U.S. health care system punishes the most important doctors
Elizabeth Torres doesn’t like the way many doctors jog from one exam room to another, their eyes focused on an electronic tablet where they tick off insurance company checklists and move their patients along as quickly as possible.
She chooses to slow things down to let her patients talk about their job, children and home life. She knows that’s what a good diagnosis and treatment plan requires.
“It’s medicine, not whacka-mole. We’re not here just to fill in boxes,” the 62-year-old said. “You’ve got to know what environment they are in, what are they eating, do they have stressful jobs, a stressful family situation?”
Torres’ job is to keep her patients as healthy as possible, the most important job in American health care. But her industry treats primary care physicians so badly that their numbers are shrinking, and there are consequences for all of us if conditions don’t improve.
Stress, bureaucracy and case load have left 64 percent of doctors with a negative view of their industry, according to a survey commissioned by the Physician’s Foundation, an advocacy group for doctors. Less than 20 percent of physicians say they can accommodate more patients.
Primary care physicians are particularly unhappy, facing the heaviest paperwork burden and the lowest pay. Forty-four percent of doctors say they plan to retire early, cut back on patients or seek a job that doesn’t involve patients.
“We’re at the bottom of the payment totem pole, for sure,” Torres said. “The amount of work we have to do is far greater than the specialist. We have to do a lot of tedious work.”
Torres calculates she works about 70 hours a week, which is typical, according to the survey. More than 80 percent of Texas physicians work more than 40 hours a week, with some averaging 80 hours or more.
Torres is also one of the shrinking number of doctors
who operate as small businesses. Only 29 percent of Texas doctors still own their practice, and nationwide the number has dropped to 17 percent as physicians join large partnerships or work as employees of hospitals where patients are too often seen as statistics.
“The key word right now is efficiency. But do you want someone who is going to listen to you and take care of you, or do you want someone who will be efficient?” she said when asked why she doesn’t work for someone else. “I may not be doing financially the best that I can do, but I am able to pay my bills, I’m happy with how I take care of the patients, and that to me is the important part.”
Torres recruited her husband to handle the billing, and they work together to pay her assistant and the other overhead costs. About 20 percent of her time is spent doing paperwork for the 22 patients she sees a day.
Not surprisingly, few new doctors want to go into primary care, also known as family medicine. Texas ranks 47th in the nation for primary care doctors per capita, according to the Centers for Disease Control. The federal Department of Health and Human Services anticipates a national shortage of 20,000 primary care physicians by 2020.
That’s bad news because routine visits to a primary care doctor who knows you are the single most important factor in preventing chronic health problems. When more Americans have a so-called medical home, the less the country spends on health care, studies show.
If we want to keep people out of the hospital, we need more doctors in the community. But we’ve created a system that discourages doctors from taking the most important jobs of keeping people healthy, and encourages them instead to become specialists who treat people after they get sick.
Reversing this problem requires rethinking how we train and compensate doctors, said Dr. Richard Olds, who has taught at many medical schools and is currently president of St. George’s University in Grenada. About 25 percent of U.S. doctors graduated from international medical schools like St. George’s, and two-thirds of them provide primary care.
Olds said part of the problem is that professors at American medical schools tell students “they are too smart for family medicine.”
“U.S. medical students largely want to become specialists, and we need to start addressing those kinds of issues,” he said.
Medical students at St. George’s perform their clinical training and residencies in primary care settings rather than in large medical centers in urban areas, Olds said.
“They go into the fields that society needs, and they are twice as likely to practice in underserved areas,” Olds said of St. George’s graduates.
Closing the pay gap between primary doctors and specialists is critical. The United Kingdom has plenty of primary care doctors and provides an example, he said.
“They pay their primary care doctors twice what our doctors are paid, though they also pay their specialists considerably less,” Olds said.
That sounds good to Torres, who gets paid $75 to $100 per patient visit. For an additional $15, she could hire a physician’s assistant to make sure patients follow treatment plans and to help analyze data generated by her electronic health record system, she said.
Despite the current working conditions, Torres said she has no plans to retire anytime soon. She simply hasn’t made enough money yet, she said.
No doubt she’ll have plenty of patients, because until we treat primary care doctors better, she won’t face much competition.