The Human Face of Primary Care
We've received hundreds of correspondence as a result of our correspondence in The New England Journal of Medicine advocating for higher primary care reimbursement. Please review our page Rescuing Primary Care for data detailing the plight of our nation’s primary care doctors and check the Updates and Other News page for links to a new OECD study that describes the health costs to our country from our primary care shortage. However powerful these and other data may be, physicians’ stories place a human face on the depth of frustration, devaluation, and difficulty paying the bills that many of our nation’s primary care doctors fight through every day. (I do not identify students and residents by name in this post due to their more vulnerable position in the medical hierarchy while the doctors named all agreed to the publication of both their names and stories.)
The youngest to contact me, a third year medical student, who had traveled extensively in other developed countries earning an MPH, wrote “primary care physicians are often better compensated than many specialists [in other countries]. I think in the US we greatly undervalue our primary care physicians...” Another student wrote asking, “Why do we have this cult of specialization?” A resident told me of the not so good natured comments he received when he announced his decision to pursue family medicine, “it was as if they [his colleagues] felt that my Ivy League background, good grades, and hard work would be almost wasted if I became a family physician. They know they shouldn't feel that way, but it was almost like only students who couldn't get into specialties should go into general medicine—the money would be a lot better.” Art Morris, a practicing family doc of 17 years, still recalls the unpleasant way specialists treated him during his residency, “Throughout my training, specialists would pull me aside and say something to the effect, 'Art, you're smart enough to go into [put their specialty here]; you don't have to go into family practice.' Even back then there was a not-so-silent prejudice.” However unpleasant these type of comments are to the doctors who wrote me, it is the reimbursement issue that most directly leads to the widespread feeling that our system devalues their work.
I received several disturbing and astonishing stories of how little compensation primary care physicians sometimes receive. Susan Miller, a Professor of Family Medicine at Virginia Commonwealth University, wrote to me about her group's decision to abandon inpatient care over reimbursement issues. It was an emotional and difficult decision for her and her partners; she knows that “it was to the detriment of our patients, but it just was not financially viable.” The decision, in part, sprang from her experience caring for a patient of 10 years, a retired army officer who developed mycoplasma pneumonia and who ended up intubated in the ICU for 2 weeks, and in the hospital for 4. Her hospital trips took her an hour a day, and she took care of her patient for 30 days, spent a great deal of time with his family, and emotionally supported him when he said that he just wanted to die. She wrote a daily progress note and orders for the patient. Then, when she submitted her charges at the end of the hospitalization, they were rejected by the insurance company while the 3 specialists who also cared for the patient were all reimbursed. The insurance company would only pay for a certain number of doctors to make daily rounds, and the specialists could all bill for specific tasks that they had performed, such as the pulmonologist's management of the patient's respiratory problems and ventilator management. The insurance company, in effect, told her that her time away from her family, the medical care she had given, the anxious conversations with the patient's worried family, and her emotional encouragement to her patient were all superfluous and valueless; she “did not get a cent.” She took care of this patient for several years after this episode and is still angry over it, but she is also disappointed not to provide hospital care for her patients: “I am very aware that my patients would like for me to see them in their time of need and that the support and knowledge of the family doctor and the continuity I could provide is invaluable, but when it was decided that my services were not necessary, that was the end.”
Dr. Miller displays no bitterness over this event; indeed, none of the generalists who wrote to me revealed any bitter feelings, but many feel discouraged by our system of reimbursement which values their time and skills so slightly. Dr. Morris, again, told me how he had spent 45 minutes with a patient talking him down from a suicide and organizing an involuntary commitment only to learn later that his reimbursement for this difficult and emotionally fraught work came to “about $20 more...than my wife pays to get her hair done.” Another wrote of his experience caring for a 52 year old gentleman with terminal esophageal cancer. He had diagnosed the poor man's illness 11 months before and provided supportive care while his patient underwent radiation and chemotherapies. Finally, there was nothing more he could offer but his kindness and effective palliative care. In the days before the man's death, he spoke frequently to the man's wife and children and helped coordinate care with the visiting nurse. The gentleman had one last office visit with his wife where issues concerning PEG tube feedings, pain management options, limits on resuscitation efforts, and other final questions were all thoughtfully discussed. The visit lasted nearly an hour; the reimbursement was less than $100. This FP, of course, would change nothing about the manner in which he treated his patient; he wrote that he felt his efforts with the family were priceless to them, but the compensation would “hardly cover expenses for an hour.”
As a procedural specialist, it was often painful for me to read this correspondence; I know that I have not always been as available to nor as thoughtful of my referring doctors as they deserve , but, most importantly, like most other specialty physicians, I have done very little to improve their financial situation. It is not just a matter of fairness across specialties of medicine; rather, and much more significantly, it is a serious public health issue for our country. One can argue with experts about the exact number of deaths, but it is impossible to deny that several tens of thousands of Americans die each year due to our lack of general physicians. This is a huge and horrific number and is many times larger than the number of Americans who have died in our nation's current wars, due to homicide, and as a result of the terrible 9/11 attacks. These persons die quietly and by neglect, but they are dead nonetheless, and their deaths stain the conscious of America's medical establishment. An academic family medicine doctor wrote me, “The problem we have always had is that public discussions of poor reimbursement are very awkward and difficult when we are talking about incomes that put FPs in the top 5% of incomes.” His and other general physicians’ sensitivity to the gap in incomes between primary care docs and their patients is quite laudable and is mirrored in many comments that I received, but no sane person thinks that a generalist chooses his profession for its income potential when, by doing so, he turns his back on specialties whose average compensation can be several multiples of his own. The motivation of the doctors discussed here is much more profound and difficult to attempt to discuss without using the word “love”. However, America and our medical system can abuse this love no longer; the tally in needlessly lost lives is far too large, and we are breaking the back of our primary care network. The United States needs more, many more, general physicians, and the most important step in attracting students to the profession is equalizing the pay among different types of physicians. This will require sacrifices on the part of specialists like me, and, difficult as it may be, we need to realize that our countrymen’s lives are far more important than our salaries.
All this brings me back to the vignette that best characterizes this quiet crisis for me; it is not exceptional; in fact, from the letters I received, it seems sadly quotidian. Jean Antonucci, a family doc in Farmington received a call one cold Maine Christmas Eve from a patient of hers with abdominal pain and jaundice. She then spent the rest of her evening arranging tests, coordinating his care and talking with his panicked family. She admitted him to the hospital and had great difficulty obtaining help from a general surgeon or GI specialist (who were both only too happy to help first thing Dec. 26). She cared for him on Christmas day and then turned him over to local specialists who performed the necessary procedures at their convenience. She devoted most of her Christmas Eve and Christmas Day to him, away from her family, and was paid $80.00. As events unfolded, her patient was diagnosed with pancreatic cancer; Dr. Antonucci continued to treat him, speak to his family, and organize his care. Her patient was a farmer, and after his initial treatments were all completed, he gave her a chicken wrapped with a red holiday bow as a tribute to all of her efforts—long and sustained--on his behalf over the Christmas holiday. He also gave her a look of immense gratitude. She put the chicken in the freezer and won’t eat it until she can celebrate his being cancer free.
The youngest to contact me, a third year medical student, who had traveled extensively in other developed countries earning an MPH, wrote “primary care physicians are often better compensated than many specialists [in other countries]. I think in the US we greatly undervalue our primary care physicians...” Another student wrote asking, “Why do we have this cult of specialization?” A resident told me of the not so good natured comments he received when he announced his decision to pursue family medicine, “it was as if they [his colleagues] felt that my Ivy League background, good grades, and hard work would be almost wasted if I became a family physician. They know they shouldn't feel that way, but it was almost like only students who couldn't get into specialties should go into general medicine—the money would be a lot better.” Art Morris, a practicing family doc of 17 years, still recalls the unpleasant way specialists treated him during his residency, “Throughout my training, specialists would pull me aside and say something to the effect, 'Art, you're smart enough to go into [put their specialty here]; you don't have to go into family practice.' Even back then there was a not-so-silent prejudice.” However unpleasant these type of comments are to the doctors who wrote me, it is the reimbursement issue that most directly leads to the widespread feeling that our system devalues their work.
I received several disturbing and astonishing stories of how little compensation primary care physicians sometimes receive. Susan Miller, a Professor of Family Medicine at Virginia Commonwealth University, wrote to me about her group's decision to abandon inpatient care over reimbursement issues. It was an emotional and difficult decision for her and her partners; she knows that “it was to the detriment of our patients, but it just was not financially viable.” The decision, in part, sprang from her experience caring for a patient of 10 years, a retired army officer who developed mycoplasma pneumonia and who ended up intubated in the ICU for 2 weeks, and in the hospital for 4. Her hospital trips took her an hour a day, and she took care of her patient for 30 days, spent a great deal of time with his family, and emotionally supported him when he said that he just wanted to die. She wrote a daily progress note and orders for the patient. Then, when she submitted her charges at the end of the hospitalization, they were rejected by the insurance company while the 3 specialists who also cared for the patient were all reimbursed. The insurance company would only pay for a certain number of doctors to make daily rounds, and the specialists could all bill for specific tasks that they had performed, such as the pulmonologist's management of the patient's respiratory problems and ventilator management. The insurance company, in effect, told her that her time away from her family, the medical care she had given, the anxious conversations with the patient's worried family, and her emotional encouragement to her patient were all superfluous and valueless; she “did not get a cent.” She took care of this patient for several years after this episode and is still angry over it, but she is also disappointed not to provide hospital care for her patients: “I am very aware that my patients would like for me to see them in their time of need and that the support and knowledge of the family doctor and the continuity I could provide is invaluable, but when it was decided that my services were not necessary, that was the end.”
Dr. Miller displays no bitterness over this event; indeed, none of the generalists who wrote to me revealed any bitter feelings, but many feel discouraged by our system of reimbursement which values their time and skills so slightly. Dr. Morris, again, told me how he had spent 45 minutes with a patient talking him down from a suicide and organizing an involuntary commitment only to learn later that his reimbursement for this difficult and emotionally fraught work came to “about $20 more...than my wife pays to get her hair done.” Another wrote of his experience caring for a 52 year old gentleman with terminal esophageal cancer. He had diagnosed the poor man's illness 11 months before and provided supportive care while his patient underwent radiation and chemotherapies. Finally, there was nothing more he could offer but his kindness and effective palliative care. In the days before the man's death, he spoke frequently to the man's wife and children and helped coordinate care with the visiting nurse. The gentleman had one last office visit with his wife where issues concerning PEG tube feedings, pain management options, limits on resuscitation efforts, and other final questions were all thoughtfully discussed. The visit lasted nearly an hour; the reimbursement was less than $100. This FP, of course, would change nothing about the manner in which he treated his patient; he wrote that he felt his efforts with the family were priceless to them, but the compensation would “hardly cover expenses for an hour.”
As a procedural specialist, it was often painful for me to read this correspondence; I know that I have not always been as available to nor as thoughtful of my referring doctors as they deserve , but, most importantly, like most other specialty physicians, I have done very little to improve their financial situation. It is not just a matter of fairness across specialties of medicine; rather, and much more significantly, it is a serious public health issue for our country. One can argue with experts about the exact number of deaths, but it is impossible to deny that several tens of thousands of Americans die each year due to our lack of general physicians. This is a huge and horrific number and is many times larger than the number of Americans who have died in our nation's current wars, due to homicide, and as a result of the terrible 9/11 attacks. These persons die quietly and by neglect, but they are dead nonetheless, and their deaths stain the conscious of America's medical establishment. An academic family medicine doctor wrote me, “The problem we have always had is that public discussions of poor reimbursement are very awkward and difficult when we are talking about incomes that put FPs in the top 5% of incomes.” His and other general physicians’ sensitivity to the gap in incomes between primary care docs and their patients is quite laudable and is mirrored in many comments that I received, but no sane person thinks that a generalist chooses his profession for its income potential when, by doing so, he turns his back on specialties whose average compensation can be several multiples of his own. The motivation of the doctors discussed here is much more profound and difficult to attempt to discuss without using the word “love”. However, America and our medical system can abuse this love no longer; the tally in needlessly lost lives is far too large, and we are breaking the back of our primary care network. The United States needs more, many more, general physicians, and the most important step in attracting students to the profession is equalizing the pay among different types of physicians. This will require sacrifices on the part of specialists like me, and, difficult as it may be, we need to realize that our countrymen’s lives are far more important than our salaries.
All this brings me back to the vignette that best characterizes this quiet crisis for me; it is not exceptional; in fact, from the letters I received, it seems sadly quotidian. Jean Antonucci, a family doc in Farmington received a call one cold Maine Christmas Eve from a patient of hers with abdominal pain and jaundice. She then spent the rest of her evening arranging tests, coordinating his care and talking with his panicked family. She admitted him to the hospital and had great difficulty obtaining help from a general surgeon or GI specialist (who were both only too happy to help first thing Dec. 26). She cared for him on Christmas day and then turned him over to local specialists who performed the necessary procedures at their convenience. She devoted most of her Christmas Eve and Christmas Day to him, away from her family, and was paid $80.00. As events unfolded, her patient was diagnosed with pancreatic cancer; Dr. Antonucci continued to treat him, speak to his family, and organize his care. Her patient was a farmer, and after his initial treatments were all completed, he gave her a chicken wrapped with a red holiday bow as a tribute to all of her efforts—long and sustained--on his behalf over the Christmas holiday. He also gave her a look of immense gratitude. She put the chicken in the freezer and won’t eat it until she can celebrate his being cancer free.