Friday, September 19, 2008

Physician shortage, access, medical students - Delivering Bad News to the Public

The public needs to be told the bad news: their present and future access to a personal physician is endangered.

Indeed, within the next ten years, the public may no longer be able to find a primary care physician, or be forced to wait months for an appointment. Yet they yearn to be able to find a physician in time and on time.

This is hardly news to newly insured Massachusetts residents who are having a hard time finding a doctor, to newly minted Medicare recipients, to Medicaid recipients in multiple states, to those who live in rural areas where long time practitioners have left or died, to older primary care doctors who can’t recruit a replacement.

The problem is:

• Medical students are completely rational. They are not entering primary care because the hours are longer, the pay is lower, the need for more knowledge is greater, the life style is less balanced, the respect is lower, yet the medical school debts are the same.

• Our society is specialty oriented. We pay specialists two to three times what we pay specialists, we pay for procedures but not for time with patients. And we believe in what doctors do, not necessarily for what they say

• We have built a specialized top-heavy, moneyed suprastructure that dominates the thinking of competing hospitals and health systems, whose leaders know that the growth and profit of their nstitutions resides in recruiting and rewarding orthopedic surgeons, heart specialists, radiologists, and other procedural specialist.

The Trip Down

I was thinking to these things on a recent round trip train ride to New York City. On the trip down, I read “Targeting Beam: New Machine Speeds Radiation Treatment.” Wall Street Journal, September 16. The article reports a new machine RapidArc speeds up delivery or radiation treatment beams from 5 to 10 minutes to less than 2 minutes.

The FDA cleared the machine in January, and it is already in 30 centers in the U.S. and Europe, and orders are in for 150 more. This is a huge and costly piece of good news since 70% of cancer patients receive radiation – either alone or in conjunction with chemotherapy. No doubt, radiation oncologists, who income generally exceeds, $350,000, will welcome the good news, as will cancer patients.

The Trip Home

So mcuh for the good news Now I’m on the trip home after attending a meeting of two large health care organizations who were addressing the problem of the looming primary care physician shortage.

There are some 300,000 to 330,000 of these physicians, and their numbers are shrinking rapidly Less than 10% of current medical students plan to engage in direct patient care as generalists rather than as specialists. Yet general primary care represents the bedrock of any health system. In the U.S. these physicians make up about 1/3 or physicians, in other developed countries they comprise about ½ of physicians.

Low Morale of Physicians and Patients

At our meeting we discussed the low morale of physicians and patients with health care around the world. Dissatisfaction among patients and doctors is rampant in Germany, Japan, Korea, and the U.S., not necessarily in that order. This dissatisfaction has been thoroughly documented in recent surveys and is most intense in those countries with heavy government intervention into the autonomy of practicing physicians, who are restless and who threatening to abandon direct patient care in record numbers in the next 3 to 5 years. The result might be lack of timely access to trained physicians.

It may be these physicians could be replaced by physician assistants, nurse practitioners, nurse “doctors,” and foreign-trained physicians, but we agreed that was not ideal The ideal solution is to rebuild the primary care base, provide medical students with incentives to enter primary care, pay primary care doctors for time spent with patient and for patient-centered services such as same day appointments, prompt responsiveness to emails and phone cares, and preventive and wellness counseling.

What to Do with Survey Information and How to Do It

At our meeting, the questions were: what to do with the alarming information contained in recent surveys, how to release it in such a way to inform but not alarm the public, and how to leverage it in such a way to influence policy makers to take corrective steps.

Should we release the information in an undigested form? What was the best way to get the information out? By going to a large public relations firm to shape the message? Should we hire strategic marketing consultants? Or should we simply wait for developments?

U.S. Developments

In the U.S., conventional wisdom is something big – really, really big – is going to take place in the first six months after the election. Given the realities that the election is likely to be a squeeker, that the economic turmoil will continue, that the budget deficits will remain huge, that these developments have pushed health care to the back burner, it is likely the new president’s options will be limited.

Getting Message Out

How to get the message out? Through existing media contacts, national and international PR firms, through political consultants, through Parade Magazine and AARP Bulletin, through mainstream newspapers and TV outlets, the Internet, or even through talk radio.

What Should Message Be?

And what should the message be?

• That doctors are unhappy. That’s not likely to resonate. How isn’t unhappy?

• That primary care doctors are underpaid? No good. Nobody likes whiners, and “everybody knows” doctors have the biggest house on the block.

• That doctor unhappiness in likely to result in a severe doctor shortage? That’s better, but not enough.

• That you’re unlikely to be able to find a primary care doctor when you’re sick. That could be effective. Personally I think the lack of access to doctors argument is likely to be the most compelling.

• That countries with broad primary care bases have more affordable costs and more satisfaction. Well, maybe, but we live in the U.S. and we don’t care much what happens in other countries.

The End Game

The end game may be to generate enough public outrage and enough rational reasoning to influence federal policy makers to reward doctors for becoming primary care doctors, for spending time with patients, and for other patient-centered activities such as responding to their desires for quick access, coordinating their care, and answering their questions and responding to their needs through efficient, effective communication systems that enhance rather than retard productivity.

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