The August 25 New Yorker carries a confounding article by Christopher Beam about vioent attacks upon Chinese physicians by Chinese patients. Among the many statistics is one from the Chinese hospital association which found that in 2012 there was one attack on a Chinese doctor in a Chinese hospital, every other week. The attacks ranged from fatal stabbings to bludgeoning, resulting in death or paralysis.
Another number: The record number of patients seen by a single physician, a pediatrician, was 314 patients in one 10 hour day, slightly less than 2 minutes a patient, assuming the doctor did not stop to eat or to go to the bathroom.
What is not clear from Mr. Beam's report is exactly how the Chinese system works: He does mention the goal is to insure all Chinese by 2020, which suggests China does not now have universal coverage, and the article cites many cases of patients who opted to not consult a physician because they could not afford the fees. It also notes other goals, including improving public health, improving service in rural and poor areas and improving immunization programs. This does not sound like a government run health care system. Checking on line, the health care system is variously described as "universal coverage" to virtually private, with "special care" clinics for the rich.
During the cultural revolution, "barefoot doctors," who had little or no medical training, and who worked part of their day in physical labor, were minted. Health care has not been a high priority for the Chinese.
All this is interesting because of what is happening in America, which is nothing less than a sea change in medical care. Like many sea changes, it is happening beneath the surface, and has gone mostly unreported, but it is profound and will affect everyone, eventually. For now, doctors in the big metropolises (New York, Washington, Philadelphia, Los Angeles, San Francisco) are still shop keepers, running small businesses, covering their own overhead by what they earn in the office from fees and from laboratory or imaging studies they order on their own patients.
But in the smaller towns from Pennsylvania to North Carolina, from New Hampshire to New Mexico, doctors have added up the sums and decided, looking at their own individual debt packages from college and medical school, they are just too over extended to take out yet another loan to cover the computers, office equipment, phones, medical devices, office furniture, office rent, malpractice insurance premiums, staff salaries, license fees, lawyers fees, accountant fees, payroll service fees. It will take a lot of freshly minted doctors years to dig out from under their medical school debt--who would want to take on more?
And with insurance company payments constricting, the earn back time, when you finally cross over from paying off overhead to actually making a profit, for many doctors, that occurs around October of each year, if they are lucky. Up to that time, all the money in goes right out again, to cover expenses. Obstetricians found, years ago, with malpractice premiums of over $100,000 a year, they were working six months just to pay off the premiums, before they could even begin to cover other expenses and, eventually, turn a profit.
Given these cold numbers, the vast majority of new doctors and now, veteran doctors in the examining room specialties (internal medicine, family practice, pediatrics) are looking to hospital systems, corporations of various types, universities, government agencies to put them on a payroll. Radiologists, pathologists, anesthesiologists have, for years, contracted with hospitals for their services. But now internists and all the internal medicine specialists (hematology, oncology, rheumatology, endocrinology, neurology) are looking to be employed. The current number most often quoted is 89% of all physicians are employees now.
Typically, the MBA corporate types offer a "bait and switch" option: Sign on for a relatively high salary, but know that is the highest salary you will ever see. After two years of that, the corporations starts squeezing the doctors to see more patients at a lower salary. Once you have moved your family to a new location, you are loathe to move again, but that's what is happening more and more as doctors see their salaries cut in half after the two year "honeymoon" period.
Who will cry great tears for rich doctors who are making six figures?
The fact is, they are barely reaching six figures, and many are not reaching more than five figures and as they make the difficult decision and pull up stakes and leave town, the patient is faced with high turnover in his doctors, as doctors simply follow the money elsewhere.
The MBA's who "manage" practices for corporations know nothing about "quality care" and they see anyone who has the piece of paper on the wall as the equal of any other--so a nurse practitioner or physician's assistant from the New England College of Osteopathy or Quinnapiac University is the equal of a graduate of Harvard Medical School, who trained at Mass General. They all can write prescriptions and charge insurance companies for the office visit. That's what counts to the MBA's. When asked about the way doctors would be assessed for "productivity" the MBA manager was faced with a description of a doctor seeing a complicated patient, who required a sonogram and a fine needle aspiration of a nodule and a history and physical and he was asked if the doctor doing all this was less productive than the pediatric nurse practitioner who saw five well babies during that same hour. "It's the number of patients," the MBA replied. That became known as the infamous "body count" answer among the doctors at the biggest health care corporation in New Hampshire. Since then, three of the four oncologists at that hospital, all three endocrinologists, two of three neurologists, four primary care internists have all quit and found work elsewhere.
The MBA's still have their jobs. In fact, from the corporate point of view, those MBA's have been "productive." They have reduced overhead, lowered the number of dollars spent on salaries for the unit. If nurse practitioners are now managing diabetic patients and physician assistants are now de facto neurologists, not to worry--profits are up.
It's all in the way you look at it.
It's a world in which the doctor has become disconnected from the patient. It's the road toward Chinese medicine.
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