A saddening trend...

It is a challenging time facing our profession. I'm not sure how things will turn out, but my passion for primary care is increasing by the day. ~R

Half of primary-care doctors in survey would leave medicine

• Story Highlights
• Doctors cite red tape from insurance companies, government agencies
  
• Med school students shy away from family medicine
  
• Shortage of primary care physicians predicted to be 35,000 to 40,000 by 2025
  

By Val Willingham
CNN Medical Producer

(CNN) -- Nearly half the respondents in a survey of U.S. primary care physicians said that they would seriously consider getting out of the medical business within the next three years if they had an alternative.

Experts say if many physicians stop practicing, it could be devastating to the health care industry.

The survey, released this week by the Physicians' Foundation, which promotes better doctor-patient relationships, sought to find the reasons for an identified exodus among family doctors and internists, widely known as the backbone of the health industry.

A U.S. shortage of 35,000 to 40,000 primary care physicians by 2025 was predicted at last week's American Medical Association annual meeting.

In the survey, the foundation sent questionnaires to more than 150,000 doctors nationwide.

Of the 12,000 respondents, 49 percent said they'd consider leaving medicine. Many said they are overwhelmed with their practices, not because they have too many patients, but because there's too much red tape generated from insurance companies and government agencies.

And if that many physicians stopped practicing, that could be devastating to the health care industry.

"We couldn't survive that," says Dr. Walker Ray, vice president of the Physicians Foundation. "We are only producing in this country a thousand to two thousand primary doctors to replace them. Medical students are not choosing primary care."

Dr. Alan Pocinki has been practicing medicine for 17 years. He began his career around the same time insurance companies were turning to the PPO and HMO models. So he was a little shocked when he began spending more time on paperwork than patients and found he was running a small business, instead of a practice. He says it's frustrating.

Don't Miss

• Waiting for the doctor ... and waiting, and waiting

"I had no business training, as far as how to run a business, or how to evaluate different plans," Pocinki says. "It was a whole brave new world and I had to sort of learn on the fly."

To manage their daily work schedules, many survey respondents reported making changes. With lower reimbursement from insurance companies and the cost of malpractice insurance skyrocketing, these health professionals say it's not worth running a practice and are changing careers. Others say they're going into so-called boutique medicine, in which they charge patients a yearly fee up front and don't take insurance.

And some like Pocinki are limiting the type of insurance they'll take and the number of patients on Medicare and Medicaid. According to the foundation's report, over a third of those surveyed have closed their practices to Medicaid patients and 12 percent have closed their practices to Medicare patients That can leave a lot of patients looking for a doctor.

And as Ray mentioned, med school students are shying away from family medicine. In a survey published in the Journal of the American Medical Association in September, only 2 percent of current medical students plan to take up primary care. That's because these students are wary of the same complaints that are causing existing doctors to flee primary care: hectic clinics, burdensome paperwork and systems that do a poor job of managing patients with chronic illness.

So what to do? Physicians don't have a lot of answers. But doctors say it's time to make some changes, not only in the health care field but also with the insurance industry. And they're looking to the new administration for guidance.

One of President-elect Barack Obama's health care promises is to provide a primary care physician for every American. But some health experts, including Pocinki, are skeptical.

"People who have insurance can't find a doctor, so suddenly we are going to give insurance to a whole bunch of people who haven't had it, without increasing the number of physicians?" he says. "It's going to be a problem."

Burnout...

An interesting repost from the NY Times. Food for thought... I know we all feel these thoughts, but it is very important to get help. It's all part of the journey.

Peace,
R

Doctor and Patient

Medical Student Burnout and the Challenge to Patient Care

Odilon Dimier/PhotoAlto/Corbis

By PAULINE W. CHEN, M.D.

Published: October 30, 2008

Not too long ago, I read a paper titled “Burnout and Suicidal Ideation Among U.S. Medical Students” in The Annals of Internal Medicine. It brought back a flood of memories.

Medical school was not easy for me. I knew that I wanted to become a doctor to help people, but I had given little thought to the process. I was poorly prepared for many things: the pressure to excel in ways that seemed so far from caring for people; rapidly mounting debts I signed off on every semester; a roller coaster existence from chronic lack of sleep; hazing from the more experienced students and residents; and the realities of patient suffering despite my best efforts.

Even surgical residency, despite the relentlessly long hours, seemed so much closer to what I wanted to do.

Some of my professors tried to “humanize” the process. They invited us to dinner in their homes, supported our extracurricular efforts to set up health screening clinics in low-income neighborhoods, and tried to make our basic science courses more relevant to working with patients. But sitting where I am now, as someone who teaches medical students and who loves helping others as a doctor, I can understand the challenge they faced. Given the fire hose of information medical students must learn in just four years, how does one ever gently take a sip?

Despite my teachers’ efforts, I was about as miserable in medical school as I had ever been. I felt alone. Neither I nor my classmates could admit to failure, and the last thing I wanted to do was to let anyone but my closest friends know just how unhappy I was. Success in medical school was the first step to a future of helping others, and I was not about to jeopardize that.

Last week I had dinner with two former classmates from that time. We had not seen each other in over a decade, and after catching up on personal news and reminiscing about gross anatomy lab and our first nights on call, one of them said quietly, “I hated med school. I wanted to quit.” The elephant in our collective memories had broken free.

With that elephant now running loose, and the three of us more comfortable with our own professional accomplishments, the conversation grew more honest. “If you look over my entire lifetime,” my other friend said, “those four years were the lowest point in terms of self esteem.” He held his hand out in the air, plotting an imaginary line that dropped precipitously to his knees.

It took nearly 20 years for the three of us to learn that we had each been miserable as medical students. It has taken even longer for researchers to discover the extent to which such feelings exist among American medical students.

In 2006, Dr. Liselotte N. Dyrbye and her colleagues at the Mayo Clinic found that nearly half of the 545 medical students they surveyed suffered from burnout, which they defined as professional distress in three domains: emotional exhaustion, depersonalization and low sense of personal accomplishment. Moreover, the researchers found that each successive year of schooling increased the chances students would experience burnout, despite the fact that they had entered medical school with mental health profiles similar to those of their peers who chose other career paths.

More recently, in the paper on burnout that had first caught my eye, Dr. Dyrbye and her colleagues widened the scope of their research, analyzing survey responses from 2,248 medical students at seven medical schools across the country. Again, nearly half of the students surveyed met the criteria for burnout. But the investigators discovered an even more ominous finding: 11 percent of all the students surveyed also reported having suicidal thoughts in the past year.

Dr. Dyrbye notes that we are just starting to learn about the high levels of distress in medical students. “It’s incredibly disconcerting,” she said. “What are the causes? And what can we do as educators to facilitate their well-being? We need a better understanding of the causes of stress to design interventions that will help improve student wellness. Students, just like doctors, need to take care of themselves in order to take care of their patients.”

Medical schools have more recently recognized the importance of this issue. For example, the Liaison Committee on Medical Education, the accrediting authority for medical schools in the United States, now mandates that all schools have a program for student wellness in place that includes “an effective system of personal counseling for its students.”

But beyond the personal implications, what are the ramifications of medical student burnout for patients?

In a third study, Dr. Dyrbye found that when tested for empathy, medical students at baseline generally scored higher than their nonmedical peers. But, as medical students experienced more burnout, there was a corresponding drop in the level of empathy toward patients.

“What do they really need to know before graduating from medical school, and how could they most efficiently learn?” Dr. Drybye asked, reflecting on one of the central challenges of medical education. “All the information we want to share with them is not necessarily what they really need to learn.”

By the time my dinner with my former classmates last week had ended, we had made plans to stay in touch and to do something I had never been sure I would ever do: return to my medical school in two years’ time to celebrate our 20th reunion. Over the course of our dinner conversation I felt strangely connected and nostalgic about medical school; I was deeply moved by what my two classmates had chosen to do with their education. One is a well-loved community obstetrician/gynecologist; the other is a psychiatrist devoted to teaching, working in a county medical clinic and caring for severely traumatized Hmong refugees. And both love their work as doctors.

As I listened to them talk about their work, I was reminded of one other thing Dr. Dyrbye had told me. “We need to change things,” she had said, “because maybe the students who are most vulnerable are the ones who are most empathic.”