Saturday, November 22, 2008

Hanging up the stethoscope

Why does a doctor hang up her stethoscope and quit? I am not speaking of a doctor who reaches her 60s or 70s and wants to retire. My doctor is in her late 40s, in her prime, who not long ago spent countless hours and large sums of money learning her craft. One who is exceptionally intelligent, has a wonderful manner, and who had a potentially bright career ahead.

This question is on my mind because my family doctor has decided to close her practice. Dr. McKelvy is one of the best doctors I have ever known. She subscribes to the idea that the patient knows her own body better than anyone else, listens carefully as the problem is described, and is not intimidated by a patient who has research in hand. You can see the wheels turning as she carefully thinks over a patient’s problem. Using a holistic approach, she will often prescribe alternative medicines along with traditional.

It took me eight years to find her after my previous doctor of 30 years retired. Having gone through about eight doctors who were only average and did not listen well, I thought I had finally found an excellent doctor who would be available for at least the next 20 years. But she is closing her practice – just at the time when, due to worsening chronic health problems, I really need a very good doctor who can think outside the box because I do not fit neatly in anything learned from a textbook. It will not be easy to find another doctor who listens as well as she does and is so good at getting the diagnosis right the first time. I will greatly miss her.

Why is Dr. McKelvy quitting? She has been practicing medicine for 25 years. When insurance companies turned to the PPO and HMO models, she found herself having to spend more time on paperwork than on patients, trying to run a small business instead of a practice. There was less and less time for individual patients as federal reimbursement cuts force most doctors to pack in more patients during each day. Dr. McKelvy refused to do this, never booking more than one patient per time slot, continuing to spend as much time as necessary for each patient, and refusing to pad her bills with unnecessary charges. (One can see why she would not easily fit into a group practice.)

As she continued her struggle to practice medicine on her own, Dr. McKelvy found she was not making enough money to keep her office open. She is frustrated by how difficult insurance companies have become – overriding her decisions for treatment and substituting a cheaper medicine for the one that, in her professional opinion, was best for a patient. Her training did not include how to run a small business, how to deal with insurance companies or how to cope with the red tape and paperwork generated by government agencies. Since she can no longer make a decent living being the kind of old-fashioned, caring doctor that patients love, she has chosen to walk away.

According to news sources, these days many family doctors are leaving medical practice causing a shortage of primary care doctors. More and more family doctors are abandoning their role as the glue of health care, with fewer young doctors replacing them, and choosing to go into higher paying specialties.

As the costs of running a practice continue to rise, insurance payments for many routine procedures continue to decrease, thanks in a large part to the decreasing payouts from Medicare and Medicaid whose payment structure private insurance companies often emulate. In fact, Medicare and Medicaid are becoming such money losers for physicians that over a third have closed their practices to Medicaid patients and 12 percent have closed their practices to Medicare patients. If we are already short on primary care doctors and a many of those still practicing are declining Medicare and Medicaid, how will we get enough primary care physicians to provide for families without raising payouts to entice and retain these doctors? And if we raise payouts so that doctors can stay in business, the overall costs associated with the healthcare system will increase.

Any new healthcare system that the Obama administration puts in place has to make primary care a reasonable and profitable option for physicians, or our shortfall of family care providers will become massive. In any new plan, even if everyone has some type of insurance, it will do little good if they cannot find a doctor.

Just take a look at the disheartening results from a survey from the Physicians’ Foundation. The study confirmed that there are not enough primary care physicians in the U.S., even though there are plenty of specialty doctors. Here are some of the disturbing findings from 11,950 doctors who responded to the survey:

*94% said the time they’ve devote to non-clinical paperwork in the past three years has increased – with 63% saying the paperwork has meant they spend less time per patient.

*82% said their practices would be “unsustainable” if the new proposed Medicare pay cuts were made law.

*78% believe there is a shortage of primary care docs in the U.S.

*60% would not recommend medicine as a career to young people.

*49% said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.

*42% said professional morale is either “poor” or “very low.”

Walker Ray, MD, Vice President of The Physicians' Foundation put the results of the survey into context: "At a time when the new Administration and new Congress are talking about ways to expand access to healthcare, the harsh reality is that there might not be enough doctors to handle the increased number of people who might want to see them if they get health insurance. It's as if we're talking about expanding access to higher education without having enough professors to handle the influx of students."

I wish Dr. McKelvy luck. I hope she has not permanently hung up her stethoscope and will find a way to practice medicine again. If she does not, it’s our loss.