Stanley Feld M.D.,FACP,MACE

The administrative difficulties in the physicians’ work environment are increasing physician discontent.

“In a survey last year of nearly 2,400 physicians conducted by a physician recruiting firm, locumtenens.com, 97 percent said they were frustrated by nonclinical aspects of medicine. The level of frustration has increased with nearly every survey.”

The important point is that it is our younger physicians who are complaining about the burdens of medical practice.

“Dr. Bhupinder Singh, 42, a general internist in New York, sold his practice and went to work part time at a hospital in Queens. When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.”

Recently, he confessed, he has been thinking about quitting medicine altogether and opening a convenience store. “Ninety percent of doctors I know are fed up with medicine,” he said.

Many healthcare policy makers dismiss these complaints as the failure of managed care. Managed care was a system policy makers developed to manage costs. It is a system that has failed to manage care and manage costs as well.

“It is not just managed care. Stories of patients armed with medical knowledge gleaned from the Internet demanding antibiotics for viral illnesses or M.R.I. scans for routine symptoms are rife in doctors’ lounges. Malpractice worries also remain at the forefront of many physicians’ minds, compounded by increasing liability premiums that have forced many into early retirement.’

Physicians are discouraging their children and their friends’ children from becoming physicians. The opposite was true in past generations.

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.

Practicing physicians are not stupid. They are adjusting their practice to decrease practice burdens. Some Ob-Gyn physicians have stopped delivering babies because of the malpractice burden and decrease in reimbursement. They are only practicing gynecology. The adjustments in medical practices are to the detriment of patient care.

“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.”

I have said over and over again that healthcare policy makers do not listen to or ask physicians for advice. The end result will be a severe physician shortage. Physician shortages are here already. The central problem is quality care for patients and not the healthcare insurance company’s bottom line. I hope policy makers are listening.

“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. “For me it’s an endless amount of work that I can never get through to do it properly,” said Dr. Jeffrey Freilich, 38, a primary-care physician on Long Island. “I’m a bit compulsive. There is no time to do it all in a day.”

“On top of all that, there are all the colonoscopies and mammograms you have to arrange, and all the time on the phone getting preauthorizations. Then you have to track the patient down. And none of it is reimbursed.”

The only services primary care physician have to sell is their time and clinical judgment. Both services are undervalued in the present healthcare system.

Once a patient is hospitalized the primary care physician loses track of the patient. Hospitalists take over. Hospitalists call many specialists for consultation and advice.

“The upshot is that the doctor who knows a patient best is often uninvolved in her care when she is hospitalized. This contributes to the poor coordination and wanton consultation that is so common in hospitals today.”

“Years ago you had one or two doctors,” a hospitalized patient told me recently. “Now you’ve got so many people coming in it’s hard to know who’s who.”

Medicare is going to cut payments to physicians 10.6% in July. Why? It is easier to cut physicians who utilize 20% of the healthcare dollar than to cut the stakeholders that absorb 80% of the healthcare dollar. Why? Physicians are not organized! They are also cheapskates and do not support lobbyists. They do not have the powerful a lobbying infrastructure that the healthcare insurance industry and the American Hospital Association.

A 10.6 percent cut in Medicare payments to physicians is scheduled to take effect on July 1. Further cuts are planned in coming years. Many doctors have told lawmakers that if the cuts go through, they will stop seeing Medicare patients.

Unfortunately, politicians do not understand the problems physicians and patients have in the healthcare system. It is going to be up to patients and physicians make these problems clear to politicians in order to Repair the Healthcare System.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Stanley Feld M.D.,FACP,MACE

The answer is “NO”. Cecelia and I wanted to contact John Cornyn and Kay Baily Hutchison about their vote on HR 6331. Their two votes defeated the House of Representatives proposal to cancel the Medicare cuts.

It is an impossible task to send them an email. Just try to find an email address. We have concluded the best way to contact a congressperson is to send him or her a fax. Actually, many fax’s and break their fax machine. Maybe then you will get their attention.

The next time I hear that a politician wants to hear from his/her constituents, I know he/her wants to seduce us to vote for him/her. He/her has no intention of listening to us.

Stanley Feld M.D.,FACP,MACE

It has been said that the older physicians are the only physicians upset by the way they are being treated by the healthcare insurance industry. The claim is older physicians are spoiled by the golden days of medicine. My reply to that statement is nonsense. When a professional is treated as a commodity no matter what his age discontent is generated. The older physicians are products of the silent generation. When the younger physicians are pushed to the edge we will hear lots of noise and have lots of rebellion. The rumblings have started.

“I love being a doctor but I hate practicing medicine,” a friend, Saeed Siddiqui, told me recently. We were sitting in his office amid his many framed medical certificates.

Uwe Reihardt said it all to my surprise in a letter to the editor of the New York Times in May 2008.

“Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.

This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.”

Many examples of discontent from younger physicians can be sited. As these physicians gain experience and understand that the healthcare system is a business to the facilitator stakeholders whose only concern is the bottom line the patient-physician rebellion will pick up steam. The facilitator stakeholders account for 80% of the healthcare dollar and add little value.

“A doctor in his late 30s, he has been in practice for six years, mostly as a solo practitioner. But he told me he recently had decided to go into partnership with another cardiologist; “Your days aren’t busy enough already?” I asked.

“As a physician, I could empathize. I too often feel overwhelmed with paperwork. But my friend’s discontent seemed to run much deeper than that. Unfortunately, he is not alone. I have been hearing physician colleagues voice a level of dissatisfaction with medical practice that is alarming.”

The discontent is building. Physicians are fed up with what they perceived as a loss of professional autonomy. They can not stand the unwarranted restrictions on their medical judgment. As demand for physician services increase we are experiencing larger and larger physician shortages.

Another physician complained. “I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.” Managed care is like a magnet attached to you.

A 42 year old physician complains that he continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ”

The endless abuse on professional integrity amazes me. A high school graduate sits in front of a computer screen deciding on what a physician can or can not do. Another healthcare insurance company assistant sits in front of a computer billing screen reducing reimbursement on questionable computer programming decisions. The appeals process is difficult and time consuming for physicians.

“Dr. Mark Linzer, an internist at the University of Wisconsin who has done extensive research on physician unhappiness, told me. “Fortunately, the data show that physicians are willing to put up with a lot before giving up.””

How long do you think young intelligent physicians will tolerate this abuse? How long do you think it will take to train another compliant work force? America has a physician shortage that is about to accelerate.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.