RVU ramblings

In the “Practice Pearls” section of the latest Family Practice Management, Kent Moore cites the Medical Group Management Association (which gives us the more reliable health statistics in America) on the average work RVUs generated by family physicians not doing obstetrics in 2007.

After a sentence like that, take a deep breath. The figure is 4,600.

That got me wondering how many RVUs I generate per year, since I’m often prattling on about productivity. Right on time, Blue Cross sent me the rolling report on my efforts for the last three years, reproduced here:



If you divide my RVUs for this three-year period by three, and divide by 0.85 (Blue Cross is about 85 percent of my business), you get roughly 8,000. Admittedly, this includes about 20 obstetrical deliveries per year, which is hardly a back-breaking number. Remember, too, that including obstetrics (since I have given the hospitalists my inpatient work) I only work about 40 hours per week, 220 days per year, with about eight weeks of holidays and vacations.

I’m talking to medical students and family practice residents here. You know, those of you who told the Admissions Committee you wanted to go into primary care, or actually chose to do so. Now you’re wondering if it’s a viable choice.

Here are random thought bearing on that choice.

1. If I can generate 8,000 RVUs per year working the same hours as a state employee but enjoying the stimulation of intellectual challenge and terrific personal relationships, avoiding the administrative burden of the patient centered medical home while providing a place where every patient knows every one of my employees and vice versa, and while earning as much money as the average cardiothoracic surgeon, what’s not to love about this specialty?

2. What’s wrong with the practices of all those other family physicians?

3. In his blog, Kent Moore also asks why (based on a Health Affairs article) a family physician would choose to spend an average of $65,000 to comply with the diktats of insurance companies. My answer: That’s half of my expenditure for salaries, so it must be nuts. Where do people get these figures? My nurses must spend at least 90 percent of their time doing meaningful service for my patients.

4. I’ve done my level best to charge Blue Cross for every legitimate 99214 or procedure (thank you, Kent and Cindy, for an excellent column). Still, I keep proving to be 18 percent more efficient than my peers – the ones, I assume, doing only 60 percent as much work as I do. How can this be?

5. I wrote about an old friend and an old student in a recent blog post. The former quit doing OB 10 years ago and is coasting toward retirement with an aging patient panel; the latter doesn’t plan to do OB at all, which is increasingly common among FP residents. I know that OB can be inconvenient, and scary. In the last 24 hours I did a delivery at 3:30 a.m. and a vacuum extraction at 4:30 p.m (followed by a shoulder dystocia resulting in a fourth-degree laceration requiring careful repair). My question: If family physicians give up OB, and therefore a preponderance of potential pediatrics, why choose family practice over med-peds?

As I draw near the end of a year’s worth of blogs, I understand much better why I am successful, and what other family physicians need to do to be successful.  

But I am losing confidence that family practice will survive.

Posted at 02:19PM Oct 02, 2009 by Doug Iliff  |  Comments[3]

The Ringelmann effect, or Has family medicine lost its élan vital?

A French agricultural engineer named Maximilien Ringelmann performed a classic experiment over a century ago that you could replicate in your own backyard, playground or office.

He measured people pulling on a rope connected to a strain gauge, both as individuals and as part of a group tug-of-war. Result: People pull harder as individuals.  

Ringelmann called this “social loafing.” We all remember it from group projects in school. Since as physicians we are overachievers, chances are you remember carrying the load for the deadbeats, as I do. Teachers think this is great. I think it’s nuts.

What happens to per-doctor productivity when a hospital buys a private practice and everybody goes on salary? Yep. Productivity plummets. That’s Ringelmann for you.

As the Dare to Slack poster says, “When birds fly in the right formation, they need only exert half the effort. Even in nature, teamwork results in collective laziness.”

On the other hand, teamwork is essential in the business of medicine. Without loyal, intelligent and hard-working (not to mention beautiful and handsome) colleagues, life would be a nightmare anywhere except a micropractice. So what are the laws of productive teamwork?

First, the team has to have a good Captain, and the lines of authority and responsibility must be clear. The buck has to stop somewhere; that would be the boss. Some bosses can’t make decisions, or they fear responsibility. Their teams won’t be productive.

Second, productivity must be rewarded. I’ve dealt with this at length elsewhere. In a solo practice, this happens by default. In a group, the compensation formula must be simple, fair and transparent. There is no shame in not wanting to work as hard as the next guy. The shame is in wanting to be compensated as if you were.

When I first came to Topeka in 1980, I intended to join a group practice run by a man I respected greatly. But I also wanted to start a private school for my kids. So I negotiated a half-time job. I didn’t want to be paid 75 percent of what the others made; 50 percent would have been just fine. There was nothing immoral about that. One member of the group just couldn’t believe I wasn’t going to be ripping them off, so I withdrew and went to work in the emergency room. But there’s no problem in principle for wanting an honest half-day’s pay for an honest half-day’s work.

What’s immoral is expecting the other members of a group to financially support your desire to carry on leisurely chit-chat with 15 patients per day.

The profession changes with the culture. When I was a resident, taking call every third or fourth night, old-timers thought I was a slacker. They had spent 120 hours a week in the hospital. But their mentors thought they were slackers, because they were allowed to be married. Not so very long ago, you see, only single men were admitted to medical school.

So I don’t want to play that game. You won’t find me looking down on someone because they want to enjoy spouse and family, as well as the medical profession. That’s what I wanted, and that’s what I got.

My disquiet comes from a suspicion that fledgling family physicians want their jobs microwave-ready; that maybe their mentors weren’t all that successful in private practice and found academic medicine a haven from its demands; that, perhaps, the specialty has lost the dynamism, creativity and entrepreneurial zeal it had in 1975.

Teamwork has its uses, but it is not the font of dynamism, creativity and entrepreneurial zeal. So when I hear the “leaders” of family medicine talk too much about teamwork, I want to ask: Quo vadis, Captain?

Posted at 12:01PM Jul 30, 2009 by Doug Iliff  |  Comments[4]

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]

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]

Shortcuts

"I work long hours, half of which are essentially unreimbursed."

So writes a passionate advocate of the patient-centered medical home in a newsletter dedicated to promoting the concept. By testimony of others, he is an excellent family physician.

My goal is to work short hours, and be reimbursed for all of them. This blog is dedicated to shortcuts – the kind that save time, without sacrificing quality.

The first shortcut that I specifically remember came from a staff neurologist at Womack Army Hospital, where I did my training. In a noon lecture he advised that when you get a woman who complains of a bitemporal headache that progresses to a hatband distribution and goes down the neck, you can stop listening. 

He's the same guy who advised that when a staff physician writes "WNL" in a note, it stands for "We Never Looked." He was kidding. He always looked, and we knew it.

Remember the "medical school physical"? The eight-page form with printed body parts that taught us the skills of physical diagnosis? The hour and a half that it took to perform? And the waste of time it would represent at our present level of experience? The key to a happy and productive practice is learning the corners we can safely cut.

Would anyone argue, with a straight face, that civilization has progressed by figuring out ways to do the same job, only slower? Of course not. But where is the research on productivity, or efficiency, in family practice? 

Many family physicians are demoralized because they feel like they're on a "hamster wheel."  When TransforMed tries to turn them into a patient-centered medical home, it seems to get worse. 

I don't feel that way. But I can't get a handle on why I'm such a distinct minority. Surely this is a more gripping problem for FP research than yet another survey tool designed to detect closet alcoholics. Lacking a research base, all I can do is make educated guesses about what makes me un-stressfully productive.

Could it be that from my first year of practice, I decided that I was going to work no more than 220 days? There are 262 Monday through Friday workdays in a year, so that's like 8+ weeks of vacation. Research: How is vacation time related to job satisfaction and productivity?

Could it be that I hire only experienced RNs, and pay them well? That way my turnover is extraordinarily low, I virtually never talk on the phone, and my histories are thoroughly documented when I walk on stage. Research: How is staff continuity and education level related to job satisfaction and productivity?

Could it be that I refused to dictate notes in the beginning, and refuse to adopt an electronic medical record now? That way I never had to read transcriptions after office hours, and I never look at a keyboard while giving patients my full attention. I use a check-box system (manual macros) and my notes are very cryptic – just enough so everybody knows what's going on. (For a really clever essay on this subject, see "Charting Then and Now" by Mitchell Cohen, MD.)  Research: How is time spent looking at or creating a medical record related to job satisfaction and productivity?

Could it be that I chose independent rather than salaried practice, so my take-home pay is influenced by every patient I see and every item I charge? That seems to help my attitude when I'm tired, and concentrates my mind on coding and business decisions. Research: Controlled for group size, how is salary structure related to job satisfaction and productivity?

Could it be that my determination to be physically fit contributes to the speed of my decision-making, and my stamina when examining the 26th patient of the day? Research: How is physical conditioning, measured by peak METs on graded exercise testing or the timed one-mile walk related to job satisfaction and productivity?

I have more questions, but that's a good start. And it makes me wonder: After four decades of academic family medicine, why don't we have more answers? If family practice goes down the tubes for economic reasons, the dearth of productivity research will be a root cause.

In the meantime – I'm not holding my breath – some of you might report on your anecdotal experience with my hypotheses (or your own). And you rookies might try testing them for yourselves.

Posted at 03:54PM Apr 27, 2009 by Doug Iliff  |  Comments[4]

Trust me. I'm your doctor.

I’m meandering my way through six questions that will determine your productivity as a family physician, to wit:

1. How fast do you work and think?
2. How many problems can you manage in an hour?
3. How much time do you spend on non-paying medical activities?
4. How much do patients trust you?
5. How efficient is your collection system?
6. How much attention do you pay to coding?

I do this under the (challengeable) conviction that when family physicians have met the enemy, he is us; that we can make specialist-level incomes if we pay attention; that the bio-psycho-social model is a time waster, and caters to the lazy or lackadaisical; and that, as TransforMED discovered (in perhaps its only useful return on an investment of millions), you can’t make a living seeing 15 patients a day – unless you choose the micro practice model, and you’re willing to empty your own trash and serve as an insurance clerk part-time.

Let’s walk into a minefield: Why does it matter how much patients trust you?

When I started in family practice, I was a big believer in patient education and informed patient choice. I’ve already told you how I discovered that most patients need an ounce of willpower more than a pound of knowledge. Since I believe in Original Sin, that wasn’t a big surprise.

The big surprise was that they really wanted me to be God.

I don’t like people who think they’re God. Many CEOs are ordinary people; but when I encounter a godlike CEO, I can’t get rid of them fast enough. (“Yes, you really do need to go to the Mayo Clinic for your $3,000 annual physical.” “No, I won’t see you at 6 in the morning.”) Give me honest, hard-working, unpretentious, blue-collar folks any day.

What I found with experience was that long-winded, derriere-shielding discussions with patients about the risks and benefits of ingrown toenail removal, including death, were promptly met with “What would you do, Doc, in my situation?”

Maybe my practice is eccentric. But that’s what I’ve found. My patients want to know what I would do. That shouldn’t be confused with What Would Jesus Do. But I’ve had to get over the discomfort of answering that question honestly.

It really isn’t the same as wanting me to be God. I was exaggerating. What they are doing is trusting my judgment, which is exactly the same thing I would do in their situation. After all, if I didn’t trust the judgment of my physician, wouldn’t I choose another?

So I got over it. I don’t have a dictatorial personality (at least in person), and learning to simply be grateful for the trust I am granted makes me a lot more productive. I don’t have to listen to myself talk, unless requested. A lot of problems are handled in a lot less time.

Trust has to be earned. It takes time, and exposure. I work with an excellent PA, but I decided early on that I wasn’t going to reroute routine colds and pains to my mid-level; those encounters are trust builders.

It takes honesty, including the humility to say, “I don’t know.” Be well-informed, and shoot straight. Sincerity is important, and eye contact is important. I have seen evidence that tapping on a laptop doesn’t hamper relationships, but I don’t believe it.

Here’s a pearl: Review the chart, including labs and the last visit, before you enter the exam room. Don’t pull it out of a slot on the door; then the patient knows what you’re up to. The point is to make them think you’re smarter than you are, or at least that you care enough to devote full attention from the moment you cross the threshold.

Kathy Saradarian, a family physician with a micro practice in New Jersey, recently wrote, “The PCMH die-hards are not allies. They are so caught up in this high-tech, low-touch, doctor-manager definition that they have forgotten who we are.”

That’s the ticket. There’s the danger. And it may not pay well, either.

Posted at 09:37AM Mar 16, 2009 by Doug Iliff  |  Comments[0]

Chronicles of wasted time

To review: This blog is about financial productivity. It is directed at medical students (to give them hope regarding a career in family medicine), residents (to give them insight into the business of family medicine) and family physicians of all ages who are still learning and growing.

Posted at 10:09AM Mar 09, 2009 by Doug Iliff  |  Comments[2]

Financial vs. medical productivity

There are two kinds of productivity in family medicine, closely intertwined.

The first (and the one I am primarily concerned with in this blog) we might call financial productivity. It has to do with the formula I gave you fortnight last. How much money did you make from your medical activities per hour of time?

The second we will call medical productivity. This involves the number of problems you address successfully per hour of time. Let’s not split hairs; obviously, managing a myocardial infarction takes more time than a bronchitis. The key is whether you manage the MI more efficiently than the FP in the next office.

I know my financial productivity by the monthly reports from my accountant, and from my adjusted gross income on my 1040. Those give me numbers I can divide by the hours I spend in the office, the hospital and the committee room.

It would be hard to know my medical productivity without a helpful semi-annual report I get from Blue Cross, which is 85 percent of my business. It looks like this:

This report is representative of all the others. Year in and year out, I manage comparable problems for about 20 percent less money than my peers. This is why I wept when full capitation ended. I didn’t practice any different under that system, but I got a share of the money I saved. All the efforts I make to educate my patients, to use generic medications, to prevent medical breakdowns – all the money I save now goes to the insurance company, and in turn (I trust) back to patients in lower premiums. 

Of course, there are other potential explanations. I may turn away walking medical disasters at the door. I may turf them to other primary care docs. Healthy patients may choose me selectively because of my practice philosophy. I may be nice to compliant patients, and nasty to the rest, who drift away. I may be lucky. 

Because I’m not concerned here with medical productivity, I don’t have to address those questions. 

There are at least six overlapping elements of financial productivity. I will reserve the right to acknowledge more under the close questioning of readers, but this is a good start:

1. How fast do you work and think?
2. How many problems can you manage in an hour? 
3. How much time do you spend on non-paying medical activities?
4. How much do patients trust you?
5. How efficient is your collection system?
6. How much attention do you pay to coding?

I said at the beginning that medical and financial productivity are intertwined. For instance, if my patients trust me, they are more likely to be compliant with my advice, and (assuming it is good advice), Blue Cross will like me more; but I will also have to spend less valuable time persuading them to follow my directions.

Similarly, if I manage more problems per unit of time, I will see patients today rather than six weeks from now, and seeing them promptly is medically more important than being smart; but it also allows me to charge more 99214s. You get the picture.

For the purpose of this conversation, there is an important question I can’t answer with confidence. To what extent are the above six elements teachable? I know I can teach a student how to read an EKG or manage adult-onset diabetes; but can I teach her to make decisions more quickly? to connect with patients more effectively? to refuse to procrastinate?

If these are immutable personality factors, then this blog is a waste of time. Time will tell. But I have one small piece of personal evidence which persuades me otherwise.

When I was on the teaching staff of a residency program, I conducted a research study as part of the first class of faculty fellows at the University of North Carolina-Chapel Hill. It was published in some obscure journal, now out of print, and I don’t even have a copy.

I videotaped residents interviewing mock patients, and then had them watch the tapes. That was the only intervention. No coaching was involved. The interviews were repeated, and the before-and-after tapes were graded according to five behavioral parameters, all of which I have forgotten save one.

It was “attending behavior.” What that meant was the ability of the resident to pay attention to the patient during the interview. There would be points off for poor eye contact, nose-picking, interrupting, non-sequitur comments or questions, that sort of thing. Today we would include excessive attention to the EMR format.

The response was really quite dramatic. In the post-interviews, residents had obviously been embarrassed by their behavior quirks. They did a good job of appearing to attend. Of course, there is no way to know if they were just faking it; one can make eye contact during a daydream. But that’s a useful skill, anyway.

So I am led to believe that young family physicians can be taught to work hard, to work efficiently, and to work well – all at the same time. We’ll see by your response.

Follow-up to the last column:

Dr. Willis asks honest and perceptive questions, which I will answer economically. Over the first 11 months of 2008, I have averaged 25 patients per day. Of my E/M codes, the top three were 99213 (56 percent), 99214 (20 percent) and 99396 (5 percent). Procedures are a very small part of my practice, and almost all of my hospital work is obstetrics and newborn care. All of my billing and collection work is done by my staff. I don’t ever say goodbye to my patients, but about two-thirds say goodbye to me when they enroll in Medicare.

Dr. Schmidt raises a philosophical issue: Is the practice of family medicine a business, or a profession? My personal view is that it is first a profession, and that business considerations must come second. Whenever there is a conflict between a professional duty to the welfare of the patient and my personal financial profit, duty trumps.

(For a 19th-century literary view of this subject, I would recommend Middlemarch by George Eliot; the struggles of a well-trained, honest young physician against the medical establishment will remind you why we don’t dispense the medicine we prescribe.)

There is a constant battle between the expectations of patients and quality medical care. I think I fight the good fight, but it would be dishonest to claim that I never throw in that towel. No one becomes a drug addict on my watch, though. My head nurse sniffs them out like a bloodhound. And nobody gets antibiotics over the phone.

Finally, Dr. Schmidt, I am indeed uncomfortable talking about making money. There is a tension there, but I’m convinced that there is no essential conflict. The most selfless physicians I know are primary care physicians, and for that selflessness we’re going out of business; and when we go out of business, health care goes to hell. So business it is. Thanks, by the way, for your recommendation of dinosaurmusings.blogspot.com.

Next time we’ll tackle the elements of financial productivity one by one.

Posted at 09:28AM Dec 03, 2008 by Doug Iliff  |  Comments[0]

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]