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[tvoivozhd <tvoivozd AT infionline.net>]

tvoivozhd---Except working for the government---in the military or in a 
Veterans Admnistration Hospital, where the pay is good if not 
spectacular, working hours are reasonable---and they can spend whatever 
time they need with a patient. And wonder of wonders, a Veterans 
hospital is thirty percent more  efficient than the average for-profit 
hospital.  Only if a patient is wealthy enough to go to the Mayo Clinic 
or Johns Hopkins will the medical care be better.  Like Rockefeller used 
to say when queried about what it cost to own a yacht---if you have to 
ask what medical care costs at a half dozen of the best hospitals around 
the country, don't even think about buying it.




1/31/05
Doctors Vanish From View
Harried by the bureaucracy of medicine, physicians are

pulling back from patient care
By Katherine Hobson

'It was slow water torture," says Paul Ryack. That's how

the 63-year-old board-certified internist describes his

working life just a few years ago. With a few thousand

patients, many of them elderly, he could barely find time

to listen to halting explanations of their immediate

complaints--let alone talk about the importance of

lowering blood pressure or losing weight--in the 15 or so

minutes he could allot to each. "I was unable to make the

time to sit with patients, to get to know them, to help

with preventive activities that we need and want," says

Ryack, who practices in Santa Barbara, Calif. His costs

were so high, and payment per patient so low, that taking

even another dozen minutes wasn't possible. "You'd go

broke," he says. The end result: a creeping sense of

burnout.
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Many doctors around the country are similarly frustrated.

A 2001 California survey of physicians found that 75

percent of respondents grew less satisfied with practicing

medicine over the previous five years. A nationwide survey

by the Henry J. Kaiser Family Foundation found that 87

percent of doctors say the overall morale of the

profession has gone down in the past few years, and nearly

60 percent said their own morale had declined.

Chat with your own doctor--on the off chance she has time

for a conversation--and she is likely to echo those

sentiments. "The practice of medicine does not offer the

kinds of rewards for what you have to put into it," says

Carl Getto, associate dean for hospital affairs at the

University of Wisconsin Medical School, who oversees a

staff of more than 1,000 physicians.

The hassle factors. Those rewards--including satisfying

relationships with patients, autonomy, high status, and

comparatively high pay--are increasingly outweighed by the

reality of a 21st-century U.S. medical practice. In their

place: reams of time-consuming paperwork that is out of

proportion to time spent caring for patients, declining

reimbursements from insurers, a loss of autonomy from

managed care, and fear of malpractice lawsuits.

For patients, the implications of these changes are huge.

Some doctors are retiring or cutting back their hours.

That means fewer doctors are available. Others are opting

for specialties, such as radiology, with less demanding

schedules. Many are cutting out certain insurers, and thus

cutting out patients who use those insurers. A handful are

deliberately restructuring their practices to see fewer--

and richer--patients. "It's like a casino," says Doug

Farrago, a family medicine physician in Auburn, Maine, and

publisher of Placebo Journal , a publication filled with

the dark ironies of current medicine. "Older docs can cash

in their chips, and younger ones are looking for a

different game," he says. In a country that will demand

more and more from its healthcare system as the population

ages, this is only going to get worse--and your doctor's

problems may become yours.

It's not surprising that the doctors who are most upset

about how things are now are the 50- and 60-year-olds who

remember how it used to be: You made medicine your top

priority and reaped emotional and financial rewards. "It

was the golden age of medicine when they came in--it was

fee for service, and you did what you thought was the best

thing for the patient," says Phil Miller with Merritt,

Hawkins & Associates, an Irving, Texas-based physician

search firm. But the rise of managed care and large

insurers, for better or for worse, has changed things.

Insurance companies may not cover the drug a doctor

prefers to prescribe for a given condition. Mountains of

paperwork are required to gain approval for consults or

outside services. Then there is the threat of malpractice

suits. Doctors in so-called crisis states have stopped

delivering babies or staged walkouts in the face of

climbing insurance rates; even where insurance is more

affordable, doctors fear being sued. That takes a toll.

So does the ever ticking clock. Insurers, doctors say,

keep reimbursements so low that it's not economically

possible for a primary-care doctor to practice with fewer

than a few thousand patients on the rolls. That's where

the squeeze comes in--the average 17-minute office visit

may not be sufficient to get enough information to

diagnose the problem and talk about the ever growing list

of health issues they're supposed to bring up, from

screening for skin cancer to advocating exercise and a

healthful diet to being alert to signs of domestic abuse

or addiction. That doesn't even count time to answer

patients' questions about drug ads they've seen or

information they've researched on the Internet. "The

average doctor sees 25 people a day," says Rachel Naomi

Remen, cofounder of the Commonweal Cancer Help Program and

a family and community medicine professor at the

University of California-San Francisco (story, page 51).

"I don't know how to say hello to 25 people a day."
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A matter of time. Worse, those meager 17 minutes may be

with a different doctor every few years, because when

employers switch insurers, or people change jobs, their

old doc often isn't part of the new plan. That's a real

loss. When you aren't familiar with a patient's past care,

it becomes difficult to track, monitor, and anticipate the

medical needs.

Patients in turn feel less connected to doctors whose

names they may not even remember; that contributes to

eroded respect. "My father had a lot of health problems

and was taken care of by a gentleman who was fairly old at

the time," recalls Jeffrey Sartin, a 43-year-old

infectious disease specialist in La Crosse, Wis. "My dad

regarded Dr. Murphy as only slightly below God, and that

awe and respect . . . is something I learned at a very

early age. That has definitely changed. Not only are

doctors not accorded respect, people are waiting to throw

brickbats at them."

Sartin hastens to add that he doesn't want to return to

the paternalistic days when patients were so in awe of

doctors that they accepted their decisions, no questions

asked. But some doctors are frustrated that while they

have less sway with patients to comply with treatment,

they have more expectations heaped on them to produce

perfect outcomes and are left holding the bag when

something--even something out of their control--goes

wrong. Says Stephen Sokolyk, a cardiologist in New

Braunfels, Texas: "We have the responsibility but not the

authority."

None of these problems are going away, because the dismay

of the elders has now trickled down to newly minted

healers. "Even young physicians who come out eager and

excited at the end of their training program encounter

frustrations early on," says Jack Lewin, CEO of the

California Medical Association. When Merritt, Hawkins

surveyed residents to see if they would still go into

medicine if they had it to do over again, those

frustrations surfaced. In 2001,95 percent said they'd pick

medicine over an alternative career. But in 2003--just two

years later--that had dropped to 74 percent. "In my

residency, if you had polled, at least half would have

said that if they could go back to college they wouldn't

choose medicine," says one new physician doing an

endocrinology fellowship.

The doctor is out. While it's still very competitive to

get into med school, some worry the best and the brightest

may soon avoid the profession altogether. Med school

applications are more than 10,000 below 1996's peak of 47

,000. In a 2001 survey by the California Medical

Association, two thirds of doctors were not advising their

kids to enter the profession. "When I did my rotations, I

had older physicians every other day telling me to get out

now," says one recent med school graduate who subsequently

dropped out of her residency program.
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You may be thinking, "I don't like Monday mornings either,

and I'm sure not getting paid as much as a doctor."

Indeed, doctors still earn a very good living--an average

of about $150,000 for family practitioners and two or more

times that for lucrative specialties like cardiology. But

doctors also spend many years in training earning little

or nothing and face big bills from med school. In 2003,

the median debt for graduates of public med schools was $

100,000 and, for those graduating from private schools, a

whopping $135,000, according to the Association of

American Medical Colleges. (In 20 years, the median debt

level has increased more than 4.5 times.) Meantime,

malpractice insurance rates are still climbing. An

obstetrician-gynecologist in Illinois could pay as much as

$230,000 per year in Illinois or $90,000 in Los Angeles,

according to Medical Liability Monitor.

All of this adds up to a growing concern that people may

soon have trouble finding a doctor. Estimates of the

shortfall vary. Miller is predicting a shortage of between

90,000 and 200,000 physicians by 2020. Richard Cooper,

director of the Health Policy Institute at the Medical

College of Wisconsin, has long predicted shortages and

also says the gap could hit 200,000 by the same year. Both

urge an increase in the number of doctors being trained,

which has been stagnant for years. The Council on Graduate

Medical Education, the American Medical Association, and

the Association of American Medical Colleges, all of whom

had projected surpluses in the past, have recently changed

positions and acknowledged the problem.

Shortages will (and do) vary by geographical area,

depending on reimbursement levels, malpractice insurance

rates, and the cost of living. The problems are always

grim in rural regions--the National Rural Health

Association says that 25 percent of the population lives

in rural areas, though only 10 percent of doctors practice

there. Most experts say shortages of primary-care

physicians will occur mainly in these parts of the

country--primary care isn't appealing for its relentless

office schedule and relatively low compensation. (Last

year, the Task Force on Wisconsin's Future Physician

Workforce said that the state is already short 506

primary-care physicians, with no relief in sight.) Already

underserved inner-city areas may also be at particular

risk. African-American doctors, who are far more likely to

treat minorities in these urban areas, are no less bummed

out than the rest of the profession; a survey of African-

American doctors sponsored by the National Medical

Association last year found that most were dissatisfied

with practicing medicine.

n California, where the cost of living is high, there are

shortages of primary-care docs, neurologists, and surgical

specialists. "The wait is three weeks to a month to see a

pediatric neurologist, and pediatric nephrologists are as

rare as hens' teeth," says Harvey Cohen, head of

pediatrics at Stanford University School of Medicine.

Already, Merritt, Hawkins reports that the average wait

for a new patient wanting to see a cardiologist is 37 days

in Boston and 22 days in New York. For an obstetrician-

gynecologist, the wait is 45 days in Boston and 31 days in

San Diego.
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Specialty problems. In certain specialties like

geriatrics, cardiology, neurosurgery, and oncology, the

shortages are projected to be nationwide, even in areas

with a high concentration of doctors. Demand for their

services will rise as the baby boomers age and develop

chronic conditions, but there isn't a corresponding surge

of interested students.

Instead, today's med students are gravitating toward

nonsurgical specialties with regular hours. In last year's

"match" of new grads to postgrad medical residency

programs, grads of U.S. med schools filled 97 percent of

the dermatology slots but only 41 percent of the family

med slots. There were about 2.5 applicants for every

family medicine position open and about 14 for every

radiology position. The American Association of

Neurological Surgeons said last year that demand was

vastly outstripping supply and noted that the field isn't

perceived by med students as offering a regular schedule

or enough personal time. Some specialties may change

training to attract more doctors. The American College of

Cardiology, for example, is considering whether to trim

the current six-year training by a year, cutting out the

interventional procedures that aren't done by general

cardiologists anyway. That would increase the supply as

well as possibly attract candidates turned off by the

longer training period.

That's not to say that young doctors are slackers or that

no one is interested in the most academic specialties. But

as a group, they are thinking very differently about their

careers than did their predecessors, refusing to put

medicine above family and personal time. One saying: The

R.O.A.D. to happiness lies in radiology, ophthalmology,

anesthesiology, and dermatology. "There is a generational

difference in what we see as important in our careers and

personal life," says Jennifer Shu, immediate past chair of

the American Medical Association's Young Physicians

Section. "Whereas career might have defined you in the

past, it doesn't anymore." She and her husband are a good

example: She took two years off to have children and now

works part time as an instructor of pediatrics and medical

director of the nursery at Dartmouth (and writes books in

her off time), and her husband is back at school for

public health and outcomes research, with an eye toward a

career in epidemiology. "I have to take care of my house,

my own life, and my son--I make limits," she says.

Statistics show that women--who now make up the majority

of med school applicants--work fewer hours than male

physicians do. But this desire to have a life is more

generational and linked to expectations about what a

medical career will and will not provide these days. "It's

very clear that all physicians are looking towards having

a life outside their medical practice," says Getto of the

University of Wisconsin.

eantime, doctors already on the job may consider changing

their practice to adapt to the new realities--often in

ways that affect patient access, especially for the poor

(the rich can always pay cash or buy more comprehensive

insurance). Only 11 percent of those elusive Boston

cardiologists surveyed by Merritt, Hawkins accept

Medicaid. About 17 percent of family practitioners

nationwide don't take new Medicare patients, and those

figures are worse in metropolitan areas. A 2002 study in

California found only 58 percent of the state's doctors

were accepting new HMO patients, while a third of

specialists had no HMO patients at all. Some are turning

to cash-only systems. All these restrictions squeeze out

the poorer segment of the patient population.
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A handful of physicians are finding relief by turning to

so-called boutique, or concierge, practices, typically

charging an annual fee to cover preventive services not

covered by Medicare. A perhaps not-so-coincidental benefit

is that the extra fees mean a smaller practice, which in

turn means less waiting time and more access to your

doctor. Though the $1,500-$1,800 annual fee has been

called elitist, Darin Engelhardt, chief financial officer

and general counsel of MDVIP, which provides business

support services to boutique practices, says only a tiny

fraction of doctors have a practice appropriate for this

kind of care. For the doctors who do sign up with his and

other services, "there is a uniform theme--the desire to

be able to take back control of a primary-care practice,"

he says.

Scant rewards. In a special report in the New England

Journal of Medicine last year, physician and journalist

Abigail Zuger compared the discontent in medicine to

similar feelings in other professional fields, including

law, nursing, and teaching. Maybe, she says, doctors are

just no longer isolated from the pressures that plagued

their colleagues in other professions. "It is an exception

whose time has finally expired," she concluded.

There are still plenty of doctors who see their work as a

higher calling or at least love their jobs. And some

studies buck the image of disgruntled docs: The Journal of

the American Medical Association reported last year that

most doctors are still satisfied with their jobs, though

they voiced unhappiness with the administrative aspects.

When done right, medicine "is one of the most deeply

rewarding lifestyles in the world," says Remen. But many

docs are feeling those rewards are only available by

practicing medicine on their own, radically revised terms.

Paul Ryack feels invigorated again--but only after making

big changes. He joined MDVIP, and his practice is down to

600 patients. Now he spends as much as 90 minutes with

some of them. "I'm enjoying what I'm doing again," says

Ryack. "I don't worry that I'm missing something because

there's a line at the door. My quality of life has

improved, and my patients love it." His is only one

solution to the problems of practicing medicine these

days, but the others that are appearing will also leave

gaps that the country has not yet figured out how to fill.