Doctors Vanish From View
Harried by the bureaucracy of medicine, physicians are pulling back from patient care
Meantime, doctors already on the job may consider changing their practice to adapt to the new realities--often in ways that affect patient access, especially for the poor (the rich can always pay cash or buy more comprehensive insurance). Only 11 percent of those elusive Boston cardiologists surveyed by Merritt, Hawkins accept Medicaid. About 17 percent of family practitioners nationwide don't take new Medicare patients, and those figures are worse in metropolitan areas. A 2002 study in California found only 58 percent of the state's doctors were accepting new HMO patients, while a third of specialists had no HMO patients at all. Some are turning to cash-only systems. All these restrictions squeeze out the poorer segment of the patient population.
A handful of physicians are finding relief by turning to so-called boutique, or concierge, practices, typically charging an annual fee to cover preventive services not covered by Medicare. A perhaps not-so-coincidental benefit is that the extra fees mean a smaller practice, which in turn means less waiting time and more access to your doctor. Though the $1,500-$1,800 annual fee has been called elitist, Darin Engelhardt, chief financial officer and general counsel of MDVIP, which provides business support services to boutique practices, says only a tiny fraction of doctors have a practice appropriate for this kind of care. For the doctors who do sign up with his and other services, "there is a uniform theme--the desire to be able to take back control of a primary-care practice," he says.
Scant rewards. In a special report in the New England Journal of Medicine last year, physician and journalist Abigail Zuger compared the discontent in medicine to similar feelings in other professional fields, including law, nursing, and teaching. Maybe, she says, doctors are just no longer isolated from the pressures that plagued their colleagues in other professions. "It is an exception whose time has finally expired," she concluded.
There are still plenty of doctors who see their work as a higher calling or at least love their jobs. And some studies buck the image of disgruntled docs: The Journal of the American Medical Association reported last year that most doctors are still satisfied with their jobs, though they voiced unhappiness with the administrative aspects. When done right, medicine "is one of the most deeply rewarding lifestyles in the world," says Remen. But many docs are feeling those rewards are only available by practicing medicine on their own, radically revised terms.
Paul Ryack feels invigorated again--but only after making big changes. He joined MDVIP, and his practice is down to 600 patients. Now he spends as much as 90 minutes with some of them. "I'm enjoying what I'm doing again," says Ryack. "I don't worry that I'm missing something because there's a line at the door. My quality of life has improved, and my patients love it." His is only one solution to the problems of practicing medicine these days, but the others that are appearing will also leave gaps that the country has not yet figured out how to fill.
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