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The Primary Care Shortage: Killing The Golden Egg-Laying Goose?

This past Monday, I was drawn to an article in the Wall Street Journal: “Medical Schools Can’t Keep Up.” The article detailed the growing shortage of primary care doctors in our country and reminded me that we in the U.S. may have something called “insurance reform” now, but without physicians to translate insurance access into healthcare, the state of our healthcare system will continue to beg additional attention and reform.

Although new medical schools are opening and some schools have increased enrollment numbers, there are a limited number of residency positions in this country. The government has always funded these residency positions and our new reform law tries to address the primary care shortage with “slot redistribution,” whereby money from unused residency positions will be deferred to primary care or general surgery residency programs. 

However, the slot redistribution strategy equates to something of a shell game when set against the fact that in 1997 Congress put a cap on funding for medical residencies, and this limit is still in place today.

Too, we must take into account that it takes time to train doctors. Students desiring to become physicians must be motivated to endure the long training periods involved. Over the 11 years of my training (4 for college + 4 years accruing debt as a medical student + 3 years as a resident), I was acutely aware of the concept of delayed gratification. Sometime in college my father told me that he’d never seen a doctor starve to death.  This observation–intended as wit– helped to illustrate the fact that I would have job security and a comfortable living in the future, a fact that did help motivate me through inevitable rough patches.

The well spoken and timeless adage, “Man does not live on bread alone,” should help us to understand that tomorrow’s physicians will not be motivated solely by the promise of job security or a comfortable salary.  Debt forgiveness to serve in underserved areas may lure graduates towards primary care but I harbor my doubts that this will make up the 150,000 doctor shortage, as estimated by the Association of American Medical Colleges.  A 2007 survey of practicing physicians found that between 30 and 40 percent would not choose to enter the medical profession if they were deciding on a career again. Thirty five years earlier, the same survey found the number closer to 15 percent. There is real risk in ignoring the reasons for such dissatisfaction–we could run out of primary care doctors, a resource as irreplaceable as Aesop’s golden egg-laying goose.

As a young man, I felt a calling towards the profession of medicine and still do today, but I constantly battle against becoming something altogether different.  A good friend of mine, an orthopedic surgeon, best explained it when he told me that he “is a part-time surgeon but a full time clerk.” He lamented the time spent focusing on medical codes, charting, and cataloging supplies while attending mandatory meetings on everything but medical knowledge. He plans to retire soon and actually wringed his hands with anticipation while sharing his plans with me to volunteer in the third world so he can “become a full-time surgeon again by becoming a part-time doctor.”

Today, we in the U.S. have insurance reform but needed health reform. Talking heads on TV are now asking how to “bend the cost-curve downward” and are starting to ask who will see the patients if there aren’t enough primary care doctors to implement insurance reform.  All good questions but I would pose one more.  How can we expect our youth to sacrifice years of their lives, amass six-figure debt, and move towards a profession that leaves them dependent on government money and  beholden to onerous and often nonsensical government rules and regulations?  Our society should take care lest we kill our goose and run out of golden eggs.

Until next week, I remain yours in primary care,

Steve Simmons, M.D.

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2 Responses to “The Primary Care Shortage: Killing The Golden Egg-Laying Goose?”

  1. Art says:

    I wonder who will write a comprehensive article on how we are knowingly and perhaps willingly causing an implosion of our healthcare and calling it reform?

    Physicians are either becoming “industrialized” into groups so their clerking requirements can be done by others and they can have “9 to 5″ jobs 5 days a week [which will lower the amounts of patients they can care for], or doing the same through large hospital groups.

    Those who are doing this are mainly the younger physicians as the older ones are of the “old school” and consider their work a profession and not a job, where hours, quality time with family and freinds were not as important as delivering quality care whatever the time or needs might be. And the decrease in interest to be primary care physicans continues to attract fewer medical students who see this field as being overworked and underpaid.

    To make up the currently needed numbers of primary care physicians, [since it takes 10 years to produce them if possible] will only be able to have them available in 2020; while there seems to be thousands of “unfulfilled and disappointed primary care physicians who average half of what specialists do, who can only look forward to treating more patients with greater problems and to being forced into “groups” so they can retain their sanity by working fewer hours treating fewer patients as their younger FP and GP counterparts do, retire, change fields or become specialists.

    So over the next few years and hopefully before 2012 we will see how or if healthcare reform improves care by open access. By 2020 there will be 60 million more people with government provided Medicare, Medicaid and “exchange” insurnace, but by 2012 we will know we have a problem Washington! The huge demand has no supply capable of filling it!

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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