Primary Care Physicians: Between A Rock and a Hard Place

I’m the husband of a primary care physician and although I may be biased I’m not stupid. I’m intelligent enough to recognize my own biases and think around them. Besides like everyone else I’m human and consume health care as does my Wife. People seem to forget that every doctor is also a patient at one time or another, and while one might think the White Coat gets you special treatment from other doctors, it doesn’t. For example the Wife had to wait 3 months to see a GI specialist just like her patients do. She refers to this specialist all the time but that didn’t get her special treatment. I was actually annoyed and told her, “But you send this guy revenue. The least he can do is give you a kickback by fitting you into his schedule.” I come from a long line of Democrats, so corruption is in my genes. She said she had to wait like everyone else.

We know health care is a mess in the United States and recognize it’s a complex problem. So whenever someone comes up with a bright, simple solution, or as is often the case the sole blame for the mess, it’s always wrong. Are lawyers and malpractice suits the sole cause of our system’s dysfunction? No.  Inflated doctors salaries? Nope. Greedy health insurance companies? No. The system is so bad now that there is plenty of blame to go around for everyone – and I do mean everyone. The system is so corrupted that if you even touch it you become part of the problem. No one seems to get that.

The esteemed Walter Russell Mead has written extensively about the health care crisis in America but lately has been falling into a trap where he focuses his blame on doctors. Case in point: A recent survey of doctors conducted by the Journal of Medicine that found the vast majority of physicians see themselves as having some responsibility for holding down health costs, but saw themselves as a minor contributor compared to other groups.

“What physicians are trying to tell us is that they don’t see themselves as necessarily any more responsible for health care costs than all of those stakeholders,” said Dr. Jon Tilburt, an associate professor at the Mayo Clinic and the study’s lead author. “They see themselves as a contributor, not a main contributor,” he added.”

Mead takes issue with this statement. “(Doctors) seem (to) overlook the fact that the current system, based on fee-for-service payments, is stacked in favor of the doctors. Health care can probably never be a fully level playing field. But if patients could inform themselves about prices before going through with various tests and treatments, they could contribute to lowering costs by opting out of unnecessary or overly expensive ones.”

Evidently Mead has forgotten the problem caused by insurance. If a patient patient pays only the fraction of the total cost of a procedure through his deductible and co-payment, there is no incentive for him to forgo the procedure. For example, a Medicaid patient comes into the office with a sprained wrist and demands an MRI. The primary care physician may examine the wrist and if she suspects it’s broken, perhaps orders an X-ray. But the patient will not be happy unless she gets an MRI, a procedure whose costs are not borne by the patient  but by the state’s taxpayer (in the case of Medicaid) or other policyholders (if privately insured). Publicly funded insurance schemes like Medicaid and Medicare particularly are ripe for abuse. Patients demand all types of medicines and procedures because they bear so little of the cost. With $3 copays doctors visits for minor ailments such as colds or the ubiquitous “sinus infection” cannot be discouraged, contributing to overuse of the medical system. Dr. Wife has been trying to do her part to stop the overuse of antibiotics, but she has been challenged by patients who insist on getting one even if taking it can cause other problems, believing that they are not getting their money’s worth unless they go home with a pill.

Patients are exhibiting signs of viewing medicine as a service industry, like a restaurant where they can order and eat whatever they want but then aren’t responsible for the bill.  In the case of the MRI, a diagnostic test that wasn’t warranted by the complaint, the woman complained to the staff about the Wife’s refusal to order it, and threatened to badmouth the practice to her friends. Since the Wife is paid according to a system that is based on the number of patients she sees, such a complaint could impact her salary. Such patients aren’t rare, and are increasingly becoming the norm. After diagnosing a patient with a minor stomach ailment the patient told the staff, “$25 and I’m told to eat yogurt.” People aren’t interested in treating their ailments; they are interested in only treatments that are active, invasive and often expensive. Their expectations and concepts of health care are seriously out of whack.

Doctors have known for years that the happiest patients are the ones who get what they want, whether its antibiotics for colds or even pain pills. There’s a scene from an episode of the British comedy “Doc Martin”, a series about a socially inept and rude but brilliantly skilled general practitioner who takes up residence in a small Cornish seaside town, when he visits the local pharmacy and learns the doctor who replaced him prescribed inappropriate treatments to his patients. “You didn’t give me these pills,” one patient says chirps, obviously glad to have a different GP, “But she did.” Dr. Martin answers “You have asthma, and those beta-blockers will kill you.”

Doctors who practice “evidence based medicine” where they do not prescribe or treat unless the illness warrants it aren’t popular with patients who are emboldened by the Internet and commercials telling them to “talk to their doctor” about the latest pharmaceutical wonder drug that doesn’t outperform existing lower-cost generics. Will they be happy with the cheaper generic instead of the pill they see on TV? As long as they are shielded from the full cost of that pill through a low co-pay, it is unlikely.  So should the doctor prescribe the new pill and make the patient happy or the generic and risk an unhappy patient who may not come back or worse, bad mouth him to their friends? Is the customer, or patient, always right? Or should the doctor always give the patient what is in his or her best interest? Most doctors strike a balance between the extremes but as patients see doctors more like waiters in a restaurant and less as health care ally it will be harder for doctors to balance doing the right thing by the patient while making him or her happy, especially when doing so can lead to negative reviews on Yelp! or its medical practitioner equivalent.

Mead is also a fan of cheaper medicine provided by physician assistants and nurse practitioners. These are mid-levels with less training than physicians who in most states must be supervised by doctors. Doctors are not paid for this extra supervision yet are the ones held responsible for any mistakes done by the mid-levels under their supervision. Some health care systems are replacing doctors with these mid-levels, finding mid-levels are able to bill at roughly the same rate as doctors yet cost half as much. Traditionally primary care physicians were viewed as the gate-keepers to specialists and inpatient admissions where the real money was made by hospitals and health care systems, so primary care practices weren’t expected to be profitable. That has changed and primary care practices are expected to be profitable as well maintaining their traditional referral role. Mid-levels are key to that profitability.

But do patients really benefit from the lesser trained mid-level? In the vast majority of cases a mid-level can offer care as good care as a physician.  Since mid-levels are salaried they can spend more time with patients unlike physicians who are on productivity or paid by RVU. Where physicians excel is their additional experience and training for less common illnesses and disease processes. A doctor receives several extra years worth of training to differentiate the sounds of horses and zebras, as the old adage goes about recognizing the difference between common and uncommon disease processes. A nurse practitioner may recognize the sound of horse hoof-beats but does he recognize the sound a zebra’s hooves make? Do mid-levels order more tests than physicians to make up for their lack of training? That is a study I would like to see done, and if true would encourage health care systems to continue to replace physicians with them because extra testing generates even more revenue for hospitals. From a payer’s perspective the overall benefit of the mid-level may be lost through the additional testing costs.

As mid-levels are added to the rosters of practices and hospitals either doctors will have to be compensated for taking on the added oversight and risk (doctors can be sued for malpractice for mistakes made by the mid-level they are supervising), or the system and patient expectations will have to change to accommodate them.

There are very good reasons why medical students vote with their feet and avoid primary care specialties. GPs are earning less and seeing more patients to compete with cheaper nurse practitioners and physician assistants. They are becoming overwhelmed with paperwork, all of it unpaid: employees needing doctor’s notes for time off, requests for electric scooters, treatment justifications from insurance companies who refuse to cover a procedure or medicine, prescription refill requests, lab results and patient notes. Paperwork is free and like anything that is free it gets abused and grows; attempts at taming the paperwork beast like the panacea offered by electronic record system adoption simply lead to even more paperwork. Some systems have cost hospitals nearly a billion dollars EACH to implement, an investment that threatens some with bankruptcy and leads to even more pressure on staff to pack the patients in. Most primary care physicians just want to do what they’ve been trained to do, practice medicine and do what’s right by the patient. Instead they have become unwitting players in a vast economic and social experiment.

There are many intelligent people in the health care debate with many ideas and contrasting positions. The system is so screwed up there is plenty of blame to go around. We need more people like Walter Russell Mead to weigh in on the subject but only if they accept the truism, attributed to Einstein, Churchill and even HL Mencken that for every complex problem there is a simple solution, and it’s wrong.

UPDATE: See this essay for what a survey of 1,400 sued doctors tells us about health care reform.

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24 Comments

  1. David Macfarlane:

    Occam’s Razor. Maybe this is deliberately ironic misspelling?

  2. Scott Kirwin:

    As a connoisseur of irony, I’m curious… What’s misspelled?

  3. David Macfarlane:

    Perhaps Occam’s? In the upper left? It is spelled ‘Ockham’s.

  4. Scott Kirwin:

    Occam’s is a common spelling, but I’ve seen it spelled all sorts of ways. I chose Ockham in the header of this site because of the philosopher William of Ockham who formulated the principle of parsimony that later became known by his name. And with that you are asleep in 3…2…1…

  5. David Macfarlane:

    Still wide awake. I would have thought it strange if such a misspelling had survived lo these many years since blog inception. I was unaware of the Occam’s Razor back story, so thanks for providing my daily educational bit. Cheers.

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