Reframing the Question of Doctor Frustration

There has been a lot of interest in the Daily Beast article written by Dr Daniela Drake, about very frustrated primary care physicians (PCP.) She quoted both Dr Kevin Pho and myself. Dr Drake noted that nine of 10 doctors would not recommend medicine to their children as a career and that 300 physicians commit suicide each year. “Simply put, being a doctor has become a miserable and humiliating undertaking.”  Dr Pho offered his own commentary here pointing out that “it is important to have the discussion on physician dissatisfaction….demoralized doctors are in no position to care for patients…To be sure many people with good intentions are working toward solving the healthcare crisis. But the answers they’ve come up with are driving up costs and driving out doctors.”  

Yes, it is definitely true that PCPs are very frustrated. In a series of in depth interviews, almost all tell me that their major frustration is not enough time with each patient. No time to listen, no time to think, no time to do critical activities. Why? Because they have to see too many patients per day in order to cover overheads. A few of those that I interviewed have left clinical practice because of these frustrations; others felt that they needed to do “something, soon,” to improve their situation.

But patients are frustrated as well. They find they have to wait a long time for an appointment, sit in the apt named waiting room and then get just a few minutes with the PCP. They observe that the doctor interrupts them within just a few moments, never lets them tell their full story, isn’t really listening and shuttles them off to a specialist or gives them a prescription while never really explaining in their terms what is going on. And they know that they pay a lot for their insurance with premiums rising every year along with lots of co-pays and deductibles. So they are in no mood to feel sorry for the PCP who earns, according a Medscape survey, about $170-180,000 per year.

The usual response of the medical community is to point out the years of education and training, the high debt loads, the hours of work and the calls at night. That other doctors earn much more. That there is an ever growing burden of paperwork, of wasted calls to the insurers and nonfunctioning EHRs. That the responsibilities are high and what could be more important than your health. All true -- but it falls on deaf ears for the family with an income of <$51,000 (median US household income in 2011, per census).

One major problem is that the average person just does not know what really good primary care could do for them and their health over time. Nor do they appreciate that primary care is or at least can be relatively inexpensive. We (the collective medical community) have not done a good job explaining the value of outstanding primary care.

So let’s reframe the frustration question.

How can patients get superior care from excellent energized and satisfied practitioners at a reasonable cost all leading to not only care of disease but prevention of illness and preservation of well-being? And if this can be achieved, will it lead to more students choosing primary care as a rewarding career?

Government is not likely to solve the problem nor will most insurers. It will be up to PCPs and their patients to create a new primary care delivery paradigm. And doctors need to take the initiative to educate the public and lobby for useful change.

There are many options. One is direct primary care (DPC) in its many formats such as pay per visit, a monthly membership fee or retainer-based (concierge) models. The latter two with their limited patient panels are often thought of as only for the elite or the rich but membership or retainer based practices need not be expensive. Several have been written up as “blue collar” plans  with low fees yet limited numbers of patients, same day and lengthy appointments, 24/7 cell phone availability and even free or reduced cost medications and lab testing.

I live in Maryland where I looked up the 2014 Blue Cross (not for profit) premiums in the local exchange. A Bronze plan for a 55 year old costs $3660 per year with a $6000 deductible, essentially a “catastrophic” plan. A Platinum plan costs $7728 per year with no deductible but up to $2000 in hospital co-pays. If the individual requires major medical care, the total out of pocket costs for premium and deductibles/copays in either plan is therefore about $9700. Buy the Bronze plan, create a health savings account and then pay the membership/retainer with tax advantaged dollars. The individual gets high quality health care in a setting where it is to the physician’s advantage to keep the patient well. Alternatively, stay with the Platinum plan and get a 12 minute visit.

As to the PCP shortage and patient education issues, Primary Care Progress is one of a number of new organizations sprouting up to bring current and potential PCPs together. To educate patients, they have produced a useful 2 minute animation.

Looking ahead, insurers might one day decide it is logical to buy the membership or retainer for their insured’s. The cost would be rapidly repaid may times over. Likewise employers could do the same leading to a healthier, more satisfied workforce with higher productivity and reduced total health care premium costs. Sounds radical but it is actually logical. Patients would get great care and maintain good health. Providers get to be the true healers they always aspired to be. The total costs of care would come way down. Maybe even more students would choose primary care as a career. Win-win-win-win.

 

 

Frustrations Among Primary Care Physicians Should Be a Wakeup Call

Primary care physicians (PCPs) are incredibly frustrated. This level of frustration should be a wakeup call. The greatest frustration is “Time, time, time”- or more precisely, a lack of time. From in depth interviews with over 30 PCPs, everyone said lack of time was the greatest frustration of their practice (or was previously if they now were in a practice that limited the patient number to a manageable level.) Each knew that they could not give the time needed to give the level of care that they were capable of giving and that their patients deserved.

Stated somewhat differently, they said that it was very frustrating to always be focused on meeting overheads and trying to earn what they thought was a reasonable income because to do so meant less time with patients and a sense of frustration and perhaps even guilt. New practice patterns have meant not being readily available to patients, not visiting them at the hospital or ER, and no longer being the “captain of the ship.”

In a Daily Beast article, Dr D Drake wrote about “how being doctor became the most miserable profession….Simply put, being a doctor has become a miserable and humiliating undertaking. Indeed, many doctors feel that America has declared war on physicians—and both physicians and patients are the losers…It’s hard for anyone outside the profession to understand just how rotten the job has become—and what bad news that is for America’s health care system.”

The complexity of the healthcare delivery system was a common frustration refrain in my interviews. In such a fragmented system, “I need to go an extra mile to communicate with my patients but there is not enough time to do it.”

Other frustrations were dealing with insurers for preauthorization of a test, procedure or referral; trying to figure out what drugs were or were not on an individual insurer’s formulary (and each has a different formulary) and in dealing with their reimbursement methodology. Some insurers are very slow to pay reimbursements which mean carrying high working capital – difficult for a small practice.  One noted the amount of time required to arrange for something like home care which, if the insurer was logical, would actually prevent more expensive time in the ER, doctor’s office or nursing home. PCPs find it exceedingly frustrating to deal with non-medical people at the insurance company who deny tests or medications that the doctor feels are very much in the patient’s best interest.

So PCPs were frustrated by government and insurance regulations, polices and roadblocks to care; by the fragmentation of the system; and by many others things but the root problem that was most frustrating was the lack of time with each patient. 

Kevin Pho MD, a primary care physician and founder of KevinMD.com a very popular blog posted about physician frustration following Dr Drake’s article. “So it’s important to have the conversation on physician dissatisfaction.  It’s important to discuss the cost of medical education, physician burnout, and the myriad of paperwork and bureaucratic mandates that obstruct doctors from giving the best care they can to patients. Left unchecked, the physician profession will become completely demoralized.  Whether you care or not, it matters.   Demoralized doctors are in no position to care for patients.”

What is very clear in this extremely dysfunctional healthcare delivery system is that the primary care physicians  (and most other providers as well) are very frustrated that they cannot give the level of care that they believe they were trained to do  and would like to do. Most of their frustrations come down to the lack of time.

They need to take back the time and give it to patients, perhaps via direct primary care or with other models that offer a higher reimbursement for a patient visit or per member per month.  But medicine is a very conservative profession; change comes slowly. Doctors will make the switch to something better only if they feel comfortable that their patients will follow them and approve. Otherwise they will retire early or go work for the local hospital and medical students will continue to shun primary care as a career. If patients want to benefit from much better care, if they want a doctor that is not frustrated and can spend time with them listening, if they want their total costs of health care to decline rather than rise, then they will need to educate themselves and then to advocate  – to legislators, to insurers and to doctors. Concerted patient action will force the issue and make change occur. When the PCP has more time, care gets better, frustrations come down, satisfaction goes up and costs come way down. Everybody wins.

Next time: The value of integrative medicine in primary care.