Friday, April 6, 2007

The current crisis.

For the last couple of days, various people on Paul Levy's blog have been weighing in about the prospects of primary care, in response to a question from a student about whether he should go into primary care. Mr. Levy is optimistic about the prospects for primary care, and concludes that the student should do what he loves. Other respondents are not so sure about Mr. Levy's optimism, and a lively discussion has ensued.

These debates almost always take for granted that there is a crisis in primary care; the question is just whether we should be optimistic or pessimistic about whether the crisis might be solved. It's important, though, to ask whether there actually is a crisis.

My stepfather was for many years a professor of US History. He would assign an essay topic early in his introductory course: "The current crisis in education." Each year, students could write passionately about the current crisis, often supported by discussion in the media about how the American education system was falling apart and the country was going to hell in a handbasket if we did not do something to reverse this change. There was always truth in the specifics; on the other hand, the fact that he assigned this essay topic for thirty years straight and always got the same response suggested that something else was also going on.

Sometimes we like to assert a unique historical crisis as a way of just expressing our feelings of not liking something. There is a lot not to like about the healthcare system, and about primary care's place in it. On the other hand, many of the most distressing problems are deep structural problems which have existed for decades, and which Americans (and their physicians) have endured for decades. We don't have to believe that there is an imminent collapse to look back and dislike what we've been doing thus far. In fact, what is actually more distressing is that we've lived with some of the same lousy aspects of our healthcare system for so long.

A few years ago there were several articles on one important aspect of this topic: time spent with patients per visit. Each showed that visit length had not declined during the period in which people had begun to become especially alarmed about managed care and what it was doing to all of us. And physician income had not declined despite many protestations to the contrary.

A New England Journal of Medicine article in 2001 reviewed visit data from the late 1980s through the late 1990s, a time period in which managed care had greatly increased its impact on American healthcare. It found that visit length was actually stable. (Admittedly, the number of guidelines telling physicians what they were supposed to accomplish via prevention and counseling during this time may have increased--perhaps contributing to the sense of inadequacy of the time spent.)

An Archives of Internal Medicine paper in 2003 confirmed (using the same data set) that visit lengths had not changed from 1987-1998; further, they showed that except in obstetrics and gynecology, physician incomes had increased relative to inflation during this period.

This just goes to show that what physicians complain about may not be what they are actually unhappy about, although they themselves are unlikely to recognize the discrepancy. It is also not clear that physician dissatisfaction has actually increased much over time. Therefore, physician complaints are likely to be highly unreliable markers of the actual problems we will face as physicians. That physicians are much more dissatisfied may or may not be true; why they are dissatisfied is even harder to say. David Mechanic, who was lead author on one of the studies of visit time, had an interesting editorial on the topic in JAMA in 2003, which I recommend to interested readers (cited below).

If there is one clear problem in primary care, it's probably undersupply of MDs trained in the United States, and that's a problem in part because of what it does to other countries. But this is one problem that the medical profession has refused to fix; instead, we've been perfectly content to import physicians from other countries (which can't really afford to lose them) to fill some of the gaps, rather than increase the number of medical school slots, and students qualified to step into them, in the United States.

Though there is much more to be said about this topic, I will conclude that from all of this, I personally take the lesson: do what you love.

I also would like to add a caveat: having said all of this, I reserve the right to complain about anything and everything related to my work as a primary care physician in the future.

Weeks WB, Wallace AE. Time and money: a retrospective evaluation of the inputs, outputs, efficiency and income of physicians. Archives of Internal Medicine, 2003;163:944-948: the authors conclude:
"...our findings are provocative. They do not confirm the prevailing concern that physicians are working harder or longer, are spending less time with patients, or are experiencing declining incomes. In contrast, they suggest that physicians are maintaining incomes without changing work hours and are able to command higher reimbursement per patient visit than in the past. There is a great deal of dissatisfaction with the health care system among physicians; exploration of perceptual reasons for that dissatisfaction may outline a course of action needed to resolve it."

Also cited:
Mechanic D, McAlpine DD, Rosenthal M. Are patients' office visits with physicians getting shorter? N Engl J Med 2001;344:198-204.

Mechanic D. Physician Discontent: Challenges and Opportunities. JAMA. 2003;290:941-946.


emily wright said...

great painting. It makes you wonder about what's going on outside the painting, like whose little boy is it, and why is the doctor talking to the standing woman, not the patient? and what is the patient's trouble, anyway, aside from being ignored by everyone except the little dog? Artist and title?

Joe Wright said...

Jan Steen (1626-1679).
The Doctor's Visit (1658-1662).
Oil on panel.

I would guess that at that time, she probably had bad humours; and the doc is taking her pulse to see whether she is starting to get a fast heartbeat from the fever these humours are beginning to cause.

Paul Levy said...

The doctor is probably wondering if a specialist is available at this time of day to make a house call . . .

Joe Wright said...

"Ma'am, she has bad humours. She needs to see a humourologist."