Obama Kvells, Docs Report Misery, and A Modest Proposal

Kvell is a Yiddish word meaning super happy and proud. My grandmother, for example, kvelled when I actually got my MD degree, even though she’d been calling me Dr. Edelberg since I was two.

This week, it was President Obama’s turn to kvell. He’d received great news about the Affordable Care Act (ACA), which, now that it appears to be working, can without embarrassment resume its original eponym, Obamacare. Enrollment has exceeded everyone’s expectations. Despite the near-fatal shaky start of healthcare.gov, since January 1more than eight million Americans got the health coverage they lacked in 2013. To add even more pleasure to the moment, the majority of new enrollees are younger, quite healthy, and not anticipated to financially drain the system.

These eight million are in addition to the three million 18-to-26-year-olds from ACA Part One who, since 2010, have been allowed to remain on their parents’ health insurance policies. That’s a total of 11 million and obviously there are more to come. Even the most jaded anti-Obamacare congressperson knows that any attempt to repeal the ACA now, yanking health insurance from 11 million people, would be political suicide.

But all is not rosy

Doctors these days aren’t kvelling about much of anything. Last week’s The Daily Beast had a chilling article entitled “How Being A Doctor Became The Most Miserable Profession” and while most Beast articles are followed by a dozen or so comments, when I last looked this one had a kite tail of 429 decidedly strong opinions. Writer Daniela Drake, MD, an internist like me who apparently sought happier pastures as both an MBA and professional writer, begins her dismal piece based on surveys taken of physicians themselves. She emphasizes that the misery is pretty much confined to primary care physicians (PCPs)–family practitioners, internists, ob-gynies, and pediatricians.

On the opposite extreme, specialists (especially surgical specialists) who are pretty much protected from day-to-day headaches and earning three or four times the income of a PCP are significantly more cheerful. For example, to get reimbursed for a $5,000 surgical procedure, a surgeon completes one claim form, submits it with his surgical procedure report, and waits for his check. To earn a comparable sum, a PCP needs to see 50 patients and submit 50 claims to any of a dozen insurers. Half of these will be denied on a technicality, requiring staff to fax over medical records to the insurer. Weeks to months later, a check, substantially less than the doctor’s professional fee, will arrive.

Simply put, says Dr. Drake, being a physician is now the second most suicidal occupation, the doctors in her piece describing their experience as PCPs as a miserable and humiliating undertaking. Not surprisingly, nine out of ten PCPs actively discourage their kids from becoming doctors. Medical students are shunning primary care like the plague, PCPs are retiring early, and physician-MBA programs (promising doctors a way into the more lucrative field of medical management) are flourishing.

Why the misery?

Because PCPs are left with everything other doctors rarely bother with, Dr. Drake calls them the janitors of the health care system. First, look at the numbers. A surgeon can only perform so many procedures in a day and then goes home, leaving residents and nurses to handle post-op care. I had hip surgery several years ago. When I woke up, the post-op nurse said my surgeon had departed for his Caribbean vacation while I was still under anesthesia, a resident left behind to sew me up.

With 11 million new enrollees in the ACA system, predictions are that a primary care doctor can have a workload of from 2,000 to 3,000 patients, far more than any physician should attempt to handle. That translates to 24 to 30 patients a day, keeping in mind that some who have multiple medical problems can’t be properly treated in their allotted 15-minute time slot. And of course each of these patients has an insurance claim for the doctor’s staff to complete, with adversarial insurance companies that delay payment by requesting medical records for review. Further bogging down the day are seemingly endless forms for doctors to complete, letters to write, pre-authorization phone calls, and still more forms for drugs, lab tests, x-rays, and referrals to specialists.

Add to this the multipage, work-related disability forms and the letters we’re asked to write: excuses from jury duty, pets on airplanes, ergonomic chairs for work, added time for SAT exams. Plus the usual dozens of lab test results to review and phone calls with specialists, social workers, family members, etc.

And hovering over each of the hundreds of daily decisions a doctor makes is the implied threat of a malpractice suit. Every physician in America gets at least one of these in her career and while most turn out to be frivolous and ultimately dismissed, the psychological trauma to a doctor can be devastating.

Little wonder Dr. Drake became an MBA!

It’s beginning to look like Obamacare is only going to increase doctors’ stress. Already PCPs are anxious about what so far seems like truly unreasonable demands beyond the increased patient load.

We all got our first taste of the ACA with the electronic medical records (EMRs) requirement. Install EMRs or face financial penalties, they told us.  If the public thought healthcare.gov was unwieldy, it’s nothing compared to EMRs. In a recent survey, 85% of PCPs confess to loathing EMRs, whose endless clicks and data entry commandments add at the least one full hour to an already packed workday.

As the ACA goes full force, EMRs add a “Big Brother is watching you” component. Your medical records will be (anonymously) connected to automated quality review monitoring and endlessly scanned. These records require dozens of additional clicks to fill in data whose presence or absence will affect your doctor’s reimbursement profile. For example, if a practice fails to show that a required percentage of women aren’t receiving mammograms, or that cholesterol levels aren’t brought down to the “healthy standard” (by prescribing more statin drugs), the doctor’s income suffers, regardless of whether women want the mammograms or any patient wants to be on statins. Standardization becomes the name of the game. If your cholesterol is 220 and you’re not on a statin, you’ll get a letter that your doctor is not providing “standard” care while your doctor gets a financial penalty.

If enough PCPs walk away (or become MBAs and dictate terms to the rest of us), your primary care provider may well become that nurse practitioner on duty at Walgreens, CVS, Target, or Walmart. Nurse practitioners give excellent care for day-to-day stuff, like sore throats and immunizations, but will off-load anything remotely complex to the PCP you’ve selected from your network. They also off-load the boring janitorial stuff, like filling out forms, writing letters, and getting your pre-auths. You can expect about the same relationship with a Walgreens nurse practitioner as you would with your Starbuck’s barista. She’ll be pleasant and competent, but won’t remember your name. And please don’t ask for her answering service number or for Walgreens to page her during her off hours.

How to cope with this projected PCP shortage

My modest proposal is to find a good chiropractic physician and use her as your PCP. There are several compelling reasons to consider this:

• Chiropractic physicians, with the exception of pharmacology and surgery, have the same training in sciences as medical doctors. They can recognize signs and symptoms of organic illness, know the limitations of their expertise, and are taught when to refer to medical doctors.
• Your chiropractic physician (and her staff) will get to know you as a person. You’ll have a set of your records on file in one place, including details on your health history.
• Chiropractic physicians know how to perform a physical exam. In addition, they can do very sophisticated musculoskeletal/neurological testing that I was simply never taught. In addition, most chiropractic offices now draw blood, order x rays and scans, and refer to surgical specialists.
• Most chiropractic physicians also have a relationship with an MD (usually their own). Alternatively, they can fax their evaluation to your PCP for uploading into your electronic medical records. Some electronic systems even allow you upload your chiro office visit to your online medical records by yourself.
• Any time you see a doctor—an MD (medical doctor), DO (doctor of osteopathy), or DC (doctor of chiropractic)–keep in mind that most symptoms aren’t caused by disease, but rather by unhealthful lifestyles. Most headaches are caused by stress and most digestive problems by poor food choices. Sadly, because they’re so pressed for time, medical doctors treat symptoms with prescription drugs rather than teaching lifestyle changes like healthful eating, stress reduction, and exercise. Instead of endlessly relying on prescription drugs (the side effects of which are the fourth leading cause of death), chiropractors are geared toward nutritional therapies, diet changes, body therapies, and other health-oriented techniques.
• Between the ages of 18 and 60, most of your medical problems will likely have their origin in your musculoskeletal system. It’s the first system to peter out as you age, and here chiropractors are in their element, balancing your body, teaching you exercises, and offering a wide variety of treatments that are not drug-based.
• PCPs refer patients far too quickly and too often to medical specialists. Although specialists are necessary, their perspective is a narrow one confined to their area of expertise. The result is that many patients receive too many complex and potentially dangerous diagnostic tests and unnecessary surgeries for symptoms that might have been treatable with simple lifestyle changes.
• Chiropractic physicians consistently receive “highly satisfied” ratings from patients. This is because they generally spend more time with them than other physicians, really getting to know their patients well. Virtually every chiropractic physician I’ve ever known will squeeze you in if you need to be seen quickly, and virtually all have a relationship with an MD they can call on if actual medical intervention is needed.
• Finally—and importantly–unlike the self-reported misery among PCPs, surveys among chiropractic physicians reveal just the opposite: feelings of personal satisfaction, acceptable levels of stress, and a strong sense of being beneficial to society.

I’ve been working closely with two chiropractic physicians, Paul Rubin and Cliff Maurer, for years. In fact, when Dr. Rubin and I founded WholeHealth Chicago, we learned that ours was the first partnership in Illinois between an MD and DC. Many of our patients actually use Paul and Cliff as their primary care physicians, calling on me (or on Drs. Kelley or Donigan) when the situation appears to need medical intervention.

All in all, I’m glad our president is kvelling, but saddened that the word misery is now linked with being a doctor. This just means, as always, take care of yourself and…

Be well,
David Edelberg, MD