I recently saw this on the AMA website:
One in five physicians say it is likely they will leave their current practice within two years. Meanwhile, about one in three doctors and other health professionals say they intend to reduce work hours in the next 12 months, according to recently published survey research.
How sad is that? The author of the study referenced was Christine Sinsky, MD. I am no fan of hers and you can read about her hypocrisy in that link.
The study she authored recommended:
To help doctors and other health professionals feel valued, leaders in health care organizations can provide:
– Transparent communication.
– Support for child care.
– Rapid training to support deployment to unfamiliar units, which may demonstrate organizational appreciation to workers.
To combat stress and burnout, leaders can:
– Focus on providing adequate personal protective equipment.
– Create supportive environments.
– Ensure access to confidential services for mental health.
– Reduce work overload through better teamwork.
– Apply a systems approach to interventions aimed at improving organization culture and practice efficiency.
Or…
Or..
How about going into Direct Primary or Specialty Care?
Nope. Sinsky will never mention that.
And while I am ranting, can we stop with this bullshit that doctors going into DPC or DSC are going to cause a doctor shortage? Doctors are leaving anyway, as this study shows. DPC is the safety net that can save them from quitting, retiring, or killing themselves.
Doug says, “Can we stop with this bullshit that doctors going into DPC or DSC are going to cause a doctor shortage?”
Math says, ” No.”
Each PCP who chooses DPC and reduces patient panel sizes by two-thirds would need to triple the length of his remaining career to cover the gap he created by going DPC. And it would take decades to do so.
Assume an average career length of 20 years for a burning out PCP, with retirement at the age of 50.
Let’s suppose that DPC makes PCP life so sweet that he works until he is 80 years old. By the end of those 30 additional years, the equivalent of one-quarter of the patients he left behind by going DPC will still be left out.
To fully close the gap his switch to DPC created, he would have to work until he was a 90 year old PCP. The good news is that he would be very experienced; the bad news is that some 90 year-olds might struggle with “24/7 direct cellphone access to your direct primary care physician”
Let me answer your thoughts with a section from my book. This was asked by another bitter person like you:
“If all primary care doctors were to go into DPC, who would take care of the patients that couldn’t afford it? Don’t you think you have a moral and ethical obligation to take care of all patients?”
Ah, the old guilt trip. The first thing I said is that if all family doctors went into DPC then maybe medical students would see the light and go that route as well. Who wouldn’t want to make $240K plus a year and be the complete doctor they always wanted to be? The way the system is set up now there are few medical students wanting to go into FP and there is a major shortage. This is why the creation of physician extenders (NPs, PAs) occurred. So, here is an idea. Maybe as FPs start to move into DPC, and this would not be fast, then the desire to go into family medicine would increase?
Second, I give away 10% of care for free. It isn’t a major problem for me and I feel good about it. It turns out that a lot of DPC docs I know do the same thing? Why? Because they are human. If all DPC docs give 10% of care away, then we would make a big dent in the supposed lack of coverage of patients.
Third, affording a $75 monthly fee is different than choosing not to pay it. There are plenty of patients that this doc is trying to speak for who just choose not to pay my fee. That is fine and it is their choice but that is all it is a choice. They choose to get cable, high data smartphones, and on and on. That isn’t a judgment. That’s a fact. For the ones who truly cannot afford that then we have other options. There is the free care that I, and other, DPC docs give. There are the federally qualified health centers. Oh, and all those NPs and PAs, that the government is pushing to take over primary care can now have the non DPC patients. That would work for me and the patients have full choice again. They have a safety net of extenders or they can pay a monthly fee. You get what you pay for.
Lastly, I want to reverse the question on this bitter doctor from the conference. Is it moral and ethical for family doctors to be the pawns of hospital administrators? To be paid the lowest on the doctor scale? I can’t remember taking the vow of poverty when I graduated from medical school. Is it moral and ethical to see patients for seven minutes because the system as it is leaves you no choice? I can make the case that is immoral and unethical! Is it moral and ethical to give patients’ data away to insurers, the government and whoever else and not know where it is going? I could go on and on.
I asked a group of DPC docs for their thoughts on this and here are their answers:
1. For that same argument, that old doctor should never be able to retire. Because by his logic it would be immoral of him to ever stop and take time for himself. As long as there are patients to be cared for, there should be doctors missing their families to care for them. I would make an argument that he has more of the responsibility than the rest of us. He’s older, which means all of his bills are paid off, which means he can work for free. He’s living off Medicare and he probably made a ton of money during the 80s when medicine was profitable. He’s probably one of the docs who sold us down the river and made it bad.
2. What happens when a doctor becomes an administrator and doesn’t care for anyone? No one bats a freaking eye. I actually got into this argument with the family doctor who just became the chief medical officer of our local ACO. What do plumbers do for people who can’t afford their services? Do they have a moral obligation to work for free? Clean waters been documented to be more helpful than most things.
3. My argument for the question “this will worsen the physician shortage” is that there is no physician shortage. I challenge students all the time to answer this question. If you look at a study done by the American Academy of family physicians, 22% of our time is wasted on non-clinical paperwork. And yes, we all know that and the insurance-based doctor spends a lot more than 22% of their time on insurance paperwork. But that 22% of the time multiplied across the physician workforce would give us the equivalent of 168,000 full-time equivalent physicians, essentially overnight. They’re only projecting the shortage of family physicians to be between 50 and 130,000 x 2025. So we don’t have a shortage of physicians, we have an efficiency issue. Direct primary care fixes that efficiency issue.
4. There is good data supporting lower costs and better outcomes with quality primary care. Given that, if third-party payment were part of a research trial it would’ve been stopped years ago as the effect of insurance on primary care is unethical.
5. The goal is to expand the pie, not shrink it. You might have thanked the retired doc and his generation of physicians for allowing this mess to have happened in the first place. Had they not been seduced by all the third-party payments, which were very generous initially (including Medicare and Medicaid), we would not be struggling to fix the dysfunctional system. He probably practiced in a time when reimbursements were great and paperwork minimal. Back then, almost all doctors were rich. The problem is that stereotype no longer fits reality (unless you are an administrator, cardiologist, radiologist, etc.) The drug dealer gives you the first few vials of crack for free. Once you are hooked, he owns you.
6. Docs from the previous generation who created the mess we inherited don’t have the ethical high ground. It pisses me off when they get all sanctimonious about charging patients directly.
7. It is interesting that they often completely ignore the otherwise monumental things DPC doctors done to lower medications and labs by 95%!! That helps the poor people everyday!
8. The more I get this question, the more it makes me irate. And here’s fundamentally why. Risk-averse docs are pissed that people are untethering themselves from what they ‘should do’ and paving a path that returns some of the integrity and intangible reward to this profession. And so they’re grabbing for evidence of why this model is corrupt. If you’ve spent your whole career gutting it out because “this is the way it is” it probably sucks to realize you could have done things another way. Fundamentally, however, the data is overwhelming. What we have is not working. It doesn’t work for patients OR physicians. Is the plan to take the population of the U.S., divide it by the number of physicians and that’s our “quota”? This question, put in mathematical terms, makes NO sense. We all seem to agree that a teacher, who sees her “clients” EVERY day, can barely manage a 1:24 ratio… So 1:3000? 1:5000? Where does it stop? I would also add that the personal and social cost for me to become a physician to then be doing 30% or more of unneeded administrative crap, leave medicine at age 45 or commit suicide… none of this benefits society either. The math that people use to imply I’m not pulling weight is garbage.
9. My Answer: No! And then ask him: Why? That question is never adequately answered. Why do doctors, uniquely among all professions, not have the same moral right to their own lives, their own livelihoods, and to set the terms of their relationships with customers? I think we have to address this issue head on. The premise of that question, that health care is a right, is THE ESSENTIAL PROBLEM medicine faces today. All practical arguments are fine, but ultimately we have to assert our MORAL RIGHT to our own life, liberty and the pursuit of happiness. We have to assert our MORAL RIGHT to freely and independently contract for our own services, on our own terms just like every other profession.
I hope you enjoyed the read. It blows your arguments out of the water.
Thanks for engaging.
This is about math, not morality.
Whatever the ethics, morals, or equities, individual PCP patient panels that are 1/3 the size require 3X as many PCPs, if every patient now on a patient panel is to remain on a patient panel. That’s 200% of additional PCP-power. Based on the current AHRQ estimate of 209,000, that’s 418,000 more primary care physicians FTEs.
Take that AAFP figure suggesting that 22% of current PCP productivity is lost to insurance hassle, then DOUBLE it to 44% for a very generous margin of error, and one might fairly predict a potential gain of 92,000 PCP-FTEs. The shortfall would still be nearly 1/3 of a million PCPs.
That tiny PCP patient panels require a mathematically reciprocal increase in the number of working PCPs depends not at all on whether the patient panel members are rich, middle-income, or destitute. Nor does it turn on whether the PCP receives payment under a subscription fee, or through fees for service, or from a corporate or government salary.
Policy makers may reasonably take such matters into consideration when considering such issues as whether to grant tax preferences for monthly DPC fees.
see third paragraph from my response above
Thanks for continuing to engage.
The paragraph to which you refer posits that 168K in FTEs can be made available by relieving insurance burden. That all 168K in “newly liberated” FTEs would find their way into reducing primary care patient panels sizes is an heroic assumption. There are some noteworthy shortages in downstream care, e.g., surgeons and OB/GYNs in rural areas, that might also be satisfied from the same new pool
But even on the assumption that all 168K FTEs are available for primary care panel size reduction, that number is not enough to do the work you assign it. A 2/3 reduction of current average primary care patient panel sizes requires tripling of the current average PCP FTEs, from 209K PCPs to 627K PCPs. Adding ALL of the “new” 168K FTEs to 209K existing PCP FTEs, would bring the total to 377K PCPs — a shortfall of a quarter-million PCPs.
At 600 members per panel, that leaves 150,000,000 patients out.
While how you feel about this is no one’s business but your own, others might legitimately be concerned that high-touch, high-access, PCP-FTE intensive, small panel primary care for some might result in PCP shortages that are problematic for others.
I have no idea why you are even on this site. This problem of doctor shortages is not caused by the doctors themselves. There are not enough residencies for one. Secondlty, there are not enough incentives to go into family medicine (the salary and the system suck). Could that change with DPC? Yes. Quickly? No. But, again, that is not the fault of the doc going into DPC who is burning out in that system. There is plenty of money in the system to pay for more family docs but instead there is a 10 to 1 admin to doc ratio. So, I ask again, why are you on this website?
Thanks for continuing to engage.
In its May 13, 2020 statement, “Building the Path to Direct Primary Care”, the Direct Primary Care Alliance actively (and quite literally) sought the assistance of the “US Government” in building, embracing, and implementing its agenda. In that way, DPCA has asked for help from all US citizens and taxpayers – including me. Your website helps inform my opinion on whether that help should be provided.
Yes, “the system” needs a lot of work. On a fair number of points, the DPC News author panel can be persuasive. On others, like the issue of whether high-touch, high-access, PCP-FTE intensive, small panel primary care for some might contribute to PCP shortages for a great many people — and likely do so for decades — less so.
When a PCP actually chooses to serve fewer patients, fewer patients are actually served. That’s not a statement of fault or guilt.
It’s just math.