Monday, January 24, 2011

Doctors in America

It isn’t easy to explain what being a doctor in America is about, or to tell what we do or even how many of us there are. People disagree about the number of physicians. It depends on how you dice and splice the numbers.

Some say there are 780,000 of us; others say 900,000. Roughly 550,000 of us are on the frontlines providing care. About 300,000 of us are primary care physicians (family physicians, general internists, pediatricians). The rest of us are specialists, though, if truth be known, many specialists practice primary care. About half of us are independent practitioners who own our practices. Groups, hospitals, and other organizations employ the remainder.

We are a heterogeneous bunch. We have minds and opinions of our own. Critics complain we are “fragmented.” In some ways, according to our critics, we are like the rats of Hamelin City who followed the Piper,

“AND out of the houses the rats came tumbling,
Great rats, small rats, lean rats, brawny rats,
Brown rats, black rats, gray rats, tawny rats,
Grave old plodders, gay young friskers,
Fathers, mothers, uncles, cousins,
Cocking tails and pricking whiskers,
Families by tens and dozens.
Brothers, sisters, husbands wives –
Followed the Piper for their lives.”

The critics are wrong. We are not rats, and we follow no single Piper.

We are good people, solid, smart, hard-working, well- intentioned, well-educated, well-trained, and well-prepared for the tasks at hand.

No national Piper speaks for us. The Obama administration does not represent our views. Only 15% of us belong to the AMA. Most of us belong to state medical societies, who are represented by the Physicians Foundation, a national organization. The Physicians Foundation is 8 years old and is still developing its voice of unity. Most physicians are members of specialty societies, each of which has its own ax to grind.

Our political views tend to differ geographically. Those of us in the South and West lean conservative. Massachusetts physicians are more liberal: 66% of 1000 doctors there favor single-payer or a public option. They regard the current reform law as too timid for progressives.

Those of us who are politically active on the national scene tend to be Republican. Eighteen of the 20 now serving in House or Senate are Republicans, and most of these physician-politicians favor repeal and replacement of the health reform law. Two things we conservatives and liberals and independents agree upon: fixing the Sustainable Growth Rate (SGR) formula and tort reform.

We physicians are said to be “bimodal,” meaning young doctors and older doctors have different perspectives. This may be partly because 50% of medical graduates are now women. Or perhaps it is because young physicians, men and women alike, are focused on a balanced life-style and benefits of being employed. The older among us tend to carry on as before, working hard and independently.

Only 2% of young medical school graduates contemplate a career in primary care. The others pick specialties, particularly the so-called ROAD fields (Radiology, Ophthalmology, Anesthesiology, and Dermatology), where hours are predictable and incomes are high. Fifty percent of young doctors are choosing employment rather than private practice.

Caught in the middle are those of us from 45 to 55, who will try to make our best go of it with the time we have left, but don’t always know which way to go. We are 50,000 short of physicians needed to meet current demand, and 25% of us are foreign-trained doctors who are helping fill in the demand gap.

The public doesn’t always understand us but three-fourths of them in polls say they trust us. They like their own doctor, but they don’t like the system and its costs. Patients do not usually complain about quality. They do not understand that for the most part we do not set our fees. Medicare in conjunction with an AMA-appointed committee does that. They do not understand we are paid according to a byzantine coding system, developed by others. Other third parties understand and follow Medicare’s lead.

The public may not understand that doctors account directly for about 25% of health costs, with the rest going to hospitals, long term facilities, other health professionals, and fiscal intermediaries. The public does not understand that third parties, insurance companies and others, tell us what we can and cannot do and what we can and cannot be paid for. The public may not understand that the health care industry employs 14 million people and has added 800,000 jobs during the recession. Health care is our most robust economic sector and makes up 17% of the GDP.

The old saying “Doctor knows best” has become a mockery. Government officials, health information technology types, and consumer experts of every stripe think they know best.

But the wise men and women among us know that a fully informed patient, acting in concert with their physician, knows best. Consumers spending more of their own money are very smart people.

Still, second-guessing has become an epidemic. Protocols, guidelines, checklists, and algorithms are the rage, and data outcome measurements have become the main criteria for separating good doctors from bad. Population management, not individual choice, is the wave of the future. Everything now is labeled as a “team effort,” rather than a personal decision. If the “team” consists of those close to the patient-doctor, maybe that’s the way it ought to be.

Our critics are fond of saying we are “poor” businessmen, yet our incomes tend to be high, usually above $200,000 for specialists. Others maintain that we don’t get it, i.e., the economic forces at work, the Internet revolution, and the demand for lower costs with higher proven value. Others assert that we deny the need for reform or the power of IPad, IPod, and Internet-searching consumers.

We get it, alright. We know the economic ground is shifting under our feet. Most of us are technologically savvy. We are simply not yet blind believers in electronic health records as the Holy Grail for Health Care Improvement and Higher Quality. EHRs, in the opinion, of many of us, are not ready for prime time and are not, at present, a wise investment with adequate returns.

Many Washington politicians, policy wonks, and those in information technology app circles maintain health care is too important to be left to doctors, just as war is too important to be left to generals. Outcome counts and body counts are what count. They could be right. Time and the health of the people and wisdom of voters will tell.

I agree with Margaret Thatcher. She observed, “I have a deep skepticism about the ability of politicians to change the fundamentals of the economy or society; the best thing they can do is to create a framework in which people’s talents and virtues are mobilized not crushed.”

Richard L. Reece, MD, blogs a Medinnovation and has a website under constuction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at

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