doc w/ Pen

journalist + medical student + artist

Health in the Headlines: The primary care dilemma

A few weeks ago, my mom went to see her doctor. While there, Mom decided to ask the physician if she had any advice for her daughter (me), a doctor-to-be.

“Yes, actually I do,” the M.D. replied. “Do NOT go into Internal Medicine, Family Practice, or Pediatrics!”

Why not? It comes down to one word: money. Or rather, the lack thereof. And this is at the heart of one of the biggest controversies and most serious issues facing the medical community, and perhaps our country, today. It was also the subject of Indiana University’s “Sound Medicine” podcast on June 13. But that story is coming up shortly.

What’s the big deal? Don’t doctors earn bank? Well … depends on who you are. The three specialties my mom’s doctor mentioned–Internal Medicine, Family Practice, and Pediatrics–have the lowest annual salaries of all specialties. Here are some average yearly salaries, according to Becker’s Hospital Review, an organization that surveys doctors every year about their income. (This data is from Becker’s 2010 study. You can find it on the Web at: http://www.beckershospitalreview.com/news-and-analysis/current-statistics-and-lists/physician-generated-revenue-and-average-salaries-by-specialty.html.)

Average Physician Salaries (2010)
Specialty Salary (dollars)
Pediatrics $171,000
Family Practice $173,000
Internal Medicine $186,000
Neurology $258,000
OB/GYN $266,000
Pulmonology $293,000
General Surgery $321,000
Hematology/Oncology $335,000
Cardiology (invasive) $475,000
Neurosurgery $571,000

While I’m sure part of it is about lifetime earning potential, part of it is also solvency potential. When you finish medical school and residency–and perhaps a fellowship as well–with some $300,000 in debt, you need a decent income to pay that off in a reasonable time frame. Because the longer it takes, the more interest accrues. And you don’t want to be paying back that loan in your retirement.

Now refer back to the list of specialists and their salaries. Note that the difference between one of the lowest (Internal Medicine, at $173,000) and the very highest (Neurosurgery, at $571,000) is nearly $400,000. Put another way, the neurosurgeon makes 330 percent more than the family practitioner. Granted, brain surgeries are complex, and becoming a neurosurgeon requires more training than most specialties. But taking care of people of all ages, with all types of conditions, is pretty complex, too. So why such a disparity?

The answer is so simple … and yet, not. The short story is that the higher-paid specialties are the “procedure” specialties. Those doctors–such as surgeons and cardiologists–do a lot of “billable” work. In other words, they tend to get paid for most of what they spend their time doing. Primary care docs, on the other hand, don’t do as much billable work. In fact, they spend a lot of time doing things that earn them absolutely ZERO money: refilling prescriptions, answering e-mails and phone calls, and looking at lab results. This is still “doctor” work–it can’t be done by anyone without that $300,000 M.D. after their name–but neither HMOs nor Medicare will pay you to do it.

Basically, primary care docs are overworked and underpaid. Sounds like fun, right? So no wonder many medical students these days shy away from those specialties–a trend that is expected to leave us with a huge shortage of primary care physicians in the coming years, especially as the Baby Boomer generation ages and requires more and more care.

In reality, none of what I’ve just written is news. (HA! Gotcha there, didn’t I? You thought this was supposed to be a NEWS column? Well … I’m getting to that.)

What is news is that this spring, an internist from Philadelphia named Dr. Richard Baron did a quantitative study of this issues. (I heard Dr. Baron interviewed on “Sound Medicine,” a podcast produced by the Indiana University School of Medicine. Check it out on the Web here: www.soundmedicine.iu.edu.) Dr. Baron’s results, conclusions, and the actions his practice (Greenhouse Internists) has taken based on those results are pretty amazing.

Dr. Baron’s study was quite simple actually, and relied on data the practice had already gathered and stored in its electronic health record. This electronic health record, which the practice adopted in 2004, is used “exclusively to store, retrieve, and manage clinical information,” as Dr. Baron writes in his paper, which was published in The New England Journal of Medicine (April 29, 2010). Physicians and other clinicians can enter clinical information into different categories such as “office visit,” “phone note,” “lab report,” and “imaging.” Dr. Baron and his colleagues then studied the volume (and corresponding categories) of their 2008 records. For more detailed content analysis, they looked at one week’s worth of phone calls and e-mails.

Below, I have reproduced a chart from Dr. Baron’s study. Note that the only work the physicians are paid for is the patient visit. From this chart, you get an idea of how much work–and how much time–goes into doing things that insurance companies don’t consider to be billable.

Dr. Richard Baron’s Study Results
Type of Service Total Number (2008) No. Per Physician Per Day
Visit 16,640 18.1
Telephone call 21,796 23.7
Prescription refill 11,145 12.1
E-mail message 15,499 16.8
Laboratory report 17,974 19.5
Imaging report 10,229 11.1
Consultation report 12,822 13.9

Dr. Baron already knew that the physicians in his practice (as well as other primary care physicians) were doing “unpaid” work. This detailed look at his practice’s records shows just how much.

These results, while more reinforcement and quantification than new evidence on this topic, still do highlight the need for a redesign of the primary care payment system. This is Dr. Baron’s opinion; it is also mine. It is, as Spock would say, “only logical.”

But what might those changes be? That is the million dollar question. It is one that the politicians, lobbyists, insurance companies, physicians, and other interest groups must pound out. And sooner rather than later, preferably.

In the meantime, Dr. Baron has made some changes in his own practice as a result of his research. First, Dr. Baron and his colleagues took a hard look at the “administrative” work (the phone calls, e-mails, looking at lab reports, etc.) that the physicians were doing. While doing much of it required an M.D., some of it could be done by a registered nurse or other (less expensive) clinician. So hiring more nurses, in many situations, is one way to cut costs and therefore boost salaries.

Another change Dr. Baron and his colleagues made was to their “productivity formula.”Greenhouse Internists, like many other practices, uses a combination of base pay and productivity to determine their physicians’ total salaries. What Dr. Baron and the others quickly realized was that their formula–which calulcated productivity based on the number of patients seen–simply mimicked the same payment system they were claiming was so unjust and arcane. Their response? Include that administrative work–the calls, the e-mails, etc.–in their own productivity formula. So while insurance companies might not reimburse a doctor for refilling a prescription, Greenhouse Internists does, in fact, consider such a duty to be “work.” And so it pays its staff physicians accordingly.

These changes do not make up for the payscale differential or the disparity in billable procedures between primary care and the “procedure” specialties, but they are a step in the right direction. Policy makers would do well to read Dr. Baron’s paper and take a look at how his practice is handling these issues. They might learn something. (God forbid.)

Health in the Headlines: An introduction

The journalist in me is coming out. And so is the future physician. “How can this be?” you might ask. Well, read on.

My love of news and my understanding of the news business have come together with my passion for medicine to inspire an idea: a weekly column, written by me and presented here on this blog, about current events in medicine and related subject areas (such as medicine and politics, etc.). I call it “Health in the Headlines,” as indicated by this blog post’s title. This feature may be, in part, what we referred to at my old newspaper job as a “news roundup.” As in, it may contain summaries of news stories that I have found throughout the week from various sources. Another possibility is my choosing a controversial issue that has been in the headlines steadily and drawing from several weeks, even months, of stories for information. This feature may also contain aspects of an editorial. Or if time is short, perhaps I’ll just post links to a handful of really great stories or podcasts and leave it at that. Oh, yes–pictures are great too. And they fill a lot of space. (This is one thing you learn very early as a journalist.)

The point is, I am going into this “feature” with flexibility. I do not want to hem myself in by saying I will ALWAYS do this, or I will NEVER do that. Nope, I want to do what I feel like doing, when I feel like it. Because after all, I want to have fun with this. But I promise that it I will try my best (as I do will all my blog posts) to make it interesting.

One more thing. You might be wondering why I’m trying to keep track of current events in health, medicine, research, etc. One reason is that when I’m interested in something (in this case, medicine), I want to learn more about it. Obviously, I will learn a great deal in school. But what you learn from the New York Times is very different. First of all, you hear from real people–not academic textbooks that are dry and technical. From those “real” voices, you get a sense of what other physicians are doing and how medicine is moving forward (or not). You get a sense of what interests you and what doesn’t. You start to develop passions and opinions and your own sense of morals and ethics.

Another reason I am doing this is to form good habits for the future. When I am a doctor, it will be necessary to keep up with this type of information (especially that pertinent to my specialty). If I start now to keep myself in the loop, it will be but a small step when I have to keep up with medical journals.

Furthermore, it’s simply good–no, necessary–to be prepared with both background and contemporary knowledge of your field. Not only will it come in handy when I am a physician (knowing the most recent treatments for X, Y, and Z), but it is also useful now. For example, when I shadow a physician, knowing something about his or her specialty allows me to ask intelligent questions (which you should do not for the brownie points but so you can actually learn something). This in turn yields specific answers. And at the dreaded medical school interview, there will also be current events questions. Cramming for that interview–which is what most people do–is a horrible idea, just as cramming for anything is a horrible idea. But if you’ve followed what’s been happening in medicine all along, those questions will be cake. (And I very much like cake.)

So this is the idea. We’ll see what happens. Maybe I’ll try it and it’ll fizzle out, who knows. For the time being, consider yourselves journalistic guinea pigs. Hope you enjoy the ride.

Note: I will post the first in this series later today (Friday, June 25).

Getting better all the time

Practice makes perfect.

I hate that phrase. In fact, I wish they (I’m not sure who “they” is, though) would strike it from the annals of common English phrases.

As an eldest child, and a dyed-in-the-polyester (I prefer vintage to chic) perfectionist, I have been working, for the last several years, to deconstruct my desire for perfection. Because absolute perfection, as pictured in my perfectionist brain, is absolutely impossible. Striving for the impossible is pretty pointless. And, as I have discovered, exercises in futility are infinitely frustrating.

So, here is my replacement phrase:

Practice makes improvement.

Or, as the Beatles put it:

Getting better all the time … 

And this morning, as I was discussing my recent work at the lab with my husband, Geoff, I realized something. I am practicing. I am improving. I am getting better all the time.

Here are a few of my observations:

  • My speed and technique have improved dramatically.

When I first started at the lab, I had to start from scratch: learning to pipette. My hands were shaky with nervousness (and sometimes over-caffeination), and I often contaminated the tip of the pipette by touching what I wasn’t supposed to–the outside of a flask, the countertop, you name it. I just didn’t have the mentality of keeping things completely sterile. Of course, I would realize my mistake right after doing it, but by then it was too late and I had to discard the pipette (and what was in it) and tear open a new one. This wasted not only money and supples, but also time.

These days, I rarely contaminate the pipettes. I move more quickly from bottle of solution to test tube or flask. My hands are more steady. I have better aim when releasing liquid (again, less waste, more accuracy, and time saving). Olga even trusts me to “passage” the cells now–divide them from, say, four plates (dishes) into eight through a series of washes and “trypsinization” (which dissolves the cells’ hold on the plastic plates and allows them to be sucked up and released into new plates–a very delicate procedure). This process has to be done very quickly or the cells can be severely damaged, even destroyed. I’m fast enough–and accurate enough–to do this now.

  • I am more autonomous.

These days, contrary to my first few weeks in the lab, Olga will give me an assignment and pretty much leave me to it. Of course, if I have questions or a problem, she is available to help, but she has the confidence–and the expectation–that I will remember the techniques, processes, and steps that I have learned and can (and will) repeat them succesfully and in the proper order.

Thankfully, Olga is an amazing teacher and explains things extremely well, so that by the time she expects me to do them on my own, I am more than prepared to do so.

The fact that I am more autonomous forces me to rely on myself more, and learn the techniques for myself, rather than rely on Olga to re-explain them every time. This dynamic also allows Olga and me to accomplish more because we can both be working on different things at the same time. Even though I work more slowly than Olga, slow work is better than no work. As she put it the other day, “If you hadn’t done this [set up a reaction], I wouldn’t have had time to do it at all.” That was the best compliment she could have given me.

  • I am more self-confident in my work.

Self-confidence has never been one of my strong points. Or so I thought.

When I was a reporter, I remember walking away from finishing the newspaper on deadline day thinking to myself, “Did I spell that commissioner’s name right?” or “Did I put the right date in for that park district event?” or “Did I write a caption for that photo of the dog park?” Heart pounding, sweating, a total nervous wreck as I walked the few blocks to my car, fighting the urge to turn back to check on whether I had done those things or not. I knew that I had, but I doubted myself anyway. I was sure I had forgotten something, so I mentally went through just about every possible mistake I could have made trying to find my error (or errors). With my lab work, I have very few such thoughts. And if one starts to creep in, I immediately squash it like the ugly, infectious cockroach that it is. I trust in my precision, my accuracy, my work ethic, my knowledge, my understanding, and my ability to follow directions. One thing that has really helped me is to develop a process for myself when I work on a task.

For example, if I am making multiple “master mixes” for a polymerase chain reaction (also called PCR–a process that creates a bunch of DNA from a very small sample), I create a checklist for the “ingredients,” along with the microliters needed of each. First, I will load the magnesium chlorite into each test tube, then put the MgCl off to the side so I know it has been added. Next I will load the “super clean water,” check it off, and put it off to the side, and so on. This way I don’t duplicate any ingredients, and I know when everything has been done (and in the proper amount). This, of course, also contributes to speed and efficiency–which never hurts. For times when those “cockroaches” scuttle up, I have, already prepared, a list of battle phrases (or cans of RAID, if you like) to use against them.

An example: “I acknowledge that I am concerned about whether I added the cDNA to the master mix, but I have checked it off on my list, and the tube has been put off to the side. So even though I don’t specifically remember adding it, I know that I did because I followed my process. As a result, there is no need to be worried about this.” Maybe it sounds hokey, but using these phrases, for the few times I have to deal with worrisome and negative thoughts, really makes a difference.

I have more self-confidence now to begin with, and when I struggle, I have another “tool” in my mental “toolbox” to help me.

  • I better understand the science involved in what we (and other scientists) do.

On May 11, my first day at the lab, I understood … um … maybe 10 percent of what Olga was telling me. OK, perhaps a little more, but it was bits and pieces, not a comprehensive picture. So I spent a lot of time being really confused and doing things but not really understanding why.

Please note — this was not Olga’s fault; she explained (and continues to explain) things very well. I simply did not have the background, nor the scientific vocabulary, to comprehend even the most elementary of explanations.

Boy, how things have changed. And I especially noticed it this week. On Wednesday, Olga had me set up the PCR reaction (see explanation of PCR in observation No. 3). Before I started pipetting, she gave me the background on what exactly we were going to be looking for in the end (with the gel electrophoresis). I took very careful notes, both so I could set up the reaction properly and so I could remember the details of what I had done. The same buzz words came up as had come up before: transcription factors, differentiation markers, fetal organoids, endogenous control. This time, though, I actually knew what she meant. In fact, I knew enough to ask intelligent (and genuine–not pedantic) questions about what she was telling me! It was a true victory.

I’m not much of a hymn-singer, but I totally got what John Newton meant in “Amazing Grace,” though in a scientific, rather than religious, context: “I once was lost, but now am found / was blind but now I see.”

The second example of this “understanding” phenomenon came at yesterday’s (Thursday’s) weekly afternoon lab meeting. Each week, the usual procedure is that one of the lab’s scientists presents his or her recent work for discussion. This week however, we did something a little different. Lab Director Rich Minshall and one of the PhD candidates, Aaron, picked out a research paper for us to read and discuss.

When I read the title early Thursday morning, I groaned. My eyes glazed over, anticipatorially, sure that the paper was going to be a total drag (i.e., completely incomprehensible to me). It was indeed just the title that gave me this impression: “Transcellular migration of leukocytes is mediated by the endothelial lateral border recycling compartment.” *GROAN* indeed.

But I started reading anyway — that damn Puritan work ethic again. And to my surprise, I was understanding things. Sure, I had to reread parts, sometimes multiple times, and look up certain concepts on the Web, but I was getting it. In fact, I was getting into it — I even started highlighting the text onscreen (I’d never done that before; it was pretty cool) so I could remember and review the highlights and main conclusions / points of the paper before our 4 p.m. meeting.

I didn’t really understand the visuals that accompanied the paper, but that was OK. I understood the ideas. And at the lab meeting, I actually contributed — for the first time. Not on the level of the Phd’ers, but who would expect that? The fact remains, I contributed, because I was able to understand what was going on–something that had never happened before.

I felt kind of like a surfer who, for weeks, had been trying to catch a wave, only to be knocked down to the ocean floor. But one day, she manages to hold her balance, and hold the wave’s crest, and ride it through. Pretty cool.

Surfing science … I kind of like that.