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]

Whatever happened to hard work?

As often happens, it was advertisements that made me think.

Two arrived the same day from Merritt Hawkins & Associates, the headhunters. Both were looking for family physicians and offering $300,000+ earning potential, which would be at the 90th percentile for our specialty. 

Shouldn’t that be enough to allow a modern medical student to consider family medicine? Or was there a catch?

The first flier offered a $240K salary with a production bonus, a four-day work week, no state income tax, no non-clinical hassles, golf at the 29th toughest course in the nation, a host of outdoor sporting activities in “the high-desert playground of the Mountain West” and a 13 percent lower cost of living than the national average – what’s not to love?

The second was to take over the practice of a retiring physician. The starting salary was $200K, with a $40K signing bonus and $10K relocation allowance, and you could keep your lab and x-ray revenue. The community was “safe and friendly” and “a great place to raise a family,” which probably translates to “boring,” which is why it also offered an “easy drive to two metropolitan areas.”

The former specifically noted “average three to six deliveries per month.”  The latter specifically noted “25 to 35 patients per day.”

There you have it. That’s the catch.

Both practices expect to hire, and I’m sure will hire, family physicians whose knees don’t shake at the thought of 60 deliveries or 7,000 patient visits per year.

Numbers like that would not have intimidated my great-grandfather Dan. He would have considered $12K (the equivalent of $300K in 1900 dollars) to be a princely sum, and as for the four-day work week – well, had he died and gone to heaven?

Even in my era (now we’re fast-forwarding to 1980) $116K would have made me salivate. And 60 deliveries per year? I trained for a couple of Boston marathons, raised four kids and started a private school while I was doing that.

Is this the real “crisis” for which the Patient-Centered Medical Home provides the “solution”?

In order to become one of the top 10 percent of earners in family medicine, do you just have to work about as hard as I expected in 1980, or half as hard as Dr. Dan in 1900?

It’s a question worth asking, because if that’s the answer, God help the AAFP in wringing enough money out of the federal health budget to lure more students away from urology.

Posted at 11:24AM Jun 19, 2009 by Doug Iliff  |  Comments[4]

Who cares?

An article in the New York Times on April 26th ("Shortage of Doctors an Obstacle to Obama Goals") was full of fascinating quotes from the best and brightest of our solons. Taken as a whole, and assuming their mouths bear even a tangential relationship to their minds, it verifies my April 23rd comment that family practice ought to be in the catbird seat when it comes to the negotiating table.

If you don't have time to read the whole thing in the New York Times, here's a sampler:

We’re not producing enough primary care physicians. The costs of medical education are so high that people feel that they’ve got to specialize. (President Obama)

The primary care physician workforce shortage is reaching crisis proportions. (Sen. Orrin Hatch, R-Utah)

Primary care physicians are grossly underpaid compared with many specialists. (Sen. Max Baucus, D-Montana)

Maybe they're just posturing, which would be habitual. Or maybe it really is dawning on them that there isn't enough primary care capacity in the the country to do what the president wants to do. And this would be the fault of ... whom? 

Well, the Relative Value Scale Update Commission (RUC), for starters – an AMA goon squad dominated by procedurists, which calls the shots with the federal Center for Medicare & Medicaid Services, which is wholly responsible for the increasing spread between primary care and specialist incomes. The Times article says the Medicare Payment Advisory Commission, a congressional advisory committee, has recommended a 10 percent increase in primary care payment at the expense of the specialists.

The specialists beg to differ. 

Now the food-fight begins. And it's about time. This one could be fought in public, rather than behind closed doors in a mahogany-paneled conference room. This is a fight the AAFP ought to win.

Who cares?

Let's look at some numbers. There are roughly 220,000 generalists in active practice in the United States, and 400,000 specialists. Of the generalists, more than 90,000 are family physicians, 60,000 of whom are "active" AAFP members. So roughly one in three physicians are generalists, one in seven are FPs, and one in 10 are active members of the Academy. Furthermore, most Americans see one of these generalists every year, and rely on these physicians to shepherd them through a health care system they find perplexing, if not frightening.

That ought to add up to a heckuva lot of clout, but it doesn't. There are lots of reasons.

Not long ago, the four generalist societies got together to figure out an action plan. Rather than howling for financial incentives and administrative simplification for their overworked constituents, they signed onto a concept called the Patient-Centered Medical Home, with a burden of bells and whistles only a bureaucrat could dream up, and love. It might be a painful net gainer for the 25 percent of family physicians laboring in a group of eight or more, but for the rest of us, it just looks like pain, period. Clearly, it was pain to the 36 practices participating in the TransforMed national demonstration project, according to the researchers' first report.

But those of us in the trenches share the blame. When the RUC meets, the specialists have spent a fortune to demonstrate why their procedures are going to save the world. We don't contribute the money that is necessary for effective lobbying.

And then there's the issue of apathy, or resignation. I recently read that almost a third of family physicians had never heard of the Medical Home. If true, that's almost unbelievable. You'd think from reading a few excellent blogs from family physicians (see bar to right) that we know the score; but we're talking mostly to each other, and a relatively small coterie of enthusiasts.

So who cares?

Posted at 03:12PM May 12, 2009 by Doug Iliff  |  Comments[3]