Physicians

Bitter doc wants more respect for primary care

A primary doctor ranted anonymously this weekend on Kevin MD’s blog about the lack of appreciation for primary care in his small Midwestern town and predicted its future demise.

The doctor practices in a medical shortage area, where the hospital administration has failed to sufficiently recruit and retain hospitalists. Here’s a portion of what he wrote:

"Not surprisingly, the recruitment and retention problem hit the hospitalist program simultaneously. Three hospitalists are now expected to manage 24-hour coverage with no relief in sight. And instead of offering the degree of compensation necessary to bring more physicians on board, the administration exploited the sense of crisis to convince the medical staff to consider opening the doors to Advanced Practice Nurses. This was the only solution, we were told, to the hospitalist shortage. The only way to stop taking extra call for free.""At this meeting, 100% of the subspecialists voted for allowing APNs to practice in the hospital. 75% of the primary care physicians dissented. The vote was overwhelmingly in favor of the measure. This happened in a system where some primary care doctors are making less than they would if they took a new position in a major city, and more than a couple subspecialists make seven figures. The abandonment of the greater medical good by our specialist friends eager to expand their already-overflowing coffers has filled me with renewed vitriol."

His rant has struck a chord in the medical blogosphere.

The Physician Executive wrote this response:

"Many U.S. doctors feel that primary care is the choice of students
with no other choice. Even Canada’s social conscience cannot mask the
prejudice entirely. … It is a nearly universal phenomenon in a world
where progressively greater expertise gets more respect than being a
generalist. Why else would family physicians so urgently proclaim that
they are specialists and not generalists? Paul Starr characterized
physicians as inveterate social climbers. A disregard for fellow human
beings, especially well-educated colleagues, is a hallmark of the need
to climb a social ladder."

"Medical science at the turn of the last century had so much
promise. As a profession, we are accountable, but we lost our way
during the 50’s, 60’s and 70’s. Medicine got more technical, more
complicated and we forgot that William Osler human ability to listen to
the patient’s story and consider the context of a life before
recommending treatments. We did not meet the expectations of many
stakeholders, no matter the fact that some of those expectations were
unreasonable to begin with. Some of us sacrificed the profession’s
autonomy and its beneficent role in society, with full wallets and a
family legacy, but not much else."

Are these just angry, bitter doctors, or are they being honest about the dismal prospects of primary care? People speak in platitudes about reforming the physician reimbursement system to value primary care, but if the reality is that the medical community views primary care as "the choice of students with no choice," any reform is dead before it has begun.

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  2. I am the very proud spouse practice manager of one Family doc, PCP and you guys just blow me away.
    It is just amazing how much all you specialists seem to disrespect the primaries who feed your practices their daily bread. It sure has been interesting sitting here on the wall like a fly hearing you all throw your trash around. You should all be ashamed of yourselves.
    And then to pass judgement on these same folks who can’t afford to pay off their med school debts, care for their own families or afford to slow down on the hamster wheel of a system has put them on is just even more shameful. It is so easy to sit there and pass judgement on others who have had to make hard choices just to survive while some how attempting to keep their doors open every day to care for all the patients that you guys dump back into our offices each and every day. I can not count so high as to tell you how many times our patients call our office to explain what you guys have supposedly done. You just want to be Marines, get in and get out and damn if the patient doesn’t understand anything or has five valid unanswered questions. But our primaries should spend half an hour on the phone for FREE explaining what your stuff means?
    I have a speech set-up now. “yes Mrs. Smith that is a great question. No I don’t know for sure why he ordered that test, but you should call him up and insist that he explain it to you. He is the specialist, this is his job, he knows why he order those for you. I’m not sure what he is trying to rule out, prove or disprove with any given test. Make him do his job. You are the patient and you have a right to know these things. No I don’t know what all the risks are involved with such a test or what the risk benefit balance here is. Again Mrs Smith you should ask your doctor, he is the specialist and he order these things.” I am sick and tired of all your lack of care, get ’em in and get ’em out. Real ethical there guys… those who live in glass houses.
    It is so easy to judge others when you and your friends have controlled and set up a system of payment that WAY over pays you for “procedures” while it doesn’t value worth a darn the hard work that many “office visit” based practices do. The RVU system stinks and specialists and the AMA have made sure it stays that way. But you think you can sit and judge these primaries many of whom can no longer afford to keep the lights on in their practices, pay and retain good staff, buy new equipment, fix and repair or update their computers while you are choking on your food because your mouths are so full… Shame on you all.
    When is the last time any specialist said, ya know I get way too much for some of these procedures, I think we need to bump office visits instead. And if office visits are worth so little and PCP’s know so little, I want to see any of you balance out the meds with a restrictive formulary for a senial senior who needs drug for that who also has hypertension, bad lipids, DM and a host of other issues to boot while informing their family of all these things and the staff at the assisted living place or the ER keep sabotaging your efforts every chance they get. And all for under a hundred bucks a 40 minute visit paid for by the idiots at CMS! Then we’ll see how smart you bozos really are. PCP’s make more calls in a day then most of you make in a week. Shame on you.
    And it is not just PCP’s or patients you guys hurt with your over control of the RVU’s for procedures verses office visits and other E&M codes. There was this great endo group that we all loved. Yes my wife is really good at caring for DM, but there are one out of 10 or 20 patients that we just can’t control and so those patients we refer out. And many times it is the fact that many patients just like addicts have to hit their own personal bottom before they will find religion as I put it and finally really change their lifestyles, eating, shopping, exercise patterns and the like. Frequently it is the referal to the endo group that finally makes it hit them that they are on a path of no return and that they better get with it. Sometimes a referal has little to do with what the PCP can or can not do, it is the patient that is getting in the way.
    Anyway this great group that gave these wonderful long visits and work up and a ton of other good stuff went broke! They lost $300k dollars proving great care for patients that really needed them because you speicalists need to protect your own gravy train at any and all costs. It is because of the broken RVU system that you specialists and the AMA protect for your greedy selves. It doesn’t matter that saving most lives and body parts happen in a PCP’s offices, that this is where the rubber really meets the road, the truth be damned, you guys need a third house in the Hamptons or an extra sports car.
    We will pay you guys $2500 to chop off some poor patients leg from diabetic neuropathy but we can’t seem to pay hard working, caring PCP’s worth a darn to save that leg in the first place and keep this patient as a product tax paying citizen instead of some poor disabled schelp on social security, Medicare and Medicaid for the rest of his life. Meanwhile we drive around in a rusted out 188K miles 10 year old Jeep and can’t afford a new car like the school teachers we care for every day. I challenge anyone of you to come see my falling down fence that no longer can contain my dog, my failing roof or my rusting out Jeep. Don’t even dare ask me if we have saved a dime for ourselves or our children’s future because that is just a cruel joke. Shame on you all.
    Now granted I think that you guys are but small change to all the waste in our present system with Big Pharma and the Insurance Carriers needing to be held the most accountable for their misdeeds and blantant greed. But you guys are right up there with them that is for sure. I want to see the major carriers and the corporate officers go broke providing care for patients, I want to see the GE, MidMark Ritter, NextGen, WA, and a host of other vendors price controled the way PCP’s are, I want to see Big Pharma just barely break even with their expenses cut to absolute zero just to get by every day. Then we can all talk about PCP’s that the entire country should be thanking for doing what they do, dragging their butts out of bed, knowing they are just going to be hit again and again every day; for holding down the fort inspite of all this endless greed and wasteful spending that never seems to trickle down to any of them.
    Keep digging your own grave here gentlemen (I use that term very lightly here). Hopefully one day soon you will all get what you deserve… The pay and respect of the average hard working PCP who has more ethics in one pinkie than most of your have in your entire bodies… I wonder how you will be judged when you meet the ultimate judge of character… I think my wife and those great endos will do just fine, but as for you….

  3. I am a board certified Family Physician who is changing from her third-party-payer-dominated solo primary care practice into a low cost, low overhead, direct practice, where patients pay me directly for their care along with a low monthly fee (less than 1/2 pack of cigarettes per day).
    I agree with Dr. Malpani, MD. Unless individuals take responsibility for their actions, inactions, choices and daily health, pain and sufferring from many preventable ailments will continue to spiral out of control. Paying a monthly fee is one step in taking responsibility for the direction of an individual’s health.
    I have recently opted out of all third party payment schemes, lowering my overhead significantly by doing so. This will allow me to take on more patients who do not have financial means to pay than I ever could when Medicare and other third party entities were dictating to me how and when I lost money and preventing me from providing true indigent care to members of my community who need it. (It is illegal to write off Medicare coinsurance amounts or to offer certain individuals in your practice free care when not offerring free care to all Medicare recipients in your practice.)
    Now, instead of going to CME sessions on how to get paid, I will be able to continue more indepth study on the issues facing my patients TODAY.
    I disagree with rbar that concierge medicine is “unethical.” What is unethical is how healthcare is paid for in this country.
    I challenge that health care is not expensive, but the payment system in the US for health care is unsustainably expensive and completely unethical. (Help me understand why a CEO making millions of dollars managing the profit margin of an insurance company is ethical. What has any insurance company done for anyone in the name of their subscriber’s health? Doctors provide health care. Insurance is supposed to pay for the health care provided, not judge, block, increase costs, etc.)
    I challenge all physicians to consider their ethical duty to their patients. Is participating in a system that clearly does not have health care of our patients as its main focus ethical? Is it ethical to participate in a system that is actually harming many individuals through endless prior authorizations and blocking of care in the name of “cost savings,” but actually only results in increased cost (cost shifting)and increased harm to patients?
    Health insurance companies are in existance to make money, as stipulated by their shareholders. Medicare is a political tool used by Congress to wield political agendas, not to provide sustainable, cost effective health care payment to help society contain costs and be healthier in the end. Our patients get lost, and hurt, in the unnecessary struggle.
    Going to a concierge model may not be the answer for every patient or every physician in the US, but questioning the ethics of the system is imperative if we truly want to uphold our ethical duty to our patients.

  4. My brother graduated number one in his class from one of the top med schools in the country, became an internist, and spent his entire career as a primary care physician. Full, proper, and accurate diagnosis of patients presenting with subtle, mixed signs, symptoms, and a wonderfully varied history is as challenging as any esoteric specialty in medicine. Actually, it’s more challenging, in my opinion. And informed, careful, experienced, complete and precise initial diagnosis (and follow-up) is the number one key to good patient outcomes and quality of health care today. Find out what’s wrong and what’s right and do no harm. Think that’s easy? That, and preventive medicine, is the most important job, and the most challenging job in health care. Period.
    Our society’s priorities are skewed. Why have nurses always been paid less than mechanics? Why are nurses replaced by superficially trained “technicians”? Why are early child care providers and those providing daily, intimate care to our “honored” elders among the lowest paid people in the USA? Why are certain medical sub-specialists paid and respected much more than are proficient primary care diagnosticians?
    Why would my brother, a top-of-his-class doctor, become a primary care physician, running a clinic attached to one of the few surviving county general hospitals? First, because many years ago he recognized our nation’s skewed priorities (which have only become more distorted, since). Our society’s medical apparatus places a much higher priority on developing new, esoteric, highly expensive and profitable, rare medical procedures, and on cornering the market on those procedures, than it does on effectively and widely distributing proper, needed, basic, comprehensive, well-proven and established medical care to the people. Second, because he recognized the importance of the best doctors and nurses bringing their skills and intelligence directly to primary patient care, where it was (and is) most sorely needed. Third, because he acted accordingly.
    It is up to all of us, now, to place “caring” and “health”, instead of “marketing” and “profits”, in charge of Health Care. We need to see that this honorable and hallowed profession, older than civilization itself, serves people’s needs, not corporate profits. The Health Care profession has been serving humanity for thousands of years. Corporations have only appeared and become dominant in the last couple of centuries.
    Doctors and nurses that serve on the front lines earn and deserve the greatest respect, and the highest rewards.

  5. I think the basic problem is that patients expect their doctors to do everything for them ! There will never be enough doctors – either PCPs or specialists – to meet demand for medical services. This is because doctors create demand for their own services !
    Until patients learn to manage their own medical problems – and to manage their doctors – we’ll never make any progress !
    Dr Aniruddha Malpani, MD
    Medical Director
    HELP – Health Education Library for People
    Excelsior Business Center,
    National Insurance Building,
    Ground Floor, Near Excelsior Cinema,
    206, Dr.D.N Road, Mumbai 400001
    Tel. No.:65952393/65952394
    helplib@vsnl.com
    http://www.healthlibrary.com

  6. Anonymous, you may be entitled to be proud of you medical skills and your practice management … but being the apparently very well paid concierge doctor for few very well off is, in my personal opinion, not particularly laudable from an ethical perspective.
    Almost everyone (and I include myself) likes to be well paid, and I do think that physicians, burdenend with long and costly training and usually also with a lot of on call duty, ought to be well compensated. But in a country where 45 million have no health coverage, I find such a selective practice model nothing to boast about. I could understand your point better if you phrased it like “in order to feel fairly compensated and have good working conditions, I chose to serve a selected few, although I understand that this model, which serves me and my patients well, is not a model that can work for everyone.”
    “Although I do not live in an especially affluent area, my patients are obviously well to do and became that way through an appreciation of the value of money.”
    I would dare to say that a lot of people appreciate “the value of money”. From a physician, I would also expect some appreciation of other values, such as compassion and consideration for people who suffer from illness but who may not be able to afford medical care.

  7. As a Board certified Family Physcian who practices as a concierge, 100% private pay physician, the best evidence that my training is adequate and my knowlege is valued is that my patients are willing to pay me out of their own pocket for my services. Though my services are fairly traditional ( I do not, for example accompany my patients to specialists to interpret), I have been turning away patients for years, all the while raising my fees. I have still not found the maximum price point associated with my services. Although I do not live in an especially affluent area, my patients are obviously well to do and became that way through an appreciation of the value of money. I make more than most of the subspecialists I refer too, even though their income is inflated via collusion through the RUC.
    I recognized early on that the RUC has fixed the game against primary care and opted out of the system. With the relative oversupply of proceduralists, I wonder what would happen to their income if they had to float in the free market.
    There are a different set of skills required to take the responsibility to ethically “quarterback” a patient through the system. I suspect Andy’s arrogance ill serves his patient in that regard. Just because he doesn’t know any well trained generalists, there must be none. Quite possibly, the excellent generalists recognize his disdain and avoid him like the plague, because he is so arrogant……..they recognize such arrogance dramatically affects the quality of the patient’s care. Most generalists are very well trained for what they do, they just don’t want to associate themselves with Andy
    The current price fixing in favor or procedures cannot last forever. As the third world becomes more affluent, it will be harder to strip them of their primary care physicians and a significant number of patients recognize that ancillary care providers such as NPs lack the professional confidence and stature to advocate for them and do not always have the skills to differentiate between illness and the worried well. I hope those who rely on these artificially inflated rates are saving their money against that inevitable day. It’s not going to be pretty.

  8. I absolutely agree with rbar. Training probably needs to be expanded to at least 4 years. I believe that there are some nascent “general medicine” fellowship programs out there. Certainly my IM training left me quite capable as a hospitalist, but I’ve done a lot of OJT since then.

  9. Me also agree that lack of health knowledge leading to the use of specialists that will drive medical costs higher and result in the unnecessary use of the procedures that specialists specialize in.

  10. The good point Dr. Bourdain made – I otherwise disagree almost entirely with his (somewhat bitter) post – is that the training of generalists and all PCPs could and should be improved. All PCPs should have short rotations and practice relevant exams in all or most medical subspecialties plus ortho, neurology and maybe psych as well as longer rotations (e.g. as electives) into OB and peds if they choose to later practice in these areas as well (obviously, gen. IM PCPs should do mainly medical subspecialties and Neuro rotations). The specialty rotations should not be just a grossly truncated version of what the specialty residents get as it is right now) … they should – by patient setting and didactics – focus on PCP relevant issues:
    -being very familiar with common conditions that are, if properly manged, not risky and routine … and how to manage those
    -being aware of the specific warning signs that indicate that a problem is not PCP routine and needs hospitalization or referral
    -having a better idea what radiologic and laboratory tests are good for and when to order them, and how to deal with common abnormal results
    -health education + patient motivation
    -PCP management of the challenging patient
    Sounds like being too much? It should be doable in 4 or 5 years (it currently is 4 years for FP and gen. IM if you count the internship). But the focus of training needs to be different. PCPs don’t need to know too much about dilated cardiomyopathy, ALS or SLE, but they have to pick up the warning signs and send the patient the right way. PCPs should know a lot about diabetes, carpal tunnel syndrome, hypertension and steroid treatment. The US already have a relatively tightly regulated graduate medical education system. A well designed rotation- and exam schedule would produce excellent generalists. The (very many) good generalists we already have are good because they can compensate for deficiencies in the PCP training by being alert, watchful and having comon sense … but we need grad. med. education that reliably produces excellent PCPs, PCPs who subsequently will be well respected and who ought to be well compensated.

  11. Docanon hits it on the head. How often have we encountered an older friend or relative who has become the victim of being treated by multiple (but very talented) specialists? It only gets worse if one or more of those talented specialists is a bit aggressive about making a buck. I am not a doc but am pro-doc as I think most docs do bust their tails and want to do right by their patients. The compensation system arguably should acknowledge specialties in some ways, but clearly is way out of hand. Procedural medicine is not always complicated medicine, and if you throw in the opportunities of some specialties to cash in on diagnostics, the compensation balance falls completely apart. You guys should learn to get along, and appreciate one another.

  12. I pretty much had my choice of subspecialties as a resident, but I chose — for multiple reasons — to be a generalist. I currently have several retired physicians as patients too….
    A lot of acute and chronic conditions can be more than competently managed by generalist physicians. This week I saw a new patient. She had recently moved from the east coast where she saw an endocrinologist for her hypothyroidism, a gastroenterologist for her IBS, a rheumatologist for her fibromyalgia, a gyne for her menopause symptoms and yearly post-hysterectomy Paps (benign hys!), and a pulmonologist for her BOOP (okay, so that one is exotic, but the treatment is still a pile of steroids followed by a taper). That is just a waste of money and time.
    In Europe 70-80% of docs are generalists and in the US 70-80% of docs are specialists. There is fairly good data to suggest that the improved outcomes and lower costs of health care in Europe are at least partially attributable to the better access to primary care. In the US we see similar trends in comparisons of large, specialist rich, metropolitan areas to more rural areas. We need specialists, but we don’t need them to manage the majority of patients.
    Decreasing procedural compensation and increasing primary care income would help, but I think that you also have to decrease the number of specialty training slots. Training graduate physicians is expensive. The number of trainees is controlled by state legislatures and the federal government. As a society we are paying an awful lot both in direct costs and loss of potential generalists by allowing too many medical graduates to train in specialties.

  13. It’s really not fair to pick on a post as ignorant as Andy Bourdain’s. Poor guy…seems never to have met a competent generalist. (and as long as he’s making sweeping judgments, perhaps he’d like to enlighten us on this thoughts concerning other categories of people)
    Rbaer is right on the money…the uncoordinated zig-zag is a real problem. I’ve seen this too many times in my own clinic. A patient comes in–usually at the urging of a family member at wit’s end–with hundreds of pages of medical records documenting the sad, sad path of uncoordinated care. Dozens of specialists, duplicative imaging and labs, unnecessary procedures, clearly erroneous diagnoses treated with toxic drugs…it just goes on and on, snowballing with each adverse reaction and procedural complication.
    Two typical examples: Mild iron-deficiency anemia treated with prolonged courses of IV iron (far be it for me to ascribe a financial incentive to the hematologist whose office dispensed that one!), and the cardiology visit where the initial diagnostic workup–without any evidence of neurological activity localizing to the frontal lobes–consists of a 1. coronary CT, 2. cath, 3. referral to an internist to figure out why the patient might have chest pain after meals. The cardiologists I work with are a very professional and competent bunch, but boy does their specialty need to do some serious peer review.
    But back to the patient in my office…so I sit there, read all this stuff, actually examine and listen to the patient, and for the first time ever give him or her a clear, coherent, and complete picture of his or her medical situation. We eliminate half the erroneous diagnoses right off the bat–just by cross-referencing test results and having modicum of clinical confidence (must be the result of my “ill-trained” years of med school and residency). We cut out the needless, harmful meds, and we lay out a rational, stepwise approach to figuring out and treating what’s actually wrong. Specialists (that I choose based on how they’ve done with prior referrals) play their role as well, but all communication goes through the patient and me. Never another duplicated test, if I can help it. My beeper is always on, and if my patients remember to call me, they don’t have to go to the ED on weekends if we can safely wait until my next session.
    This is the reason I went into primary care…not ordering screening tests or providing routine care to basically healthy people: you don’t need a medical degree to provide those services. But what I’ve described here isn’t easy, takes considerable time and brainpower, and _does_ require some real medical talent. Diagnostics and care coordination are, in my opinion, the most intellectually demanding tasks in health care…and these also happen to be the lowest-paid, per neuron fired. Many procedures, which tend to be compensated in an economically irrational manner, can be done by non-MDs. Why on earth would the skills required to perform a competent routine screening colonoscopy require more than 3-4 years of training after high school? (after all, gastroenterologists largely conclude their endoscopy training after just 1 year of hands-on experience…and a tech could be taught not to order a ceruloplasmin level as part of every initial workup for elevated transaminases)
    The low-tech solution to uncontrolled health care costs and inconsistent quality of care is to beef up the primary care workforce. Though it might be considered uncouth to say this, the easily way to accomplish this is through increased payments, relative to procedural specialties. Increase Pcare incomes, or decrease procedurist incomes…I don’t care which. England’s NHS has shown a way to do this (albeit accidentally), and look what happened to the numbers and qualifications of med school grads going into primary care.

  14. Agree rbaer. The lack of health knowledge leading to the almost exclusive use of specialists will drive medical costs higher and result in the unnecessary use of the procedures that specialists specialize in. If you want your knee operated on see a knee surgeon, if you want your back operated on see a back surgeon, as that is what you will get because specialists don’t make money NOT doing what they do. The best diagnosis and least cost treatment may not be seeing a specialist but a good GP. Unfortunently again money is driving this system, not healthcare.

  15. As one who has practiced in both an academic setting and as a sub specialist in a rural community, I can offer the opinion that the plight of primary care physicians in the medical social/political hierarchy begins with their training. They simply are ill-trained. One to three month rotations in many specialties do not make them specialists in anything. They dont have the medical judgement or the medical knowledge to care adequately for the sick. They survive only because of the fact that most people who go to doctors are either not sick, or have illnesses from which they will recover whether they see a doctor or not. The problem is further exacerbated with their colleagues by their own insecurities. They tend to hold on to every patient that comes through the door during office hours, but all of a sudden become totally stupid and refer everything out after hours and on weekends. The fact is that the*family physician* is a warm cuddly term that in fact was an ill-conceived concept designed to fill gaps in rural medical care. The training is attenuated and the result is a physician who is simply not prepared to make sound scientific judgments in the real world. I do not know any sub specialist who would himself put his care in the hands of a Family Physician. The medical schools have to do a lot better if this situation is going to change.

  16. Without PCPs, many more patients would be lost in a zig-zag path through the heart centers and outpatient surgery mills.
    I believe the medical community (and later the general population) has to change their attitude towards PCPs. They have to value the PCP as the generalist who knows a little about everything, oversees a patient’s healthcare if specialists are involved, and who will be the first reponder to mild symptoms that may be benign but actually can indicate a serious problem that may be better treated if caught early. The specialist has the luxury of knowing more about certain conditions while largely ignoring everything else. But in general, the degree of specialization is not the prerequisite for high status – think of CEOs who should not only know their company, but have an idea about the whole market. Or think of high level administrators.
    While status and attitudes matter, the value of the PCP should be reflected by fair compensation. There is certainly no reason for some subspecialists to go into the 7 digits. This amount of money certainly has the inherent danger of corruption, i.e. have the best of the patient take 2nd place after monetary considerations. Disclaimer: I am a subspecialist doing few procedures.

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