The crisis of primary care physicians

[ReginaW]

The crisis of primary care physicians

May 29, 2008
MRS. J. LOOKED baffled and hurt. I had just explained that I would no longer be her primary care doctor. I was leaving the field after just three years. "I have had three different primary care doctors over the past 10 years," she said. "You can't leave now. I was just starting to feel comfortable. I am getting older now. I can't keep changing doctors!"

Primary care is in crisis. Current primary care doctors are quitting, and medical students are pursuing other specialties. Primary care has lost its attractiveness as a profession because of poor compensation and plummeting job satisfaction. Primary care physicians are in short supply, and in Massachusetts, this problem has intensified in the wake of healthcare reform, as more than 300,000 previously uninsured individuals have joined in the search for available doctors.

As a former primary care physician, I am most troubled by the antagonistic state of the patient-doctor relationship. The system sets us against each other. Like many in the field, I chose primary care because I love people. I wanted to take care of the whole person, body and mind. I wanted the intimacy that comes with knowing your patients well and following them over many years. These goals are difficult to achieve in primary care today. After two years in my practice, I walked into an exam room one day and introduced myself to a patient. "We have met before," she replied, clearly aggravated. I was horrified and saddened.

Patients are angry, and rightly so. They feel frustrated by the inability to get timely appointments with their physicians, rushed by the 15-minute visits and the seemingly harried doctors, ignored when they do not receive letters with lab results or follow-up phone calls. They feel disrespected when they come to their medical appointments on time and then sit in the waiting room for 45 minutes. All of these feelings are justified. We are not offering high-quality care.

Doctors feel angry, too. We have too many patients. It is not uncommon for a full-time primary care doctor to have upwards of 3,000 patients. It is impossible to know all of these individuals well, to give adequate focus to each person's unique situation, to sift through the piles of paperwork and lab data daily. Our days are divided into 15-minute sessions, back to back. We move frantically from exam room to exam room, trying desperately not to fall behind in our schedule. We are given incentives to see patients as quickly as possible. We live in fear of litigation.

We are drowning, and in this overwhelmed state we lose our ability to take good care of people. Outwardly, we may feel resentful and burdened. Underneath, many of us feel loss, deep sadness, and personal failure.

This rift between patient and doctor is painful and destructive to the core of medicine: the therapeutic relationship. In an environment where patients and doctors don't know each other well and appointments are rushed, it is inevitable that more medical errors occur and that resources are wasted as expensive tests are substituted for communication. By contrast, research indicates that medicine practiced in the context of solid primary care relationships allows for earlier detection of chronic diseases, and, ultimately, better outcomes and monetary savings, to say nothing of patient and doctor satisfaction

In this election year, patients and doctors need to come together to support healthcare reform aimed at revitalizing primary care. To begin, our medical reimbursement system must be restructured. Our payment system values invasive treatments and procedures over time spent talking with your doctor. We need to reset these compensation levels to favor communication, care coordination, disease prevention, and chronic disease management. Doctors should be rewarded for keeping patients well. Incentives should be based on quality outcomes and efficient resource use, not on patient volume.

Most important, primary care physicians should be valued as team leaders and advocates, poised to help patients navigate the complex medical system. There is no reason why so many patients like Mrs. J. need to feel lost and abandoned in a country that spends far more on healthcare than any nation in the world.

Dr. Annie Brewster is an urgent care physician at Massachusetts General Hospital.
Home / Globe / Opinion / Op-ed Annie Brewster

© Copyright 2008 Globe Newspaper Company.

[LessLiz]

Gotta love it -- the first thing we need to do to fix health care is raise the salary of family practitioners. Let's look at how underpaid they are.

http://www.allied-physicians.com/salary_surveys/physician-salaries.htm

Seems that a FP (family practitioner) is hugely underpaid. Those who do not include obstetrics in their practice can expect to earn only $161K in years 1 and 2, and $135K in years 3 and above with a max of $239K. Those with an obstetrics practice can only expect to earn $182K in the first 2 years, $204K at years 3 and above with a max of $241K.

I can see where the primary problem is lack of pay for general practitioners. It is reminiscent of insurance companies complaining about drug prices because we know how unprofiatble insurance companies are.

[Nancy LC]

I think nurse practitioners might be a good alternative for most of the stuff an FP does.

[ReginaW]

Gotta love it -- the first thing we need to do to fix health care is raise the salary of family practitioners. Let's look at how underpaid they are.

http://www.allied-physicians.com/salary_surveys/physician-salaries.htm

Seems that a FP (family practitioner) is hugely underpaid. Those who do not include obstetrics in their practice can expect to earn only $161K in years 1 and 2, and $135K in years 3 and above with a max of $239K. Those with an obstetrics practice can only expect to earn $182K in the first 2 years, $204K at years 3 and above with a max of $241K.

I can see where the primary problem is lack of pay for general practitioners. It is reminiscent of insurance companies complaining about drug prices because we know how unprofiatble insurance companies are.

IMO salary is relative....given the level of education and years attaining the MD and then the number hours worked/required each week once in practice, I'd say it's a fair observation that compensation is poor for many GP's and family practitioners.

Personally, I never begrudge anyone the salary they make - not the CEO pulling in a million+ a year, the attorney pulling $500,000, the university professor pulling $250,000, or the doctor pulling $100,000-$300,000....why should I? Seriously, should doctors work for free? For minimum wage? What exactly is proper compensation? How is such determined? And, by whom?

[Nancy LC]

I can understand why a doctor would want to specialize though. You probably see fewer patients and can spend more time with them and also make a lot more money. Maybe have fewer hassles with insurance?

[Wifezilla]

How many doctors have actually sat down and did the math....
The hours, etc... it takes them to go through insurance forms and the things they must do to conform their practice to insurance requirements?

What is it going to take for a doctor to realize they no longer work for the patient and they are just slaves to the insurance industry?

Then, which doctors are going to have the guts to say ENOUGH and only work for THE PATIENT? Take payments only directly from the patient? Post their rates on the wall? Tell the insurance companies to take a flying leap?

[Zuleikaa]

How many doctors have actually sat down and did the math....
...Then, which doctors are going to have the guts to say ENOUGH and only work for THE PATIENT? Take payments only directly from the patient? Post their rates on the wall? Tell the insurance companies to take a flying leap?Some doctors and specialists are doing just that.

[ReginaW]

I didn't suggest that $100,000 is miminum wage, however, the median salary across the US for all physicians & surgeons is $147,000.

The average doctor graduating today will have spent a minimum of 10 and upwards to 15 years just getting their education finished to practice medicine.....that is 10-15 years of not earning, which sets them behind peers who entered the workforce ahead of them by 4-8 years (those who are college educated). So right there, they're in a hole from a financial perspective for the number of years they can earn before retirement.

Now add to that, the average medical doctor graduating today will have an average 20 year payback on student loans, which now sit at around $300,000 for graduates entering family or internal medicine....some who specialize are graduating with upwards of $500,000 or more in student loans today. I still remember one of the residents from when I was in L&D having my son - he called himself the million dollar man since by the time he was going to make it into practice, his loans would total over $1,000,000!

But let's use the $300,000 in student loans - with a 20-year payback, the monthly payment on their student loan alone is $2500 a month.

So once they graduate and are in practice....how much do they work? The average family physician in the US clocks 72-hours a week with patient visits, paperwork, reporting, etc. - that's almost twice as many hours as the average person working in the US who clocks 40.25-hours a week (2006 figures).

What does a salary of $147,000 translate to now?

147,000/52 weeks = 2827 per week
147,000/12 months = 12,250

2827/72 = $39.26 an hour

12,250 - taxes (4290 for 35%) = 7960 per month take home

7960/312 (hours worked each month) = $25.51 per hour

7960 - 2500 (student loan) = 5460 per month after taxes and student loans

5460/312 (hours worked) = taking home $17.50 an hour

When you compare that to the average government employee, with an average salary (2006) of $58,992....who works 37.5-hours a week.....that's $1135 a week - $30.26 an hour (4918/mo), less taxes (28%) is $818 a week (3545/mo)....an average student loan debt of $30,000, so loan payment of $230 a month....leaving 3315 a month.....for 162.5 hours a month, or taking home $20.40 an hour.

So how attractive is that $147,000 average really?

[cnmLisa]

Gotta love it -- the first thing we need to do to fix health care is raise the salary of family practitioners. Let's look at how underpaid they are.

http://www.allied-physicians.com/salary_surveys/physician-salaries.htm

Seems that a FP (family practitioner) is hugely underpaid. Those who do not include obstetrics in their practice can expect to earn only $161K in years 1 and 2, and $135K in years 3 and above with a max of $239K. Those with an obstetrics practice can only expect to earn $182K in the first 2 years, $204K at years 3 and above with a max of $241K.

I can see where the primary problem is lack of pay for general practitioners. It is reminiscent of insurance companies complaining about drug prices because we know how unprofiatble insurance companies are.

Actually, it is very rare for an FP to practice obstetrics. The malpractice insurance is exorbinant (even getting out of reach of specialized OB/GYNs). It's not worth the risk anymore.

I practice in rural health in a community of about 9,000. We have recently lost 2 internal medicine docs--our community is struggling. We have been trying to recruit an OB/GYN for over a year, an ortho for 18 months plus. It's a shame.

[KarenJ]

Seriously, should doctors work for free? For minimum wage? What exactly is proper compensation? How is such determined? And, by whom?

Doctor's salaries seem exceptionally poor. They also have to pay for the overhead, the supplies, the rent, the insurance, the taxes, the gas bill... just like everyone else who operates a business. But then they have the whopping Malpractice insurance they are required to carry. The whole thing has become so skewed, that "the market" can no longer determine compensation. It is the insurance co that does it.

Then, which doctors are going to have the guts to say ENOUGH and only work for THE PATIENT? Take payments only directly from the patient? Post their rates on the wall? Tell the insurance companies to take a flying leap?

I remember when I was a kid, my Mom would write a check to the Doc. We had insurance, but back then it was really insurance, in other words it existed purely to offset the cost of MAJOR problems. It wasn't for shots, colds, scrapes, and hangnails.
Take insurance companies out of the picture, and watch how quickly the system heals.

[Rachel1]

Family doctors also have to rent office space, hire/buy the practice's furniture, equipment, and supplies, and pay secretaries, receptionists, etc. A lot of their income doesn't go into their pockets - it gets plowed back into the business. And let's not forget the various taxes they pay on their earnings.

Rachel

[ReginaW]

Family doctors also have to rent office space, hire/buy the practice's furniture, equipment, and supplies, and pay secretaries, receptionists, etc. A lot of their income doesn't go into their pockets - it gets plowed back into the business. And let's not forget the various taxes they pay on their earnings.

Rachel

Physicians on staff at a private hospital or through a university hospital rarely have to deal with all the details of running a business as well as practicing medicine, unless they have a private practice in addition to their hospital position.

Those in private practice have some serious overhead to manage and get right if they're going to be able to pay themselves....overhead includes everything from personnel (receptionists, insurance, office manager, RN's, transciptionist, etc.) to specific medical equipment, office space and it's expenses, chasing collections, malpractice insurance, business insurance, salaries, benefits, matching social security, continuing education of self and staff, professional licenses, professional organization memberships, journal fees, employee "fringe", legal and accounting fees, medical supplies, office supplies, software licenses, capital equipment (computers, etc.), sometimes labs with equipment...this list goes on.

When people hear a private practice pulls in $1.2-million in a year, most don't realize the bottom-line "profit" on that sits around 8-15% (depending on actual overhead costs), in such a case leaving between $96,000 to $180,000 for the doc to pay himself and fund his retirement in a year (if he's a solo practitioner).

[ReginaW]

An article that talks about one of the proposals (http://takingnote.tcf.org/2008/06/a-fresh-look--1.html) out there for healthcare reform includes this,

"Dr. Ezekiel Emanuel proposes a bold plan for health care reform that offers free, high quality health care to all Americans. No premiums. No deductibles. Low-co-pays. Under this plan, the government insists that all insurers offer the same comprehensive benefits to everyone, including: office and home visits, hospitalization, preventive screening tests, prescription drugs, some dental care, inpatient and outpatient mental health care and physical and occupational therapy."

And goes on to this,

"How do we fund it? Emanuel, who is the Director of the Clinical Bioethics Department at the U.S. National Institutes of Health, proposes a 10 percent Value-Added Tax (VAT) on consumption. For a median-income family earning $50,000 a year and spending virtually every penny, this means that they would pay $5,000 a year (10 percent of $50,000) in taxes on their purchases. But in return, they would receive health care benefits worth more than $12,500 (the current average price for comprehensive insurance that covers a family.) In addition, because The Guaranteed HealthCare Access Plan would replace employer-based coverage, many workers could expect a raise roughly equivalent to what their employer now pays toward their premiums."

Wow, now doesn't that sound like a bargain?

Here is what I've noticed no one really wants to talk about in the discussion about how to 'fix' the situation - the fact that, of those insured (either by private insurance, employer-benefit insurance or government programs), 80% utilize less than $1200 a year in medical services, 10% utilize between $1200-3000 a year, and 10% utilize greater than $3,000 a year in services.

Employer-based insurance, included as a benefit, averages $9,600 a year per employee (indiviual and/or family coverage with or without employee contributions toward the policy) on a group policy....the "range" for that average is $3,600 a year to $14,500 a year (depending entirely upon size of group, number of employees, policy benefits, individual versus family coverage, etc.)....Government programs spend an average $8900 per person covered and that includes administrative costs, reimbursements, etc.

Personally I think it's highly unlikely that employers are going to simply transfer to their employees the money they spend for health insurance into salary. And even if they did, insurance as a benefit is untaxed - even though an employee does not see it in real dollars in their pocket, it's there but they do not have a tax burden attached to it.

If an employer did take the average $9,600 and moved to the salary column, and the average salary in the US is $44,000....taxable income rises to $53,600 to pay taxes on.....and now shouldering an additional 10% for healthcare.

With $44,000, taxes will take about $12,300 and leave $31,700 take home.

With $53,600, taxes will take about $16,000, healthcare VAT at 10% will take $5,300, and leave $32,130

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But what if you're employed by a bigger company, with a much larger group, and lower cost-per-employee?

Say you earn $50,000 and your employer is paying $5,000 a year on your policy....your salary could potentially go to $55,000

With $50,000, taxes take about $14,000 and leave $36,000 take home

With $55,000, taxes take about $16,800 and the healthcare tax another $5,500....leaving $32,700....you make more, take home less.

--------------------------

How about "big earners"...someone making $150,000 a year whose employer is paying toward the higher end, say $12,000 a year for health insurance per employee?

With $150,000, (higher tax bracket) taxes take about $48,000, leaving $102,000

With the money spent on health insurance transferred to salary that means you're up to $162,000, taxes take $52,000 and the healthcare VAT takes $16,200....leaving $93,800...make more, take home less.

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Now imagine you're in good health and are one of the 80% of those who utilize less than $1,200 in medical services a year.....is such a program like this really a bargain? Is it really a "makes sense" approach to changing how things are now?

[TejanaCJ]

A little personal experience...I run a medical transcription service company and currently one of my clients is a large orthopedic practice in a sparsely populated Western state. They have been looking for another orthopedist to join them for years. They have had to add a physiatrist and a PA. The area has a large number of practicing PAs. Two previous orthopedists in their practice have moved on to growing practices in more metropolitan areas. The money is better, the shared expenses are less. That is one reason you see orthopedic practices with 10, 20, even 30 orthopedists in central and satellite offices.

On another note, factor in the absolutely necessary insurance processing department of a practice and transcription costs. I have had clients, granted larger practices, whose transcription bills were $6,000 a month. These services are required for insurance purposes. A report has to be generated to get insurance approval. Letters and consultations have to be generated to keep business flowing. Nurses may make less than in a hospital setting, but they still are in demand (so many are coming from the Philippines these days, especially on the West Coast) so their salaries cannot be pittance either. Even the PAs make handsome salaries as do the nurse practitioners.

I know of three physicians who left what seemed to be lucrative practices because they no longer could justify the costs and how they were practicing medicine to keep that practice going. One internist went to Kaiser and this was a physician who was so popular and well respected she had closed her practice to new patients because the costs were less for her and she thought could practice more like she wanted to. One just quit, but her husband kept his specialty practice going. The third retired early. There did not seem to be any health-related problems. He just had had it.

After working for hospitals, offices, and clinics for these 37 years, the demands on these doctors (many of whom I do not like at all personally) is tremendous. What it takes to get into med school, complete med school, and run a practice leaves little time or energy for real life, family life. They do sacrifice for their dreams of being a doctor, and I for one do not resent what they make at all. I worked for the University of California San Francisco within the last 10 months and the expertise and devotion it takes to stay on top of the newest procedures for spine surgery and shoulder replacement, which is what I worked on, is life consuming. How they keep up is by sacrificing so much of their personal life. These docs were seeing 40 patients plus or 80 patients a week on two clinic days and operating three days all day long. Any time for keeping up with the field, very little. On call for the weekend? Residents may have handled it at the University, but not for the local doc.

I really believe there are not enough doctors to practice the kind of medicine they want to practice and the kind we as patients want them to practice.

[KarenJ]

[URL=http://takingnote.tcf.org/2008/06/a-fresh-look--1.html]
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Now imagine you're in good health and are one of the 80% of those who utilize less than $1,200 in medical services a year.....is such a program like this really a bargain? Is it really a "makes sense" approach to changing how things are now?

That would be me, and no it is not a bargain. That would mean I'd have to shell out more money for services I'm not using.
I have heard horror stories from family & friends who live in socialized medicine countries (Denmark & Italy), and it's not the answer.

[LCivility]

I live in a small (pop. 4000) remote town, even by Alaskan standards. Our doctors do obstetrics and every other kind of medicine and surgery. If the planes can't fly in winter, then the doctors have to be able to cope with anything. It is intimidating for many new GPs to not have any backup specialists at hand. Small town docs here have to diagnose with one eye on the weather, and one eye on the family circumstances. Does this person have anyone at home who can assist? Will they take their meds? can they afford this treatment?

I strongly disagree that nurse practictoners can stand in for Family Practitioners. No slam on nurses, but doctors are far better trained.

Our doctors enjoy the challenge of managing serious acute and chronic conditions. We have known our doctors in and out of the office for over 20 years. They do a brilliant job of adapting medical care to the needs of the patient. But they give up a lot to do that. Not just the money they could be earning elsewhere, but the fact that they are essentially always on call. They are always "the Doctor" everywhere they go, everything they do, all day and all night.

The ones who can stand the strain consider themselves REAL doctors. And so do I.

[ReginaW]

How they keep up is by sacrificing so much of their personal life. These docs were seeing 40 patients plus or 80 patients a week on two clinic days and operating three days all day long. Any time for keeping up with the field, very little. On call for the weekend? Residents may have handled it at the University, but not for the local doc.

From the perspective of a wife, it truly is juggling...and anyone marrying a doctor that isn't fully prepared for the time commitments is going to be disappointed if they think they're going to see much of their spouse.

DH clocks no less than 70-hours a week, on IVF weeks (they do batch IVF since the practice is smaller) that easily rises to 90-hours....usually averages about 80-hours a week seeing patients and taking care of various things like paperwork, dictations, etc. Due to his specialty, and being a private practice, he has to have office hours 7-days a week....so it's crazy complicated to plan vacations or even attending a conference, and definitely inhibits time together or as a family!

Then he has to complete 50-hours CME a year....has to study for re-boarding tests every year in his specialty, and is currently studying to get board certified in his sub-specialty....so those together probably add another 3-hours a week.

Then there is keeping up with published studies and papers in the various journals....DH basically ends each evening reading about an hour before falling asleep - not books, but journals - he reads 'em between patients, while traveling, takes them on vacation and it's nightly routine to read 'em before falling asleep....even with that, the pile to read grows faster than he can get through 'em all.....in all his reading before bed is about 30-60 minutes a night.

Add in medical society responsibilities and assorted socializing you're expected to do....it all adds up to very little time left for a life outside medicine.

On the "plus" side - DH's specialty doesn't require much "on call" time - each year he is "on call" (24/7) for one month and then done.....weekend days are half-days, so he's done around noon, and usually able to be home by 1:00 on Saturday and Sunday......his office does "early AM" appointments (starting at 6:00) rather than evenings, so he's usually done seeing patients by 6:30pm and definitely home by 8:00pm each night at the latest, and usually rolls in around 7:00-7:30.....that is, if there are no emergencies or surgery (emergency) in the evening......IVF weeks are definitely killer weeks - the first appointment on those days starts at 4:30am....and his schedule can run past 8:00pm at night....but that's one week a month.

Sleep is definitely something docs compromise on....DH manages with less sleep during the week and we plan for naps on the weekend as catch-up for him....most mornings he's up 4:00-4:30 and not getting to sleep until 10:30-11:00.....IVF weeks he can be up no later than 3:30 and out the door by 4:00!

Time with family has to be managed with compromises....for us we make it absolute priority to eat dinner together every night and just live with DS going to bed later than a typical 3-year old....time with dad is more important than getting to bed at 7:30 (bonus, he sleeps later in the morning than kids going to bed earlier)......he goes to bed around 8:30-9:00 instead and DH and I have an hour or so of time to ourselves before we head to bed.

Weekends he always makes time with DS - a few hours fishing, a couple of hours hiking the Indian mounds, taking him to the playground, etc. - and we make time to figure out something to do as a family so we're also spending time together with DS. The "big sacrifice" truly is "us" time....somehow we manage to schedule at least one night a month where it's just us.....and pretty much see the compromises and sacrifies of time together as investment in our family and future....at some point DH will retire and we'll have lots of time to do much of the things we simply cannot do right now with the demands on our time.

[Carmen51]

When someone spends many years and thousands of dollars for an education and takes on the responsibility of literally saving lives on a daily basis, I have no problem with them receiving just compensation. What about athletes, actors, musicians, talk show hosts, etc? Those people often make more in a week than a doctor makes in a lifetime and they are worshipped for being able to throw or catch a ball. The salaries of just a few ball players or actors would fund healthcare for the population of a state for an entire year.

[catfishghj]

I believe that we would have plenty of doctors if we had better nutrition. I believe most sickness is nutrition related.

[rightnow]

The way I see it, unless significant change is made in the eating habits of the country, as well as in current medicine, we're just going to spiral into implosion. Eating habits are going to fuel the 'population explosion in illness-care' exponentially just as they've been doing. The more money we pay chemical corporations to chronically medicate us, the more power they have politically. The same goes for the grain/sugar industries.

When I look at it objectively, I don't see a happy ending. I see a Brazil-like (the movie) situation where eventually it's totalitarian and the people are totally dependent and bureacratized.

Subjectively, I maintain the irrational hope that somehow, carbohydrate-related research and media will make enough of a dent, eventually, to be a small ray of hope for the bigger picture.

[jschwab]

Some doctors and specialists are doing just that.

That's how we lost our doctor - she was an FP, does births, started an prenatal/delivery program at a facility for homeless pregnant teenagers and worked her butt off .. and got very burnt out. Now she doesn't take any insurance at all, so she has time to actually talk to her patients.

[jschwab]

I live in a small (pop. 4000) remote town, even by Alaskan standards. Our doctors do obstetrics and every other kind of medicine and surgery. If the planes can't fly in winter, then the doctors have to be able to cope with anything. It is intimidating for many new GPs to not have any backup specialists at hand. Small town docs here have to diagnose with one eye on the weather, and one eye on the family circumstances. Does this person have anyone at home who can assist? Will they take their meds? can they afford this treatment?

I strongly disagree that nurse practictoners can stand in for Family Practitioners. No slam on nurses, but doctors are far better trained.

Our doctors enjoy the challenge of managing serious acute and chronic conditions. We have known our doctors in and out of the office for over 20 years. They do a brilliant job of adapting medical care to the needs of the patient. But they give up a lot to do that. Not just the money they could be earning elsewhere, but the fact that they are essentially always on call. They are always "the Doctor" everywhere they go, everything they do, all day and all night.

The ones who can stand the strain consider themselves REAL doctors. And so do I.

Nurse practitioners are not nurses - they can write prescription and treat and diagnose. Along with physician assistants, they are a great solution to the problem, IMO. After seeing REAL doctors for years, I have been seeing a PA and after her an NP for the past couple of years and I can assure you, I will never go back. They are much more highly skilled at diagnosis than the doctors I've seen, especially on the kinds of issue family doctors are supposed to excel at. If I have an emergency I'll see a doctor, but never again or a sick or well visit.

[ReginaW]

Nurse practitioners are not nurses - they can write prescription and treat and diagnose.

How freely they can do that depends on the state....some states are very liberal others require collaborating physician signatures and/or limit script writing to only particular schedule drugs (limit or exclude narcotics for example).

[cnmLisa]

Nurse practitioners are not nurses - they can write prescription and treat and diagnose. Along with physician assistants, they are a great solution to the problem, IMO. After seeing REAL doctors for years, I have been seeing a PA and after her an NP for the past couple of years and I can assure you, I will never go back. They are much more highly skilled at diagnosis than the doctors I've seen, especially on the kinds of issue family doctors are supposed to excel at. If I have an emergency I'll see a doctor, but never again or a sick or well visit.

Ahummm, Ahummmm.

Just for clarity---nurse practitioners, certified nurse midwives, certifed registered nurse anesthitists....we are all NURSES with advanced education i.e. Masters degrees. We not only are advanced practice nurses, but we also must keep our nursing licenses valid also. And yes, we have prescriptive authority in almost all states (I think Georgia was the last hold out), we diagnose, we treat, and get reimbursed ~ 85% of the medical reimbursement.



I strongly disagree that nurse practictoners can stand in for Family Practitioners. No slam on nurses, but doctors are far better trained.



I'll have to disagree with this in some instances, such as....
I am a certifeid nurse midwife and have been for over 10 years.
I have been a clinical professor at a school of medicine, worked in private practice, and now practice in rural health. Women's health, prenatal care, family planning, birth and post partum are my expertise. I have worked with FPs who are great FPs but do not really know their way around women's health--it's like dabbling. Around women's health do I think I know more and am better at it--you bet, it's what I do day in and day out, they don't. That's just a fact not a slam. Same goes with the internists.

(Regina, as usual we're posting at the same time)

[rightnow]

My stepmother, a minor hypochondriac (who conveniently, or tragically, seems capable of giving herself whatever she's most paranoid about, so eventually, she's right!), has been to a zillion doctors. She went a nurse practitioner a couple years ago and it seemed to change everything. She didn't just get drugs thrown at her, she really felt like the woman understood her. And aside from her bizarre religious faith in the ADA diet, the NP has managed to relax her more about her health than anyone she's ever seen. I sometimes think that for all these years, feeling like she was a number and wasn't getting real attention or serious consideration just fueled her health worries. Once she found someone who took the time and she trusted, when she was told to relax and not worry about something, she finally did.

[Nancy LC]

Heck a good computer program could stand in for family doctor for a lot of things. Granted not for certain procedures but for diagnosis the cycle is:

1) Take symptoms and signs
2) Run tests
3) Based on test results give diagnosis or run more tests

It's a lot easier to update the information in a computer than it is in a doctor too.

And computers are good listeners. :)


On NP's... I see one for my gynecological exams and I really like her much better than the actual Gyno doctor. She's thorough, takes time to talk to me and ask probing questions. The gyno himself is rushed, tried to push me into surgery for something that didn't need surgery, I got the feeling he was more interested in increasing his bottom line than my health.

I'm planning to see one, off plan, for my thyroid issues.

[ReginaW]

I strongly disagree that nurse practictoners can stand in for Family Practitioners. No slam on nurses, but doctors are far better trained.

I'd have to disagree on this too...all doctors may have more educational time, but training doesn't translate to higher quality or higher level of competence.....don't forget, half of all docs out there graduated in the bottom half of their class!

I think NP's bring real value to a medical practice...patients often prefer the longer time they can take with them, they're well-educated and qualified, they can often more quickly transfer information on a patient to a doctor when needed than the patient can directly to the doctor since they have more time to talk to the patient and probe details, they know when to ask for help or bring the doc in if needed, and for routine visits definitely make sense.

[Nancy LC]

Regina, that's just nuts (the schedule). I know a lot of women doctors are cutting down on their hours. Why don't men doctors do it too? Maybe if their schedule were more sane more people would go into the field.

I sincerely doubt it's the doctors salaries that are driving health care costs so high. I suspect it is testing, drugs, surgery happy surgeons making big bucks (and the hospitals that employ them), and insurance companies that are the driving forces behind these escalating costs.

[ReginaW]

Regina, that's just nuts (the schedule). I know a lot of women doctors are cutting down on their hours. Why don't men doctors do it too? Maybe if their schedule were more sane more people would go into the field.



For DH it's just the nature of the specialty....women ovulate on their schedule, not a 9-5 M-F....LOL....we do manage even though our schedule really is crazy!

He is also in a very small practice - his partner is semi-retired, working the last year an average 12-days a month, always within the IVF week, so DH's ability to get a weekend off or even a weekend day off is pretty limited. He takes one when he can - in the last three months, he's managed five Sunday's off which is GOOD!

Both he and his partner are the "earners" in the practice - the buck starts and stops with them and their providing the services to patients....they're it - for example, if either goes into the OR, the office basically comes to a standstill until they return from surgery....they have to make the money needed to pay everyone, the expenses and then themselves...it's not unreasonably difficult to do, but even though they're a small practice, they have HUGE overhead for the IVF lab & surgical suite that're in-house.

With two of them, one semi-retired, it's managable.....DH usually can take a couple of weeks for vacation and know his partner is there for patients and can get to the annual conference too which is another five days out of the office.

BUT.....we're going to be seriously challenged in the coming months/years - DH is buying the practice July, his partner is retiring, so he will be solo until he can recruit either an NP for routine office visits (like annuals and scans) or find an RE willing to move here and live in the midwest! Yeah, he's going to make some changes to the schedule - he'll technically have two Sunday's closed (except the Sunday's into and following IVF)....but will need to have an RN on call and be on call himself (so an expense without revenue)....but at least he'll not have to go into the office unless a patient does need to see him.

Like I said if you marry a doc, you gotta be prepared for little to no time with him!

-------------------

ETA: Bonus!!!! DH just called (it's 4:30 here) - he's done for the day....just needs to swing by the hospital to check on a patient, pick up some din-din and then he'll be home.....odds are running high he'll roll in by 5:15 if his patient is doing fine! A good Friday indeed!

[LessLiz]

That salary survey cites base salaries -- i.e. the doctor is an employee -- or net income -- i.e. after expenses including insurance, rent, etc. -- or hospital guarantees -- again, net of expenses.

I don't find anything compelling in the MDs take out loans and spend years on education, and I would like to know where all those $250K college professors work. I have as much education as any MD, I paid for 100% of my education, and much as I would like to be one those $250K college professors, I am not. I do, however, average more than 60 hours per week working.

The average salary for an assistant professor at Yale, typically someone with 0 - 5 years experience, is $82K. The average salary for an associate professor at Yale, typically someone with 4 - 8 years experience, is $91K. The average for a full professor, typically someone with 6 or more years experience, is $165K. A full professor with 6 years experience tends to be a superstar.

I would submit that Yale is not paying close to the average salary for professors. Salaries by rank at University of Missouri, Columbia, the highest paid campus in that system, are 58K for assistant profs, 71K for associate profs and 103K for full profs.

I don't begrudge doctors or anyone else their income. I do, however, have an issue at the idea that they are underpaid or that the fix to the US system is to increase their salaries.

From http://mdsalaries.blogspot.com/2008/01/american-versus-australian-european.html


A 2004 analysis done by the Economic consultants at the National Economic Research Associates came up with the following summary comparison of average Hospital salaries earned by Doctors :

USA: $266,733
Australia: $203,132
Netherlands: $175,155
Britain: $127,285
France: $116,077
Italy: $81,414
Denmark: $73,236
Spain: $67,785
Germany: $56,455

http://www.spiegel.de/img/0,1020,575805,00.jpg

[ReginaW]

The average salary for an assistant professor at Yale, typically someone with 0 - 5 years experience, is $82K. The average salary for an associate professor at Yale, typically someone with 4 - 8 years experience, is $91K. The average for a full professor, typically someone with 6 or more years experience, is $165K. A full professor with 6 years experience tends to be a superstar.

I believe my comment was I don't begrudge the university professor making $250,000...and they're out there....I didn't state that was an average at all.

I do, however, have an issue at the idea that they are underpaid or that the fix to the US system is to increase their salaries.


On average, yeah, as a whole they're paid well....but that doesn't mean that some are compensated poorly - there really are docs out there struggling to get by because between the expenses, overhead and all that and the hours they need to put in, they can't make enough after everything is paid...in some areas it really is at a "crisis" level either because an area is underserved or costs have spiraled out of control in bigger cities that sometimes get "saturated" with too many docs.

For example.....OB's in the northern VA made about $175,000 a year back in the late 1990's.....in the years we lived there, we watched, year over year that decline to an average $135,000, then $122,000, and a couple of years ago, $115,000. Much of the decline was due to rising malpractice and rising real estate costs....it was futile to charge more, the insurance companies only paid so much per office visit or patient, period.....and there really are human limits on how many pregnancies and deliveries one can expect to manage in a year, so expanding patient load really wasn't much of an option either.

Yeah, cry me a river, right....but honestly, who in their right mind is going to think it's cool that they're working just as hard as before, but now taking home 31% less while inflation has gone up, up, up all the while? Don't most reasonable people expect that they can at least earn the same, heck even increase earning, even by small amounts, over the years they work?

[ReginaW]

I have as much education as any MD, I paid for 100% of my education

I specifically was talking medical students today and the level of debt they're incurring to pay for college, medical school, and any additional programs for specialty.

College these days is running upwards of $40K at many schools, some of the top ones are more than $50K; Medical School can be more than $50-60K a year....quick math, $160,000 for four years college, $200,000 for med school - $360,000 for eight years....would you still be able to pay that 100% out of your pocket today if you were a student admitted to a good school?

How much additional would you need for incidentals each year? How much do you need for housing, food, etc.?

And incidentally, MD's do pay for their education too - just over time and with interest!

[LCivility]

Re: nurse practitioners.

I will have to respectfully continue to disagree. While having someone who can listen is definitely an asset to any medical practice, I still maintain that listening is best done by a qualified and well compensated doctor. The family practitioner can then refer patients to specialists, including midwives and nurse specialists or PA's, as my own gp did. How will doctors treat the *family* unless they really have time to listen? How will they learn to take LC seriously (for example) unless by listening to and observing their patients? At least, that is how it works in this local practice.

I admit, my 25 yrs of doctor experience is vastly different than what is common in the real world. It is one of the reasons we live here on the edge of nowhere.

[Rocketguy]

http://www.amazon.com/Money-Driven-Medicine-Reason-Health-Costs/dp/006076533X/ref=pd_bbs_2?ie=UTF8&s=books&qid=1212803677&sr=8-2

"Money Driven Medicine: the real reason health care costs so much" by Maggie Mahar

I have just started reading this book. I am concerned about the future of medicine and national healthcare.

This book is an eye-opener. In reading just the parts of it available for preview on the Amazon.com site, I realized that I was ignorant of the issues. I sort of knew some of them, but the situation is much deeper than I could have imagined.

There is a long history of how things came to be. There was the initial desire of the MD's (via the AMA) to keep the business focused on the doctor-patient relationship and to keep third parties out of it. Third parties included insurance companies and the US Government.

There was the tradition of community hospitals which have been slowly gobbled up by for-profit large agglomerates. The large agglomerates are driven to become ever larger to satisfy the demands of Wall Street to keep the stock prices high. Ultimately, the problem is that the high prices of healthcare stock are unrealistic because for-profit hospitals are basically profit limited. The high prices of the stock are based on growth and absorption of smaller chains, not so much on the inherent profitability of the hospital business. Sounds similar to one of the TelCom scams based on growth.

The death of JFK was what was used to sell Congress on Medicare by President Johnson. This was a major intrusion of the government into the healthcare business.

And, I haven't finished Chapter 1.

This is a complicated messy business, this modern medical care.

I thought that I had a grasp of it, and how to fix it, until I began to discover how much of a giant mess the whole thing has grown into.

I fear the "simple solutions" that will come out of the next administration. Either the "D" faction or the "R" faction.

[jschwab]

"Just for clarity---nurse practitioners, certified nurse midwives, certifed registered nurse anesthitists....we are all NURSES with advanced education i.e. Masters degrees. We not only are advanced practice nurses, but we also must keep our nursing licenses valid also. And yes, we have prescriptive authority in almost all states (I think Georgia was the last hold out), we diagnose, we treat, and get reimbursed ~ 85% of the medical reimbursement."

Sorry, I should know better than to divide y'all. I used to know alot about the movement (hard-fought) to make advanced nursing a clear advancement opportunity for nurses but I fell into the trap of diminishing the nurses who are not in advanced practice. I know lots of nurses in my family and CNM's, too, because of my midwifery connection. I just lost a dear friend who is a CNM - just forgot how powerful the nursing profession is at ALL levels.

[jschwab]

Re: nurse practitioners.

I will have to respectfully continue to disagree. While having someone who can listen is definitely an asset to any medical practice, I still maintain that listening is best done by a qualified and well compensated doctor. The family practitioner can then refer patients to specialists, including midwives and nurse specialists or PA's, as my own gp did. How will doctors treat the *family* unless they really have time to listen? How will they learn to take LC seriously (for example) unless by listening to and observing their patients? At least, that is how it works in this local practice.

I admit, my 25 yrs of doctor experience is vastly different than what is common in the real world. It is one of the reasons we live here on the edge of nowhere.

I think this might be a matter of setting and environment. My NP is the senior member of her practice which includes a couple MD's and a DO. She can refer us to any specialist, order any procedure, write any prescription. My physician assistant was the same way. Maybe there are differences I don't see in authority or experience that are not transparent to the patient, but at the family practice level, the difference for me has just been all in the attitude and skill at diagnosis. I can't begin to tell you the serious mistakes my doctors have made, in one case almost costing my daughter her life (an unlicensed midwife saved the day) and some other extremely silly stuff like sending my other daughter for plastic surgery for a pimple. But the NP and the PA just are always dead on with diagnosis.

Janine

[cnmLisa]

just forgot how powerful the nursing profession is at ALL levels.

Yeah, we can be a snarky group when we get our dander up:p :lol:

[1000times]

Yeah, cry me a river, right....but honestly, who in their right mind is going to think it's cool that they're working just as hard as before, but now taking home 31% less while inflation has gone up, up, up all the while?
There seems to be a lot of that disease going around, and you don't have to be a doctor to catch it, either. Last year, with a few hundred hours of overtime, I managed to get back to what I took home in 2000 (working no overtime). Maybe this year I'll get up to what I took home in 2001, but I'm not holding my breath.

[LessLiz]

There seems to be a lot of that disease going around, and you don't have to be a doctor to catch it, either. Last year, with a few hundred hours of overtime, I managed to get back to what I took home in 2000 (working no overtime). Maybe this year I'll get up to what I took home in 2001, but I'm not holding my breath.Exactly. People rarely step out of their own universe and discover how many people they don't include in their "people like me" group are experiencing the same things.

I could rewrite the article that was posted to make an argument that the first step to fixing scientific research is to give university professors pay raises. Unbeknownst to most people, working hours for university professors engaged in research are brutal, and for younger professors it is particularly brutal.

I was at a retirement event for a professor two years ago that was attended by around 150 profs. The retiring professor, who is a bit of an activist, hosted a discussion about working conditions, hours worked weekly and salaries. He asked the older people in the room to comment on what their experiences had been after asking younger people. There was little doubt that lifestyle, income and satisfaction levels had worsened over the years. There was also little doubt that the retires believed what the assistant and associate profs related -- they had seen it happening.

What they failed to grasp is it isn't just research professors this is happening to -- it is happening in many career areas in the US.

[LC FP]

I have the greatest job in the world. I get to talk to patients every day about diet and nutrition and insulin and fish oil and vitamin D. And almost all of them get it. I get to lecture about it to FP residents and medical students. For most of them it's the first time they've ever heard it, and I know it makes a big impression on some of them. Even my colleagues grudgingly admit that I'm right and have modified their recommendations. I've made exactly zero progress with the local dietitians and nutritionists. All is as it should be.

I don't get paid enough, but who does? I'm losing out to inflation every year just like everyone else.

But if I was still in private practice and not in education, I wouldn't have the time or opportunity to do any of that without taking a severe pay cut. Private practice for primary care doctors is a meatgrinder, and after ten years of it I was burned out. The worst aspect of it is that, unless you're some kind of medical entrepreneur, it's a dead end job.

[fujiwara]

Speaking of losing financial ground...a few years ago, I had a career. Now I am a housewife/seamstress with sporadic income. But being home allows me to cook nutritious meals and save on gas, and have energy to put up with BS.

I blame companies outsourcing jobs. That started the money flowing OUT of the country instead of IN and WITHIN the country.