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3% of Doctors Aren't Frustrated

By purepedantry on June 19, 2008.

Well that is not good:

In a survey last year of nearly 2,400 physicians conducted by a physician recruiting firm, locumtenens.com, 3 percent said they were not frustrated by nonclinical aspects of medicine. The level of frustration has increased with nearly every survey.

...

In surveys, increasing numbers of doctors attest to diminishing enthusiasm for medicine and say they would discourage a friend or family member from going into the profession.

The dissatisfaction would probably not have reached such a fever pitch if reimbursement had kept pace with doctors' expectations. But it has not.

Doctors are working harder and faster to maintain income, even as staff salaries and costs of living continue to increase. Some have resorted to selling herbs and vitamins retail out of their offices to make up for decreasing revenue. Others are limiting their practices just to patients who can pay out of pocket.

There are serious consequences to this discontent, the most worrisome of which is that it is difficult for doctors who are so unhappy to provide good care.

Another is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners.

Last year, residency programs in family practice took only 1,096 graduating medical students, the fewest in the last two decades. The number increased just slightly this year. Students who do choose internal medicine increasingly are forgoing primary care for subspecialty practices
like cardiology and gastroenterology.

The desire to expand coverage -- indeed the desire for universal coverage -- is a fine sentiment, but it won't happen if we continue to treat doctors like dirt. There are so few people in my medical school class that went into primary care that I could probably name all of them, and this largely because primary care is filled with many frustrations with disproportionately little compensation for those frustrations.

Some might respond that in the end we can rely on doctor's good faith and commitment to service to keep them working. These are fine things, but they only go so far and last so long.

Of my many concerns with the desire to expand coverage to the millions of uninsured is that in doing so we will fail to fully compensate doctors for the additional load. Medicare payments are already schedule to decrease. The current system is headed straight for doctor shortages in key disciplines as far as the eye can see. People who think medical care appears by spontaneous generation are going to be sad when they realize there are no doctors left provide it.

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"The dissatisfaction would probably not have reached such a fever pitch if reimbursement had kept pace with doctors' expectations. But it has not."

I really don't want to hear physicians cry about not making enough money.

Note that it doesn't say that doctors are treated like dirt, only that their income has not kept up with their expectations. What are their expectations? That they will have incomes that are ten times the top of the "middle class" income? A doctor can enter an orthopedic surgery practice and within a few years make more than $1 million a year in gross income*. Give up half of that for the costs of running his practice and he still is an extremely wealthy person. If his income drops to $900,000 a year, or even $750,000 a year, he is still extremely wealthy. Now that might not be the case with some doctors in some areas, but, please. Everyone in the US knows that the surest way to wealth in this country is to become a physician.

* In one case, the income range for a particular orthopod with a fairly ordinary practice was reported to range from around $800,000 to around $4.5 million, depending on a number of uncertainties. If a physician is unhappy with that income (which, by the way, allows him to cut his practice to about 80% by the time he is 50 and retire comfortably any time after that), then he is most definitely in the wrong profession. We don't need to give doctors more money, we need a better class of person becoming doctors. You know, ones whose main motive for becoming a doctor isn't to become wealthy.

We don't suffer from a shortage of dermatologists or orthopedists, but primary care physicians. Reimbursemnt runs at the upper end as jobs go, about 90-140K per year. However, most american medical grads exit school with at least 120-160K in educational debt, and, in primary care, spend about 3 years of residency at a normal living wage (30-40K).

PCPs work with very small margins, often taking home about 20-40% of their gross income, the rest going to running the office. Depending on where they practice, they are often forced by insurers to see a certain number of patients, and spend a great deal of unreimbursed time calling for authorizations, etc.

In other words, it ain't as rosy as it seems. Doctors aren't starving, but there is little incentive to spend 4 years of undergrad, 4 years of med school, and 3 years of residency and accumulate debt, in order to not be able to afford to send your own kids to college.

If we want PCPs, we have to incentivize people. There are few jobs that require 11 years of (not free) education/training just to walk in the door, and when they can extend that training just another couple of years and make 500,000/year, they just aren't going to become a primary care doc.

I have no objection to physicians, especially PCPs, making a decent income. If the numbers you cite are correct (I found some other numbers, but I have no idea whether they are good. They are at http://www.physicianssearch.com/physician/salary2.html) then PCPs do not make enough. I presume by reimbursement you mean gross income. If that is the case, then PCPs really are underpaid. I would love to see their income rise, but in this country, that means that the public ends up paying not only their increase, but also an increase in insurance rates, since I doubt that the insurance companies will act as a pure conduit for that additional money flow. If I were emperor, I would offer GPs and internists a $200,000 takehome for a 40 hour work week with facilities and staff provided, with incentives for performance and a way to weed out the worst, all at government expense. And with regional adjustments. Yes, socialized medicine. No insurance, no middle man to take out his cut. Horrors. I would fund it by taking what the pubic pays for insurance and putting it towards medical care, and I would make gigantic cuts in other programs, specifically the military budget. But that will never happen in this country short of a catastrophic social and economic failure.

I said everyone knows the way to get rich in this country is to become a doctor. But what most don't know is that there is another way. Go to work for a military contract. Work a few years, make some good contacts with your government customer. Then quit and start your own business, taking your customer's programs and funding with you. That' s where great gobs of money could be saved: let government employees do the research and development, and then let private contracts build the actual hardware. Right now most complex, highly technical programs are managed by technically ignorant government contract monitors. There's a lot of money in this government that could be used for better things. Like medicine.

They threaten to lower medicare reimbursements every year because it lets them avoid increasing rates with inflation. It's really scummy. Maybe if we weren't spending trillion on wars medicare would do a better job. Using this as an example as an attack on the program itself is misplaced however. Before we had shitheads running the government, medicare was one of the best payers and was the bread and butter of many providers.

Further, the private providers aren't some kind of night in shining armor coming to save the day. They are just as awful, and have dozens of behaviors equally frustrating to providers, including the type of "mommy-may-I" crap, and second-guessing every clinical decision that makes medicine not worth practicing. They are worse, if anything, because ultimately they are beholden only to their stockholders, the oversight is a joke, and at 30% overhead (compared to medicare's 3%) they aren't exactly a money-saver in the long run.

The answer is that whatever the system you get what you pay for. Private systems base their reimbursement on medicare rates (and often pay a lower percentage by the way). Raising medicare reimbursement is a sure way to improve things overall. Eliminating inefficient private systems that benefit from a higher proportion of healthy clients (medicare covers the over-65 crowd - private insurers largely get the workers and the young and still pay less) might actually be beneficial if that money is used to subsidize the people that actually need the care, rather than enriching stockholders and 27% more in administrative costs...

I doubt that whining about decreased reimbursement will make much difference even in a single payor systems as long as third parties are doing the paying. The real issue is that decreased satisfaction is decreasing the number and quality of new physicians and making them more likely to opt for higher paying specialties. Primary care physician numbers are shrinking at an alarming rate. When my generation retires i ten years there will be a 20-30% shortage in all forms of primary care. Where do the people go then--the ER? Medical schools have tried to help prserve the financial largesse of physicians by severely limiting numbers of graduates. Maybe it is time we considered doubling the number of entrants to med school and making significant incentives to enter primary care such as reimbursing them better than specialist--that idea will go over big with the specialty groups and the AMA.

By JT Young MD (not verified) on 21 Jun 2008 #permalink