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The family doctor is drowning in patients and paperwork. Is this the end of managed care?

Practice Under Pressure


If your family doctor seems a little stressed out and doesn't have as much time to catch up on your children and your job and your favorite hockey team, there's a reason. More than one, actually.

Long hours, more patients than ever, reams of paperwork and increasing overhead to comply with managed care demands. Decreasing income. And there's no relief in sight. Medical-school students are shying away from family practice as they see seasoned doctors working dawn till dusk for pay that is a fraction of what a specialist can get.

What is happening to the doctor who, for decades, has been the foundation of your medical care?

It's 7:55 a.m. Dr. Richard Gergoudis stands behind his desk in a crisp white lab coat, two stethoscopes dangling from his neck and a telephone receiver jammed in his ear. He's talking rapidly in his customary quiet voice about blood pressures, pulse, height, weight and a host of afflictions, from conjunctivitis to cancer. He's catching up on dictation he didn't get done the day before. And he already has two patients waiting anxiously in exam rooms down the hall.

All over his tiny windowless office deep in a warren of halls and exam rooms, piles and piles of patient charts await his attention. Some piles contain his newly transcribed notes — he'll look each one over before it gets refiled. Four piles contain some 25 charts each with lab reports attached to their covers — he'll call each patient to inform them of results rather than send an impersonal card. Another pile, on his desk, is made of charts of patients who called him late the day before.

With his nurse, Carolyn Rice, by his side, he takes a cursory look at the callback pile to see what kind of action will be required: a prescription refill, a lady who can't get out of bed, another woman he says he'll call to check to see if she's improving, a pre-authorization needed for a patient to get a prescription filled for a medicine not approved by her insurance company.

"She needs a call from me," he murmurs, checking one phone message. "She has a personal issue." Another needs special attention — she has called, fearful that she may be headed for a recurrence of cancer. Dr. Gergoudis plans to call her oncologist, then call her back to tell her he's called.

At 8:15 he steps into his first patient's exam room and greets her warmly. He asks about a doctor he'd referred her to: "Did you like him? Was he nice?" He inquires about her job, her exercise, her appetite. She confides that she recently broke up with her boyfriend. He remembers the relationship, sympathizes, encourages her for making a healthy decision. The patient confesses that she hasn't had a mammogram for much too long; Gergoudis is firm in his directive that she must make that appointment right away.

"For me, part of the fun is the dynamic of the patient-doctor relationship," Gergoudis says, as he returns to his office to dictate notes on his first patient of the day. "Coming here brings out the niceness in people. It's a privilege, really, to work with them. I remember hearing someone say, 'Everyone who comes to see you is paying you a compliment because they're asking your advice.'"

But often that advice must be engineered delicately, always with time management in mind. "When I walk in the room, I have an agenda. Maybe I want to discuss cancer-detection strategies. But the patient also has an agenda. … Some bring a long list of complaints. By the end of the visit, you hope you've gotten things accomplished."

While on an average day Gergoudis's office takes 750 phone calls for the six providers who practice there, "we do focus time and attention on patients who are here," he says. "When someone has taken the time to come in, we owe them that."

When asked why he chose family practice over the many possible medical directions he could have taken, he says, "I enjoy talking to people and getting to know them. I like looking at the care of the whole person and being the coordinator of their health care. Ninety percent of my patients become friends, and I want to take care of them. It's that rapport and those relationships that appeal to me."

Since he went into practice a decade ago, he says, "the business of medicine has put more pressure on doctors to be more productive in terms of numbers. You have to see more patients in a day. Our volume has definitely increased almost 50 percent."

Part of that is due to the affordability of health care — low co-payments have inflated the number of patient visits. Many doctors have stopped taking new patients.

Gergoudis says that having a good support system at home makes all the difference when you're working a 60-hour week. "It would be impossible to do what I do without the support of my wife." He starts work at 7 a.m. and returns home between 8 and 8:30 p.m. Cognizant of the wear and tear of such a schedule, he worries about new doctors just starting out who are going through the shock of the reality of being a primary-care physician.

"I'm not sure everybody has the stamina for this," he says.


A busy primary-care physician normally has a patient base of 2,500. Gergoudis has 3,500 to 4,000 patients who've chosen him as their "provider."

Gergoudis starts the day with 19 or 20 scheduled visits, eight of which are physicals, and by the end of the day he'll have seen 35 patients. Twenty will call before 9 a.m. wanting to see him that day and some will be "worked in," a euphemism for sandwiching patients who are willing to wait as long as a couple of hours to see the doctor. Though Gergoudis practically runs from patient to patient, he manages to greet each patient with his trademark calm and collected countenance.

Lunch is frequently provided by sales reps from pharmaceutical companies, but Gergoudis contends that "we are not swayed by gifts and all that." "A Chick-fil-A sandwich," he notes, "is not going to get me to prescribe their drug."

The drug-sales reps lurk everywhere, from the sample closet (where they are forbidden to pitch doctors) to the halls where they check their minicomputers. "We have a sign up asking them not to detail doctors in the drug closet because it takes away from our time with patients," Gergoudis explains, as he grabs a dose of antibiotics and races back to an exam room.

By noon, Gergoudis has discussed blood pressure, smoking, ulcers, sleeping habits, bone density, diabetes, muscle relaxants, a cough, a sore throat, an estranged husband, HIV, a baffling pain in an armpit, football, golf, alcohol use, decongestants and Viagra. He has carefully considered a request for painkillers — "you have to be wary of pain-med requests." He has seen new patients, conducted four physicals, returned phone calls, dictated some notes, called a couple of specialists, made plans to do rounds later, glanced at a towering pile of mail.

Lunch? He's running an hour behind. "Some days we just work right through lunch," Carolyn says, as she sweeps into an exam room, tears off the wrinkled paper table cover and sets it up for the next patient.

It's not far-fetched to say that doctors like Rick Gergoudis may be a dying breed. They're making a valiant attempt to practice old-fashioned medicine in a newfangled system, but it's clear that the system may get the best of the tradition.

ou may have heard your grandmother talk about old Doc White. He saw you in his office on the same day you called. He came to your house when you were too sick to get out of bed. When he billed you, you paid in full or worked out a payment plan with him. He knew you were good for it because he'd known you all your life.

Things are different now.

The same guy is called a "primary-care physician," a term coined by insurance companies. The category technically includes general practitioners, family doctors, internists, pediatricians and obstetrician/gynecologists, all of whom may be seen directly by a patient, that is, without a referral from another doctor. You had to choose him or her from a list of "providers" that your insurance company gave you, and, if your employer switches companies, you may have to choose someone else regardless of whether you've spilled your guts to him about your health history. He'll never come to your house; if you're a relatively healthy person, he may not even remember your name.

You'll pay your doctor less when you leave his office because you're only responsible for a "co-payment." That's a good thing. But the insurance company is paying him less, too. Your doctor receives only a part of the full balance of the bill.

Adding to the pinch, Medicare recently reduced its standard reimbursement to doctors. So, mindful of his bottom line, he's packing extra patients into his day to help make up the difference. That means less time in the exam room with you and more stress for him. Plus, there are tons of paperwork that he must provide the insurance companies to whom he is beholden.

And then there are the hundreds of patients who really need to see a specialist but are required by their insurance company to see their primary care doctor first to get a referral. And there are the pre-authorizations required of doctors who want to prescribe a medicine not covered by your insurance plan.

So what ever happened to the family doctor? Formerly in business for himself and able to set fees and provide the care he felt best met the needs of the patient, he now gets his patients from "managed-care" contracts (two kinds: capitation and fee-for-service, neither of them terribly profitable) he's signed with insurance companies.

Originally set up to control rising physician fees and make health care affordable, the downside of managed care is now wreaking havoc for doctors and their patients.

Some doctors are doing their best to comply with the system and provide quality care. Others, frustrated by the stress on their personal lives, unwilling to compromise on the care they feel their patients deserve and discouraged by income potential, are opting out.

In the Richmond area, family doctors can make roughly $100,000 to $150,000, according to the doctors interviewed by Style. Specialists can make double or triple that amount, depending on the complexity of the procedures they perform. Cardiovascular surgeons, for example, command among the highest salaries, up to the half-million mark.

Dr. John Harler practiced internal medicine as a family physician for 21 years. A year ago he gave it up. A native Richmonder, Harler attended the University of Richmond and Virginia Commonwealth University's Medical College of Virginia, then chose internal medicine for its diagnostic challenges.

"My first love was the challenge of making the diagnosis," Harler says. "I chose primary care mainly because I felt like I could put that skill to best use there." He set up business as a solo practitioner and developed a patient base of families who made his professional life rewarding. But soon a little thing called managed care changed all that.

"It became more and more difficult to give people the time they need and, thus, to do the things necessary to be a good diagnostician," Harler says. "The number one thing that stands out in my mind when you think about how to be an effective physician … is that the number one tool you use is your ears. If we listen long enough and ask the right questions, if we have the desire and compassion to listen plus the skill from our training along with wisdom from experience, then you can be a good doctor. If you can't use all of those tools because you don't have enough time, then diagnosing is hit or miss and guesswork, which lead to frustration for the patient and the doctor."

Harler found that with the constraints of managed care he was unable to provide quality care and maintain a sense of his own well-being. Some doctors call it "mangled care." Harley explains: "Mangled care is the management of the cost of practicing medicine, and the patient gets mangled in the process. It's not designed to be an effective way of managing anything."

He finally decided that the kind of medicine he wanted to practice could not be practiced within the current system. "In order to maintain revenue — I should say that 1985 was the last time I had a raise — you have to see more patients per day," Harley says. "To do that, you have to spend less time with patients. I just got to the point where I was working 16 hours a day, trying to do the office, the hospital and the paperwork. ... The stress was too much and I had reached a point of diminishing returns where I wasn't doing the patients any good. There was no alternative but to get out."

Now Harley works for the state in a hospital, puts in eight hours a day and earns the same income. "But no stress," he emphasizes. "I punch a clock, something I never thought I'd ever do. It's called survival. And I'd much rather be able to give 100 patients 100 percent of what they need than 1,000 patients 10 percent of what they need."

r. Robert Hurley, an associate professor in VCU/MCV's department of health administration, has been teaching classes on managed care for 15 years. He has seen the rise of managed care and is now noting the markers of a fall.

Like Prohibition, he says, "managed care seemed like a good idea at the time, but it has been difficult to really put into practice. And now we may be looking at repeal."

Historically, he says, "managed care was meant to empower the primary-care physician, but problems arose. The features proved burdensome. … Numbers of patients, referrals, pre-authorizations … all of that was hassle-ridden."

Family physicians have been caught up in an odd paradox, Hurley points out. Managed care was set up to contain the cost of health care. Managed-care contracts attempted to do so by paying doctors less for their services. Doctors, in turn, counteracted the cash cut by seeing more patients, a practice that ostensibly has helped them maintain their bottom lines, but surely created more stress — and, ultimately, lower quality of care.

Looking at primary-care doctors' practices through the lens of a contemporary business model, Hurley says, "I think we're seeing the end of a cottage industry of the practice of medicine."

In other areas of business — retail, banking, law, etc. — we've watched the megagroup come in and take over with streamlined management and the security that comes with being bigger.

Compared to this trend, the primary-care physician is "an anachronism," Hurley says. "And we haven't come up with a new mechanism to make the option more efficient and stable. The idea that a primary-care physician is still sitting in his office with a couple of nurses and a girl out front is antiquated."

The only entity on the Richmond scene to challenge that structure is Patient First, a business initially set up to offer urgent care at a cost less than that of the hospital emergency room. Over the years, however, Patient First has worked out contracts with insurance companies that have allowed them to develop a healthy — literally and figuratively — patient base. The company has pulled a number of well individuals, who only occasionally need care, away from the patient base of family practices.

"It's killing us," one family doctor says of the Patient First model. "We're left with the chronic cases who need constant care, and in a capitated plan, where we're paid a fixed $6 per month per patient, regardless of how many visits that patient makes, it's not good."

Another potential contender, though one that will probably not have as sweeping an effect, is the new concept of "boutique" doctors. As recently reported in the New York Times, two Manhattan physicians are setting up a new form of private practice where they will charge $4,000 for a year of care that includes round-the-clock access and a host of other perks to about 300 patients. Because it is accessible only to those able to pay, this solution has been criticized, but it suits the doctors who are sick of not making a decent wage. It also suits patients who can afford the plan and who want to avoid the managed-care routine.

Insurance companies, too, are heeding the call of customers who want to skip the primary-care-physician and referral step and go directly to specialists.

As with most anything in life, Hurley notes, if you're willing to pay more, you get more choices. So as insurance companies begin to back away from the managed-care model and give patients more options, premiums are beginning to rise.

Is there a future for the family doctor? "If I were a primary-care physician, that's a question I'd be puzzling over," Hurley says.

The vast array of information available on the Internet is enabling patients to educate themselves about highly specialized medical topics about which their general physical may only be superficially knowledgeable. Generalists, says Hurley, "can't know everything about everything. You can't be an expert in all areas. As we see heightened specialties and alternative channels of medical care, it does cast some doubt on the long-term role of the primary-care physician."

The areas where the family doctor still excels are in the coordination of a patient's care, especially where there are several specialists treating the same person, and in the personal relationship and reassurance the doctor can offer. But even that reassurance component has its competition — patients can get help from phone lines, online discussion groups and the volumes of data available on the Internet.

It's no wonder that, according to the American Academy for Family Physicians, requests for family-medicine residency matches have been declining for the last four years. After all, it costs the same for a future family doctor to attend medical school as a future cardiac surgeon, but the generalist's income will be hundreds of thousands less per year than the specialist's. Same number of years in medical school (specialists undertake years of specialized training after med school), same hard work, same blood and guts, often the same debt. But generalists and specialists receive very different incomes, in part because specialists' jobs include costly procedures; in addition, they have a much higher reimbursement rate than generalists'.

A recent report by the family-physicians' academy stated: "Long hours, low reimbursement and high medical-school debt don't add to the specialty's appeal, and students have begun to turn to other specialties that provide better pay and more control over lifestyle choices."

Said a doctor who contributed to the report, "We've let the hassles of managed care — which are very real — overshadow the immense satisfaction that we receive from being in direct contact with our patients. We've somehow got to change that."

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