Frustrated by mounting regulation, declining pay, loss of autonomy and uncertainty about the effect of health system reform, doctors are slicing back the number of hours they work and how many patients they see.
Between 2008 and 2012, the average number of hours doctors worked fell by 5.9%, from 57 hours a week to 53, and doctors saw 16.6% fewer patients, according to a survey of almost 14,000 doctors released in September. If the trend continues through 2016, it would equate to the loss of 44,250 full-time physicians, stated the report, conducted by the doctor-recruiting firm Merritt Hawkins & Associates for the Physicians Foundation. The foundation was started in 2003 with more than $30 million from class-action settlements that 22 state and county medical societies made with health plans.
This is a silent exodus, stated Mark Smith, president of Merritt Hawkins. Physicians are feeling extremely overtaxed, overrun and overburdened.
Only half of doctors will continue their current practice during the next three years, the survey said. Many plan to cut back on hours, retire, see fewer patients, seek hospital employment, work part time, transition to a concierge model or seek a nonclinical job in health care. Sixty percent would retire this day if they could, compared with 45% in 2008.
A quarter of doctors cited long hours and lack of personal time as among the least satisfying elements of their careers. Nine in 10 doctors concurred that most doctors are unsure where the health system will be or how they will fit into it during the next five years.
Theres a great degree of uncertainty and angst related to problematic reimbursement, the high-regulation environment and many other things, stated Walker Ray, MD, a retired pediatrician and vice president and research committee chair for the Physicians Foundation. Now, what this all is about is more than professional grumbling. All professions at times have unhappiness surfacing. What were looking at are trends where doctors are in their own individual minds and their own individual practices, making decisions that may affect the supply of doctors going forward.
The less-intensive doctor work schedule could hamper access to care for the 30 million Americans the Congressional Budget Office estimates will obtain health insurance coverage under the Affordable Care Act during the next decade. The U.S. Census Bureau also projects a 36% rise in Americans eligible for Medicare during that period.
In 2010, the Assn. of American Medical Colleges projected a shortage of 130,600 doctors by 2025, with half of the shortfall occurring in primary care specialties. That estimate accounts for the work patterns of older doctors and female doctors, who are more likely to work part-time schedules, stated Clese Erikson, director of the AAMCs Center for Workforce Studies. But the projection does not factor in growing hospital employment of physicians, a trend noted in the foundations report.
Hospitals directly employ about 20% of practicing physicians, according to the American Hospital Assn. Many other doctors are employed in group practices owned by health systems. The proportion of doctors in independent practice is now a minority, states the MGMA-ACMPE, the entity formed by the merger of the Medical Group Management Assn. and the American College of Medical Practice Executives. That matters because hospital-employed doctors work fewer hours and see fewer patients than do independent doctors, the foundations survey showed.
20% of practicing doctors were directly employed by hospitals in 2011.
Employed doctors averaged 53.1 hours a week, compared with 54.1 for doctors in private practice. Employed doctors saw 17% fewer patients 18.1 a day compared with 21.9 a day seen by practice-owning doctors. Slightly more than 20% of employed doctors worked fewer than 40 hours a week, compared with 18.4% of doctors with an ownership stake in their practice. More than 60% of doctors younger than 40 are employed by a hospital, doctor group or other entity.
We know that an employed doctor is less productive than a practice owner, stated Smith of Merritt Hawkins. Physicians are looking for a safe harbor [in hospital employment], for someone to say, I think I see whats coming, and I can mitigate this risk for you.
The foundation survey was sent to more than 630,000 U.S. physicians. Despite the low response rate, an academic consultant cited in the report stated the surveys margin of error is less than 1%. Smith stated a sample of nonresponding doctors was later contacted to answer a few of the surveys dozens of questions, and their responses were highly consistent with those of doctors who finished the full survey. Respondents were likelier than the general population of doctors to be white, male, older and in solo or independent practice. Yet the lighter workload seen was not limited to the older doctors surveyed. Doctors younger than 40 averaged 19 patients a day, compared with 19.8 for doctors 40 and older.
Leaders at doctor organizations stated the low morale reflected in the survey is unsurprising.
Many doctors have been beaten down pretty significantly by the current system and have developed an unfortunate cynicism about the potential for change, stated David Bronson, MD, president of the American College of Physicians.
More than 60% of doctors younger than 40 are employed by a hospital, doctor group or other entity.
Long-term trends have hit smaller, independent practices especially hard, stated Glen Stream, MD, president of the American Academy of Family Physicians.
People in small and solo practices are struggling, with all the administrative and regulatory burden of insurance and payment challenges, stated Dr. Stream, an employee at a hospital-owned clinic in Spokane, Wash. In a small group, you dont have any negotiating power with insurance companies. If youre in small or solo practice, life is hard.
Physician leaders stated the survey results highlight the need to expand federal funding for residency slots, which have been capped since the Balanced Budget Act of 1997. The AAMC, American Assn. of Colleges of Osteopathic Medicine, the American Medical Association and many other doctor organizations support expanding residency slots.
On Sept. 25, Rep. Joseph Crowley (D, N.Y.) introduced a bill to boost Medicare-funded residencies by 15%, or about 15,000, during the next five years. Rep. Aaron Schock (R., Ill.) introduced a similar bill in August, and Sen. Bill Nelson (D, Fla.) proposed comparable legislation in September 2011. The AMA has publicly supported Nelsons bill, which has not received a hearing or been put to a vote.
Shortage sparks debate over NPs role
The looming doctor shortage is drawing more attention to the use of nurse practitioners, doctor assistants and other midlevel health professionals to help maintain access to care. But the shift toward more team-based care in patient-centered medical homes should occur in a physician-led environment, the AAFP stated in a Sept. 18 report. The American Academy of Nurse Practitioners objected to the report, arguing that NPs could help fill the doctor gap by independently treating patients.
Dr. Stream, of the AAFP, stated a two-tier system of primary care doctors for some, nurse practitioners for others is untenable.
To the people who propose that to fill this gap that we should somehow modify our expectations of the kind of care people should get that is not what we want in this country, he said. Its not a viable, ethical or reasonable solution.
Primary care doctors complete 21,700 hours of education and training over 11 years, stated the AAFP report. That compares with 5,350 hours of training and education NPs get during five to seven years. The AMA backed the academys report, noting a recent survey showing that 86% of patients believe they benefit from a physician-led primary care team.
Physicians and other health professionals have long worked together to meet patient needs for a reason the physician-led team approach to care works, stated AMA President Jeremy A. Lazarus, MD. Patients win when each member of their health care team plays the role they are educated and trained to play.
In 2012, only half of surveyed doctors stated they will continue their current medical practice over the next one to three years. The other half are pondering other options respondents could select any that applied to them. Many plans involve treating fewer patients, and that shift could impede access to care amid projected doctor shortages and expanded health insurance coverage.
What feeds doctor frustration
Three-quarters of doctors have a pessimistic outlook about the future of the medical profession, states a recent survey. More than 80% state the profession is in decline. Doctors stated the following factors respondents could select any they felt applied played a very important role in the professions decline.
64.5%: Loss of clinical autonomy
58.6%: Physicians not compensated for quality
54.4%: Erosion of physician-patient relationship
45.9%: Money trumps patient care
43.7%: Scope of practice encroachment
6.9%: Too many part-time doctors
Copyright 2012 American Medical Association. All rights reserved.
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