Friday, August 27, 2004

What happens when there aren't enough generalists?

First, conscientious generalists get overworked, like this doctor:
Working 12-hour days and five-day weeks in her solo practice, she often double or triple books patients.

While most doctors in the area close their books to new patients when they get overloaded, the Aldinga Surgery GP refuses to. "I try to see people within a few days which is at my own detriment," Dr Mayne said. "We try to fit patients in at some stage, within a couple of days.

"Other people (GPs) just say `I am seeing this number', other GPs have a four week waiting time.

"But I have been here 18 years. I don't really want to knock back an 80-year-old woman who has been seeing me for many years."

Dr Mayne said demands on GPs had increased dramatically in recent years.

"The area has grown immensely and there is just no help," she said. "You can't get locums, you can't get people to do sessions, can't get partners in a practice.

"Waiting times for specialists have made people totally disillusioned by the public hospital system, this all puts more pressure on GPs.

"It has got to crisis point. I am sick of it, I don't want to do it for much longer."

A diary kept for The Advertiser by Dr Mayne showed she was seeing an average of 40 to 50 patients a day.

Secondly, frustrated generalists give up:
Christchurch doctors are walking away from their practices as the shortage of GPs spreads from rural areas to the cities.

Increasing paperwork, the growing threat of litigation and the lure of more lucrative positions in other health-related sectors are taking a toll on existing doctors and making the profession unattractive to debt-laden medical graduates.

A New Zealand Medical Association report shows the number of GPs nationally has dropped almost 10 per cent over two years, and with rural communities already in crisis, health professionals are now saying Canterbury's urban centres, once flush with doctors, are starting to suffer.

The West Coast has the lowest rate of active GPs per capita in the country, with some doctors reporting more than 6000 patients on their books.

In Rakaia, residents have been without a permanent GP for months, and the community has formed a trust to take administrative pressures off the doctor and keep the practice alive. The community is served by a locum and are close to securing a permanent replacement.

The Christchurch School of Medicine's public health and general practice department head, Les Toop, said compliance costs and uncertainty within the profession were putting people off taking on even the most sought-after practices.

"It's happened for some time in rural communities but now it's starting to be seen in the bigger centres. Some doctors aren't even bothering to advertise, they're just shutting up shop."

Thirdly, the remaining generalists are under more pressure because there aren't enough physicians. Overwork. Burnout. Rinse. Repeat.

OK, big deal. These news stories are from Australia and New Zealand. This couldn't happen here in the US, right? It already is.

As a retired schoolteacher with health insurance, Dot Goodwin never thought she would have a problem getting an appointment with her family physician.

She became ill and discovered that her doctor of 30 years had joined another practice.

The doctor who assumed his practice wasn't taking new Medicare patients.

"There I was, bad off, and had to go to the emergency room for treatment," she said.

An emergency room worker told Goodwin about a doctor with a new practice in Decatur. A Lawrence County resident, Goodwin got an appointment with the doctor and continues to see him.

She is one of the lucky few who are able to find a primary care physician in Alabama. Sixty-two of Alabama's 67 counties have doctor shortages so severe that the state has declared them Health Professional Shortage Areas.


Barganier said some primary care doctors in Alabama treat as many as 8,000 patients.

"There is nothing like being the only physician in a town or being only one of two," Midgley said. "It's hard to take a vacation, it's hard to have family time because you're working all the time."

He called it a self-perpetuating cycle.

"It's hard to attract new doctors because they won't have any backup," Midgley said. "What we have said is that our medical schools need to do more to address the problem. They need to turn out more primary care physicians than they do."

I would argue that churning out more primary care physicians won't happen because let's face it: what medical student would want to walk into this kind of situation? One of the solutions has got to be increasing the reimbursement rate for primary care physicians so that they can make a decent living without working themselves to the bone. If medical students see happy family doctors, they will want to become a happy family doctor, too.

What happens when there aren't enough generalists? Patients and doctors suffer.