Letters to the Editor
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Think about the market-based solution to this market-based problem...
We need more doctors. Medical schools are not lacking for applicants. Let more in!
The medical cartel decided how many doctors we "needed" and cut class sizes to increase scarcity.
Do we really need more doctors like the one who drives a Bentley up and down 1st Ave in NYC with a vanity plate reading "PRE HMO"?
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No respect
Primary care physicians get the lowest remuneration, the sickest and poorest patients, the longest hours (outside of ER). What' in it for them. Doctors giving botox and laser facials make a lot more.
It's time to stop pimping the social conscience of these doctors and make their pay commensurate with their responsibilities.
And, no, I'm not a doctor.
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This is a conversation I had not long ago
Some answers --
Nationalized health care and free medical school for those who commit to system as PCPs for a minimum of ten years.
An end to making medical school/internship/residency an endurance contest. Some sanity is already starting to infect the system, but education of any sort simply should not look like years long ordeal.
More medical schools. Doctors benefit from this artificial monopoly. No one else does. Does the invented exclusivity of our medical schools really protect us when our new doctors come from foreign countries?
And a new one inspired by this article -- rational reimbursements for specialists. By the time you see a specialist, you are either totally broke or insured; in neither case are you searching for the "best value". A textbook example of market failure in setting prices.
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Marcus Welby, ARNP?
I am frequently suprised that doctors do not address the role of nurse practitioners in filling the primary care gap. Family Nurse Practitioners now outnumber primary care resident graduates. Numerous studies have shown that the care they provide to be equal to that of physicians.
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FNPs and PA's
The last time I saw a real MD was years ago. They've all been replaced with FNP's and PA's. They do a fine job.
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Status of Family Doctors
There are other subtle things going on that drive medical students away from general practice. Here are just a few more:
Look at your local medical school's class pictures: between WWII and about the mid-1970s, women were all but excluded, but they began entering medical schools in significant numbers in the late 1970s. In order to maintain some kind of competitive edge, male students moved toward specialized medicine, such as neurosurgery, and out of fields where women were increasingly present, such as family practice and OB/GYN. Virtual denigration of general practice resulted because, from a male perspective, if women can do it, it must not be very difficult or important.
While physicians were routinely fairly well paid for most of the 20th Century, the Era of Greed that followed Ronald Reagan into office brought with it a shift in focus to the bottom line and seminars on how to "maximize" the return on insurance payments through creative coding and itemization. A "tonsillectomy" used to be billed as a single fee, not the laundry list of Q-tips, sutures, cotton balls, admission kits, room prep fees, etc., that appear on your statement nowadays.
General practice can be a lonely affair in rural areas and small towns where there may be few/no opportunities to interact with social and educational peers. Other attractants, such as access to ski resorts, golf courses, nice restaurants and the arts are typically absent in rural settings. Would you want to move to some backwater, where the pay and variety of illnesses offers nothing to brag about at medical conventions?
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And how will this "more respect" goal be accomplished?
Honestly, this is a pretty shallow rendition of a complex problem.
You're giving short shrift to the debt issue. With the escalating costs of undergraduate + medical school it is not uncommon for newly minted MDs to start their internships with $200,000 in debt. No one makes any headway on that debt as a house officer so basically a new GP at the age of 30 is still carrying $200,000 -- just when they are starting out as the low man in a practice. Maybe they married a med school classmate -- tack on a few more $100,000 dollars. This is an enormous debt load and starting salaries for GPs are not particularly high.
Yes, they made choices -- expensive ones, but when you are a second year resident and you start "doing the math" -- doubling your starting pay with the possibility of achieving a much higher ceiling by extending your training by a few years becomes more enticing. When I was finishing my specialty training about 10 years ago many of my colleagues were still actively moonlighting and *hoping* to pay off their debts by the time they were 40.
Many of the complaints of today's practicing physicians (GP and specialist alike) are the same -- pressure to see many more patients combined with endless paperwork and at least 1 hour a day (if lucky) arguing on the phone with HMO/insurance representatives. For many older MDs, their day-to-day lives changed drastically -- these are the folks discouraging younger people from pursuing medicine.
Compounding these issues is the frustrating complexity of today's medicine. Patients are sicker at a younger age with chronic ailments that either could have been avoided with better (or any) preventative care -- problems that snowball and start affecting multiple organ systems requiring frequent hospital stays. Being a GP in any undeserved region is like spending your day shoring up leaking dams.
Any approach to "raise respect" has to be coupled to changing the nature of medicine to help make it rewarding again (not necessarily from the monetary standpoint)-- starting with 100% medical coverage for 0-18 year olds to start decreasing the incidence of early-onset obesity, diabetes, etc. Followed by the availability of step-wise graded coverage for folks who don't have insurance via employment. Even if these problems cannot be fully circumvented, it is far better to manage patients before they become ER "frequent flyers".
When coupled to a real streamlining of the payment bureaucracy and yes, debt reduction -- general practice will become more viable.
It's a multi-tiered problem that will require creativity and resolve to fix.
Oh and the MD on Park Ave -- he's busy drag racing with one of Ronald Reagan's welfare queens in her Cadillac. Be serious...
JT