By Mark David Blum, Esq.
(*An ongoing discussion of the state of the art of the business and practice of medicine and possible alternatives thereto).
American medical schools are reporting a dramatic shortage of students intending to practice primary care or family medicine. Practitioners report that more than half of those already in a primary care practice would quit if they had a practical alternative.
It would seem on the surface that being a primary care practitioner is at the heart and soul of medicine. Only they become close with the patient and become the patient’s partner is assuring and protecting the patient’s health. This long term special and at times intimate relationship should be at the core of what it means to be a primary care physician.
Clearly the primary care doctor job is nowhere near as sexy or macho as being an hospitalist in an Emergency Department or a specialized surgeon. No blood, no guts, is seen as being no glory. But real medicine, treatment and diagnosis, is found in a day to day basis in the offices of the family primary care practitioner. This is the meat and potatoes of the practice of medicine.
So the question arises as to why is there a rising shortage of primary care practitioners? To me, based on dozens of conversations with doctors and hospital personnel as well as my own life and practical experience, tell me the problem is married to one of my own primary pet peeves about the business of medicine. In its’ neverending pursuit of excellence and the seemingly unending mysteries about human anatomy and physiology coupled with technology and pharmacology changing daily, medicine has so fractured into too many subspecialties. In a discussion about a hospital wing dedicated solely to injuries to the hand, a Master Sergeant friend once said, “doctors learn more and more about less and less until one day they will know everything there is to know about nothing.”
Two stories best exemplify the complaint. This past week, a child I know went to the doctor and the doctor wanted to draw some blood to run some tests. The doctor’s office is at Northeast Medical Center in Fayetteville. Instead of drawing the blood at the doctor’s office and messengering the sample to the lab, the child and her chauffeur were compelled to drive downtown to a hospital outpatient clinic where the blood was drawn and quartered.
When this tale was shared, my panties got all twisted. What a waste of time and money to make the patient drive 15 miles to have blood drawn. I know that every doctor who has a license and every RN who has a license, as one element of skills that must be demonstrated, is the ability to draw blood. What a waste of time and money. The duplication of resources is obnoxious. In my opinion, the primary care physician abdicated his responsibility.
The second story involves a young lady who is on a-years long, daily taken prescribed medication. When she runs out, she goes to the pharmacy for a refill. One day she goes for her usual fillerup and the pharmacist says “no”. Apparently, the patient’s primary care physician had denied the refill because, “the patient had not been in to see the doctor in a couple of years.” The young lady had no reason to see her doctor; she had not been ill nor injured. Knock on wood, she has been healthy and happy and had no reason to seek out a medical consult. At the point of a prescription pad, the woman was compelled to see and spend time saying ‘hello’ to her primary care physician. In a better world, the pharmacist would issue the prescription herself. Instead, the primary care doctor gets paid.
Both of these tales make the point of the health of the primary care practice. Both share the same demon which if exorcised from the calculus, would change the course forever. It is all about the dollars and cents. A doctor gets paid by an insurance company only so many dollars for a routine office visit. (Like police say about traffic stops, there is no such thing as a “routine”, but that is another discussion. God is in the details). An insurance company is not going to pay the doctor more money because the doctor drew a couple of ampoules of blood. So, instead the doctor shares the insurance wealth with another doctor who can get paid if he draws the blood and get paid again for running the labs. The parking garage gets a cut, the oil companies get a cut, and the hospital gets a cut. Amazingly, the insurance companies themselves are demanding that this be the procedure.
It seems to me that the primary care physician needs to be more than just a pill pusher. This is the doctor who has to take the time and invest the energy and resources to make a long term commitment to a patient to be there for that patient. Each part of the practice of medicine which is delegated out depletes the skill set and involvement in the outcome of a medical issue. Every time a primary care physician abdicates his responsibility to a hospitalist or to a “specialist” when the primary care physician is well aware he or she can do the job, it has to leave the doctor feeling less valuable and satisfied.
There are only two parts to medicine: Diagnosis and treatment. Satisfaction should come in the form of success in both. But what doctors have done is to pander to insurance companies and allow price fixing to drive down what doctors charge per visit. The backsplash of course is doctors overbooking so as to maximize profits. Twenty dollars per patient is de minimus but see ten an hour with five waiting and suddenly its profitable … if the doctor wants to work in volume and has the energy for long days.
The other mess the insurance company price fixing has caused is doctors creating new ways to bill. Not only do they seek compensation for each visit, but they want to charge for every test run, every instrument used, and every paper pushed. This new form of billing was met by the insurance companies the same way; pressure and price fixing. In the end, for many a doctor, doing it yourself and not getting paid for it is the primary cause of opting out. Like the little girl and the blood test, if you are not going to get paid for it, why do it when someone else can.
If I gave the commencement speech at the local medical school, amongst my babble would be a solemn vision of a different form of medicine. I would encourage them to be doctors, not specialists. The joy of medicine is in the helping others part and real satisfaction has to come from making the right diagnosis and healing the patient. Patience is something the students need to learn. The business will take care of itself. I never heard of a starving doctor (or lawyer).
But nothing is going to ever be right until the animal called “insurance” is removed from the game. Right now the general public demand is for universal coverage of some form. Tempting the government with low rates and promising to cover everybody, the insurance industry is making it worse. They are poised to get legislation that makes sure 330 million Americans will have insurance. To me, this is an appalling way to approach the issue and the wrong place to start. In fact, putting the Insurance industry in charge of the nation’s health care delivery system will indeed so factionalize the business of medicine that the practice thereof will all but be forgotten.