For centuries, doctors diagnosed illness using their own senses, by poking, prodding, looking, listening. From these observations, a skilled doctor can make amazingly accurate inferences about what ails the patient.
Technology has changed that. “We’re now often doing expensive tests, where in the past a physical exam would have given you the same information,” says Jason Wasfy, a cardiologist-in-training at Massachusetts General Hospital in Boston.
As a result, many doctors are abbreviating the time-honored physical exam ”” or even skipping it altogether….
A real physical exam takes more than the 10 minutes allotted per patient, whereas
he can bop in and say have this, this and this
test done and go on to the next room/patient. So what if the test cost $xxx.
It is no coming out of his pocket.
That is the problem. I made a point of alloting 45 minutes to a new patient and 15 minutes to a follow up. I began work at 7am, worked through lunch and finished clinic around 6pm, after which I did hospital consults until about 9-10pm. I also worked about 6 hours/day most weekends (either doing consults or catching up on reading sleep studies, eegs etc). I always did compulsive neurological examinations and reviewed the old records. I found in a large group practice (run by a nonprofit Catholic hospital) where I had some 45% medicare; 20 % medicaid and 25% private and 10% uninsured (usually hospital ER patients) taking that kind of time with an office overhead that was some $300,000 dollars before I saw a penny, I ended up owing the practice money and didn’t make a dime. I was billing over a million dollars, collecting a little less than 300,000, and working over 80 hours a week, and I did not make enough money to pay myself what a hairdresser would make. I went over the data with the business manager who pointed out that obviously I need to “see patient’s faster” and that if I only spent 20 minutes with a new patient and 10 minutes with a follow up, I would be able to earn over 100,000. Alternately, since medicaid did not even cover office overhead, and medicare barely covered office overhead and did not contribute to my salary, I could refuse to see children (all medicaid) or consider limiting the numbers of seniors that I was willing to see. I did not like either option, so I elected to try a different practice with lower administrative costs. I found a very efficiently run practice in a hospital that was also a nonprofit that had administrative costs of only about $150,000. I continued to allot 45 minutes to a new patient and 15 to a follow up, and I continued to begin work at 7am, work through lunch, finish at 6pm and see hospital consults (usually again unpaid since they were mostly uninsured or medicaid) until around 9pm, working some six hours/day most weekends. I also agressively expanded my offerings, (I have 5 board certifications), carving out time for sleep studies, and neurophysiology, and limiting the number of new child consults (all medicaid and all complex) to one daily for which I alloted an hour and one half at the end of the day. Doing this, I managed to earn about 210,000 (a big help in paying off student debt and mortgage, not to mention the night time sitters that looked after my young children while I was at work) but was really unbelievably tired. I was also not having any fun, and my children missed me.
Currently I work for the government, and I continue to allot 45 min for a new patient and 15 minutes for an old. I earn a lot less, but I usually get home by 8pm, and have my weekends free.
The reason doctor visits are so short, and why so many physical exam skills are atrophying is that office overhead is so high. In private practice I and 3 other physicians shared some 12 people. These included nurses, billing people, folks to argue with insurance, medical record folks, transcriptionists, and of course folks to make sure we kept within the law. In government service I have a nurse whom I share with 2 other docs. I type my own consult notes while I speak to the patient (I type fast). I do not have to buy malpractice insurance.
The solution to the problem of health care costs is to lower the cost of overhead. As long as the government and regulators add more regulations to the burdens physicians face, the faster docs must work. Most docs would love to spend more time with patients than to run around seeing 50 people at 10 minutes a visit. However we do have to cover out overhead. Obviously one cannot work for a year and pay for the priviledge rather than earning money. We too pay rent, we too have student debt, and somebody needs to be home with the children when the physician is called out to the ER to see the sick kid with no insurance. That somebody expects to be paid. We need to be paid also.
So the options for making sure that practices (which are small for profit businesses not public services paid for by taxes) stay in the black are to:
1. See more patients faster. (This is what most docs do).
2. Refuse to see patients with medicare, medicaid that do not cover costs. (And right now government is cutting payment for medicaid and medicare despite the fact that they already do not cover costs).
3. Reduce overhead by reducing regulation, litigation and documentation and billing expenses. Right now the government is adding to the overhead by increasing regulation, and by insisting the physicians pay an extra 100,000 for a completely computerized medical record that will make it easier for governments to regulate physicians, and lawyers to sue physicians, but will add to both costs and time for the doctors (who are expected to pay for this service to government and lawyers).
Which solution does this forum think would be best?
Clueless, thanks for the valuable input. You thoughts are consistent from what I have heard from family members in a variety of roles in the medical field. Here are a few of my suggestions:
1. Return insurance to its proper role. Cover preventive care and major medical; the rest is out of pocket.
2. Encourage personal responsibility. (How – good question!) Estimates suggest that @75% of our health care expenditures arise from “lifestyle choices”.
3. Increase use of paraprofessionals to focus M.D. time where it is most needed.
1. Returning insurance to its proper role would reduce “unnecessary visits and testing”. It would not lower physician costs, though it would lower government and insurance costs. It would increase patient costs.
2. Personal responsibility. Would not lower physician costs though it would be helpful for government.
3. Increase use of paraprofessionals to focus M.D. time where it is most needed. My nurses made more than I did per hour and only saw simple patients who needed a Mom more than they needed a doc. The problem is not physician pay because with the exception of the surgical subspecialties and some elite procedure based specialties like Cardiology, nurses get paid more/hour than doctors do. A good LPN gets about 40,000, a Nurse practitioner gets close to 100,000 and all work a 40 hour week, seeing not very sick patients in a fashion that would be considered “leisurely” for a doctor. A busy family physician seeing patients at 10 minutes a patient makes 180,000 and works an 80 hour week. The nurse practitioner he supervises sees patients at 30 minutes/patient, makes 100,000 and works a 40 hour week. It would be cheaper to have a physician replace the nurse, but most hospitals will not permit physicians to just work as nurses or physicians assistants because if they let us do that, there would be a stampede of doctors looking to lighten their loads by becoming physian assistants. That is what happened in the Phillapines where doctors switched to being nurses so they could have more money and more free time. I do know two board certified (excellent) physicians who work for independant surgeons as “physician assistants” because they prefer to have the time, and money to the pretigue of bieing a “doctor”. They also do not have to with hospital call, the problems of running a small business, and they go home at 5pm.
The problem is the costs of running a business that takes care of sick people who by definition always need more of the doctors time, and always are less able to afford his services. This has always been the problem.
All of this points out why I am happy with the medical care that I have received from the VA Medical System. I’ve been under their care since 1986, and I’m seen twice a year for routine exams; each time for about 45 minutes on the average…..sometimes longer, depending on the situation, and each time, I feel that I’m getting my doctor’s full attention. I’ve come to know her very well, and I know how busy she is. I’ve made it a point to tell her how much I appreciate the quality of care that she gives me.
The reason the VA system works is because it employes strategies 2 and 3 in post number 2 above. That is to say:
2. Refuse to see patients with medicare, medicaid that do not cover costs.
(The VA has its own set of payments that does cover costs)
3. Reduce overhead by reducing regulation, litigation and documentation and billing expenses. (Government physicians are covered for malpractice by the US Treasury. There is a formulary and providers stick to it with rare exceptions that requires clearance. Expensive tests like MRIs must be approved, and since the patient cannot sue just because they don’t get their MRI, physicians accept this.
But mostly, the VA does NOT accept all comers. Ordinary private (nonprofit and for profit) hospitals MUST do so. In a civilian hospital every person must be seen whether they have insurance or not. It is illegal to “turf” to another hospital if your hospital can handle the problem for paying customers. At the VA and DOD hospitals, only vets are seen. If a bleeding illegal immigrant or a 9 year old with a head injury shows up, he will be given first aid, and driven by ambulance to the nearest non-government hospital.
Re. #2 and #4:
I hear what you’ve written here.
However, you write that “most hospitals will not permit physicians to just work as nurses…”
Well, nor should they. I rather also suspect the state will deem it illegal for you to work as a nurse unless you have a nursing license. If you go through Nursing program, pass the R.N. exams and get licensed as an R.N., most any hospital will hire you as an R.N. — maybe not a hospital where you’ve worked as Dr. Clueless, M.D.
Were I in your shoes, I’d go the government physician route too. Or perhaps switch into Anesthesia.
Physicians are permitted to work as physician assistants without relicensure, however most hospitals would rather have a family physician work as a physician than as a physician assistant. Thus, one has to work for an independent physician and these are getting fewer. Physican assistants are more expensive on a pay/hour basis than are physicians despite the fact that they have less than 1/2 the training or debt. Therefore hospitals do not wish to encourage their physician serfs to transfer to a physician assistant position.
My point was that the midlevel provider route (nurse practitioner or physician assistant) would not save money since both these people earn more/hour than all but the highest paid physicians.
BTW nobody can “switch into Anesthesia without doing a 4 year residency”.
However as it happens I like my job, which hopefully will remain stable and is likely to remain as stable as anything else in America. (Military physician is also an option, they now take physicians up to age 62 with annual reemployment physicals). If things go sufficiently badly that the country cannot afford military physicians or must insist that they see patients at 10 minutes a clip or not earn a salary, then my game plan is to simply to do locums in Australia or New Zealand (both of which eagerly recruit US physicians and which speak English). I might also consider India or Singapore depending on the rules change coming up, and many of my friends are considering jobs in Saudi Arabia. However although I have received letters of interest from Arab nations, I would go there only as a last resort because even though the money is outstanding I would not be able to practice my faith).
So the bit about working as a nurse was not meant to be serious. You are right, a doctor would be forced to go to nursing school because that is the way the regulations are written in the US. Switching to nursing is a strategy for Philapino physicians where it is easier for doctors to retool as nurses than it is in the US. That is not a viable option here, however there are plenty of options for physicians with my qualifications besides simply working faster and faster for less and less money in the US, while earning less than one’s employees. I merely point out that since there happens to be shortage of not just physicians but nurses and other midlevel providers the other options that most physicians are likely to select may not benefit the American people as much.
The good news is that since it is specialists and the ICU that has lengthened life expectancy from about 62 to over 80, losing physicians (whether to other nations, or to lower level physician assistant type posts or to retirement or simply to apathy and mediocrity (since no complex case can be sorted out in 10 minutes) will result in solvency for both medicare and social security. That, after all, was the whole point of “health care reform”. When there are fewer physicians, none of whom cannot spend more than 10 minutes with any patient, however complex or ill, then care will be delayed and eventually the “problem” will die. Then costs will come done.
Clueless,
Let me amplify:
1. Very definitely lowers cost to patient due to lower but wiser utilization (e.g. not running to ER for a splinter) and greater patient responsibility. Same is true for higher deductibles on auto or home insurance. A few lose; most win, lower total costs.
2. True, but you don’t consider the residual effect.
3. Our comments are not contradictory; they show different aspects of the problem.
The key is to look at the cumulative effect of these and other changes. E.g. if we eliminated all 75% of the self imposed health costs and split those savings between patients and doctors, doc pay could increase/hours decrease substantially at the same time as patient coasts could drop 37.5%, leaving insurance cos. with the same large profits. I know this is simplistic example, and the 75% could never be obtained. But there are many other aspects that have not been discussed (tort reform) that would also contribute. Lowered costs will ultimately benefit both patients and providers.
#7 I wonder about your throwaway line “or go into anesthesia.”
I am an anesthesiologist with young children.
On an average week I have one 24 hour call, where I am at the hospital from 7AM to the following 7AM, and 1 or 2 backup calls, where I could be called in all night long if there is an emergency to cover OB while the 24 hour call person is in a case, and 1 or 2 calls from home from a second hospital, where when I am on call I come in at 6 AM and work until the cases are done and be available all night long for emergencies.
On my regular days I work from 7 -3 or 4.
People seem to think that anesthesiologist have an easy life, and get paid a lot of money.
I work surgeon’s hours, and the hours that babies come into the world. My free time is minimal, and I am very tired most weeks
And once January rolls around the extra money I earn will be diminished because I am one of those “very rich.” I work very hard for my money.
My brother is a cardiac anesthesiologist (transplant team). He works harder than I do. Most of the elite specialties that earn a lot of money work very hard for it (certainly those who work in surgery). I do not grudge them their income. Again, if one looks at pay/hour most physicians compare unfavorably to plumbers, teachers, etc.
Apologies if “or go into Anesthesia” offended folks. It was not intended as a throw-away. I am acutely aware of how hard people can work in the field and of the residency. Nevertheless, Anesthesiologists reliably take home a comfortable net income, and some other fields of medicine do not. Our friend Clueless (board certified in multiple areas) was writing about the merits of ditching medicine in favor of non-physician careers involving patient care. I think that would be a loss, and Neurology is not a bad background for an Anesthesia resident.