Productivity
I’m a family physician. I am presented with medical problems; I make diagnoses; I prescribe treatments. That’s what I do.
This blog is about a problem: Family practice, and primary care in general, is facing extinction.
My diagnosis is that financial incentives for medical students are currently skewed so strongly toward specialists that only idealists will apply. For an amplification of this opinion, see "Ten Hard Questions About the Future of the Specialty."
To hear academic poo-bahs say basically the same thing, see “The Future of Primary Care” in the NEJM, which arrived on my desk today.
The cure is for family physicians to make more money, thereby becoming more attractive role models for medical students. That’s what we’ll be discussing. If you think there is another reason medical students want to be dermatologists, you are excused. This blog won’t scratch your itch.
Still with me? We need to talk about productivity. This is about as pleasant a subject for others of you as a two-fingered rectal exam. You are also excused. Teach in a residency program, or work for a multispecialty group, or a hospital, where your labor serves as a loss leader for the Referral Cycle and your salary is somewhat higher than you would earn in our unfree market for medical services.
Nothing to be ashamed of. You wanted to be a physician, not an entrepreneur. But this blog isn’t for you, so please read no further. I wish you could raise your income, of course, because that would help us save our specialty. But I have no experience as an organizational change agent (five years in the Army Medical Corps, and I never tried; my father often said I was the sort who beat my head against the wall because it felt so good when I stopped, but he was wrong. It didn’t feel that good).
On one hand, this conversation is disgusting. I feel it, and I think it. When I read the comment by Dr. Schmidt, my heart leaps up. I make a lot more money than he does, but I live on what he earns; and it is enough to make me very happy. Because I indentured myself to the Army to avoid the “mountain” of debt facing medical students (the mountain is lower than the price of the first house they will buy out of residency and could be avoided entirely by any number of public service programs, including the military), I am unsympathetic to their plight.
And yet these medical students – and a scattering of other FPs contemplating change – are my target audience. My message is this: You can make as much money in family practice as you can as a specialist. And that’s a heckuva lot more than you need. But if that’s what it takes to save family medicine, here we go.
Productivity defined: Your net hourly taxable income from your work as a family physician. Here’s a worksheet for you to fill out to give you this figure. It requires estimates, but honest estimates; all the time you spend in committee meetings must go into the denominator.
Task Force Six of the Academy’s Future of Family Medicine Project came up with a productivity figure for the average family physician: $71 per hour. That was based on an annual salary of $167,000 including benefits; a 51-hour workweek, including 40 hours of direct patient contact; and I guessed at the critical item they omitted, a 46-week work year.
When the New Model is fully implemented, including open access scheduling, group visits, EMRs, e-visits, huddles, yada, yada, yada – the figure rises 26 percent, to $89 per hour. And – hold onto your hats, now – if the New Model results in increased medical financial productivity, and employers decide to grant us additional reimbursement based on their cost savings, we could earn an average of $114 per hour. Compare that to your figures.
My productivity in 2007 was considerably higher than that. Even after removing the income from a couple of special sources – a medical building that is debt-free because I was a buyer, not a renter, from the beginning, and the shared rent from a minor emergency center operating from our building – my net still leaves me in the top 10 percent of family physicians, and comparable to a radiologist or cardiologist.
I may be a little weird. When I was in medical school clinical rotations and all of us had finished our work around dinner time, my classmates would retire to a break room to spend a few hours sucking up to the interns and residents. I would go home. I still do. When my work is done, I go home. Medicine is not my whole life.
In the pre-EMR era, lots of family physicians dictated their records. Then, when their charts came back from the transcriptionist, they would review their transcriptions after they had finished seeing patients. Not me. I hand-wrote my records, as cryptically as possible, so when the door closed, I could go home. Still do.
That should generate enough controversy for the next fortnight, so I’ll sign off for now. If you want to read ahead, take a look at my "Solo Practice" article. It was written 10 years ago and reprinted in 2003 in the "classics" issue of FPM.
What do you think about productivity? Is it immoral? (If so, check out the Archives of Family Medicine; it’s mostly about morality.) Are you a helpless pawn of the evil insurance companies? Or are you Making It? Jump into the conversation, and I’ll get back to you at the end of November.
And a final word: All of us are works in progress. As Malcolm Gladwell points out geniuses are only occasionally precocious. The great mistake is to cease striving.
Posted at 10:43AM Nov 14, 2008 by Doug Iliff | Comments[3]
