Excellent blog from the AAFP about a big problem

[doctorcoug]

in medicine.

We work hard, but really enjoy the 60 hour weeks, maybe because a lot of docs got sick of working 110 hours during the 80s and 90s.

My wife really wants me to take one of those 40 hour a week VA jobs. I'm pushing hard to be the doc that does 60 deliveries a year, sees 35 patients in clinic, and has 5 in the hospital. I'm probably going to lose, but it is worth the shot.

http://blogs.aafp.org/fpm/makingit/entry/whatever_happened_to_hard_work

[Jarid in Cedar]

in medicine.

We work hard, but really enjoy the 60 hour weeks, maybe because a lot of docs got sick of working 110 hours during the 80s and 90s.

My wife really wants me to take one of those 40 hour a week VA jobs. I'm pushing hard to be the doc that does 60 deliveries a year, sees 35 patients in clinic, and has 5 in the hospital. I'm probably going to lose, but it is worth the shot.

http://blogs.aafp.org/fpm/makingit/e...d_to_hard_work

Cut back on the clinic numbers and you can split the difference on hours with your wife. You pretty much described my practice except I see closer to 20-23 patients a day. My hours average about 45-55 depending on the severity of call.

[wuapinmon]

Cut back on the clinic numbers and you can split the difference on hours with your wife. You pretty much described my practice except I see closer to 20-23 patients a day. My hours average about 45-55 depending on the severity of call.

What do you do if you want to go on vacation? This is the dilemma for FPs, no? Your patients depend so much on you that you feel like you can't get away for more than a few days. My FP here worked on Memorial Day.

[doctorcoug]

Cut back on the clinic numbers and you can split the difference on hours with your wife. You pretty much described my practice except I see closer to 20-23 patients a day. My hours average about 45-55 depending on the severity of call.

It will be interesting to see how this all plays out. We have young children and I think she is sick of being a single mom (I didn't even come close to 80 hours in school, I remember putting in 100+ hours all the time).

Hopefully, when I'm a senior, the decrease in hours will calm her. I do envision a compromise.

[Jarid in Cedar]

What do you do if you want to go on vacation? This is the dilemma for FPs, no? Your patients depend so much on you that you feel like you can't get away for more than a few days. My FP here worked on Memorial Day.

When I was in solo practice, it was tough to get away. I had to arrange with 2 or 3 different doctors to cover my patients. We would have to plan time away several weeks in advance. I have 2 partners now, so it is much easier to just drop things and go, and still have trust that my patients are being well cared for by my partners.

[wuapinmon]

When I was in solo practice, it was tough to get away. I had to arrange with 2 or 3 different doctors to cover my patients. We would have to plan time away several weeks in advance. I have 2 partners now, so it is much easier to just drop things and go, and still have trust that my patients are being well cared for by my partners.

Does pooling resources with partners, staffing, facilities, and efficiencies increase your earning potential, even if you have to share more of your income with others? When I look at the ramifications of insurance for all, one thing that strikes me is, without a huge increase in the number of competent doctors, of all specialities, the wait times we gripe about now could be far far longer. I see huge practices as models of efficiency to use the most precious asset, the doctor's time, and alleviate the need for the doc to do anything more than see patients and read research to keep up on the "best practices" in their field.

[Jarid in Cedar]

Does pooling resources with partners, staffing, facilities, and efficiencies increase your earning potential, even if you have to share more of your income with others? When I look at the ramifications of insurance for all, one thing that strikes me is, without a huge increase in the number of competent doctors, of all specialities, the wait times we gripe about now could be far far longer. I see huge practices as models of efficiency to use the most precious asset, the doctor's time, and alleviate the need for the doc to do anything more than see patients and read research to keep up on the "best practices" in their field.

The equation works out until you get to about 5-6 physician. At that point you are sharing enough resources to maximize productivity and profitability. After that number, you start to see a negative impact as the cost of infrastructure/resources needed to support a larger practice starts to outweigh the increased revenues that adding another physician would produce.

[doctorcoug]

The equation works out until you get to about 5-6 physician.

I'll be ready in 3 years

[wuapinmon]

The equation works out until you get to about 5-6 physician. At that point you are sharing enough resources to maximize productivity and profitability. After that number, you start to see a negative impact as the cost of infrastructure/resources needed to support a larger practice starts to outweigh the increased revenues that adding another physician would produce.

Ok......what's the next magic number up? I ask, because I've seen some rather large surgical practices, and the one I went to this morning for my heel spur has about 25 doctors with two each for different specialties. I saw a podiatrist, but they have endocrinologists, surgeons, ENTs, and all kinds of stuff. By the way, for an achilles heel spur, after three months of Voltaren therapy and wearing leg brace (day and night) with no distinguishable reduction on x-ray of the inflammation, he has given me something called Medrol (Methylpred) with a 6, 5, 4, 3, 2, 1 decreasing dosage for six days. He says it's going to really attack the inflammation, could make me feel flushed and will make me very hyper. I start tomorrow morning.* Do you have anything to add/warn about the drug? I'm a little worried about it making me hyper, especially since I seem to offend the ladies of CUF when I'm under the influence of anything stronger than Coca-Cola, that and I teach Spanish and am an extrovert, so a hyper extrovert speaking Spanish muy rapidamente can be beyond obnoxious.

[Jarid in Cedar]

Ok......what's the next magic number up? I ask, because I've seen some rather large surgical practices, and the one I went to this morning for my heel spur has about 25 doctors with two each for different specialties. I saw a podiatrist, but they have endocrinologists, surgeons, ENTs, and all kinds of stuff. By the way, for an achilles heel spur, after three months of Voltaren therapy and wearing leg brace (day and night) with no distinguishable reduction on x-ray of the inflammation, he has given me something called Medrol (Methylpred) with a 6, 5, 4, 3, 2, 1 decreasing dosage for six days. He says it's going to really attack the inflammation, could make me feel flushed and will make me very hyper. I start tomorrow morning.* Do you have anything to add/warn about the drug? I'm a little worried about it making me hyper, especially since I seem to offend the ladies of CUF when I'm under the influence of anything stronger than Coca-Cola, that and I teach Spanish and am an extrovert, so a hyper extrovert speaking Spanish muy rapidamente can be beyond obnoxious.

Don't worry about the medrol, it won't kill you but you may want to kill who prescribed it to you (sleep disturbance is not unusual while you take it)

Back to your original question. I would say my model is more appropriate for primary care practices where the majority of the work is in office and is overhead heavy. Surgeons(of all types) on the other hard work more in the hospitals and have much less overhead to deal with, so larger practice models work better for them. That said, in very large multispecialty clinics, the clinics themselves are profitable, but the individual docs are not making as much as they could(they are also not bearing any of the risk as well). IMO 4 surgeons in a small clinic would make more per surgeon than 4 surgeons in a group of 50.

[wuapinmon]

Don't worry about the medrol, it won't kill you but you may want to kill who prescribed it to you (sleep disturbance is not unusual while you take it)

Back to your original question. I would say my model is more appropriate for primary care practices where the majority of the work is in office and is overhead heavy. Surgeons(of all types) on the other hard work more in the hospitals and have much less overhead to deal with, so larger practice models work better for them. That said, in very large multispecialty clinics, the clinics themselves are profitable, but the individual docs are not making as much as they could(they are also not bearing any of the risk as well). IMO 4 surgeons in a small clinic would make more per surgeon than 4 surgeons in a group of 50.

How would you address the doctor shortage if insurance is available to all? What could your clinic do, if anything, to ease the effects of the shortage?

[doctorcoug]

How would you address the doctor shortage if insurance is available to all? What could your clinic do, if anything, to ease the effects of the shortage?

I hope he responds to your question. The PCP shortage is huge and is going to hurt.

What I think docs will end up doing is pushing back follow-ups for little things, scheduling in the important stuff, and bring in a bunch of med students for a month and run school physicals in July or August . Oh, and we will get back to working 80+ hours a week.

What will probably end up happening is that mid-levels will push for unsupervised licenses. I hope it never happens, but unless we provide incentives for greater than 5 percent of the US grads to go into PC (paying PCPs better), then we have little alternative. People that have 2.5 years of training after college will be managing patients. It is not what this country needs.

[wuapinmon]

I hope he responds to your question. The PCP shortage is huge and is going to hurt.

What I think docs will end up doing is pushing back follow-ups for little things, scheduling in the important stuff, and bring in a bunch of med students for a month and run school physicals in July or August . Oh, and we will get back to working 80+ hours a week.

What will probably end up happening is that mid-levels will push for unsupervised licenses. I hope it never happens, but unless we provide incentives for greater than 5 percent of the US grads to go into PC (paying PCPs better), then we have little alternative. People that have 2.5 years of training after college will be managing patients. It is not what this country needs.

DoctorCoug, if the government had paid for your med school in return for five years after residency, with a decent (not huge, mind you) salary during residency, would you have gone that route? Do you think more people would go into medicine if the schooling was so expensive?

[doctorcoug]

DoctorCoug, if the government had paid for your med school in return for five years after residency, with a decent (not huge, mind you) salary during residency, would you have gone that route? Do you think more people would go into medicine if the schooling was so expensive?

It totally depends. These programs already exist (Army, Navy, Air Force, National Health Service Corps, Primary Care Loans). However, these all require you to be a slave of some sort. The military, it is a slave to defend your country. My wife didn't want any of that.

With the NHSC, you are required to work in primary care in an underserved are (BFE, or the bronx). I wasn't committed to doing primary care until my 2nd year. I applied for the NHSC, but I wasn't accepted (mainly because my demographics were not bronx nor BFE, though they are now). I will join the NHSC in their Loan Repayment Program and will get $50K for the first 2 years, then it increases the next year to 30, then 35 and stays there until it comes back down a little later.

Obama has stated his intentions for helping more docs go to primary care and it is to expand the NHSC. The problem is, there will be shortages in the suburbs with this new plan, so expanding the NHSC is not a viable option.

Reimbursements to PCP physicians need to expand to allow the shortage to go away. This is a problem, because Obama wants this done now, and these things take time. For instance, most med students decide against primary care during their 3rd year rotations. Why wouldn't they? The PCP docs look burned out and make pennies compared to the surgeons and proceduralists that don't have to see nearly as many patients in clinic (clinic can be hell on earth sometimes).

So, for our shortage to decrease, I think this is a 3 year process, if you had a major "shock" to the reimbursement scale to take PCP starting salaries from 140-160K to 230K. You do this, PCPs will see the first year that they didn't have to bust their butts to make 200K, so they will see less patients, be happier, and convince med students to join the field. This is a years fix, not fix overnight.

Back to your question, if the government offered to pay my salary, no strings attached other than 5 years accepting only medicare/medicaid and allowed me to choose any specialty, then, without a doubt, I would have accepted their funding.

[Jarid in Cedar]

How would you address the doctor shortage if insurance is available to all? What could your clinic do, if anything, to ease the effects of the shortage?

One way would be to make medical school a 6 year enrollment, but make entry allowable without a Bachelor's degree. Most students have been in school 9-10 years be the time they hit residency and add another 3-5 years for that. By the time the average surgeon can enter practice, he is likely 32-33 years old. If the average time to residency was reduced to 6 years, each graduating Dr. would be in practice 4 more years. That doesn't sound like alot, but over time, it would help with to overall attirtion rate of physicians.

The other practical side of it is to have better triage systems over the phone to assess who needs seen, who can wait, and how to get them back into the loop if they aren't seen, but don't improve. Unfortunately, this is very labor/infrastructure intensive, hence costly. Because of this, you will not see too many practices take this approach.

Lastly, the approach that we are taking is to have the medical assistants do more of the "data gathering" for the visits and also implementing the planned action(set up tests, fill out forms, etc) and free up the physicians to do the real nitty gritty which is interpretting the data and determining the course of action. I have some heartburn over this approach as well, but it is showing promise.

Unfortunately, I agree with Doctorcoug, you are going to continue to see the proliferation of midlevel providers (PA's, NP's) to fill the primary care gap. This pains me in ways that are unholy, but the writing is on the wall.