OP-ED | Proof Is All Around You In Practices Across Connecticut
by John A. Foley, MD | Sep 25, 2012 6:00am
(8) Comments | Commenting has expired
Posted to: Opinion
The Connecticut physician shortage is not approaching: it is already here. How nice of the Connecticut Trial Lawyers Association to decide that patient access to medical care is worthy of its attention. Don’t be distracted by its habit of playing fast and loose with research. I’m not.
Rather than boring you with a dissertation on the differences between primary and secondary data and the limits of secondary data (in the 2008 University of Connecticut report cited by Neil Ferstand), the Connecticut State Medical Society stands by the findings of its 2008 Physician Workforce Survey (Link to full report and tables) and its 2009 Primary Care Survey (Link to full report) and the upfront discussion of the limitations of that research. That said, let’s talk about Connecticut’s physician shortage and why it exists today.
I have just joined the more than 45 percent of Connecticut physicians who are age 50 or above. The American Medical Association tracks that as a benchmark age, because that’s when studies show physicians start thinking about reducing their hours and how long they’ll continue practicing full-time. The cavalry isn’t coming to replace us. In 2011, not one of the 14 residents and interns from the Yale School of Medicine who chose to remain here intended to practice in primary care; 29 from the University of Connecticut’s graduating class stayed – 8 in primary care. That’s just slightly better than the 2009 Journal of the American Medical Association study that showed 2% of the graduates of U.S. medical schools entered residency in primary care.
In fact, the Association of American Medical Colleges and the Council on Graduate Medical Education are just two of the many organizations projecting patients will be facing a national shortage of physicians in the not-distant future. AAMC estimates the deficit will reach 63,000 physicians in all specialties just over two years from now. (Link to AAMC research) A host of national medical specialty organizations, from the American College of Physicians to the American College of Emergency Physicians, has similar projections.
We have all chosen to live and work in Connecticut – why aren’t our young physicians? The majority of Connecticut’s physician practices still have between one and four physicians. They are small businesses facing the same everyday pressures as all other small business across our state. But their financial projections are far less rosy from the outset. After leaving medical school and residency with an average of more than $150,000 of student loan debt, before seeing a single patient, one must pay Connecticut medical liability insurance premiums that are among the highest in the country. Then, unlike the copy shop around the corner or the diner up the street, a solo physician has next to no ability to set the prices he or she will be paid. Physicians are barred from negotiating collectively under outdated federal antitrust laws. The doctor is David up against Goliath negotiating contracts with insurance companies that determine what he gets in “reimbursement” for each and every service he provides. We’re not talking about the expensive medical testing done in hospitals, either. Some physicians would love to be able to compete with hospitals for that business, but the State maintains a cumbersome and excruciating Certificate of Need process that costs a physician upwards of $30,000 just to apply before a physician can invest tens, or even hundreds of thousands of dollars more on the high-tech equipment they want to buy. All talk of capital investment in electronic medical records aside, there are scores of small practices that still don’t have Internet connections.
At the same time, Connecticut has an above-average percentage of Medicare recipients, according to the AMA. Congress has enacted more than a dozen short-term patches to stave off Medicare cuts that directly affect the bottom line in my cardiology practice and hundreds of other medical practices across the state. No business can stay afloat when it suddenly faces revenue cuts of 20-30% for a significant percentage of its business. I’ve seen practices around Connecticut take out lines of credit to be able to make payroll while Congress was making up its mind what to do. That’s no way to stay in business. What’s worse: these cuts directly affect access to medical care for more than 563,000 Medicare patients and 51,000 active and retired military personnel and their families who are caught in the middle.
The Connecticut physician shortage is significant enough for Quinnipiac University to be adding a third medical school to our landscape, one focused on primary care and intending to provide incentives to students who stay here to practice medicine. Universities don’t create medical schools for short-term problems. It takes years to make a new physician; this investment won’t start paying off for awhile. But in the meantime, CSMS proposed last session, and the state Senate unanimously passed, legislation to create “targeted health areas” that would help make our state, and in particular its underserved areas, more attractive to physicians.
There are 49 other states that also need more physicians to meet their needs. New Jersey, Pennsylvania, New York and Massachusetts all indicate physician shortages. It’s time Connecticut did something to make itself attractive to physicians. Because my colleagues and I are getting grayer by the day and patients are counting on action. We hope we can count on the trial bar to exercise its newfound concern for patient access to medical care by advocating for legislation that makes Connecticut more hospitable for young physicians, such as addressing our medical liability crisis and creating incentives that help medical practices stay open.
John A. Foley, MD, is the president of the Connecticut State Medical Society and the New London County Medical Association.
Tags: John A. Foley, Neil Ferstand, physician shortage, doctors, shortage, hospitals, primary care, Connecticut State Medical Society
(8) Comments
posted by: edvolpintesta md | September 25, 2012 2:26pm
As president of the Connecticut State Medical Society Dr. John A.Foley understands only too well the serious problems that Connecticut physicians are facing.
In his OP-ED piece of September 25 “Proof Is All
Around You In Practices Across Connecticut” he offered several good reasons why Connecticut has an insufficient number of primary care physicians.
One in paricular merits repeating. He pointed out that the cost of liability insurance in Connecticut is one of the highest in the nation and as such is a serious burden for primary care physicians to bear.
Most physicians see the malpractice system as unnecessarilhy harsh and adversarial and as a resuklgt are hesitant to take on Medicare patients who often have complicated medical conditions. Naturally, limits greatly the access of the elderly to healthcare.But it also applies to any patient with serious illness. Many of these patients end up seeking care in the emergency room, overtaxing the physicians and nurses there and taking attention away from patients who are true emergencies. More over,besides being inappropriate, getting care from the emergency room for routine illness is extraordinarily expensive.
The point is that the malpractice system in Connecticut is overly adversarial and eliminating its harmful approach would have the beneficial side-effec of increasing access to health care for the elderly. This is a laudable goal considering that people are living longer. And all of us have parents and grandparents who we would not want to see succumb to an illness because they could not find a primary care physician to take care of them.
posted by: Matt W. | September 25, 2012 4:02pm
edvolpintesta: Would it make sense to require emergency rooms to refer non-serious injury or illness to local clinics rather than keeping and treating a runny nose for $5000? I’ve never quite understood this.
posted by: Neil Ferstand | September 25, 2012 4:55pm
Thank you for responding to my post Dr. Foley. Even if it was a response deflecting from the underlying question as to whether there is “credible” data existing at the state level as to who is and who is not practicing medicine in Connecticut and not the opinions fostered by surveys conducted by medical societies and their anecdotes.
In addition, as my wife continues to remind me, there are probably thousands of women in Connecticut who have chosen to use their gynecologists or internists for all manner of medical advice and treatment instead of primary care physicians. A condition discovered by researchers at Mt. Sinai Hospital who found and published in the Annals of Internal Medicine, that more than 41% of our most basic health care needs are taken care of by specialty doctors. http://archinte.jamanetwork.com/article.aspx?articleid=1351353.
The bottom line is that the data reflective of numbers of licensed physicians existing at the Department of Public Health continues to grow each year - from 13,374 in 2000 to 16,962 in 2011. It would do the state a world of service if the Connecticut State Medical Society cooperated fully with the Department of Public Health and encouraged its members to comply with online license renewal so true and accurate data can be compiled.
Everything else is conjecture.
posted by: edvolpintesta md | September 25, 2012 7:33pm
Matt W’s question is a good one because it helps to clarify the primary care physician shortage.
The answer is that many of the people who end up in the emergency room for so-called routine illnesses are there because they couldn’t get an appointment with their primary care doctor because he/she was too busy or because many primary care doctors not accepting new patients.
Also some of the patients who show up in the emergency room for a simple sore throat have an underlying medical history that is complicated and the physicians don’t want to accept the risk involved, especially since it is not their patient in the first place.
But I too could never understand why a sore throat treated in the emergency room should cost much more than one treated in a doctor’s office.
posted by: edvolpintesta md | September 26, 2012 7:21am
Regarding Neil Ferstand’s response to Dr. Foley. With all due respect to Mt. Sinai Hospital, its report( which I have not read) that 41% of society’s basic health care needs are taken care of by specialists is completely and thoroughly at variance with my personal experience and I would say with that of most physicians in Connecticut.
Mr. Ferstand made another statement that requires correction. He suggested that women in Connecticut use their gynecologists and internists for “all manner of medical advice and treatment instead of primary care physicians”. The problem here is that with a few minor differences, an internist is a primary care physician. And although decades ago internists were seen as medical consultants, today that role that has been superseded by specialists. Internists now are classified as primary care physicians, a division that includes family physicians, general practitioners, and pediatricians.
Some specialists, gynecologists in particular, may take care of a few of their patients’ general health needs. But they do not take care of their ongoing chronic problems like diabetes, hypertension, and heart disease. These represent the core of what primary care physicians attend to.
Clearly, the public debate on what is right or wrong with the health system is filled with misleading conclusions and assumptions. It is a very complicated topic.
I only bring to the discussion my personal observations and those of many of my colleagues.
My point is that reports like the one Mr. Ferstand mentioned from Mt. Sinai Hospital confuse everyone including physicians like me and administrators like him.
Over-reliance on statistics, as helpful as they may be, can make discussions of the adequacy of the medical workforce, in this case primary care, confusing and unproductive especially when they fly in the face of what many physicians experience.
posted by: edvolpintesta md | September 26, 2012 10:31am
Regarding Neil Ferstand’s response of Sept. 25:
He mentioned that according to a Department of Public Health the number of licensed physicians grew from “13,374 in 2000 to 16,962 in 2011” and used this to suggest that a physician shortage does not exist in Connecticut. But he did not mention what, if any, was the change in the number of inhabitants during that eleven year period. It seems fair to say that this is crucial information for his argument. For since he ignores mention of any population changes during the years 2000-20111, the question of whether the number of physicians is adequate or inadequate becomes almost meaningless or at least confusing.
This is another example of statistics leading us astray and arousing confusion not only among interested citizens but among policy makers and lawmakers as well.
Even if the population of our state did not change during that time period, another factor enters which accentuates the question of whether the number of physicians is adequate or not. I refer to the increasing complexity of medicine and how because of it, providing care has become more time-consuming than ever before.
What does this mean? It means, paradoxically, that doctors have become “inefficient” time-wise as result of advances in medical science. It is rare, for example that a patient comes to the office without having a blood test or an X-ray, or a scan of some sort done to aid in their diagnosis or to monitor their blood chemistries because of medication that they are taking. This takes time and in a sense makes the physician “inefficient” or less productive in the use of time.
Coincidentally, it is not unusual for some patients, especially the elderly who often have multiple medical problems to be taking as many as fifteen or more different medications! When I started practice thirty-seven years ago, I considered it remarkable if a patient was taking 5 medications. Monitoring medications in the elderly and the side-effects that sometimes result and finding acceptable alternatives is a time-consuming labor that was not as common a few decades ago. It is one of those subtle factors (there are others) that is often overlooked.
In fact, this has fostered a whole new group of specialists called “hospitalists”. Hospitalists take care of primary care patients when they are admitted to the hospital. Why is this? For two reasons. Hospital care has become so complex that in most instances, it is better off when left in the hands of physicians who specialize in it. Besides, hospitalists are hospital-based, and being in the hospital full-time they are best-positioned to respond quickly to any changes in a patient’s medical problem.
The second reason that gave birth to “hospitalists” is that because primary care physicians are so busy in their offices taking care of patients, using hospitalists frees them up for more time to be available to their patients. Not having to travel to the hospital and make rounds can save up to two hours or more for a primary care doctor.
This discussion would be incomplete, however, if it were not mentioned that primary care physicians’ efficiency has seriously diminished because of the inordinate time and emotional toll that is taken by having to deal with insurers’ intrusions: Getting clearances for ordering tests, consultations, and prescribing some medications is not only mind-numbing, it is a serious and dangerous distraction.
The point is that the increased number of physicians in Connecticut during the period 2000-2011 has some relevance regarding the physician workforce. But that relevance is not only small but the information itself only adds to the difficulty of trying to arrive at any rational interpretation of the adequacy or inadequacy of the primary care workforce.
Clearly, there are many factors that must be taken into account when discussing workforce sufficiency. Partisan interests, as well-intentioned as they may be from all sides, must be examined in as complete a context as possible.
It is hoped that the information submitted, with all due respect for the time and effort expended by Mr. Ferstand, broadens the context of this important discussion and will encourage the addition of further comments.
posted by: CSMS President | September 29, 2012 12:56am
Mr. Ferstand,
Once again, we thank you and the trial bar for your interest in the practice of medicine and your desire to assure the public that everything is okay, regardless of the volumes of work done by professionals who have spent their careers studying the health-care system. Unfortunately, we cannot simply say, “There, there,” and soothe the problem away.
However, I am happy that I can fully agree with you on one statement you made in your comments: Many patients do seek primary-care services from Internists and OB/GYNs. Internists are primary-care physicians. OB/GYNs are defined in Connecticut statute as primary-care physicians. And the number of physicians providing hands-on patient care in Connecticut in those specialties is declining. It would be our pleasure to focus specifically on the plight of the obstetrician in Connecticut and have a lengthy public discussion. However, as we found it difficult to argue with the trial bar’s opinion of “credible data,” it is, once again, difficult to respond to your recent assertions as you clearly are not familiar with the delivery of health care.
In response to your unfounded comment about CSMS partnering with the Connecticut Department of Public Health, if you took the time to speak with any state agency involved in the delivery and quality of health care, they would confirm that CSMS has been a partner and at the front of the line working with other professional health-care organizations. I would never deliberately make false assertions, but I do not believe any members of CTLA have been serving on the numerous committees, task forces and subcommittees that are working to transform the health-care system and ensure access to services exists for all Connecticut citizens. We find that our energy and expertise are most effectively spent on those activities than in isolating single issues selectively in a vacuum.
posted by: edvolpintesta md | September 29, 2012 11:44pm
Regarding Neil Ferstand’s post of September 25: unfortunately Mr. Ferstand makes the erroneous assumption that there is not a shortage of primary care physicians because the number of licensed physicians has risen by a little more than 3,000 in the period from 2000 to 2011.
This again is a good example of how statistics can be misleading. What do I mean? Many physicians who have licenses are not involved in direct patient care. For example, doctors who move away often renew their licenses in case they change their minds and want to move back. Residents and fellows are often licensed but they don’t have independent practices. And neither do those physicians who teach or are involved in research or work for pharmaceutical companies are not are not directly.
The point is that using the data that he has to estimate the sufficiency of the physician workforce lends itself to great error because they ignore these important distinctions.
Again, it must be pointed out that primary care physicians are in a sense made “inefficient” by the insurance system which overwhelms them with administrative drudgery. Thus, for the sake of clarification, it might be said that a primary care doctor of today is probably 20%-25% less efficient than he/she was a decade ago.