Physicians or Practices in Transition      3/97

by Del Meyer, MD

Medical practices are in transition, most to some form of managed care. These changes do not appear to be transitory. Physicians may not be in transit in the same direction. Some have modified their practices into alternative medicine, which is the topic of our June issue. Many physicians are moving towards alternative careers. Some have goals which are not yet well defined.

For Profit Health Maintenance Organizations (FP-HMOs) and Managed Care Organizations (MCOs) have gotten our attention much as the proverbial farmer got his donkey’s attention by hitting him over the head with a two by four. Some of us may be in a coma. Others are only slightly dazed. Some of us are walking in tune. Others are marching to a different drummer. Some seem to be in trances. A few, like Dr Chopra, are making a fortune on putting others in trances.

Dr Steve Walsh, a San Francisco psychiatrist outlined in San Francisco Medicine, (republished last month in San Bernardino’s BULLETIN) how many of his physician patients are dis-identifying from medicine as their sole or major source of self-esteem and sense of value. His physician patients are refocusing on goals which are larger than self. This can include re-identifying relations with others, including family, loved ones. They are also re-negotiating a contract with life which may be more balanced with work, love, and play.

Two of my colleagues at the university are now 90% administrative. They have told me that if they got fired from their alternative job, they would just return to patient care. Yes, we used to be able to do that. But now the practice might not be there or be limited by managed care. In the past we could always hang out the shingle and patients would seek our expertise. We were known for that expertise, and for our ability to diagnose and treat. Now patients only come because they are forced into a specified selection of a doctor they don’t know. They have no knowledge of the expertise of these doctors that were selected for them.

The doctor who has been selected by or for the patient may be cast in a new scenario, one in which the patient is not only unappreciative of that physician’s professional skill, but also may demand services without utilizing the expertise of the selected doctor. They simply tell their new doctor that the only reason they are utilizing an office visit is to be authorized to consult with a previously determined team of consultants who will administer a previously determined treatment plan. This week I had a patient who demanded eight referrals on her first visit. She was hard pressed to identify any significant benefit that she had derived from any one of them, except the dermatologist who was following some precancerous skin problems, none of which she could identify on her skin. Unfortunately, I was unable to dissuade her from any one of these eight consultants. With the average MCO cost of consults averaging about $500 for a six month period, this patient was insisting on her "right," which she believed was guaranteed by her insurance agent, to use $8,000 worth of consults (each consultant told her they needed to see her twice a year or $1000 for a visit twice a year) on an outpatient budget of $400 per member per year. One patient utilizing resources allocating to 20 patients and not even having any major health problems, can cause a lot of stress in a well intentioned physician who can get the normal request for five consults down to two. To have managed to trim her request down to even six consults in this case would have been ruthless and cost many more hours in duplicating charts and explaining one’s actions to the MCO & FP-HMO.

It is no wonder that a large number of physicians I know are looking for an alternative way of making a living which utilizes at least some of their professional skills. But what are the options?

If one has the credentials, academic medicine may be a consideration. The American College of Physicians indicates that the median pay for faculty in internal medicine is from $142K for professors to $102K for assistant professors. These numbers closely correspond with the AMA reports for internists in private practice from $150K for the median to $110K for the 25th percentile range.

Some of our colleagues have become physician executives at group practices, managed care plans, and hospitals. Senior executives are earning more than ever before. According to the "Physician Executive Compensation Report" by the Tampa, Florida based Physician Executive Management Center, average total compensation for senior physician executives is $183K, up 5% from last year and 16% over the last two years. In exchange for the increased pay, however, the report found that 87% of physicians executives in senior management positions have no clinical responsibilities. This represents a dramatic change from 10 years ago when half of all physician-executives also had clinical duties as part of their jobs. Losing the clinical quotient is regrettable. Just thirty years ago, many deans of medical schools still made an occasional clinic visit or gave an occasional lecture, or were participants in a research project. This kept them involved in the tripod of academic medicine: patient care, teaching, and research. When one leaves his or her roots, one tends to lose touch with them. When this occurs, our administrative leadership no longer represents us.

Administrative medicine may not be a consideration for many doctors. It is well known that the best physicians frequently don’t have good administrative skills. This increases the chasm between those of us caring for patients and those telling us how to care for these patients. One caveat gleaned from this ACP report, is how administrative physicians determine incentives to increase the volume of work we do. Reams of data are collected on a wide range of clinical decisions made by each physician. These decisions include length of stay, accuracy of the physicians coding, completeness of the charts, participation on committees, teaching, references on research, cholesterol and mammography screening, and other benchmarks. I was unable to find any incentives for astuteness of diagnosis. The very thing that marked the differences among us in the past, the quality of our diagnosis and treatment, is totally irrelevant in this new environment. How tragic. Essentially all of the factors mentioned above can be done by physician assistants, the bastardized specialty which we were responsible for creating. The allied health specialty that we thought we could control, can, by following these incentives, command higher incomes than those of us making the lifesaving diagnosis. One physician in Sacramento pays his PA the same amount as himself. He states that his PA was able to more than double the practice income, so why shouldn’t he have the additional half?

Given that occurrence, perhaps the next transition to a real alternative career for physicians is to become a physician assistant--all the rewards of patient care, but none of the responsibilities. And our patients would still refer to us as Doctor.