Doctoring in the trenches, using our knowledge and techno-gadgetry to enhance or save lives, is uplifting. Reading news on heath care reform is “not so much.”
Reform has yet to begin, but businesses and doctors are already changing their behavior. As chronicled in this depressing piece, it is clear that doctors are joining consolidated practices and choosing to be salaried more often.
“Last month, a hospital I’m affiliated with outside of Manhattan sent a note to its physicians announcing a new subsidiary it’s forming to buy up local medical practices. Nearby physicians are lining up to sell—and not just primary-care doctors, but highly paid specialists like orthopedic surgeons and neurologists. Similar developments are unfolding nationwide.”
Common sense would argue that a salaried doctor without any productivity incentive will see fewer patients. It is human nature. No, most doctors will not just clock out when someone is really sick, but the pressure to add elective patients on a busy procedure schedule, or full office day diminishes greatly when there is no skin in the game.
And, the demand/supply equation is growing increasingly askew. Demand for healthcare is on the rise. Thanks to our skill and technology, patients live longer. With increased longevity comes more chronic diseases. As medical technology advances forward, so does the accepted standard of care.
As demand rises, the supply of care is decreasing. Due to falling reimbursement, more doctors are opting out of medicare. Salaried doctors will see fewer patients. More middle-aged doctors are either retiring early or choosing non-clinical careers. Talented young people are choosing medicine as a career less often–but even when they do choose to doctor, they are less likely to choose primary care. Ask veterans how easy it is to see a specialist?
The loser in the above equation is the consumer of health-care–you and me.
Think this isn’t real, just a blogger droning on.
Consider Mr M:
Call Mr M (your patient), “he had a small stroke and wants to know whether he should take warfarin to prevent another one,” comes the text message.
So I call, and Mr M, an 85 year old who is incredibly functional tells me his story.
“Which hospital were you at,” I ask.
“I didn’t go the hospital, it was the weekend, I didn’t want to bother the doctors, and it was only numbness on my left side… “I am a lttle better now,” he adds with an optimistic tone.
His MRI, ordered by his primary care doctor showed an isolated small stroke. The decision comes down to the choice of two disparate blood thinners. After explaining the dilemma, I add, “we really need you to see a neurologist.”
“That’s what my primary care doctor said as well, but I called two neurologists, and the soonest they would see me was two months.”
Both neurologists he called are employed by a hospital. Is this just a coincidence?
I’m engaged now, so Mr M’s decision will get made something like this: in between ablations tomorrow, I will mosey down to the radiology cocoon and find one of the incredibly talented neuro-radiologists my hospital is fortunate to have, and go over the MRI. Then, I will call the neurologist and tell him the story and MRI findings. With these two opinions, I will make a decision on blood thinner and call the patient with the answer. He will no longer need the neurologist opinion.
It will be fun finding out the answer. It will help the patient. I will be reimbursed zero for an hour or so of my time. This fact is ok with me, in my present state, but not so with many doctors, and is it really fair?
This scenario is the tip of the iceberg.
JMM
TheTaddy says
Dr. M,
I found your blog entry from this morning intriguing. However, I also found it to be quite misleading. Your anecdotal story of “Mr. M” describes a functional 85 year old male having suffered an acute to subacute stroke. The two neurologists contacted to arrange outpatient follow-up care could not see this gentleman for at least two months. These two physicians contacted were also reported to be hospital employees….. suggested by you to be likely more than just coincidence. I would argue that it was indeed just that, a coincidence.
It is a well known fact that there is a significant shortage of neurologists practicing in the Louisville metropolitan area. A cursory Google search for adult neurologists in Louisville yielded a return of 41 individuals. My own perusal of this list discovered 5 physicians that are no longer practicing, reducing this operational number down to 36. This is relative to 83 listed cardiologists, discovered via an identical online search method.
I would invite you to call any of these listed neurologists and attempt to locate a practitioner that is either able or willing to see Mr. M sooner than two months. I propose you will find the same response, independent of said neurologist’s practice model (employed vs other).
On similar topic, I find your argument regarding salaried physicians and self-incentive to be only partially true. In today’s age of the salaried physician becoming more commonplace, so is the incentive-based contract. Very rare is a physician on a flat salary beyond the first one year of contractual agreement. Even in this first salaried year, the pretense of the salaried physician acting independently and hanging it up as the clock strikes 5pm couldn’t be further from the actual truth.
In full disclosure, I am a salaried physician. However in this first year of employed status, I have been introduced to many checks and balances in the system: The office manager whose job is to ensure a set number of RVUs are met within my office, my own productivity which helps to calculate salary in years 2 and 3, and my own inherent sense of right & wrong. The days of clocking in and out as a physician remain reserved for Emergency Room physicians and those hospitalists truly functioning on a “workshift” model of practice.
Lastly we should come back around, full circle to Mr. M. In his story you indicate that after you have formally reviewed films with neuroradiology and informally discussed via telephone with a neurologist that Mr. M “will no longer need the neurologist opinion.” I couldn’t disagree more. No neurologist practicing standard-of-care medicine would (or should) suggest that a long-term treatment decision be made after simply viewing and/or discussing the results of an MRI done one week prior. If this infarct appeared small vessel in origin, he warrants further investigation down that road (i.e. carotid u/s imaging, lipid panel, etc.). If his scan was more suggestive of an embolic event, then testing should of course be focused in that direction (echocardiography, +/- holter monitoring, etc). Bottom line, a discussion with respected colleagues (formal, informal, or otherwise) with subsequent tentative agreement reached upon treatment, doesn’t replace the ever-important workup.
As always, I enjoy the thought-provoking nature of your writing. Keep up the good work. TS
Anonymous says
We have somewhere between 13 and 15 neurologists whose only job is to staff our 350 bed hospital so there is no manpower shortage here. The average wait for a new out patient neurology consultation is somewhere between 4 to 6 months which is 2 standard deviations longer than any other specialty group. (Mr M may well have died on the wait list here long before he was sent to the lab for his lipid profile) The neurologists are also the only practicing (non hospital based eg pathology, radiology) physicians to have been hired by the hospital. Must have found yet another coincidence.
DrJohnM says
TS, thanks for such a thoughtful comment.
“I would invite you to call any of these listed neurologists and attempt to locate a practitioner that is either able or willing to see Mr. M sooner than two months.”
Yes, it is true, I could have got on the phone and tested my “doctor,” capital, in trying to get Mr M an appointment sooner. The point though, is that the primary care doctor already referred Mr M for consultation, and most patients will not have an aggressive, blogger cardiologist as an advocate for their healthcare. It's not just neurology, it could have been orthopedics or neurosurgery or nephrology.
For the purposes of brevity, many of the medical specifics were omitted. The specifics didn't add much to the point: that salaried doctors are but one of the many factors which will limit patient's access to health-care. A fairly thorough work-up–as you outlined–was indeed done.
I started this game in 1996, when fee for service was in its heyday. Cardiologists, Neurologists, and Primary Care docs were drilling it hard, late into the evenings. Now, things are different. Roam the hospital at 1700 or later, and you see many fewer doctors–primarily the shift-working Hospitalists and the General Surgeons who by the nature of their work, are there all hours. It's a different paradigm, or culture now. Not saying better or worse, just different.
JMM
Thinker says
There are many problems with healthcare. Mr. M is just a symptom. As a consumer Mr. M lacks the knowledege to make an informed decision regarding his care. He is a the mercy of the physician. Most physicians do not make compromises in the recommendations of care based on self-interest or defensive medicine but how is an uninformed consumer to make that distinction? I propose you are thinking of at least one physician that has questionable motives. This violates a basic economics principle that consumers are able to make informed decisions with knowledge of the product or service. Mr. M chose to ignore his own instinct to go to the ER on a weekend (why? and where did he learn to resist his instinct?) Despite a numb arm and most likely years of patient education that an 85 year old must have had, Mr. M chose to be treated remotely via telephone because he knew it would be cheaper & less time consuming than an office visit. His care may be decreased but he lacks the knowledge to make that distinction. Perhaps, it is a disservice to afford him such care. When a consumer believes he receives more benefit than the costs to him decisions cease to be made cost-effectively.