Doctors under duress

These are tough times for American physicians, believe it or not. Doctors are getting sued more and respected less, and are working longer hours for smaller paychecks. They are drowning in challenges to what they do from every quarter when once they almost walked on water. Malpractice insurance premiums are skyrocketing, and it takes more time to do the paperwork from a patient visit to the office than it does to actually treat the patient. The result is that practicing medicine these days can feel like constantly being on the wrong end of a big shot in the can.

A doctor complaining about hardship does seem a bit like Britney Spears complaining about lint in her navel, because a “tough” life for most doctors is a relative thing, and the practice of medicine remains a good living. Physician gripes, however, must not be taken with too big a grain of salt. Alarming trends in the practice of medicine speak to a future of too few doctors unless we coddle the medical profession just a wee bit.

First and foremost, physician incomes are going down. Payers of all type have cut reimbursement to doctors, some by 20 to 40 percent in the last two years. Medicare reimbursement to doctors is to be cut 17 percent over the next three years, a cut of more than $22,000 annually for the average primary care physician for whom the average salary is less than $120,000 and practice overhead is 60 percent. One can argue that physicians earn too much, but if we want our brightest people to work brutally long hours taking good care of us they must be at least as well paid as a guy who designs computer games.

These cuts will make it harder for physicians to see patients for whom they are not adequately reimbursed. Only 68 percent of American physicians, and only 83 percent of family physicians, are now willing to take on new Medicare patients. This trend comes at a time when several thousand Americans are turning 65 every day and enrolling in Medicare. For Medicaid patients, and those without any insurance, the numbers are even worse.

Just as doctors’ incomes are dropping, malpractice insurance premiums are rising faster than a big belch. Premiums for some doctors have increased by more than $100,000 in the last year. The business is so bad that The St. Paul Companies, the country’s premier malpractice insurance group, pulled out of the business entirely last year. That is the like the Department of Defense saying it is going to give up the Navy.

In Nevada, among the states hardest hit, the state medical association estimates 250 physicians will either be bankrupted by premium increases or leave the state this year, bad news in a state already short of doctors.

At the same time doctors have lost some of their social status. While they never really walked on water, being a doctor was hot enough stuff that they dried off quickly. Their status has been eroded by the demystification of medicine, medical errors, and much more.

The Massachusetts Medical Society’s 2001 Physician Practice Environment Index, which must have too much time on its hands if it can develop such indexes, estimates the quality of the practice environment for American physicians has dropped 15.6 percent since 1992. Whatever that means, it is not a plus. It may be why a large majority of American physicians do not recommend a career in medicine to their children.

None of this has been lost on smart kids looking at medicine versus rocket science as career options. Enrollment in our medical schools declined this year for the fifth year in a row. The number of doctors training to be family physicians has declined by 20 percent over the same period, and to be general surgeons by 30 percent The quality of physician life, including pay, is crucial to these young people; the average medical student graduates with at least $100,000 in debt, then faces several years of residency training at low wages for long hours.

The result of all of this is a looming shortage of physicians and dwindling access to physicians for patients with Medicare, Medicaid and no insurance. By some estimates there will be a shortage of 200,000 physicians in the United States within 10 to 20 years. Our population is aging and older patients need more medical care, more physicians are retiring early or changing careers, and fewer new ones are coming along. States such as Maine, which already have difficulty recruiting doctors, may suffer disproportionately from this shortage.

The answer to physician angst is complex, and is not simply more money. Doctors are not just princes and princesses who just need the hard pea removed from under the mattress. They need to be happy and healthy when called in at 3 a.m. to treat our crushing chest pain. They need social policy and personal well-being which sustain the long term viability of the medical profession. They need us to take some care of them. Otherwise, after we have taken the two aspirin and gone to bed, for many of us there may be no doctor to call in the morning.

Erik Steele, D.O. is a physician in Bangor, an administrator at Eastern Maine Medical Center, and is on the staff of several hospital emergency rooms in the region.