Think I am crazy? Look at the Premed board to remind us of ourselves.

For reasons that everyone else went into medicine I went into medicine also: stability, salary, prestige, ego, respect, intellectual capacity, competitive drive. On my medical school application, I wrote that I wanted to go into primary care, and I meant it. So I got into a primary care school. I actually chose primary care because it is it the most interesting specialty to me. Unfortunately, no one in medical school ever pulled me aside to say, "psst, stupid, think twice about primary care." I was naive to believe other people didn't go into primary care because they weren't good at it, or weren't interested in it. I thought doctors are doctors. How much difference in lifestyle can there be? Surely, there would be a system so ensure that there are day time, and night time doctors. Does the aviation industry let pilots fly during the day, and then answer phone calls from the control deck that night overnight, every 5 days or so? How bad can it be? Let other people make a quarter million dollars a year, but I was going to live a normal life and be very happy with $150,000/yr.

Now 7 years and $150,000 debt later, here I am, beloved by patients and employers, but wondering what went wrong. You might think that I am a disgruntled employee and am terrible at my job, but the opposite is true. I am one of the most popular internists because I am personable, and spend a lot of effort and time, regularly outside of the pay period, to practice what I believe is the kind of medicine that I or my family members deserve. But it comes to at a price of burn out for me. I am not quite there yet, but I can see it happening a few years down the line. I just keep on wonder, how do I get out of it? How do I go back to being a normal human being again who can sleep every night uninterrupted? How do I have a 40 hour week, with 20 minutes for lunch everyday. How do I not look at the clock and think, gee, how can I cut the patient off? How do I treat patients with kindness and respect even though I know in the back of my mind that they can come back and sue me and ruin me financially? How do I do everything that we are suppose to do according to evidence medicine, but still stick to the schedule of 15/30 minute schedule?

Is it that I don't like medicine? Or is it that I don't like the health care system that dictates how I can practice? I think it's the latter.

I am proud to be a physician. I don't think 97% of patients are asking for ridiculous demands.
I don't need to make more money. If I can see fewer patients a day, I'd be happy. If I don't have to fight with insurance companies and memorize all the rules about billing and payment, I'd be happy. If I don't have to give 40% of income for overhead mostly related to insurance paper pushing, I'd be happy. If I can get compensated for the time that I spend in filling out paper work, and answering phone questions I'd be happy. If I can sit down and talk to patients like a regular human being, I'd be happy. If there is a "no-fault" compensation fund, sponsored by all parties involved, that compensate patients who are harmed through honest human errors during medical care, I'd be happy. If I don't have to keep on working, simply because of my debt obligation, I'd be happy. I am not out to get more. What I want, is a better medical care system where I can deliver high qaulity care, without burning out myself, and without cheating patients and giving them as little as possible.

But none of my wishes are true. $130,000 sounds like a lot of money but so many of us are still shopping at K-mart and Target, wondering whether we would make ends meet. The paycheck after childcare, mortgage, tax, living expenses, retirement savings, and loan payments is not that much. My experience is so prevalent amongst PCPs that I work with, that I think wow, here we are, a bunch of really smart, caring, good-willed physicians who chose to do primary care, but are miserable. Why is that? The more I think about it, the more I realize that partly it was my fault that I didn't investigate carefully when I was younger. Partly, I think the government and academia push this fantasy of primary care on young people. In this way, it is like the credit card company giving out huge loan when you are young and naive, and then expect you to pay back much more years down the line. It is like the government going to the poorest parts of the country and give out brochures about luring young people to join the miliatry. That's fine, but the truth--the bad and good--should be said upfront. Otherwise this is irresponsible goverment and policy. Without advocacy for ourselves, for our patients, and for a control of supply and demand, for transparency of health care spending, the status quo is likely to continue.

Unfortunately, doctors cannot unionize--that's the law.

I'm not sure you're correct in saying that it's against the law for doctors to unionize. I was in a union as a resident. In Los Angeles the doctor's are unionizing...

http://www.aaem.org/unions/launion.shtml

Mya
I am not sure if physicians can unionize. I have been told by several lawyers and colleagues that we cannot.

There is an exception for residents. When I was one we happened to be one of the biggest residency programs that was unionized. But residents are not "physicians" per se? Is there a state by state variation on this issue?

Gotta look into this, but my suspicion is that we cannot...otherwise you would think we would have long ago?

I am so angry and so sad. I have been practicing for five years. And I have never been happy. Oh, there are certain moments that make me happy. But generally, every day, I am unhappy. I absolutely hate going to work every day. I hate nasty demanding patients. I hate that the government tells me what I am supposed to write in my notes or it is fraud that means I could go to jail. I practice a time consuming medicine not well suited to the treadmill-therefore I am a failure because I do not work fast enough. I am being sued by a two patients who are non compliant.

Since I have started practice- I have gained 50 pounds. I look in the mirror and I don't recognize myself. I like my home. My home life is good. I just don't know what to do anymore. I feel trapped by the medical student loans. The rape of medical student loans. I feel trapped and I am struggling to restructure my life in such a way that I am not trapped.

Doesn't it suck?!

Maybe, maybe not. Physicians have historically been a group of people who believe "to each his own." We are not used to working together, and getting polically involved on our own behalf. We are doormats, conforming to HMO demands, governmental demands, etc. Highly professional, high earning people tend not to unionize. Not a Republican way of doing things. We were the employer...not the employee. There was no reason for the older docs to feel the need to speak as one.

Up until recently, MDs were making very good livings...enough to not rock the boat. But now, we're being "raped" and must do something. In Nevada...things didn't change until the physicians walked off the job. Then, this cumbersome "legislative process" and all those "rules" were suddenly nonexistant. We are in charge of medicine...and it is our responsibility to take back control. And, until we do...we'll remain in our bent-over positions...waiting to be...raped again.

The only way to do this is to have one voice. Whether it's the AMA, or some sort of union-type of organization...

...one voice.