Out of Practice: The demise of the primary care practitioner

The business of practicing medicine has not been good for doctors over the last 30 years. A post of mine called “Are doctors tired of practicing medicine,” on a site for primary care physicians, elicited the following complaints.

• Doctors are no longer doctors, but poorly paid employees of the health insurance industry.
• Without changes in how we treat doctors, more will retire early and med students won’t opt for primary care.
• Everyone in the system is unhappy, obnoxious, or unsupportive, not just the doctors.
• Maintaining electronic health records has a higher priority than caring for patients, and the effect on morale is disastrous.
• The work doctors once did has been taken over by nurses, NPs, PAs, and hospitalists. We saw it coming, so we have only ourselves to blame.
• No time for patients and too little reimbursement is extremely stressful.
• Students these days prefer “lifestyle” specialties that pay well and give them nights and weekends off.
• Even though you may love what you do, paying off med school loans lasts way too long, and that’s frustrating.
• Despite modest financial ambitions and a strong motivation to help people, “managed care medicine really killed the doctor in me.”
• This is not what doctors signed up for.
• Interruptions, time pressure, low pay, high overhead, unrealistic expectations – who needs this?
• We are not tired of practicing medicine … WE ARE EXHAUSTED.

There was not one response from a happy and satisfied physician.

From Marcus Welby to managed care

Dr. Frederick M. Barken, primary care physician, has written a book about why he chose to stop practicing medicine at the relatively young age of 51. His story documents the erosion of personal satisfaction for doctors and the quality of care for patients.

Barken was a premed college student in the seventies, in the days when Marcus Welby provided the image of what it was like to practice medicine. By the mid-1980s, when Barken was establishing his solo practice, conditions had already changed.

[T]he government and private insurers had begun a concerted effort to contain the escalating cost of health care by fiat. The kindly family doctor was diminished, downgraded, and de-professionalized to a “provider,” a bland descriptor on a clerk’s requisition form. Even worse, New York State’s Medicaid, insuring the indigent, classified me as a “vendor,” a term which sent me into orbit then, and which today still rankles. Hemmed in by profession-specific price controls, reams of restrictive regulations, heavy-handed threats of federal penalties and expulsion from Medicare participation for suspected infractions, I became disheartened. My patients, however, still held the traditional view of their doctor as a knowledgeable authority figure and a personal source of comfort, advice, and strength. They did not know that the supportive scaffold, their primary care physician’s practice, already had developed dry rot.

The 1990s brought HMOs and managed care. For patients who had the right insurance benefits, doctors became gatekeepers to specialists and high-tech diagnostic equipment. Despite the bureaucracy and “banditry” of the health insurance industry, Barken was willing to continue his practice as a solo practitioner in his small office, offering support to his patients.

How to provide for the aging baby-boom generation

By 2007, however, when Barken closed his practice, the increasing age of his patients had added a new burden.

Mirroring a national phenomenon, a trend toward the geriatric, my practice increasingly was composed of the fragile, chronically ill sufferers of multiple degenerative diseases, all laden with the psychosocial complexities of the first superannuated, add-on generation in human history. …

Now, in 2011, the dark cloud of Medicare insolvency hangs on the horizon, saturated with the heavy burden of 78-million nearly-geriatric Baby Boomers. My quite traditional, small, solo private practice, so 20th-century in concept is no longer viable in a modern Walmart business environment of “everyday low prices” and paper-thin profit margins. Few primary care physicians today are able to meet the extraordinarily large volume of care demanded by the soon-to-be-senescent Woodstock generation. Something must give.

Barken’s conclusion: “Primary care medicine is collapsing, a victim of economists’ tenets of maximized efficiency, profit, and productivity.” His book, Out of Practice: Fighting for Primary Care Medicine in America, will be published in mid-April.

From a Publishers Weekly review:

[The medical profession is] overwhelmed, underfinanced, and ill-equipped to deal with older patients suffering from complex medical issues. Barken warns that doctors, patients, and politicians will have to accept that the primary physician’s role must change, that a bigger health care industry isn’t necessarily a better one, that malpractice liability, along with its high costs and demoralization of doctors, must be reined in. Primary-care doctors must resist the pressure to prescribe too many drugs and must manage a plethora of specialists who want to administer overly aggressive treatments that have little impact in prolonging life or making patients more comfortable. Physicians treating aging patients must also see them not as solitary units but as part of a well-prepared, involved family. In the end, he says, American health will be saved by its most important virtue: a strong physician-patient relationship.

Related posts:
Are doctors tired of practicing medicine?
Marcus Welby vs. the specialists
Physician as lone practitioner
The doctor/patient relationship: What have we lost?
Should doctors work weekends?
Reluctant patients: The mental health of doctors

Resources:

Image: ISBN

Frederick M. Barken, MD, Out of Practice: Fighting for Primary Care Medicine in America