The amphetamine generation
Yesterday an old friend stopped by for a visit. Jack and I ran cross-country against each other in high school, pledged the same fraternity, moved out together into a rental house (the three guys upstairs ended up in medical school, the three downstairs smoked dope – this was the ‘60s), and graduated together as physicians. Probably hadn’t seen him in 20 years, though, as we went to opposite coasts for our family practice residencies.
Talking to him about life in California reinforced my conviction that all medical politics are local. Managed care is still maybe 40 percent of his practice (it’s now zip for me) and Blue Cross pays him 90 percent of Medicare values (it’s much better in Kansas).
Jack is smart, dedicated and fit. He sees patients the same day they need to be seen, and his practice schedules office hours until 8 p.m. Even on days when he doesn’t have late hours, he may not get home for dinner. As reimbursement has been squeezed, he has responded by simply seeing more patients each day, up to 36. Don’t worry about the quality of their care.
Still, it hasn’t been a hardscrabble existence. He owns a condo in Hawaii and a 700-acre ranch in northern California, to which he escapes to mend fences weeks at a time. It’s a five-hour flight to Hawaii, and a five-hour drive to the ranch. But he’s kept the same wife, a fine one, and raised three boys in the process.
He works at medicine more than I do. That’s just bad luck, but more docs want to live in California than Kansas. As he points out, there’s warmth and sunshine every day. That’s the same argument the Left-Coasters made when Utah tried to poach businesses with TV ads promoting low taxes: “Kiss your assets goodbye” is the way they put it. California responded: “Who wants to live in the desert?”
The solo FP with whom I own a building worked hard for a long time, but he’s smelling the roses more these days. Not roses, exactly. He keeps a live-aboard sailing yacht on the Chesapeake.
Why the shameless capitalist-pig boosterism?
Because I’m conflicted, as anyone can tell if they've read these posts from the beginning, last October. On the one hand, I believe that the income delta vis-à-vis the procedural specialties is pirating the primary care physicians we need to make health care work. On the other hand, if you’re willing to work hard, family practice still offers a better life than maybe 99 percent of the other opportunities outside the medical profession.
I had a couple of beers with an old student from the Great Ideas class I taught for six years – at the private school I started in my spare time (there’s that lifestyle argument again). He’s in his final year of a family practice residency and halfway believes what I’ve been preaching. He confirms that his classmates don’t have much stomach for the rigors of private practice.
The dénouement is this: Due to this generational tectonic shift in animal spirits, the AAFP is forced to gallop to the rescue with an initiative that chiefly appeals to bureaucrats, and individuals who used to occupy the low end of the animal spirit Bell curve – which has now shifted to the left.
I suspect this is why so many of my college-age patients make an appointment to beg for Adderall to get them through finals. This is a generation that needs chemical pepping-up. (Mine apparently needed marijuana, but let’s not go there.)
In the interim, I just got word that I passed my boards, so I get another decade to watch the world pass me by.
Posted at 08:00AM Sep 14, 2009 by Doug Iliff | Comments[7]
No-man's land
At the moment I am attending a seminar sponsored by the Kansas Medical Society entitled “Revitalize Your Medical Practice: Creating a High-Performance Work Team.” The nationally-known speaker is a guy like me – about my age (60), and a graduate of a family practice residency and teaching fellowship. The differences are that Harvard Medical School turned me down, and I returned to family medicine after six years in the emergency room. He stayed.
He makes a number of well-researched points that are worth considering in detail, but here’s an important one: The four critical competencies for physicians in 2009 are clinical ability, productivity, teamwork and bedside manner.
This blog is dedicated to the second of those four, and he mentioned in passing that some office-based physicians seem to be under the misimpression that they are owed a living for seeing 10 patients a day. This echoed something TransforMed’s Jim Arend told me a couple of years ago: that some of their test practices thought they could make it in family medicine averaging 16 patients per day per doctor.
They can’t. Here’s why.
Aristotle’s Golden Mean (like Jesus’s Golden Rule, Kant’s Categorical Imperative, Mill’s Utilitarianism, and all other deservedly “great” ideas) is only true most of the time. When it comes to practice staffing and structure, the Golden Mean isn’t desirable.
Between micropractice and full speed ahead is no-man's land, a place where you have all the pains of modern clinical practice, and none of the rewards.
Micropractices are the Amish of family medicine: They enjoy the simple pleasures, and accept a lower salary. They are rarely under time pressure, but they file their own insurance claims and empty their own trash.
Most of us see the appeal of that style, but for one reason or another have chosen a different path. We hire people to answer the phones, file the paperwork, and check patients into rooms. The pain comes from managing those people. The rewards are financial, we hope.
With that payroll comes a moment of truth every payday. You, or another person you hire, write a bunch of checks and live on what is left over. The problem with family medicine is that there is not enough left over to attract medical students into our specialty.
Physicians don't get rich unless they manage insurance or pharmaceutical companies. We are all – specialists and generalists alike – piece workers, just like teenagers stitching together Nikes in Sri Lanka. Our "pieces" are charge codes or, as a matter of shorthand, our patients. If we manage physician extenders, we may profit to a small extent from the labor of others. But not much. It's mostly on our backs.
Now the key question: How many patients a day do you have to see before you earn your first nickel? That is, how many patients does it take to simply pay your bills?
The answer to that question depends on a number of variables, but in general it will be in the low teens; say, for the sake of argument, 13. When you get to 14 a day, you're making (a little) money, maybe $100. That's $2,000 per month, right up there with a full-time Wal-Mart greeter.
Bump it up to 18 a day, and you're an average family physician at $120,000 per year. You're keeping the entire profit from those extra five patients. The rent is the same, the staffing is the same; your supply costs went up a little, and everyone is working harder. The medical students still aren't interested.
But let's say you could average 25 per day. Now you're going to need a bigger office, and at least one more nurse, so the break-even is up to 15 patients from 13. But your profit from patients 16 through 25 is $240,000 per year. You can bank it, or you can take more vacation with a lower salary – or you can hire a mid-level, book 30 or 32 patients per day, take more vacation and earn more too.
The medical students are starting to sniff around. You're looking more like a dermatologist every month.
If any financial lessons are learned from TransforMed, this will be one of them. Of course, we knew it all along.
However, somewhere on the road between the wild, woolly and entrepreneurial days of family medicine 40 years ago, and the present-day experience of family practice residency, this commonsense knowledge was lost.
Because I left academic family medicine in 1980, I don't know how we lost it. My residency director semi-retired from a busy practice in upstate New York, where he saw 30 to 40 patients per day. I doubt many STFM members have that sort of experience; what they know and teach is important, and good, but it has not translated into financial success from their disciples.
I have two very close friends from my early years in medical school and private practice, both dentists. They got a thorough schooling in the business of dentistry. They both were grateful for their payback time in military service, because it gave them a chance to build up their practice speed (as they put it, how to turn the burr) before taking out big loans to start their businesses.
I'm afraid that young family physicians still don't get much practical help with business, and to make matters worse, they no longer have mentors who assure them that they can turn the burr without sacrificing the joy of personal relationships. So they join multispecialty and/or hospital-owned groups where their pay has little direct relationship to productivity – and it doesn't matter, because their service is only a loss-leader, a pipeline into the procedural roundabout. Worse, the lack of entrepreneurial incentive makes them resent that same-day patient who really needs to be seen today.
That's a shame. I wish I knew a way out of this wilderness, where I seem like a voice crying. The present incarnation of the Medical Home may help to sort out the inherent problems and inefficiencies of large groups, or it may not. The lobbying efforts of the Academy may wring a 10 percent increase in payments from Medicare or big insurers, or they may not.
All I know is that I'm having a good time in solo practice, and have for 23 years. Come on in; the water's fine!
Posted at 09:39AM May 05, 2009 by Doug Iliff | Comments[5]
