Can't Find a Doctor? You're Not Alone
Amber Meiwes is happy to tell you what's wrong with primary care in America: It's hard to get any, and when you do, it's a health risk.
During a long struggle with recurring stomach pain, Meiwes got used to waiting three weeks to get in to see a doctor—and then being hustled back out in mere minutes. "They had way more patients than they really can see," says Meiwes, 29, of Piedmont, Okla. "They would say, Take an antacid and go home." When she fell ill on weekends, her only options were an after-hours clinic or the emergency room. It took three years of office visits and ER visits before she got a diagnosis: inactive gallbladder. "I got to the point where I wouldn't even go to the doctor anymore."
It's not supposed to work that way. A primary-care doctor is supposed to be the go-to doc for almost every ailment from ingrown toenails to suspicious breast lumps—the trusted guide to the system who knows the patient, her medical history, her family. Any time the patient must navigate the bumpy and often frightening path through specialty care, it's these internists and family and general practice doctors who make sure that nothing critical falls through the cracks. Indeed, study after study has shown that patients fare better in areas of the country not overpopulated by medical specialists and where primary-care physicians handle the bulk of care. Yet increasingly, the system is fraying. Consider:
• Twenty-nine percent of people with Medicare said they had trouble finding a doctor who would take that insurance in 2007, up from 24 percent the year before. That's 11.6 million people.
• Two thirds of Americans say they have a hard time getting medical care on nights, weekends, and holidays, according to 2007 survey by the Commonwealth Fund.
• Just 30 percent of Americans say they can get in to see their doctor on the same day—putting the United States second to last among industrialized countries, ahead of Canada, according to the Commonwealth Fund survey.
• In California, almost half of emergency department patients surveyed in 2006 by the California HealthCare Foundation said they thought their problem could have been handled by a primary-care physician. Two thirds of those people said they couldn't get an appointment with their doctor.
• In Texas, 24 counties now have no primary-care doctors at all.
• In Alaska, not one of the 749 private-practice physicians was taking new Medicare patients for primary care in November 2007.
The shortages don't reflect a lack of doctors; the number of physicians per capita rose 77 percent between 1970 and 2000. But given the choice, most new doctors simply reject primary care. A specialist performing a procedure—a colonoscopy, say—is commonly paid three times as much for 30 minutes as a primary-care physician who spends that time talking with patients about how to manage their heart failure or diabetes. An internist or a family-practice physician might start off making $100,000 to $150,000 a year, but specialists make about twice as much on average, says David Dale, a Seattle internist who is president of the American College of Physicians. And a typical medical student graduates with $130,000 in debt.
As a result, the number of grads choosing residencies in family practice, internal medicine, and pediatrics fell 7 percent from 1995 to 2006, according to congressional testimony from the Government Accountability Office in February. And while half of residents in internal medicine chose to go into primary care in 1998, now just 20 percent do. In the past few years, many have instead chosen to join the growing ranks of "hospitalists," a new genre of internist who manages the care of patients while they are in the hospital. Hospitalists may make $200,000 a year to start, with fewer hours than a private practitioner and none of the start-up costs or managerial headaches.
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Reader Comments
LOST IN HEALTH CARE
I started my career as a Respiratory Care Practitioner, then applied to both Medical school and Physician Assistant School. Ironically, I got accepted into both.
I start this Summer in PA school in New York. I have choose not to go to Medical School just due to the decrease salaries and the increased cost. It would of cost me around 300k for medical school and taken me 10 years of education to me a Neonatologist to complete my goal. If I continue as a RCP, thats 10 years of an $80k salary minimum, thats $800k lost in salary at minimum plus a lost in regular daily activies.
In end, PA school would cost me $50k, average salary is 100k, and can still provide greatly in the health care system at a decrease expense.
Fixing the system
It's nice to see that the lay press is finally covering what we family physicians have been saying for the three decades I have been in the business: only comprehensive, long term disease management is going to impact the health of the population and save money. However, we have never been paid to do that. Every insurance plan is set up with a 1930's model of paying for illness. Even HMO's failed to fix the problem because in order to sell the plans, they had to tell subscribers they could see any specialist they wanted as long as we, the "gatekeepers," allowed them. The incentives were to do less for people.
The physician and in particular the patients should be incentivized to prevent problems. Why do we pay thousands for angioplasty and coronary bypass but almost nothing to prevent the need for these procedures?
As a family physician and geriatrician, I will commonly manage up to 15 problems in one visit. I get the same reimbursement for that as when I manage 3 problems in a 30 year old, but the complexity is far greater in a 90 year old. It's hard to convince physicians to do this when they can take out cataracts or do invasive cardiology and make 3-4 times more. So, if one day soon all Americans have insurance, there will be no doctors to care for them. It would be like all of us having cars but no gas.
The other issue there is little discussion about is end of life planning. 75% of Medicare dollars are spent in the last ten years of a person's life. We all must decide for ourselves when enough is enough rather than trying to extend another week or month of life when death is inevitable.
I have the utmost respect for nurse practitioners. I work with several daily and have been a nurse practitioner educator so I know what they can do. Our patients will be best served by a team that has an NP and a physician working together. Every day I discuss the management of some of the more difficult patients in our practice with my NP. Her training allows us to work together so I need not always see every patient. Without the physicians in our office, she would have to refer many patients to another specialist. That does not save money in the long run since we are able to manage about 90% of our patients' needs together. We are not in competition; we are a partnership.
If the system will help us in primary care to do what we do best and give us the means to accomplish it, we can fix health care in America.
Prmary Care
C. MacLean RN:
Your diatribe against physicians is also "typical" for the discusssion presented by advance nurse practitioners. I am a physician who was a nurse first, so I have been through both routes and see both sides of this story.
I agree that nurses are taught to focus on patient education and to incorporate the entire bio-psycho-social model in dealing with patient care and management. But nurses simply do not study the same breadth and depth of knowledge of diseases as physicians do, period. I know, I did them both.
I also agree that society needs to focus on prevention and healthy lifestyles. But are you truly suggesting that just because I have the letters "MD" behind my name means that I do not advocate such healty behaviours as smoking cessation, weight control, exercise, etc. to my patients? Hogwash!
I am willing to review independent studies that show that primary care nurses provide the same level of care as physicians. But for someone never trained in medical school to state that medical students aren't taught how to see the entire patient or that they aren't taught to listen or talk to a patient is quite simply incorrect and only reveals self-serving personal bias. As an example, my resident physicians' conferences this month include presentations on the care of a culturally diverse patient population and delivering difficult news. There are rotations for medical students to learn hospice and end-of-life care (I took one as a 4th year medical student).
Also, my opinion as a physician educator is that the skill of communicating is more a part of the student's interpersonal skills he/she brings to the learning process and is not easily taught to any student. Put simply, it depends more upon the personality type of the student, not which discipline they pursue as to how good a communicator that student becomes in the professional setting.
So let me be at the front of the line in saying that nurses are wonderful colleagues in the teaching of patients and coordination of their care, but that does not mean that they have become the doctor. I know, I have been both.
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