“It was urgent-care, pump-it-out, production-line work,” she says.
With a patient load of more than 2,000, she struggled to make connections or even to remember names. Says Ibrahim: “I would grab lunch at the grocery store, bump into a patient I had seen that morning, and not remember that I saw them.”
Having decided it was time to leave clinical work, she began exploring jobs on Capitol Hill and research work at NIH and the Centers for Disease Control and Prevention. After just five years in practice, she was going to give up seeing patients and abandon a career that had been her dream.
Ibrahim’s story is not unusual. In a survey of family practitioners and general internists last year by researchers at the University of Wisconsin, about half called their work life chaotic; a quarter reported burnout. Fewer than a quarter said that their practice “strongly emphasized quality.”
Doctors blame Medicare and insurance, which offer more generous reimbursement for procedures than for the office visit, history-taking, and conversation that are critical to primary care. There’s always been a gap between reimbursement rates for specialists versus primary-care physicians, says Janice Ragland, a Herndon doctor who’s president of the Virginia Academy of Family Physicians. “That gap used to be two to one. Now it’s four to one.”
According to an annual survey by a national medical-placement firm, family doctors, pediatricians, and general internists are the lowest-paid physicians, making $171,000 to $186,000 a year. Orthopedists make nearly $500,000 a year, while radiologists take home nearly $400,000.
“There’s too much work and not enough pay,” Ragland says. “We spend probably 40 percent of our time on paperwork, phone calls, reviewing labs—work that doesn’t get reimbursed.”
Faced with low reimbursements, general practitioners often pack as many patients into a day as possible. Even then, they may put in long hours, hustling through ten-minute appointments to maintain a practice that gets by on thin margins.
Doctors in training hear these war stories and choose specialties that promise more money—particularly those physicians-to-be who’ll leave medical school in debt. In the past ten years, the number of medical-school graduates who choose residencies in family medicine has dropped by half. Numbers also have fallen, if not as dramatically, in pediatrics and general medicine.
Declining entry into primary-care medicine reflects a generational change in attitudes as well. Years ago, doctors going into practice were committed to working sunup to sundown to give patients full access, says Dr. Shyrl Sistrunk, associate dean for curriculum management at Georgetown University School of Medicine.
“That’s really not a model being propagated now,” Sistrunk says. Med-school students are interested in a career with flexibility so they can take time off for children, relief work abroad, or other ventures.
“Rarely does a student talk about the money they want to make,” Sistrunk says. “They talk about the lifestyle they want.”
The declining number of young primary-care doctors couldn’t come at a worse time. General practitioners are retiring in large numbers just as waiting rooms are filling up with baby boomers who’ll need extensive medical care in the coming decades. The shortage of primary-care doctors will only be more noticeable if the health-care reform moving through Congress succeeds in giving millions more Americans access to doctors for the first time.
Sandy Ibrahim was scouting non-clinical jobs when she heard about PartnerMD. She attended one of the company’s recruiting events, where company officials and doctors mingled over cocktails. Then she went through a year of interviews and vetting, including trips to Richmond.
Ibrahim liked PartnerMD’s promise that she could spend the time with patients to practice medicine as she had been trained. She sensed that the job would translate to a better balance of her work and home life.
“Yes, I’m a doctor,” she adds. “But I’m also a mom, a wife, a sister, and a daughter. I have many other hats that I wear. Maybe it’s my generation, but being a doctor can’t be my entire identity.
“I took a pay cut to come here—a $25,000 pay cut. That’s how miserable I was.”
Nearly two years later, Ibrahim has nearly 400 patients. Though some are from her old practice, she didn’t remember some when they showed up at PartnerMD.
Each patient gets a yearly health assessment that includes bloodwork, a physical exam, and a session with a nutrition-and-fitness coach. The process takes up to three hours. At her old practice, Ibrahim says, she crammed physicals into 15 minutes.
On any day at PartnerMD, she sees eight to ten patients, about a third of her load before. “You just get to know so much more about each person,” she says. “I now have the kind of relationships with patients that probably took my former boss 15 to 20 years to make.”
The extra time allows her to focus on prevention. “Let’s say a patient comes in for a physical, and his blood-glucose level comes back at 101,” Ibrahim says. “That’s just barely prediabetic; normal is less than 100. In my old practice, we’d see how the patient did at his next physical. Or maybe we’d have him come back in six months.”
“Here, when I get a level of 101, I have the time to research that. I’ll go back and look at old records and try to pick things up in their family history, lifestyle, medications, or other factors. And I’ll tell him: ‘This is what I want you to do. I don’t want to wait until you are diabetic.’
“That’s pretty aggressive. In my old practice, we might have waited until the blood-glucose level was 120. But I don’t want to wait. We’re trying to catch those pink flags before they become red flags.”
Dr. Timothy Soncrant was also looking to do better preventive care when he opened the David Drew Clinic in the late 1990s. The founder of the clinical-treatment program at the National Institute on Aging, Soncrant created a small practice whose signature is a marathon annual physical with a battery of tests that include image screening for cancer, blocked arteries, and aortic aneurisms.
Today he and colleague Jeffrey A. Elting, a White House physician for Bill Clinton, manage the care of no more than 1,000 patients, each of whom pays about $4,000 to $5,000 a year for the physical and routine care.
Many doctors who convert to concierge medicine don’t go it alone. After more than 20 years in medicine, Bethesda internist Alan Sheff made the leap only after MDVIP, the Florida-based for-profit concierge network, evaluated his patient base to determine whether enough of them would follow him to the new venture. Company officials also helped organize several town-hall-like meetings, each with hundreds of patients, to explain the change.
“A physician who tried to do this on his or her own could really break the practice in an irreversible way,” Sheff says. He opened his doors in 2003 with about 300 patients, nearly all from his old practice of almost 3,000. He’s now capped his patient load at 550, and he has a waiting list.
MDVIP collects the $1,500 annual fee from patients and pays the physician $1,000. Sheff says he likes that MDVIP sets quality and service standards for its doctors; offices must be staffed to answer the phone—“By the second ring!” says Sheff—and he must give patients written reports following physicals.
“I don’t have to wear the business hat all day long,” he says. “I’m back to being a doctor.”
Mark Vasiliadis and Kevin Kelleher, longtime family doctors in Northern Virginia, opened a concierge practice in 2004 while continuing to run their traditional office. They considered MDVIP but ultimately decided that they wanted their new business, Executive Healthcare Services in Reston, to reflect their own standards of care.
“We had the sense that we would be constrained in their practice model,” Kelleher says. “Our goal was just to provide better and unique care; it wasn’t to become concierge doctors.”
Vasiliadis and Kelleher limit their patient loads to 300 patients each—about half of a typical MDVIP practice. Each pays a retainer of $200 a month, or $2,400 annually, with children at $50 a month. Nearly 100 percent of patients renew, Kelleher says.
Kelleher says they focus their practice on wellness and prevention. They see the primary-care doctor almost as a coach who motivates his patients to do the work—through diet, exercise, medication, and the like—to maintain their health and keep small problems from turning into big ones. When they need specialty care, they consult with the outside doctors and track patients’ care and progress.
Tech entrepreneur Roger Mody came to Executive Healthcare Services shortly after the new practice opened. He was 41 and had largely ignored his health—until Vasiliadis found a potentially life-threatening problem. Vasiliadis became the quarterback for managing his care; within days, the doctor had set up appointments with specialists, and surgery was arranged to head off the trouble.