I agree with your sentiments. Cognitive services are undervalued, and primary care physicians are underpaid. Your rants beg the question: What would be a fair method for compensating cognitive services, and what level of income would fairly value the primary care physician
When lack of time prevents us from rendering what we feel are satisfactory services to our patients, we can elect to see fewer patients and make less money. Physicians would still be better compensated than 95% of the workers in this country.

I agree completely with you. As a general surgeon, I have similar though less compelling arguments concerning my reimbursement per unit of effort as opposed to other surgical specialties, especially orthopedics. This is not a valid complaint, as this state of affairs was well known to me when I was choosing a career path decades ago. With the large amount of bureaucracy and overhead that internists have, you really get screwed.
A technical point that may save you a minute here and there: for a follow up visit, 9921x, either history or physical exam will suffice to satisfy the CPT requirements to get reimbursed. You do not need to do both. Of course, some patients like to be examined, to get the “hands on” experience, but if you are running behind schedule, it is something that you can skip if not important to the patient’s care, and no need to waste time documenting an exam that did not need to be done in the first place.

You are exactly right and we are playing a game we can’t win. AFter doing this for four years, I decided to go back and do a subspecialty, cardiology. This spring I only got two interviews and no offers. Therefore now I am applying to hem-onc which will be a little easier to get into. I’m not sure why we are all allowing ourselves to be martyrs. When I’m leaving the hospital in the morning after my AM rounds, I pass the specialists in the parking lot coming in to do their work. Likewise when I come back from my office to see a new patient at 6pm, I’m walking in and they are walking out,…to their new mercedes next to my old honda.
b

grand rounds 48: cut the fat and give me the bottom line

Welcome to grand rounds 48, the weekly collection of the best of the medical blogosphere. editor’s choices . . . medrants writes about time and the general internist. soundpractice.net asks, “how much should doctors make?” . . . and…

As a patient, not a doctor, I love reading about the needs of my doctors – because I have no idea! The time crunches that are so frustrating to me are as frustrating to them, not to mention the other problems they deal with on a daily basis.

Just wanted to let you know, then, that as a patient who has a general internist as her PCP, I DO appreciate the time, energy, and mental accumen you all put into working with people like me. Do doctors accept tips?

It is disheartening for me, a student, to hear about the ‘market pressures’ selecting for more specialized, procedure based medicine. I want to embrace the challenges of internal medicine – a variety of patients, difficult cases, and a broad field of knowledge – but I also don’t want to get stuck in a situation where insurance is constantly devaluing cognitive medicine. A resident at my rotation laughed about my future plans saying, “So you’re turned on by writing twenty 3-page progress notes a day at the third lowest pay scale in medicine? Be my guest.”
Statements like that make me wonder why I would want to be a ‘martyr’, and that worries me about medicine’s future.

Though it may be entirely undoable on a political basis, the solution is so obvious it is frightening.

We currently have about two specialists in this country for every primary care physician. The average income of the primary care physicians is about $150,000 per year, while the average specialist earns about twice that. (I am a neurologist, so this is not about goring “the other side.”)

Only a fool would suggest that the specialists work harder, are smarter, or are more valuable than primary care physicians. The differences in our personalities that lead us to know something about everything or everything about something are just differences. They’re not virtues or flaws.

Simple math tells us that if the 2/3 of the physicians earning $300,000 give up $50,000 each of their income to increase the income of the 1/3 earning $150,000, everyone would make $250,000.

The specialists would be taking a hit, but why isn’t that less wrong than the primary care physicians living with twice the harm.

If the reason anyone entered medicine was to be rich, we don’t want them.

And if an average of $250,000 per year isn’t enough to justify doing what you do, you hate it too much and should quit.

Now, all we need to do is convince the overpaid Gods that working with your head is just as valuable as working with your hands and the problem’s solved.

Anybody see a flaw in the logic?

David

David B. Ketroser, M.D., J.D.
Neurology (still practicing Neurology after 25 years, and also a practicing Plaintiff medmal atty for 5 years)

Hi there, I’m your patient — the fat one who wants to be your friend and doesn’t think he’ll ever have that heart attack. [why won't you give me your email address??]

Okay, okay….but I do value a doc who knows me, remembers more about me than JUST the chart. I actually had one of those — in an HMO setting, no less. Took a while to train him. Did it with humor, attentiveness to him as a human being, not just as a doc. If he’d been a bluegrass musician in the bargain, it would have been nirvana.

Of course, he trained me, too: Get to the point, do what you’re told. Come prepared. I’m a WLS patient so labs are of extreme import. Once I made the case for them, he ordered them, probably catching flak from the admins.

Then he went off to private practice in Pasadena and now I have to start all over, and I’m not sick enough to see the new doc more than once a year for a physical and I’ll never get him trained within my lifetime at this rate.

To get, at last, to the point: I agree the Primare Care needs to be rewarded. I question whether the rewards should necessarily be monetary. I too don’t want a doc who’s in it for the bucks. Being related to a few, I’m getting good, I think, at spotting them.

How can we pay physicians in both monetary and non-monetary ways to make them want to get into primary care? And how can we do this in a managed-care setting (hey, HMOs were created by the excesses of fee-for-service, and they’re not going anywhere)?

I don’t want a doc who’s starting and stopping the meter, but I don’t want one who can’t take the time to know me. Are these mutually exclusive?

/jwb

You haven’t sold THE problem, pj, you’ve solved YOUR problem. We need primary care doctors, so the solution to the need for a reasonable wage for primary physicians’ efforts isn’t to note that some can leave.

That’s like saying if you don’t like America, you should leave.

The real answer is that if you can identify a problem for 1/3 of all doctors and find a solution for them all, that’s far superior to finding a solution for yourself.

Do people often do things exclusively for financial benefit? Yes.

Is that the only benefit that drives behavior? No.

Would specialists still be paid a reasonable wage at an average of $250,0000 per year? Of course.

In the same way that the payers have forced lower payments across the board down doctors’ throats, they could force a fairer payment scheme if they could find a reason to do so.

The reason to force lower fees for everyone was to lower premiums and make profits. The reason to change payment priorities is fairness. That is not going to happen based on the open market. It will only happen based on government fiat. And for that, we need a government based on fairness, which is not the watchword of the current administration (their idea of the Golden Rule is “them that have the gold make the rules”).

I’m glad you’ve found a part of medicine you find tolerable and reasonably compensated. Now acknowledge that for this positive outcome to be widely available requires some selflessness with our selfishness.

That shouldn’t be too much to ask of a profession that claims to care about the well-being of others.

David B. Ketroser, M.D., J.D.
Neurology