Family doctors: An endangered breed

[East Detroit]

NEW YORK [[CNNMoney.com) -- Luis Manriquez and Katherine Glass share a common -- and increasingly rare -- ambition: They both want to become family doctors.

"As a primary care doctor, you are a gatekeeper of the medical system," said Manriquez, 26, who with Glass is a first-year student at the University of Washington School of Medicine. "Primary care is where you can have the most immediate impact in affecting patients' lives by managing their health."

Still, Manriquez realizes that he's setting himself for considerable challenges.

For one thing, as a family doctor, Manriquez will probably make one-fourth the salary of a specialist while trying to pay down $140,000 on average in medical school debt.

"That's why only the most committed pursue primary care. Kudos to them," said Jonathan Weiner, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

http://money.cnn.com/2009/07/16/news/economy/healthcare_doctors_shortage/index.htm?cnn=yes

[Sstashmoo]

And ya' get to hang out on internet forums all day. Sweet job.

[ccbatson]

A free market would help the primary care folks most of all.

[sumas]

I did not even know that family doctors still existed. When I was young, we had one. He did house calls and all that. When he retired, that was the end of that.

My husband and I do not have health care insurance. I totally agree that managing health is important but with little access due to finances we have to limp along. Recently, my husband had what appeared to be a serious health issue and we went to emergency which is a poor subsitute for primary care. We did get referred to a low cost clinic for follow up. The doctor we saw there was superb. He recommended follow up tests which we simply cannot afford and he understands that. I totally believe that national health care should be in place and save money in the long run. The ER visit fees were waived due to our situation. The clinic fees were reduced but if this situation persists my husband will qualify for SSI. Isn't access to primary care more cost effective?

[East Detroit]

A free market would help the primary care folks most of all.

I would rather have someone dedicated to people, rather than another money grubbing capitalist as my doctor.

[oladub]

A free market would help the primary care folks most of all.

Why do you say that? I am not agreeing or disagreeing with you but what is your basis for saying that? I realize that the more the government has mettled in health care, the less affordable it has become. However, 'a free market' would take us to a new world without [[government) physician licensing or an FDA. How would that help primary care providers?

[East Detroit]

Why do you say that? I am not agreeing or disagreeing with you but what is your basis for saying that? I realize that the more the government has mettled in health care, the less affordable it has become. However, 'a free market' would take us to a new world without [[government) physician licensing or an FDA. How would that help primary care providers?

No ICD-9 codes, no DRGs; basically they could charge what they felt like and really rake in the cash. I guess thats the bottom line for some people.

[oladub]

ED, Those codes have something to do with classifying diseases according to Wikipedia. How do they relate to Bats' contention that "A free market would help the primary care folks most of all."?

[East Detroit]

ED, Those codes have something to do with classifying diseases according to Wikipedia. How do they relate to Bats' contention that "A free market would help the primary care folks most of all."?

They are used in part by insurance companies and the government to mandate a specific payment [[no more) for a specific diagnosis. Particularly the DRGs. So, doctors and hospitals spend a lot of time trying to find as many of the codes as possible to pin on a patient so they can try to make money. Patient broke an arm, thats a code that pays $x... but he also looks thirsty so let's stick on the code to say he is dehydrated and add $y to what we get... etc.

CCBatson's "free market" would eliminate such groups, probably eliminate poor people getting care, and allow medical care to work purely as a capitalist mechanism. Doctors charging the highest rates that people will pay... and those on the bottom not being able to afford it. Win/win for those who consider themselves Darwin's best.

Meanwhile, medical practitioners that care more about patients than cash perhaps would help all those who couldnt afford the "market prices." Or perhaps they wouldnt.

[rb336]

I realize that the more the government has mettled in health care, the less affordable it has become.

That is a totally unsupportable comment

[oldredfordette]

I had a great family doctor until about a month ago, he closed his practice [[bad news). He began teaching young doctors to open their own practices [[good news). He's completely committed to the idea and wants to help.

He's also a supporter of universal health care.

[oladub]

Becoming a doctor is no longer about helping anyone. that breed is long gone.You could be wheeled into an er with all 4 limbs missing and if you are uninsured the best they will do for you is clamp down the veins to stop the bleeding and set you out in front of the hospital to wait for ride home.

There are no more doctors left in this country. They died in the early 70s.

My daughter is a primary care physician. Her boyfriend is an internist. Both grew up in lower middle-class families. They work 60 hour weeks often doing their paperwork after dinner or on Saturday. She has to deliver babies at all hours of the night. Neither cares much about money. Most of their patients are poor. My daughter is recovering from a pulmonary embolism herself which I suspect has to do with years of overwork. When their schedules allow them to get together on weekends, they wind up falling asleep on the couch. Her boyfriend often misses dinner [[an issue) because he does a lot of unrequired work at the hospital, has long conversations explaining things to families, and double checking. They drive a Ford Escort and a Chevy Malibu. Everyone of her young doctor friends I've met are similarly more focused on work they enjoy than whatever they get out of it. Remember that med school now costs about $100,000 at a state school and the nice paychecks do not appear until doctors are about 27 and deeply in debt. So from my perspective, what you wrote is total nonsense.

Doctors deal with whatever work shows up in front of them. Your problems are with health care management and government policies.

Every one of the young doctors I know would like a more Canadian like health care system . They would gladly give up the larger paychecks for more time off. Who would serve the public then is another problem.

Sorry to diverge from Bats comment but yours was so absurd it needed addressing. I'm still trying to find out why Bats thinks that, "A free market would help the primary care folks most of all."

[ccbatson]

A free and just market and selfishness results in the highest quality of service at the lowest cost...always. What better place to have these characteristics than health care?

[turkeycall]

A free and just market and selfishness results in the highest quality of service at the lowest cost...always. What better place to have these characteristics than health care?

Selfishness will result in low cost? "Selfishness" and "low cost" are mutually exclusive terms. One is the antithesis of the other.

[elganned]

A free and just market and selfishness results in the highest quality of service at the lowest cost...always.

Do you ever have anything to offer beyond tired re-statements of right-wing economic dogma offered as if it were established fact?

[grumpyoldlady]

We live in Minnesota, and had never heard of the "PA" [[physician's assistant), or the "NP" [[nurse practitioner). We started going to a clinic in the small town nearby [[760 people). The doctor there always seemed more interested in rushing us out the door than listening to what we had to say. Once he was gone when we needed an appointment, and the PA saw us. She listened carefully, asked lots of questions, made good notes, and made sure we were satisfied with answers and had no more questions before she let us leave. She moved to another clinic about 35 miles away, and we followed her there. For personal family reasons she is no longer practicing. My husband now is being treated through the VA system, and the local outreach VA clinic has a PA and a doctor. The PA spends loads of time with us...the doctor seems to busy to pay attention to what we are saying to him. I actually think sometimes the PA's and NP's are more up to date on meds and new discoveries than the doctors are. There are still many, many family practice doctors here in rural Minnesota.

[ccbatson]

Not under a free market Turkeycall...here's how:

Dr. Smith competes with all of the other Dr. Smiths out there for patients. Patients bid with their patronage looking for the best quality and the lowest price. Dr. Smith produces at an optimal quality and price in order to gain the business and to get paid. Purely selfish interests can be in place and the consumer gets the best quality and lowest costs.

[ccbatson]

PAs and NPs are extenders of Physicians [[ideally) they can't practice independently, and both you, and they, would not want them to.

Your anecdotal story and experience is not sufficient to draw a conclusion regarding types of health care systems [[private versus government). In favor of a private system and against the public is the presence of incentive in the former and absence in the latter.

[ccbatson]

PAs and NPs are extenders of Physicians [[ideally) they can't practice independently, and both you, and they, would not want them to.

Your anecdotal story and experience is not sufficient to draw a conclusion regarding types of health care systems [[private versus government). In favor of a private system and against the public is the presence of incentive in the former and absence in the latter.

[rb336]

In favor of a private system and against the public is the presence of incentive in the former and absence in the latter.

i would rather have the clear increase in positive outcomes, lower infant mortality, and higher life expectancy of the latter. the "incentive" you talk about? that is to cram as many "pieces of work" [[as you once crassly refered to your patients) into the shortest period of time, to get as much referal money for pointless tests as you possibly can, and to get kickbacks for the latest poorly-vetted toxic chemicals Big Pharma tries to push down our throats

[oladub]

Originally Posted by oladub
I realize that the more the government has mettled in health care, the less affordable it has become.

rb replied, "That is a totally unsupportable comment"

rb, Regulations cost money. If prescriptions were not required and all drugs were over the counter, they would be much cheaper. Hillary and McCain were even trying to make vitamins into prescription products. The cost of providing Medicare services are sometimes more than the cost of delivering the service so hospitals routinely transfer some of that cost to patients with insurance. Hospitals require expensive construction although some patients could make do with an attached Days Inn. The government drives some qualified medical people out of health care because they don't have the proper government credentials. It should be up to the patient to decide if they want to go to a cheaper immigrant Russian doctor, chiropractor, nurse, or whatever for treatment in a free society.

Even HMO's were foisted on us by a Democrat Congress. Richard Nixon signed their legislation in 1973. "In the Senate, Kennedy, author of the HMO Act, also encouraged its passage: ``I have strongly advocated passage of legislation to assist the development of health maintenance organizations as a viable and competitive alternative to fee-for-service practice. ..... This bill represents the first initiative by the Federal Government which attempts to come to grips directly with the problems of fragmentation and disorganization in the health care industry. ..... I believe that the HMO is the best idea put forth so far for containing costs and improving the organization and the delivery of health-care services.'' In a roll call vote, only Senator Herman Talmadge voted against the bill. -ronpaullibrary

Put it like this. Is it cheaper for a doctor to deliver a service by him/herself or a doctor with a paid government employee looking over the doctor's shoulder and some paper shufflers to keep track of everything the doctor does for the government employee?

As you know, the President is trying to make health care, he says, $1T more expensive. Others are saying $2-3T. Since someone will have to bare those costs, it is another example of government causing health care to become less affordable. If it doesn't show up on someone's doctor bill, it will show up as some new tax.

It doesn't have to be this way. If Michigan simply adopted Ontario's system health care costs would decline. However our topic is about what our government has done and now plans to do.

Hitsville, Kid, singular, and other of her med school friends I know. Granted, there are no doubt some there for the money. Would you rather they went to law school or were bankers getting bonuses from Bush and Obama? One of the obvious things that Med schools could do to lower what doctors charge is to train twice as many doctors. Its not like there is a shortage of med school applicants. Double the number of doctors and they wouldn't be able to sell their services for as much as much because of increased competition. It wouldn't necessarily even cost the taxpayers anything.

[oladub]

I would prefer that people be thoroughly pre-screened prior to being allowed to go to med school narrowing it only to those that actually believe in helping others.

those that are found later to be in it specifically for the money and show their practice as a turnstile meat market should have their licenses revoked,prosecuted and tossed into jail for it.

I disagree. My suggestion was to double the number of med school opportunities to create something approaching a surplus of medical personel, competition for jobs, and thus a supply/demand equation resulting in lower compensation. I really don't care what a person's alleged motivation, religion, philosophy, etc, is as long as they are competent. My suggestion would make it less possible to make huge earnings in medicine so the really greedy would be less attracted to the field.

I have another suggestion to reduce physician cost. In some counties, doctors do not have a bachelors degree component in their education. They take nothing but medical related courses. This allows them to get through school a couple of years earlier to begin practice. We should also allow this option as well as design programs that would allow nurses and medics a streamlined path to become doctors. These options would make becoming a doctor less expensive.

I would even consider state licensing exams to funtion more like bar exams. If a person passes, they can be employed as a doctor. This would allow doctors from counties such as Cuba and Russia to be licensed here without monkeying around with two years of liberal arts. I keep hearing about underserved medical communities. We need more doctors. I don't care if they are aspiring saints or saving up for a yacht. If there were more doctors, you could better shop around for the most empathetic doctor. I could shop around for the most competent doctor. We might wind up at the same doctor's office but maybe not.

[mjs]

Granted, there are no doubt some there for the money. Would you rather they went to law school or were bankers getting bonuses from Bush and Obama? One of the obvious things that Med schools could do to lower what doctors charge is to train twice as many doctors. Its not like there is a shortage of med school applicants. Double the number of doctors and they wouldn't be able to sell their services for as much as much because of increased competition. It wouldn't necessarily even cost the taxpayers anything.

I can't verify if the AMA works like the ABA, but I suspect it does and one of the most aggravating things of bar associations has been that they feel one of their roles is to limit competition. For example, all state bar associations except California require bar applicants to have attended a school approved by the ABA and the ABA limits the number of applicants a school is allowed to accept. One of the things that limiting competition and training facilities creates is high tuition because the expected ROI is high. As a result, a great deal of attorneys feel they are unable to take lower paying public service and nonprofit jobs. Another result is that it creates a system where attorneys either work a ton of hours for large firms or go off on their own. Often, the people on their own started off working a ton of hours for others so they could pay off their debts. Sounds like our medical profession to me. Debt ridden individuals forced to work long hours in an undermanned field.

I've never heard of engineering organizations telling schools that they can't have an engineering department or business organizations telling schools that can't offer MBAs. If a school can train people to pass the medical exams and make it through their residencies, let them train whoever can qualify.

[mjs]

Oladub, we must have been typing the same basic idea at the same basic time. You identified another way the ABA and AMA rules seem similar. Unnecessary academic requirements that seem to be put in place just to limit competition and justify higher salaries. I went to law school. It requires a bachelor's degree but it doesn't matter what the degree is in and has no prerequisites. So, why does it require a bachelor's degree then? Drop the bachelor's requirement and add a year of generalized classes to the attorney curriculum and you have yourself a four year bachelor of arts. Charge bachelor of arts tuition and bam, everyone can have affordable legal access. And, just like medicine, cheaper access is earlier access and earlier access will save alot of bigger problems down the road.

[firstandten]

As you know, the President is trying to make health care, he says, $1T more expensive. Others are saying $2-3T. Since someone will have to bare those costs, it is another example of government causing health care to become less affordable. If it doesn't show up on someone's doctor bill, it will show up as some new tax.

It doesn't have to be this way. If Michigan simply adopted Ontario's system health care costs would decline. However our topic is about what our government has done and now plans to do.

But Oladub, we are already paying 2.5T on private health care insurance and the cost is going up! You are focusing on Obama's cost but what about the cost of doing nothing. Obama's cost assuming its $1T won't be on top of what its costing us already. If gov't is making health care unaffordable then private insurance companies are going to make health care unthinkable and we can just start dying in the streets.

I agree with you about Ontario's and Canada's health care system. Obama is trying to come up with a public option that keeps all the major players in the game or a unique American plan. These players lobby our politicans donate money etc. The politicans know reform is needed but they want to keep the money coming. Obama knows he can't get universal single payer health care passed, a political impossiblity so he does the next best thing. disgusting ! Next item on the agenda after health care refom, should be campaign finance reform then maybe the system will start working for "we the people"