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May 25, 2009


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R Sekhri

I am an internal medicine doctor who has left IM practice after 10 years to recertify in sleep medicine. I just could not be all things to all people. My panel was 85% women (not unusual for a female physician) and the average age of patients I was seeing was over 70. When I started "full time", I was working 70-80 hours per week (with hospital call), my marriage suffered, I could not get pregnant, life was a wreck. Finally, at 2.5 years in, I almost had a nervous breakdown, and went part-time, which was still coming out to about 50+ hours per week, but of course with a huge paycut. After I had some health issues (thyroid cancer) I realized that I could not save primary care or my patients on the 20-minute appointment for a full PE, management of all medical problems, all prevention measures PLUS all the baby boomer compliants of pain. I knew I had to save myself. I had always been interested in sleep medicine and I decided to retrain. Right now, I feel like a half-breed -- when some of my specialist colleagues complain about a primary care doctor "missing something" or a referral being inappropriate, I feel like belting them -- they have ABSOLUTELY NO IDEA what life was like in IM! And they protect their own specialist RNs more than they would protect the time of a IM or FP MD -- IM and FP are the dumping grounds for everything in the end and no one acknowlegdes it.

Paul Spilseth, MD

Three years ago, I left an active, adult primary care position at a large multispecialty clinic. I developed personal relationships with many people over three decades and I miss these continuing interactions.

I developed and used a basic electronic record over 12 years within the group. I electronically recorded problem lists, medication lists, allergies, health maintenance schedules, social history, family history, and patient encounters using voice transcription. My group was interested in purchasing an expensive EMR, and they had difficulty understanding how I was able to do these things successfully at low cost. I also kept complete paper records with the clinic system, but I left because I was no longer allowed to continue to innovate and use my technology.

As a generalist, I felt undervalued by a partialist-dominated group. Income was distributed within the group based on work RVUs, but each speciality received different dollar amounts per RVU based on regional norms which was unfair to primary care physicians. Within the group, generalist received less income for equal unit of work than proceduralists.

I am currently doing urgent care working evenings and weekends, and would consider going back to a small primary care situation if the environment of primary care was less toxic. It appears that innovation and adaptation to change can be accomplished more easily in small, flexible practices.

Steven Horvitz, D.O.

My practice did not bite the dust. But I left the third parties in the dust in January 2008 whenn I terminated participation from all insurers except traditional Medicare. While my practice is growing, it is not yet back to the level it was pre-termination. But it is growing!! It also allows me to treat individuals like individuals, not like cattle. It also allows me as much time as I need per patient.
The answer to our healthcare system is not more government or third party involvement, but less. we need a system that allows a level playing field for all.
More on my transition is on my blog at http://doctorsh.blogspot.com/

Gordon Moore

Posted with permission from Dr. Vargas:

Just an update to you all, who have been a tremendous help over the recent years:

I am closing my practice, New Mountain Medicine (since 2006) and have accepted a job in nearby Asheville as medical director of their hospice and palliative care agency of CarePartners. It is a big step-up in responsibility, but it will allow me to do medicine that I love with more influence than I have now in my current agency.

I am excited about this change, though I admit that I do feel some grief at closing what I had hoped would be my primary care saving grace. It just didn't work out the way I thought, but then I believe that if we are careful not to force our destiny on ourselves, we can be led by a wisdom that is greater than our own.

Thanks again, everybody,
Charlie Vargas
Franklin, NC

aldebra schroll MD

below is an exceprt of a letter I sent to our president and sevaral senators in March of this year.

Dear President Obama,

I am considering leaving my primary care practice; I'd like to tell you why. Although, it has been only six years since finishing my training, I am seeing my colleagues leaving the field. In our office of eight physicians, three doctors have left in the last several months. Many medical students and doctors are looking for work outside the realm of patient care. I am one of them.
The longer I do this, the more I have come to understand that listening is the most important thing I do as a physician, it is not high tech but to be heard, really heard, is critical to healing. Unfortunately this is not what is valued in our current medical climate.
Physicians who spend more time with patients are considered under productive. When did medicine become another production model and when did patients become units of production?
A recent article from a popular physician business journal recommends that doctors give up their lunch time, eating on the run so as to see more patients and be successful. Am I the only physician who thinks this is crazy? Lunch time is my opportunity to catch up with paper work. As it is I have taken a second consulting job to try to keep up with expenses. I was disappointed to see our local spa charges more for make-up consults, hair coloring and perms than I see from Medicare for my services. Since graduating from medical school, doctors have been battling with Medicare to prevent the projected pay cuts based on the sustainable growth rate. With the impending cut of 21% to physicians in 2010, frankly I just don't have the stomach for it anymore.
Everyday has become a struggle. Irate patients swear at my office staff when insurance denies coverage for prescriptions or referrals I recommended. The patients identify their physician as the face of medicine and take out their frustrations on my staff and me. Although my biller has become resigned to this behavior, it is not right.
Then there is the issue of fear. Every day I have to wonder if this is the day I get sued. This fear drives up the expenses related to our health system.
Increasingly I find it more difficult to practice medicine the way I was trained and that is something I am not willing to compromise on.

J. Michael Niehoff, MD

I am a Family Medicine/General Practice physician in Baltimore and have been in practice for the past 25 years. I started in a single physician office located in the heart of an established neighborhood that served many elderly patients. It was very convenient, in fact, many patients could even walk to my office. I employed 3 office staff and enjoyed this practice tremendously. Unfortunately, after several years the practice was forced to close because of declining Medicare payments for preventive care and excessive insurance red tape.

I took full time position at a local hospital clinic, which is much larger and the care is less personal. Every year I have been in practice there are more and more insurance regulations and restrictions and more time required for paper work. I know physicians that have left private practice to start medical careers in the military, prison system, "members-only" practices, and offices that accept cash only at the time of the visit (no insurance).

I do not know what the answer is but I look forward to one day being able to practice medicine with the same spirit and enthusiasm I did 25 years ago.

Susan A Miller MD

I left private family practice in 2003 after 23 years because of the toxic financial environment and my feeling that my continued cooperation was just helping to prop up a broken system that is harming my patients. I did not quit entirely like at least 3 other family docs I know. I did not become a boutique practice like one of my ex-partners and several other docs in my town. I did not retrain in a specialty like two of my resident partners did. I have been working in Quality Improvement since 1994 along with IHI and the Idealized Design folks to make a better delivery system. In 2005 I became a Patient Safety fellow. Currently I am a Professor of Family Medicine in a large health system where I work every day to train someone to replace me and to improve the delivery and safety of care to patients. At least now I have a retirement fund and disabilty insurance and I don't have to be embarrassed about not being able to fund my employees for a decent health insurance plan. When I am not at work, I try every day to help to get the health insurance industry to go the way of the buggy whip and to get out of my doctor patient relationships so that everyone in this country will have the health care they need when and where they need it at a cost that we can bear.

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