More than Just Medicine on the Minds of Today's Physicians

When rheumatologist Suleman Bhana embarked upon his career as a doctor in 2001, he believed he was entering a "noble" profession, one that would help others while providing him a good, stable salary.

Fast forward 12 years, and the 35-year-old physician is still excited about his choice of career, which he says provides an emotionally and intellectually rewarding experience. However, as a young doctor he finds himself encumbered with challenges that get in the way of providing great patient care, such as "navigating the murky waters of a convoluted billing and coding system" and an exhaustive work schedule - all while carrying medical school debt and trying to raise a toddler.

"There is an idealistic naïveté that many of us going into medicine have when starting our path from undergraduate college onward," says Bhana, who practices with a medical group in Summit, N.J. "We have notions of what a physician is perhaps from television, movies, personal encounters as a patient, or family and friends who are physicians. …For those of us practicing in the U.S., once we get into residency training, the curtain of the powerful Oz is pulled back and we see the deep inner workings of [a] highly dysfunctional system that does not reward health nor does it reward care."

Many physicians sympathize and identify with Bhana's sentiments, according to our 2013 Great American Physician Survey, Sponsored by Kareo, taken by 1,172 doctors earlier this year.

The majority of doctors say they're happy with their choice of profession and specialty, and many feel hopeful about the future of medicine. However, a growing number are fed up and feel weighed down by multiple issues, such as too much third-party interference, not enough time to provide optimum patient care, and financial responsibilities.

*Find out what's happening in the personal and professional lives of your peers; check out our infographic here.

How docs are holding up

Most physicians are happy they became doctors: Sixty percent of respondents said given the chance to go back in time, they would do everything roughly the way they did it the first time, and 14

percent said they would still become a physician but select a different specialty. However, 22 percent said if they could go back in time they would choose a career in a profession other than healthcare. When you account for age, the differences in attitudes are more staggering.

While 72 percent of doctors ages 65 and older (and 61 percent of those ages 56 to 64) strongly agree with the statement "I like being a physician," just 44 percent of physicians between the ages of 36 and 45, as well as 47 percent of physicians age 35 and under, said the same thing.

Solo physician Richard Bensinger, who practices in Seattle, still works between 51 hours and 60 hours per week at age 69, because he loves it so much. But he feels badly for many of his younger physician peers, who often carry staggering debt that deflates their take-home pay.

"I've observed that many medical school graduates have accumulated $150,000 to $250,000 in debt," says Bensinger. "By the end of training at age 32 or so, you would like to reap the reward of all that effort by being able to afford perhaps a house and car, not to mention the cost of opening up a practice. With such a crushing debt it becomes impossible and the only option -which is increasingly taken - is to join a large group or become a hospital employee."

Medical school debt isn't the only thing eating into physician happiness.

Concerns about healthcare reform and the economy have taken center stage, with slightly more than six out of 10 physicians calling each of these "extremely important" in their lives.

These concerns are especially evident as physicians are waiting to see how the provisions of the Affordable Care Act (ACA) will shake out.

Meanwhile, there is growing frustration with increased third-party interference: Thirty-two percent of physicians said if they had to pick one reason above all others for not becoming a physician, that's why. Perhaps, then, it's no surprise that physicians are looking for a way out of traditional fee-for-service. Forty-three percent of physicians say they're considering or have considered switching to a direct-pay practice, to do away with insurance altogether. And 31 percent of physicians say they are considering or have considered switching to a concierge-style practice model, whereupon patients pay an annual fee for premium care.

"It seems like there's a lot more openness toward that [concierge] model now," says Laurie Morgan, a San Francisco-based healthcare consultant with Capko & Co. "It definitely reflects what we're seeing, too, in the market. I think some of the wariness was just that patients wouldn't be interested in such a model, but there's been a lot more proof of concept of that model in the marketplace. There's less hesitation to say 'we'll never offer that.'"

Morgan says a few physician practices she works with are experimenting with doing a concierge-hybrid model, by offering "enhanced" services to patients willing to pay for them.

"I met a physician who was transitioning to a concierge-type model but didn't want to let down or lose patients who still needed to see her but couldn't afford that, so what she offered to concierge clients were things like the ability to reach her by phone, the ability to get in to see her more quickly," says Morgan. "…With her existing patients who were not able to make the switch, she had a [physician assistant] who could see them on a more urgent basis."

*For more insight on trends and challenges facing physicians over the next few years, listen to our podcast at http://bit.ly/GAP_trends.

What doctors want

Physicians love providing great care for patients, and 77 percent said they went into medicine because it is clinically stimulating.

Still, a growing number of physicians feel underpaid.

And it's not just third-party interference that's got them down. They also feel stymied by patients' lack of coverage, and the pressure to see higher volumes of patients in less time. All of these things are barriers to great care and great patient-physician relationships, our survey reflects.

Thirty-seven percent of survey respondents cited a lack of adequate insurance coverage as the primary barrier to good healthcare, and 19 percent said the biggest barrier is not having enough time to educate patients properly.

"There's a pressure to see more patients in less time, with increasing liability, and a greater hassle factor," says Walker Ray, a 72-year-old retired solo pediatrician who is now the vice president of The Physicians Foundation, a nonprofit organization focused on helping practicing physicians. "It has created an environment in which physicians …feel they are in a process of powerlessness. They don't feel like they have the ability to influence the healthcare system."

In addition to more time with patients, physicians also want more time for themselves. Our survey revealed:

• Sixty-eight percent of physicians said they don't have as much time as they should for their personal lives; 56 percent of physicians said they wished they worked fewer hours per week;

• More than one out of three said they'd be willing to sacrifice money to work fewer hours per week;

• More than one out of four said they spend fewer than six waking hours with their family during the work week;

• Sixty-seven percent of physicians eat dinner with their families three or more nights per week; and

Slightly fewer than one in five physicians get little or no exercise outside of work.

Bracing for healthcare reform

Support and opposition for the healthcare reform law is split down the middle with just about an equal number of physicians on either side of the fence.

Yet, as many of the provisions of the reform law are coming to fruition, anxiety about the future seems to be increasing. To top that off, most physicians - 84 percent, according to our survey - don't believe that physicians are well-represented in Washington, D.C.

"I think we should forget the ACA and provide universal healthcare to all Americans," says Elizebeth Harmon, a 55-year-old OB/GYN who practices in Salem, Ore. "When we decide that everyone needs and deserves medical care, we can then start focusing on prevention and better health instead of the crisis intervention system that we have now for poor people. In the meantime, anything that provides medical care to more American citizens is a move in the right direction."

Of particular concern to many physicians is the reform law's Medicaid provision, which goes into effect in 2014, and looming Medicare SGR cuts. The predicted influx of Medicaid patients - the law expanded the program to individuals with incomes that are less than 133 percent of the federal poverty level - has many concerned about whether they should continue to accept the notoriously low payer. In our survey, 6 percent said they are closed to new Medicaid patients, and 9 percent said they are considering dropping the program altogether. Similarly, 11 percent said they are considering dropping Medicare, and 5 percent of physicians are closed to new Medicare patients.

But healthcare consultant Susanne Madden, president of The Verden Group, says those numbers are lower than she expected.

"Certainly we heard 'the sky is falling, the sky is falling' with reform coming, with so many doctors thinking they would be flooded by these low-paying patients, if you will," says Madden. "But if you think about it, quite a few states have taken advantage of the [Affordable Care Act's Medicaid provision] that has moved compensation for Medicaid to 100 percent of Medicare [rates]."

Madden also notes that current healthcare reform is a sign of the times. Many payers are already moving away from traditional fee-for-service models.

"Doctors are looking at 'Obamacare' as the source of all of these changes, but that's not really the case," says Madden. "These changes were beginning to roll through anyway. Payers had already begun to look at cost trends and pay-for-performance programs. Obamacare was just layered on top of that. Realistically, Obamacare has made many things easier for physicians."

While most physicians taking our survey noted their concern about the healthcare reform law, it's interesting to note that 59 percent said they haven't made any changes to their practice because of it.

Moving forward

Physicians who answered our survey had a lot to say about the future - as well as their plans for it. In the next five years, 46 percent of physicians plan on continuing to practice medicine as they do now, 3 percent plan to join an accountable care organization or Patient-Centered Medical Home, 8 percent plan to transition to concierge or direct pay, and 7 percent plan to transition to a hospital or merge with other practices.

No matter what their plans, nearly one out of five physicians said they would try to discourage their children from becoming doctors, while 27 percent said they would encourage their kids to follow in their footsteps.

"I have one child thus far, and my greatest hope for him is to pursue a career that enables him to elevate his fellow human beings, secure a stable financial future, and allow time and opportunity for diverse personal interests," says Bhana. "I just do not see pursuing a career in medicine, at its current state, as the only or best means to achieving these goals."

Although Ray, who retired from his post as a solo pediatrician several years ago, reminisces about the "good times when there was a better doctor-patient relationship," he doesn't know if he would recommend it.

"I'm not sure I would recommend being a physician now," says Ray. "It would be a tough decision, fraught with a lot of discussion for a young person."

Bensinger, meanwhile, still feels being a physician is satisfying - even if the salary potential isn't as high as it used to be.

"Being a doc is a terrific thing," says Bensinger. "I'm not one of those who goes around saying 'medicine is in trouble in the future, you should look into something else,' [but] medicine, because of the payout structure and a variety of other things, is losing the chance to really make a killing anymore. There used to be cardiac surgeons with seven-figure incomes. Such is not the case anymore."

In Summary

Today's physician is generally happy, but feeling an increasing weight of regulatory burdens, financial setbacks, and personal frustrations on her shoulders. Here's what our 2013 Great American Physician Survey, Sponsored by Kareo, revealed:

• Most of you eat dinner with your families three or more nights per week, but still feel you don't have enough personal time;

• A growing number of you say you're considering or have considered switching to a direct-pay practice or a concierge-style practice model;

• Most of you would do everything the same, if you got a do-over; and

• Most of you plan to continue in the same way over the next five years.

Marisa Torrieri is an associate editor at Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

This article originally appeared in the September 2013 issue of Physicians Practice.