Blog | Tuesday, July 20, 2010

The canary and the primary care physician

This post by Alan Dappen, MD, appeared at Better Health.

Why do you cage me? by tanakawho via FlickrThe vexing problem with "truth" when it comes to health care is to understand its limits. Let's start with two popular notions. The first, canaries are harbingers for detecting chemical leaks. The second, primary care specialists claim higher salaries for their work will prevent their extinction. Both claims sound plausible, but then come the conditions, the nuances, the variables and empirical testing and observation--the so called threads of truth.

Notion 1, The Canaries: In 1972 my brother passed through the military's basic training and was Vietnam bound until a perfect score on a standardized test, his Phi Beta Kappa and a chemistry degree from college rerouted his destiny to a remote patch of the Utah desert. Instead of being a foot soldier, he gave back to his country in a chemical warfare lab.

As the story goes (the lab was highly classified, luckily I was not there to be a primary witness), 1/10th of a drop of a nerve agent just on the skin could kill a person in less than a minute. Understandably, the lab employed the services of many caged canaries for testing possible leaks of the nerve gas. This became a time-honored safety measure.

One day a lab tech took the established belief and subjected it to empirical testing. The results rocked "the-canary-in-a-nerve-gas-lab" notion to its core. In reality, the lethal dose needed to kill 50% of the canaries was much higher than it was for humans. Instead of humans scurrying out of the lab to safety, the conclusion of the study predicted that in the event of a nerve gas leak, canaries would be chirping away in their cages senselessly while a roomful of humans lay lifeless on the lab floor.

The brass, confronted with the cold hard facts, summarily dismissed the canaries.

Next, let's consider Notion 2: Money Can Revive Primary Care, which is built on the belief that throwing more money at a problem can fix it.

I start anecdotally with my cohort of family practice residency friends who are now in their late 50s. Of the eight doctors I keep up with, three no longer see patients. One is retired, one quit medicine 15 years ago and one serves as an administrator. Another three work part time in patient care ranging from one to three days a week. Only two of us remain in clinical medicine full time.

Observational data suggests that enough money is to be made to either retire early or to work part-time. The comment I hear most often from this very dynamic and intelligent group? "I'm so done with medicine. I've moved on with my life."

Next, 90% of primary doctors work for someone else (e.g. Kaiser, Group Health, hospital systems, the Veterans Association, private companies, health management groups). Even "private practices" is a misnomer since insurance companies control and out-compete the doctor for the patient. Patients no longer employ doctors but hire intermediaries to protect them from predatory and unpredictable health care costs. Not surprisingly, the middle man who pays the doctor cares little about physician morale, work hours or paying one penny more than they have to acquire a doc. We are nothing but replaceable units.

Also, nurse practitioners are rapidly being seen as the new primary care workforce because it is believed that they are easier and cheaper to train and their emerging numbers will create a supply and demand curve that can easily stamp out any mirage of a doctor magically being offered more money just because MDs are "special" or deserve it.

In addition, health care, even after "reform," is bankrupting America more than any other sector of our economy. Primary care physicians' incomes already approach 95% of all American's incomes. The tolerance to pay more money for physicians' crocodile tears will be but deaf and blind pleadings upon the public and our bosses.

Lastly, the equation between happiness and money in numerous studies show repeatedly that physicians can't buy more happiness with more money. They already sit well along the threshold of money where the happiness curve flattens and no longer responds to money. More money will mean hedging for fewer hours or quitting faster if nothing changes the morale and conviction of the current primary care workforce. Certainly my cohort of residency friends exemplifies this finding.

In sum, a prediction: The brass, confronted with the cold hard facts, will refuse physician pay raises and hire nurse practitioners and physician assistants instead. Canaries will not save chemical warfare workers. More money will not save the endangered primary care physicians. Canaries have enough purpose flying, singing and looking beautiful. The struggling primary physician movement might want to go back to the basics or their mission and take control of their own destiny. There are a plethora of physician collectors who are willing to pay just enough to keep you in a cage. There are also a few primary care physicians out there who have taken flight and have refused to give up hope that others will follow and focus on mission, not money.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.