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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.

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2 Comments:

Blogger ryanjo said...

Sadly, much of this commentary is true. The insurance bosses are already tightening the noose around primary care physician's neck (witness the economic credentialing rating system being blogged about currently). The majority of patients don't really care, as long as they get their unneeded antibiotics and sleeping pills refilled promptly.

The future for the average American with health insurance will be primary care from an insurance company-approved Walmart or CVS Minute Clinic (the perfect storm of corporate medicine), and urgent/serious care from an ER doc or inpatient hospitalist. God bless 'em, they'll probably survive through all the CPOE-generated medical errors, and feel great about it afterwards since it was all paid for by somebody else's money.

The desperate, intelligent, well-off, and those with chronic and intractable problems will seek out the vanishing primary care doctors, who have had to opt out and work for cash. Suits me just fine...

July 20, 2010 at 5:32 PM  
Blogger Toni Brayer, MD said...

I think you are wrong. (I don't know about the canary, but I do know about primary care). The low pay of general IM correlates with low regard from academia and other specialists. When (pick one) derm, pathology, radiology, anesthesia began making more money, all of a sudden the residencies were filled with the best students, esteem was raised and voila...no shortage.

The best and the brightest used to do Internal Medicine and general patient care. Perverse payment schemes changed that and health care became more fragmented and expensive.

Primary care should be the cornerstone of the nations health care system. The work is long, arduous and meaningful. Pay should be commensurate and getting the right physicians in place should ultimately save the nation money.

I do agree that none of this will likely happen, but not for the same reasons you espouse.

July 21, 2010 at 10:27 AM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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