Author: Stephen Moberg

In the past seven blogs I’ve been looking at the various forces that have created a perfect storm lined up against primary care medicine. In this eighth installment in a series of nine it’s time to face the reality that medicine is currently experiencing a significant exodus of older physicians. It’s been estimated that one out of three practicing physicians in the United States is over the age of 55. As a result, a significant percentage is approaching full retirement age and quite a few of them can scarcely wait.

In addition, a high percentage of physicians are facing burnout and are ready to retire early. As we have seen, surveys show that over sixty percent say they would retire early, if they could afford to do so.

With the older adult population growing, the demand for physicians will intensify over the coming years.  According to American Association of Medical Colleges estimates, the United States faces a shortage of more than 90,000 physicians (of all specialties) by 2020 – a number that will grow to more than 130,000 by 2025.

The surveys indicate that as many as 60 percent of physicians over the age of 55 will retire in the next three years. The more seasoned physicians, who have already endured the transition to electronic medical records, the advent of HMO’s, bundled payments, being acquired by a larger group practice, have too many battle scars to face another round of major change.

As I described my own circumstances in The Familiar Physician: Saving Your Doctor in the Era of Obamacare, my children are grown and off on their own. Moving away from the parental and financial responsibilities of child rearing and education are part, but hardly all of the reasons I regularly hold retirement debates with myself and often with my wife. I also understand and have personally experienced the sense of powerlessness many seasoned doctors feel. At this point, I don’t know too many colleagues who if they haven’t set a retirement date in stone, have at least penciled it in on the calendar.

Retirement may seem a long way off to many physicians who have been practicing only a short time. But for those on the cusp, the challenges inherent in health care reform and the need for re-invention on a number of levels may prove a strong enticement to emulate Elvis and simply leave the building.

There’s a perfect storm positioned over primary care medicine and a dwindling stream of new primary care doctors is one of the elements that threatens the field. One thing you can generalize about medical students is that they’re smart, young (generally) people. So they’re likely aware of surveys that reveal decreasing optimism about primary care medicine by current practitioners along with evidence of high numbers of PCPs retiring early or changing careers.

What they’re also aware of is a primary care system that has failed, as Cuba Gooding Jr. famously put it to Tom Cruise in the movie, Jerry Maguire, to “Show me the money.”

Of course discussing money is awkward at best because it’s not what motivates most people to enter medicine in the first place. But if payment for services rendered isn’t what drove existing PCPs into the field it is managing to drive prospective ones away.

Talking about physician income in The Familiar Physician: Saving Your Doctor in the Era of Obamacare, I referenced a 2009 report from the American College of Physicians that called the compensation gap between primary care and other disciplines a “strong disincentive for younger physicians.” Over the course of a long career, this disparity can add up to over $3 million dollars. With typical medical school debt averaging around $140,000 the problem quickly comes into focus.

Some of my colleagues believe the decline in the PCP training ranks is related to a parallel decline in personal commitment or altruism. I don’t agree. I think today’s generation of college pre-med students, medical students and residents is rich in idealism and continues to hold the basic belief that the medical profession offers a rare chance to make a difference.

At the same time, they are realists. They look around at the primary care field and see uncertainty and discontent. They see that their hard work can lead them to the bottom of the pay scale within their profession.  Most students respect primary care and understand that it’s the backbone of the U.S. health care system. I think they admire primary care physicians.

But for some clearly defined reasons, they don’t want to be one.

And the mismatch of supply and demand couldn’t have come at a worse time. As Beverly Woo, M.D., of Brigham and Women’s Hospital in Boston so powerfully stated the problem, “Although the line of students signing up for a career in primary care medicine is getting shorter, the line of patients in need of primary care doctors is getting longer every day.”

In a series of nine blogs, we’ve been looking at the Perfect Storm and its metaphoric counterpart in primary care medicine. A lack of optimism about the future is one of the forces bearing down on the field and here’s evidence:

The Physicians Foundation, a non-profit organization that “seeks to advance the work of the practicing physician” recently conducted one of the most comprehensive physician surveys ever carried out. The survey reached over 630,000 doctors selected from the nation’s largest physician database.

The study was developed to reveal, among other areas of clinician response, current morale levels, perspectives on health care reform, practice patterns, career plans and issues impacting patient care. What it indicated, is that the malaise I have personally experienced and described in The Familiar Physician: Saving Your Family Doctor in the Era of Obamacare, is impacting many other doctors within the profession.

Over three quarters of the doctors surveyed revealed themselves to be somewhat or very pessimistic about the future of the medical profession, and over 80 percent agree it’s in decline. Keep in mind this included physicians at all stages in their careers, not just older doctors looking back on “the good old days” and bemoaning the loss.

A distinct majority would not recommend medicine as a career. Over a third would not personally choose medicine again for their own career. Over 60 percent of physicians would retire today if they could.

While uninsured patients may be applauding the provisions of the ACA that hold the potential for improved access, the physician community has some concerns.

Physicians know only too well that the improved access in general and optimal outcomes in particular will be complicated for many people by the fact that they haven’t had a regular doctor for years. In the past, many of these individuals countered a lack of health insurance by going to emergency rooms for care, paying cash or nothing at all and ignoring all but the direst of symptoms. Now, they may be postponing any type of treatment in anticipation of finally being covered.  As a result, medical problems will be more complex and expensive.

For many practitioners the surge of more and sicker patients threatens to overwhelm an already fragile practice within a damaged and disillusioned primary medicine community. At the same time it drains the time, energy and creativity that could otherwise be directed toward care delivery innovation.

The inability to find solutions, brought on by the sheer weight and number of the problems is part of the reality that led so many current doctors in the Physicians Foundation survey to express their strong pessimism. And it’s what’s influencing growing numbers of medical students and residents to vote with their feet when it comes to choosing a career in primary care.

Throughout the history of medicine and particularly in the past two decades, innovative drug treatments offer a remarkable record of improved health outcomes and quality of life. At the same time, however, prescription drug expenditures are a significant component of total health care expenditures. In fairness, a large part of the expenditures are related to increased utilization. But overall costs are increasing nonetheless. These increases, coupled with higher co-pays and other forms of increased cost sharing on the part of patients, are associated with decreased adherence to treatment regimens and even the discontinuation of needed medications.

For the primary care physician, poor compliance (or adverse reactions even when compliance is perfect) can mean additional office visits, often paid through a reduced Medicare reimbursement.  So for that already overburdened practitioner the cycle continues.

A recent article in Medical News Today estimates that the number of drug prescriptions written each year in America comes out to the nice round number of four billion, roughly 13 prescriptions for every American.

Digging a little deeper, the administration of prescriptions goes far beyond the act of simply writing the script and handing it to a patient. A systematic approach advocated by the World Health Organization illustrates just how detailed and complicated the process has become. Their eight-step approach checklist includes:

• Evaluate and clearly define the patient’s problem

• Specify the therapeutic objective

• Select the appropriate drug therapy

• Initiate therapy with appropriate details and consider non-pharmacologic therapies

• Give information, instructions, and warnings

• Evaluate therapy regularly (e.g. monitor treatment results, consider discontinuation of the drug)

• Consider drug cost when prescribing

• Use an electronic medical record or other computer-based tools to reduce prescribing errors

With only very minor exception the pharmaceutical revolution, has benefited all of us through its ability to provide some of the greatest medical innovations with regard to better health over longer lifetimes.

But when administering prescriptions and managing related care become so labor intensive, and when keeping up on the expanding literature associated with these new pharmaceuticals proves to be a separate skill set, there’s no question that the continuing expansion of pharmaceutical options creates a major strain on the primary care physician’s ability to effectively treat growing numbers of patients.

In The Familiar Physician: Saving Your Doctor in the Era of Obamacare, I wrote that the looming possibility of financial failure changes everything. At the very least it focuses your attention. I was referring to my own experience at a particular point in my Family Medicine practice, but from what I read and hear directly, growing numbers of primary care physicians across America are struggling to make the business end of their practice work. That objective becomes even more important in light of the fact that many of them have already given up on the ability to fully enjoy their personal lives and families, take vacations and carry out a normal workday schedule.

Office staffs are harried and swamped with electronic documentation requirements, records, insurance forms, referrals, appointments, daily urgent call-ins, scheduling tests then reporting results, answering their correspondence – and patient care in the midst of all of it – that they barely have time to take a deep breath.

The cuts to physician payments are a steady sound from Washington and it is particularly difficult for physicians to continue seeing a growing rise in Medicare beneficiaries, especially in small or solo practices, with the constant threat of reimbursement reductions of 25% or more.

These financial difficulties coincide with a time in which as a nation, we are leaning hard on primary care medicine as a field and primary care doctors as a group to help guide us across a different health care landscape. In a dysfunctional payment system based on volume rather than value, many primary care practices have neither the incentive nor the time to follow up on patients the way they would like to or to provide more comprehensive medical management, especially when chronic conditions are involved.

Resources for management and overall care coordination are especially strained when older patients are seen by several different specialists.

When I was in active practice I worried about how I would be able to survive financially.  But most of all, I worried about the patients.  I still do.