Primary Care, Hospitalist, Specialist … Plumber?
Patients want access to care but what do the docs need?
By George Martin, MD – Senior Medical Director for Health Integrated
I am reminded of one late night at the emergency room. I was to provide care and admit a sick child to the hospital. While finishing the paperwork, the father of another patient appeared and recognized our presence. The comment was, “Well doc, have you got this shift?” My answer easily could have been “Yes and the shift before and the shift after and the shift …” You get the picture.
A common model for private practice then and now is for primary care physicians to gather into small group practices or small coverage groups. Thus three to five physicians will rotate on call “after hours”; perhaps every fourth night and every fourth weekend. Commonly, they will also have Saturday office hours and will make rounds on patients that are hospitalized. The average work week then is at least 60-70 hours. Because the need to generate revenue is the driver of the practice profit, little time is given to vacation. In total, this drives an average hourly wage of $50.
Pose the question to Ask.com, “What is the hourly wage for a plumber?” and here’s what you’ll find: [A] decent journeymen [will make] $90+ per hr, Master plumbers around $200 per hr and [plumber] Helpers normally $50 per hr.
So the average hourly wage for a primary care physician is about the same as for a plumber’s helper. Now the average surgical sub-specialist, such as a cardiovascular surgeon, is quoted to make four times the salary of a primary care physician. However, if you calculate the compensation on an hourly basis it calculates to $550 per hour or 11 times the compensation of a PCP! Can you spell primary care shortage? Is it any wonder with the financial disparity?
In this circumstance, we would expect that the delivery model must change. And it is changing. The most dramatic change over the past 10 years has been the advent of the hospitalist concept. Few, if any, large hospitals are now without a cadre of internal medicine physicians, practitioners who have limited their practice strictly to providing care to hospitalized patients. The compliment to this development is the cadre of internal medicine physicians that have given up their inpatient duties and are not solely practicing in the office.
The major issue is the improvement of life style for the primary care physician that is possible as a hospitalist. Now, PCP offices tend to be open defined hours and the demand is high enough that the schedule is full for the next two weeks. Any patients that need to be seen immediately are likely to be referred to an acute care facility. This includes the other major change – the development of walk in or urgent care centers – or they may be sent to the emergency department.
Care at either an emergency department or an urgent care center can be and often is excellent. However, they function without adequate access to historic patient information and they are, of necessity, problem and not patient focused. There is also the problem that the information generated at those sites fails to be available to the PCP at a later date, so coordination of care suffers significantly.
I am reminded of the truism: Our system is perfectly designed to achieve the results that we realize. The exception here is that our healthcare system was never designed. Like the metaphorphosis of Harriet Beecher Stowe’s immortal character, Topsy, I s’pose our new system “just growed”.
How do we right this ship? Or can we? Tell me what you think!
You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.
As always, thanks for reading and for your input.
George Martin, MD
