Where have all the doctorsgone? The realities of aharsh health care businesslandscape are taking a tollon America's physicians, as the pressures ofmanaged care, boatloads of paperwork,and fear of malpractice suits add up to doctorburnout. And doctor burnout is leadingto less access to medical care, as doctorstake early retirement or try to cut back ontheir patient load.
US News & World Report
A Feb. 7, 2005 cover story from the 2-million circulationasks, "Who NeedsDoctors?" A career in medicine, once richin emotional and financial rewards, has become a burdenfor many physicians, especially among primary care doctors,where shrinking managed care fees make hugepatient loads almost a necessity. And with more patientsto see in an average day, doctors have to cut back on thetime spent with each patient, affecting the quality of thecare they are able to give.
Symptoms of Disenchantment
In a 2001 California survey, 75% of doctors said theyhad grown less satisfied with practicing medicine over theprevious 5 years. In a 2003 Kaiser Family Foundationsurvey, 87% of doctors said that the overall morale of themedical profession had declined over the past few years,and 60% said their own morale had fallen off.
The disillusionment sets in early, according to somesurveys of doctors-in-training. In an initial 2001 surveydone by Merritt, Hawkins & Associates, 95% of medicalresidents said they would pick medicine as a career if theyhad to choose again. A follow-up survey 2 years latershowed that percentage had shrunk to 74%.
Among those whose morale has been hardest hit,however, are doctors in the 50- to 60-year-old group.They have been around long enough to remember medicine'sgolden age, when doctors were free to do what wasbest for a patient without being concerned about whetherthe patient's insurance company or managed care planwould balk at approving the necessary treatment.
Even as applications to medical schools haveremained flat or declined over the past several years, theneed for doctors is expected to grow in future years as ageneration of baby boomers reaches the age where theywill require more care. And while estimates of a doctorshortage project a shortfall of anywhere from 100,000 to200,000 physicians over the next decade or so, in someareas of the country and in some medical specialties, theshortage is already here.
Primary care medicine, with its heavypatient loads and relatively modest income,has seen a sharp decline in the number ofdoctors in practice. In many areas of thecountry, especially in rural settings, patientsmust wait several weeks for an appointmentwith a primary care doctor. Specialistsin cardiology, neurosurgery, and geriatricsare in short supply in some areas;Bostonians, for example, wait 37 days foran appointment with a cardiologist.
Relief is nowhere in sight. Medical students are optingfor specialties that afford a better quality of life, shunningareas like primary care, neurosurgery, and obstetrics.Last year's class of medical school grads filled just41% of the family care residency slots, as opposed to97% of the dermatology openings. Graduates are optingfor specialties like radiology and ophthalmology, whileavoiding others that they perceive as not offering regularschedules or enough personal time.
Filling the Gap
Rushing in to fill the void left by the doctor shortageare a number of health care providers that don't have anMD after their name. From nurse practitioners (NPs) tophysician assistants (PAs), from pharmacists to psychologists,these nonphysician clinicians are becoming moreprominent players in the nation's health care arena. Moreand more often, patients with common complaints likeear or bladder infections are likely to see an NP or PAinstead of a medical doctor.
As the shift to nonphysician providers gains steam, atug-of-war between doctors and nondoctors is takingplace over who can provide care and under what circumstances.Until recently, for example, only physicians couldwrite prescriptions and provide patients with necessarycare. And when NPs and PAs appeared on the health carescene, they were allowed to care for patients only whendirectly supervised by a physician.
That's changing. In some states, NPs andcertified nurse midwives have gained the rightto treat patients without physician supervision.Some states allow optometrists toperform limited eye surgery; some let pharmacistsgive immunizations and prescribemorning-after birth control pills. The right toprescribe prescription drugs is an especiallysticky issue, spawning turf wars like the onebetween psychologists and psychiatrists who are battlingover prescription privileges, a fight that psychologists havealready won in New Mexico and Louisiana.
Are They Safe?
Doctors who oppose the encroachment of nonphysiciansinto areas that were once the exclusive realm ofMDs often cite safety issues as a cause for concern. In thecase of many of the nonphysician providers who are askingfor a larger role in the health care picture, there isn'tenough research to make any judgments. In the case ofNPs, however, more than 100 studies have documentedcare delivered by nurses with advanced training anddegrees, and none have shown that care by NPs has anegative effect on patient health.
Safety issues, some nonphysician groups say, are acoverup for basic economics. The conflict is basicallybetween nonphysicians who want a bigger slice of thehealth care pie and physicians who want to hang on towhat they have. One example is certified registered nurseanesthetists (CRNAs), who provide almost two thirds ofall anesthesia care, and are locked in a battle with anesthesiologistsas they fight for the right to provide anesthesiawithout physician supervision. So far, CRNAshave won in 12 mostly rural states.
The financial impact can be sizable. When Florida'sstate medical board created standards that requiredCRNAs to be supervised by an anesthesiologist for office-basedsurgeries, some CRNAs lost as much as 70% oftheir income. The regulations have since been overturnedby the Florida Supreme Court.
The Boutique Solution
Some doctors have found the answer to their malaiseby catering to patients who can afford to pay annual feesranging from $800 to $2000. By generating more incomefrom fewer patients, doctors in plans like MDVIP(www.mdvip.com) can bypass the assembly-line medicinethat managed care has forced them into.
In return for annual fees, patients haveaccess to an expanded menu of services,including same-day or next-day appointments,house calls, off-hours access to aphysician, more time spent per doctor visit,counseling services, dedicated phone numbers,and other upscale perks. Many doctorsin boutique practices even go to specialistappointments with their patients.
Physicians in these boutique practicesbelieve they've found the answer to 60-plus-hour workweeks,large patient loads, declining reimbursements,growing overhead, and managed care bureaucracy.Some critics, however, see an ethical dilemma in boutiquemedicine, which they say creates a tiered system of healthcare, providing wealthier patients with a type of carethat, ideally, all patients should be able to receive. Ahealth care system that is already the costliest in theworld, critics point out, ought to be able to meet allpatients' needs without forcing them to pay more.