Who is your doctor?

Primary care physicians are the initial entry point for healthcare for the majority of Americans.

Develop pneumonia; go to your family or internal medicine physician (internist) to be prescribed an antibiotic. Need your blood pressure or cholesterol checked? Develop a sore knee or swelling in your leg? Once again, go to your primary care physician.

Image courtesy Dedde'

Primary care physicians are a patient’s guide to a bewildering array of technology and specialists. If you require a specific diagnostic test or consultation with a specialist, your primary care physician will help you navigate through the maze, choosing the path that is best for you. He or she will order a chest x-ray for a cough and fever, provide vaccines to prevent flu or pneumococcal pneumonia, perform an annual physical. If you require hospitalization, your primary care physician will admit you. He or she will order diagnostic tests like MRI’s, ultrasounds, x-rays, and blood testing, usually performed in the hospital or a hospital-owned facility. If you require the services of a gastroenterologist, orthopedist, general surgeon, or neurologist, your primary care physician will refer you to the appropriate specialist.

That’s how it’s supposed to work, at least in principle. In fact, during the first eight decades of the 20th century, it did work that work way for the most part. Your primary care physician acted not just as a provider of healthcare, but as your advocate, someone who knew you and worked to protect your welfare. Your family doctor often knew your parents, maybe even delivered you at birth, and cared for your children. His children often went to the same schools as your children. He and his family lived in the same town and sometimes went to the same church.

That hardly happens any more. It’s more likely you got the name of your primary care physician from a doctor referral service provided by a hospital. Or you picked a name off a list provided by your health insurer. It’s also common to see one doctor, only to see another a year later. Two, three, or more different primary care physicians over a five-year period are common. Doctors come and go, since physician turnover in clinics and practices has been on the increase for years. Insurance companies frequently force policyholders to change doctors, requiring you to choose from a list.

The end result of this shuffling of primary care is increasing impersonality of the relationship. You probably don’t know your primary care physician outside of the 10-minute interaction you had six months ago. She probably never met your mother and will likely not care for your children. Two years from now, she will likely not be your doctor any more, replaced by someone else who obtains the details of your health from a chart. Your chart is more likely to be electronic, with the details of your health history listed in a checklist. There’s little room to detail the idiosyncrasies and quirks of your unique personality or health profile. Throw into this impersonal equation the fact that many doctors have become scared of patients because of potential for lawsuits, often over the most trivial of issues, or because of an error of oversight or misdiagnosis.

This flawed and impersonal system, though emotionally unsatisfying, can still work if each doctor who assumes a patient’s care maintains the ethic of putting health and welfare above all.

But what if your primary care physician is not just an advocate for your welfare, but is a representative of the hospital? What if there are hidden, unspoken financial incentives paid to your doctor to direct you to the hospital for diagnostic testing, hospitalization, and referral to specialists? If a headache becomes a $4800 MRI, or chest pain becomes a $4200 nuclear stress test, then a $14,000 heart catheterization, your primary care physician becomes the purveyor of far greater financial opportunity for the hospital. The entire interaction, founded on the proposition that your doctor actually cares about you, collapses in a heap of financially motivated testing and procedures. It appears to work, and you and your family can still obtain access to healthcare. The problem is that you’re likely to get too much of it.

This message has not been lost on the shrewd administrators at hospitals. Take a look at the ranks of primary care physicians who refer patients to some of your local hospitals. It is typical that a hospital system maintains several hundred primary care physicians on their payroll, all of whom are expected to refer patients to the hospital, cardiologists, and other proceduralists. Why so many?

Most primary care physicians today have signed contracts with a hospital. In other words, they are employees of the hospital. This practice is not unusual: the American Medical Association reported that 4 of 5 primary care physicians are now bound by such employment arrangements across the U.S. In effect, 80% of primary care physicians are legally bound by contract to direct patients to cardiologists who work at hospitals.

On top of contractual obligations, there are financial incentives for the volume of procedures that are generated as a result of referrals. The more procedures generated from an internist’s or family practitioner’s practice, the greater the end-of-year productivity bonus will be, not uncommonly totaling tens of thousands of dollars. Dr. Ted Phillips (not his real name, since he declined to allow me to use it) received a bonus check of $9,437 this year for his “productivity,” defined murkily as the return on specialist referrals. While the bonus may have helped him pay for his son’s college tuition, it clearly was a situation that made him acutely uncomfortable when asked.

Several primary care physicians are also quietly dismissed every year from the ranks of employed physicians for not maintaining a minimum flow of patients into the system.

Another hazardous point of entry: Many patients enter the hospital through the emergency room (ER). A patient in the emergency room is at his or her most vulnerable, seeking help for an urgent complaint and usually willing to accept whatever the ER physician advises. Hospitals know this. That’s why many systems insist that the ER physicians be employees of the hospital, with their practice habits subject to control. A patient goes to the ER with chest pain or breathlessness. The worst thing that can happen from a financial standpoint is for the patient to be evaluated and discharged. For this reason, a growing number of hospitals employ ER physicians, then proceed to legislate practice patterns. Consulting a cardiologist is strongly encouraged, since they generally provide access to the downstream revenue-producing procedures offered in the hospital. That way, what might have been a four hour, $2500 ER visit is converted into a $10,000 to $40,000 hospital stay, even when nothing was wrong in the first place. There are millions of people nationwide who have the hospital bills to prove it after being discharged with a diagnosis of indigestion.

Caveat emptor: Buyer beware.

Comments (7) -

  • JPB

    7/27/2008 4:45:00 PM |

    Wow!  This is an incredible conflict of interest!!  No wonder I have felt so much pressure to do this and that despite never being sick and having no symptoms.  

    How did medicine get to this point?  The better question is 'How can doctors live with themselves?'  

    We all know that everyone has to earn their living but but this milking of the system and of patients is truly horrible! It is especially insidious when you are dealing with someone you need to trust implicitly and who tells you that you need to do these things because he/she is worried about your health!

  • Jenny

    7/27/2008 5:15:00 PM |

    I thought you might be interested in this article on a physician in Arizona who is remodeling his practice to offer concierge health care.
    As an advocate of free market solutions, I will be looking for a physician in my area with the same philosophy.  But I don't really expect to find one, as I am in an area dominated both by a State University Health System, and a Private University Health System. My own PCP is in the private University system.  We are asked to sign arbitration agreements with the University in case of  some untoward event (I refused, but I believe many patients believe they must either sign or go untreated, or else do not realize what they have signed.) Now the system has implemented a program that is ostensibly designed to help patients develop preventive health practices.  You are provided a liason person ( a nurse I assume) to check in with once/month by phone,and in that conversation you are asked about your goals and what you're doing to reach them, and given the usual status quo, conventional advice about concerns.  (This person will never even set eyes on you, after all.)   Still, it  doesn't sound bad, even sounds as if they are making genuine if nonsubstantive efforts toward helping people be proactive.  But I would not be surprised if the whole scheme were somehow rigged to the advantage of the University insurance plan, such as being enabling them to see if you are receiving more treatment (such as seeing an acupuncturist or chiropractor) than "they" think is appropriate or taking only the drugs "they" approve, and I also suspect that one day it will no longer be voluntary, and that you will be coerced toward only the practices they approve of.  Why are they offering payments for participation, is my question, and what do they do with the information you give them?  I will be opting out of that too.

    As far as free market solutions and the concierge model go, many will argue that it is too expensive and will only provide care for an elite.  The Arizona physician will charge a flat fee of $1500/year, and that will entitle his patients to direct access to him by phone or email, and at least 30 minutes of his time per visit.  His practice will have to be smaller than in the past in order for him to give more to each patient, but he will be able to actually practice medicine rather than be a cog in a corporate machine. Surely there are free market models that can be devised for the average person as well.  To object that the cost of modern health care is prohibitive may be simplistic.  Why is it prohibitive?   Can it be because the market does not function freely under the triple chokehold of insurance, drug company and government collectivism?    If patients and physicians were able to devise alternatives to the present environment of health care and PARTICULARLY if true, effective preventive practices (and many are already available at nominal cost but not promoted) became the norm, costs could plummet.  Hail to the pioneers such as Dr. Davis and the TYP members, and to the Arizona Concierge physician, who are striking out for new territory.  We will all benefit tremendously.

  • Bad_CRC

    7/27/2008 7:27:00 PM |

    Dr. Davis,

    Your fellow cardiologist Rich Fogoros also addressed this breakdown of the role of doctor as advocate, but he argues just the opposite: that PCPs today are essentially employees of the health insurance companies, tasked with controlling costs by minimizing tests, procedures, specialist referrals, etc., like claims adjusters.  His version certainly seems to be more true where I live.  I can't speak to the extent to which my PCP is under pressure to stay within a quota (however informal) for monthly rheumatologist referrals, CT scans, etc., or the degree such pressure taints his patient interactions, but I do know that he works in a clinic owned by the same (insurance) company to whom my employer and I pay my premiums, and that the same company also owns the local hospitals.  Clearly the profit-maximizing thing in such case is to maximize (healthy) policyholders and minimize claims (treatment).  There's no profit in gratuitous caths and bypasses when the hospital is the insurance company.  Fogoros claims that this sort of vertical integration became the rule when the HMOs bought up all the community hospitals and clinics in the late '90s.  A friend of mine (under my same plan) suffered a nasty GI tract problem and had to beg and fight her PCP, over 2-3 months of almost constant vomiting and other fun, for a referral to a gastroenterologist, who did finally diagnose and cure her.  The PCP was clearly in over his head, yet kept futilely giving her the same garden-variety pills (antiemetics, PPIs, etc.) and at one point told her, "Look, I can't just send everybody to the GI to have him say, 'Take the Purple Pill!'"  So Fogoros' "covert rationing" seems to go on in my town.  Can you reconcile that with what you're saying?

  • Anonymous

    7/27/2008 9:59:00 PM |

    All my adult life I've been told by doctors I have "borderline hypertension" (about 140/90). None, however, ever even suggested that I take an anti-hypertensive. Now I have atherosclerosis and can but wonder what might have been. Let mine be a cautionary tale.

  • Anne

    7/27/2008 11:34:00 PM |

    Not all insurance plans require a person to go through the PCP for referral to a specialist. I have seen patients who are seeing multiple specialists where it seems no one is in charge of the overall picture. These people may be given duplicate tests and incompatable medications. Doctors don't always communicate with each other. Shouldn't there be one chart that follows the patient from doctor to doctor?

    When I was seeing a university PCP I found it difficult to get tests such as vitamin D, B12 and A1C.

  • Michael

    7/30/2008 11:13:00 AM |

    Practicing primary care in the US in the current environment is incredibly challenging, but still very rewarding. As an employed family physician in Massachusetts, I am pulled in many competing directions: the hospital encourages referrals and admissions into the system the patient's insurance company discourages some referrals and limits access to certain medications and expensive tests.  There is more paperwork and bureacracy than ever.  Patients are more informed now, and often come in with information, some of which literally may be based on one person's opinion from a website or blog.  There are often many issues to try to sort through in one visit, a visit which is often limited by time pressure that exist as doctors try to see more and more patients.

    Despite this, I still feel it is a privilege to be chosen as someone's family doctor.  I tell my patients that I will try to treat them like my family and give them the same advice I would give my mother or my daughter.  I see my role as their guide, and I try to lay out the different options, and then tell them which one I would personally choose, but that it is ultimately their body, and they get to make the decisions.

    What it comes down to for me is that medicine is still about the interaction between the doctor and the patient, and if a patient is unhappy with that interaction, then they have the right to try to find a new doctor where they will feel cared for.

    I had to also respond to Jenny's post about concierge medicine.  It is definitely an attractive option for some patients and physicians.  I once read it explained like this: "Imagine you're a plumber, and someone says I will pay you more money to do fewer plumbing jobs, so you can spend more time on each job, and really focus on doing the highest quality work you can, really get back to what it was that drew you to being a plumber."  Who wouldn't want that?  My problem is that it is not extrapolable.  If a primary care concierge physician only has 300 patients, there is going to be a huge shortage of primary care doctors in this country.  My training in both medical school and residency was oriented around taking care of all the patients that needed help, not just the few hundred that could afford an annual fee of several thousand dollars a year.

    There is a group of doctors who have come together in Seattle to practice medicine in a very intriguing model.  It is called Qliance (www.qliance.com).  It has some similarities to a concierge practice, but is much more affordable.  They don't take insurance, there are direct monthly costs that are charged to the patient which covers unlimited visits.  Additional tests are paid for by the patient.  This model financially aligns the patient and physician, and the usually-hidden costs of medicine are out in the open.  One physician who works there described it as very refreshing to feel that you are really working for the patient.  It won't be the answer for everyone, but it may be the answer for many.

  • Anonymous

    3/1/2009 5:06:00 AM |

    Anne posted that some patients are seeing multiple specialists without having a primary care doctor.  

    That's my predicament, and I wish it weren't so.  As an 57 year old woman with multiple annoying health problems including diabetes, hypertension, and some difficult-to-treat chronic pain (chronic daily migraine, neck problems), I can't find a PCP who will stick with me: They are apparently so unnerved by the list of maladies that I must deal with that they decide I must be crazy, not ill, and stop working on my behalf.  

    I just hate trying to be my own PCP!  I'm terrible at it!  The idea of having a PCP who would help me manage all this stuff is a dream!  And I haven't had a physical in over a decade because I can't keep a PCP.  And although my specialists kindly try to fill that gap in my treatment, I know that not having a PCP is dangerous.

    However even with my excellent insurance and ability to pay and living in an area with an unusually high number of doctors/capita, apparently I fall into a category of patient that PCP's just can't deal with.