Many of us adults are cared for by internists or primary care physicians. We're told they're unhappy because they only make $175,000-$210,000 annually and that results in a shortage as new doctors gravitate into specialties that can pay twice that amount.
What's wrong with these contrasting pictures?
At minimum, they challenge a confusing and highly suspect hypothesis suggesting that we could improve
The theory starts with data indicating that internists and family physicians are paid much less than specialists like cardiac surgeons and concludes that they're offsetting such small payments by making patient visits shorter and referring an increasing number of problems to specialists.
A declining number of new doctors are becoming primary care physicians apparently because of compensation disparities, feeding fears of a shortage and complaints about increasing waits for appointments.
If the visits were longer, reformers suggest, more problems would be solved without referrals, making life simpler for the patient and creating a safer and less expensive environment by reducing the amount of surgery that results from today's referrals.
Does this argument reflect reality? I've never found it convincing.
In the short run, it has a logical flaw. If primary care doctors are shortening the average visit to up the volume in an effort to maximize their incomes, then paying them more for longer visits would inevitably lengthen the queues we're seeing today. If the average visit goes from 20 minutes to 30, the number of patients seen daily has to decline.
Over time, proponents argue that this problem would be resolved because more new doctors would go into primary care, thereby easing the supply problem. There's no reason to believe that would work, though, unless payments were doubled, which is not going to happen in an era where many bills are already far too high.
Most primary care doctors earn less than $200,000 a year while general surgeons pull in $271,000-$358,000. So paying primary care physicians even 25% more would cost of lot of money, but still leave a significant gulf for new doctors who were following the money. On the other hand, not all doctors do follow the money. The lack of shortages in pediatrics and psychiatry, where earnings roughly track what primary care physicians make, suggests there are other influences at work here.
Having already declared that an hour-long visit lasts 50 minutes, psychiatrists don't have a lot of leeway in increasing their volume. Pediatricians, though, offer an interesting model that may have lessons for other areas of medicine. They delegate a substantial amount of decision-making to paraprofessionals and tend to offer same-day service for illnesses that seem serious, a combination that many adults would find attractive.
The norm is a morning "sick call" period when worried parents call to share their concerns with expert non-doctors who do triage, separating the kids who'll be helped by a day of quiet recuperation from those who need a physician's attention.
It is a model that seems to work.
If there's an appetite to spend more to enhance primary care, convincing internists to adopt the triage model already used by pediatricians might be a more sensible investment than simply upping reimbursement levels.
[Many thanks to Dr. Chris Johnson, who helped me think this through, bears no responsibility for my conclusions and blogs engagingly at http://www.chrisjohnsonmd.com/blog/ when he's not caring for patients].
Thank you for this insightful piece. Most pediatric colleagues of mine earn significantly less than the $200K benchmark cited above, particularly now in the wake of economic slowdowns across the board (in which parents seek to minimize visits for arguably less-urgent matters in an attempt to reduce co-pay outlays). It's true that money is not what attracted me or my colleagues to pediatrics, nor is it what attracted my daughter to a pediatrics residency when she just as easily could have pursued more lucrative fields. The reward for treating kids is not monetary, but rather, consists of a hug from a four-year-old during a follow-up visit, or a warm handshake from a young parent who knows the heartache of a sick child. Every day includes reminders of what's important in life, and why excellence for its own sake is the goal of those perceiving such reminders. Having said that, I recall when HMOs of decades ago held forth the same carrot to primary care physicians, promising what they could never deliver and perhaps never intended to provide. Not only did primary care physicians continue to content themselves with lower fee schedules, but they viewed with chagrine the fact that they were expected to take a loss with immunizations, and participate in rationing by being cruel gatekeepers who denied referrals and studies. If the current Washington standoff results in something akin to the status quo, both litigators and insurers will continue to salivate on Pavlovian command. Most primary care docs would like to see a single payer system, as originally favored by a young Obama when he was a community organizer on the streets of Chicago, but somehow those lofty goals have been chiseled away by the relentless erosion of something called politics.
Jim:
Generalizations are tricky, of course, but it is fascinating that job satisfaction among pediatricians is extremely high. This comes from a 2001 study in the journal Pediatrics ( Vol 108, p. e40) of 5,704 pediatricians, internists, and family physicians: "Despite lower incomes, general pediatricians reported the highest levels of satisfaction and the least job stress of all 4 physician groups."
Pediatrics is still chugging along as a career choice among seniors in medical school, too -- in spite of plummeting numbers of students choosing primary care careers overall, the percentage of senior medical students choosing to be pediatricians has held steady. So money isn't everything.
As a family physician I have a couple of comments. First, doctors caring for adults don't have the luxury of wide open schedules able to accomodate lots of patients who want to be seen the same day. Why? A vastly larger percentage of adult patients suffer from chronic diseases. Most children take zero or one medication and have a medical problem list that's essentially blank. On the other hand, many if not most of the adult patients I see take numerous medications for several conditions. They don't come in for diarrhea; they come in for diarrhea, diabetes, hypertension, depression, headaches, rectal bleeding, and a rash, all in the same visit. This takes a lot of time and we can't schedule 20 patients in the morning and 20 in the afternoon, like my pediatrician friends can.
Also, when medical students rotate through our office, they see how frantic our days are, overstuffed to the breaking point with too many patients, inadequate time per visit to take care of numerous issues, and a constant blizzard of forms, phone calls from patients, medication refills, lab results to review, etc. etc, all for no additional income. They think to themselves that it looks like a pretty hectic, grueling, unpleasant workday, and it is. They then choose a different career path that pays 2 or 3 times as much for a lot less hassle.
So, I hate to say it, but you're pretty much wrong in your post. If the money isn't increased substantially, you'll never get anyone with a choice to do the job.
And the notion of shorter visits equaling more referrals absolutely does occur in the real world. Just today I referred patients to dermatologists and ophthalmologists for issues I could have solved myself if I had enough time. I can't do in 12 minutes for $75 what a trio composed of a dermatologist, gastroenterologist, and orthopod will collectively have 1.5 hours and $1500 payment to accomplish. But if you gave me 30 or 40 minutes and paid me $250 I sure could.
I'm not holding my breath, though.
I have the greatest respect for practicing physicians who obviously have many incredible skills I lack. That said, I'm often struck by the apparent passivity of these masters of the medical universe who see themselves as imprisoned by the system. Mark's note is an interesting illustrative example. if you think you could solve the patient's problems on the spot in another 45 minutes and an added $250 payment, why not offer that deal to the patient. given the stress and logistical issues, I'd personally take that deal in a minute.
Jim,
You would be right if we lived in a world without insurance. However the patient 99% of the time is not the payor. So in the case when insurance is involved Insurance will say that they will only pay for 15 minutes and that no matter how complicated or what I do they will pay me $40.
If I take 45 minutes to solve the problem, I still get paid the $40 form the insurance company.
The patient does not have to pay out of his pocket so he is not going to pay me $250 to save the insurance company $1250 dollars.
If I refer out then the patient gets to pay another copay (maybe $25 or $35) and get the work done.
A little known fact for most people is that the insurance companies use higher costs as a bargaining chip the following year either with the premium payer or if they only act as a broker then with the employer to raise premiums, which they are happy to do since all their profit formulas are percentage based and if healthcare costs go up they automatically make more money.
So Jim, if you had insurance you would not take the deal in a minute, you would probably look at what your pocket outlay is and go to the specialist.