When Navarro started her St. Louis-based firm, Work Transitions, 17 years ago, that group didn't include physicians. Now they account for one-third to one-half of her clients. "They're showing up even more frequently than teachers, lawyers and social workers," she notes wryly. "These are very bright people with a very limited perspective on the world. When they start getting unhappy with medicine, their whole world caves in."
One of her clients is Dr. Edward A. Palank, 53, a practicing cardiologist for 25 years who rose to the directorship of the New England Heart Institute. He heard about Navarro through the fast-souring medical grapevine, just as a corporate hospital merger and angry community backlash had taken the last bit of joy out of his practice. Humbly, he worked with Navarro for months, finally forging a plan to start his own medical-communications firm and several other endeavors.
Palank grew up watching patients come to see his dad, a general practitioner who set up his office in their house. "Medicine was what I wanted to do from second grade on," he recalls wistfully. "The only semblance of managed care in my dad's day was the barter system: We'd get the plumbing fixed if my dad provided an office visit.
"The doctor-patient relationship is what it's all about," he insists. "Can't be measured." There's always been room for improvement, of course: "Physicians wait, on average, only 17 seconds before interrupting a patient," Palank groans. "Now, with managed care, there's even less emphasis on listening. You have management saying, 'Do this,' and HMOs saying, 'Do it this way.'"
He misses the patients but not the frustrations. "If someone has a hot belly and it's an appendix, you take the appendix out," he says. "At 2 in the morning you don't make a conference call or develop a consensus, you act. That's what makes you a good clinician. Now, you have to check on the procedure, you incur a financial penalty if you do not discharge the patient, you have to follow algorithms and you really should not deviate.
"It may be the correct standard 90 percent of the time," he concedes, "but your ability to treat that other 10 percent is.... " He breaks off, then mutters, "Your hand will get slapped. You will have to explain to some secretary who has no knowledge of medicine and is checking off boxes. I once testified before the Labor Commission about someone entitled to disability, and it was denied because the diagnosis I gave them wasn't on their list."
Tired of Arguing
Dr. Sara Lawson (not her real name) is a 43-year-old gynecologist on the West Coast. She, too, is consulting Navarro, trying to figure out whether to restructure her practice or explore options outside medicine. In an effort to explain, she blurts out a story about a patient who called on a Saturday morning, about to leave town but panicked by a mysterious swelling in her vagina. Lawson surprised herself by sending the woman to the ER instead of seeing her, which would have violated HMO rules, disrupted her family's day and earned her about $10 in reimbursement.
"When you decrease reimbursement so low, you can't motivate somebody to do a procedure," she says later. "At $200-$400 for a hysterectomy, why would I want to go to the hospital to do the hysterectomy, then round on the patient for two days, when I can just stay in the office?"
Lawson sounds callous, speaking these thoughts out loud. And she's not happy about it. "When I first started, I'd see a patient any day of the week if they needed to be seen," she points out. "Managed care has deteriorated the physician-patient relationship. The contractual, financial relationship is no longer between the physician and the patient; it's between the physician and an insurance company who doesn't always have the patient's best interests at heart."
A single parent whose bankbook doesn't reflect the bucks people assume, Lawson's paying for naivete. She tried five years to make a go of it in solo practice -- took out loans to buy medical equipment and leased office space, then couldn't fill the rooms with patients. When she succumbed and got herself onto some HMO panels, she found herself busier than she could stand -- but money was still tight. So was the vise of paperwork.
"If I want to do a procedure," she explains, "I have to submit paperwork, diagnosis, procedure, support it, send copies of the ultrasound, medical exam, history...." Managed-care companies don't often deny major procedures, she adds fairly, but they shun preventive screenings (like a $200 bone-mineral-density screen) and drag their feet on covering promising new -- and therefore expensive -- medications (such as raloxifene, a new "smart" estrogen that maintains bone mass in menopause without increasing the risk of cancer).
Lawson's tired of arguing. "I had a patient who was 42 and had an ovarian cyst," she recalls, "and when I tried to get her surgery authorized, the vice medical director said, 'Is she having pain? Why does she need to have it taken out?' I said, 'It's a cyst -- you don't know what it might be.' She said, 'Well, it's not cancer.' I said, 'How do you know?' The odds were low, but it was possible. Finally, I said, 'Look, it's standard of care (accepted managed-care protocol) to remove this.' Then they agreed."
When Lawson looked around, she saw "doctors leaving, doctors retiring early. Every few months there would be somebody who closed a practice." Meanwhile, in hospital OB/GYN meetings, the topics were changing. "We used to talk about when to initiate antibiotics when a woman has ruptured membranes, or how to manage an ovarian cyst. Now we talk about financial issues, managed-care contracts, how to minimize care to the patients. Can you decrease the number of prenatal visits? The number of times someone needs a Pap smear?
"One hospital trained janitorial staff to answer patient bells," says Lawson. "If I'd call about a patient, I'd have a hard time finding the nurse, and it'd take her a while to get oriented; she wouldn't know them by name." One day, Lawson called to check on a patient and was told, "Oh, her baby's doing fine." Whereupon she dryly reminded the nurse that Mrs. Smith had just had a hysterectomy.
Another time, a colleague was paged while talking with Lawson. A patient was undergoing ultrasound, and it looked as if she had ovarian cancer. Trying to swiftly schedule the patient for surgery, the other physician groaned, "Oh, I'm going to have to get a resident." When Lawson said that that should be easy, her colleague said, "No, they don't like to operate. They want to go home on time."
Granted, residency used to be a ring of Dante's Inferno, and the new regulations limiting work hours are a welcome reprieve. But in Lawson's opinion, attitudes are turning a little too 9-to-5. "You are producing a new generation of doctors whose expectations are different," she warns. "They don't expect to make as much money, and they don't expect to work hard.
"But you get what you pay for."
It's Just Not Fun Anymore
Every doctor has flashes of discontent, hints that the practice of medicine isn't what it could be. Today, more doctors are heeding them. Unable to reconcile themselves to managed care, they're leaving the frustrations of clinical practice for jobs as health-care executives and consultants; retiring early on disability; leaving medicine altogether.
In California, where managed care soaked in like cocoa butter, a 1995 survey showed 21 percent of office-based physicians over 50 wanting to retire or sell their practices within the year. A San Francisco survey of mental-health practitioners found 43 percent considering leaving the field. Last year's American Medical Association focus groups identified work pressures and job insecurity as leading causes of dissatisfaction with physician careers. The most recent Family Practice Management journal reports that nearly seven of 10 physicians consider themselves anti-managed care.
Then there are the articles: "You Don't Have to Plug Along," in Dermatology Times. "Changing Courses" in American Medical News. "Thinking About a Career Change?" in the Health Care Almanac. "Goodbye Hippocrates! Yes, There Is Life Away from Medicine" and "Which Doctors Are Quitting Medicine?" in Medical Economics. These articles give tips about administrative and pharmaceutical jobs; they tell stories about a psychiatrist now selling real estate, a neuroradiologist designing Web pages, a cardiologist teaching tennis. (There's even an ophthalmologist who started the Managed Care Blues Band, recording "You Picked a Fine Time to Leave Me, Blue Shield.")
Finally there are the career counselors and management recruiters, who say physicians are littering their doorsteps ... for the first time ever. Susan Cejka, president of Cejka & Co., a St. Louis-based firm that conducts physician and health-care-executive searches, calls the departure from clinical practice "a major trend. It generally happens around age 40. About 80 percent become disenchanted; 10-15 percent actually leave."
The renunciation isn't always dramatic. "What you are seeing," explains Cejka, "is a tremendous rise in physicians who become managers and consultants." She does acknowledge the "hassle factor" of managed care but puts more emphasis on the end of loyalty. "Patients no longer revere physicians," she says gently. "I think it was the patients that held the physicians in place. They couldn't bear to leave their patients. And now, for a $10 change in co-pay, your patients leave you."
After hours of listening to her clients' wails, Navarro describes the shift in terms of trade-offs. "There's a huge gap between doctors' expectations and today's reality," she observes. "They expected a huge educational debt, long hours, lots of responsibility and, in return, a lot of independence, money, job security and a chance to do good in the world. The reality today is that their freedom to practice medicine is curtailed by insurance companies; their compensation is declining relative to the cost of living; the possibilities of self-employment are limited or nonexistent, because insurance companies are reluctant to contract with individuals; and job security is shaky."
Navarro patiently guides clients through an inventory that forces them to "reach down into their guts and their souls." Sort of like exploratory surgery -- without anesthesia. "It's gut-wrenching," she admits. "They look at three to eight different ideas before they can hone in on what is right for them." Then comes a job hunt or more education, "which is mind-boggling, considering how much education these folks have.
"Sometimes," she adds, "they just decide to play their cards differently, define a niche, position themselves. Today's physicians have got to earn their keep; they've got to show revenue. They can't just be brilliant anymore."
Time Is Money
It's hard to muster pity for overpaid, overadulated demigods who've scraped their knees on what, for most of us, are everyday demands to be more useful than brilliant. According to a Medical Group Management Association survey, specialists' income increased by 6 percent between 1993-1997. The consumer price index rose 11 percent. Suspicion lurks: Is all this Hippocratic bitterness just the result of thinned pocketbooks? And if so, why should the rest of us commiserate?
The answer's simple. If time is money, money is time, and the change in physician compensation is also changing the amount of time physicians have to spend on us. HMOs pay them not by the amount of work they do but by the number of patients on their panels. Quantity's what counts. And unless you're a Houdini who can listen thoroughly and make a patient feel heard in five minutes, the physician-patient relationship suffers the consequences.
St. Louis psychiatrist Dr. K. Lynne Moritz is watching younger colleagues piece together part-time jobs that require a road-trip commute, just to supplement their therapy-leery managed-care practices. President of the St. Louis Metropolitan Medical Society and director of the St. Louis Psychoanalytic Institute, Moritz decided several years ago not to belong to any managed-care panels. Her patients either carry expensive indemnity insurance or pay out of pocket. But younger psychiatrists, "who don't have a reputation to fall back on for referrals, have great difficulty doing anything except managed care," she notes. "And managed care wants them to do only medication management. It's a very tricky business, because they often pay you more for a 15-minute medication-management visit than they do for 45 minutes of therapy."
One new psychiatrist was doing a fellowship in child psychiatry and was working at a clinic that recommended eight-minute visits. "Twelve minutes were recommended for a new evaluation of a geriatric patient," Moritz exclaims. "You can't even write down the meds they are taking in 12 minutes. This is terrible for physician-patient relationships. And if you don't have a relationship with your patients, they flush the medications down the toilet."
Back to the visit in question: "A 7-year-old girl was telling her grandmother and the psychiatrist -- for the first time -- that an uncle had been using her sexually," recounts Moritz. "All of a sudden there was a banging on the door and a nurse saying, 'Doctor, your time is up -- you must move on."
Brave New World
"Doctors have been seriously well-paid, and they have not stepped up in terms of accountability," observes Dr. Mary Frances Lyons. A board-certified cardiologist at 29, she left clinical practice several years later and now conducts executive-physician searches for Witt/Kieffer, Ford, Hadelman & Lloyd. "Now other entities are giving out the terms of how doctors will do business, and doctors have to accept that." How's it going? "Not well," she says dryly. "You hear a lot of 'We don't get enough input'; 'They are trying to control us'; 'They can't make us do this'; 'Why did I go to med school?'"
Doctors tend to be a bit passive-aggressive, she adds. "They vote with threats -- 'I'll take my patients across town' -- and use maneuvers that can be perceived as vindictive and childish." On the other hand, "their professionalism is totally intact when it comes to decisions about their patients. They will never knowingly make a poor decision about patient care just because they are mad about managed care."(There are indirect consequences, though. Navarro went to see a specialist at Barnes and the physician walked in fiery mad, fresh from a four-hour meeting about restructuring the department and furiously preoccupied.)
"They are not thinking about health-care systems, they are thinking about 'my practice,'" Lyons continues. "One of the most difficult corners for health-care executives to make it around is becoming a company person." All that time learning to hone and trust your own judgment, just to cede it to an organization? Besides, playing well with others isn't part of medical preparation. "Culturally and sociologically, physicians are cloistered during roughly 10 critically formative years," observes Lyons. "You study real hard and make enough good diagnoses, you can be as weird as the day is long, but no one can say you can't practice because you're a geek."
That freedom's changing, though. "Your payer might get a few complaints and take you off the panel, and there goes a third of your practice," notes Lyons. "This is the stuff doctors were protected from when they could just hang out their shingle. Now they are vulnerable to the exact same things the man in the street has been vulnerable to, lo these many years."
Swinging with the Shift
Dr. W.C. Williams, senior vice president of the National Association of Managed Care Physicians, is waiting patiently for his colleagues to get with the program. "They think it's all the managed-care plan's fault," he says. "It's the employers driving the situation. They said, 'The price for insurance is escalating 20-39 percent a year, we're not going to pay it, find an alternative system.' And the physicians just sat back and did nothing."
Williams understands their paralysis: "It's difficult to be in an exam room one minute and behind a negotiating table the next. But when they are moanin' and groanin', it's because they have not gotten up and done something about the business side. I talk all around the country, trying to get them motivated and proactive and back in the delivery system. What they're in is chaos."
Dr. Roger Rathert was a pediatrician for 27 years, working in a large group practice of 170 physicians in Wisconsin and recruiting for their clinic. Then Cejka & Co. recruited him. "I wasn't particularly frustrated with managed care," remarks Rathert. "I just felt I had accomplished a lot and wanted to try something new. The people I deal with have accepted that managed care, done properly, is a good thing, and they are looking for people who value that.
"I think what a lot of physicians object to is what's called 'case management,'" he volunteers. "There's sort of a cookbook for managing a disease, with recommended courses of action. They will say they don't like cookbooks; they want to do things the way they were trained, and they say that's just as valid as a formula provided by someone else. Well, I'll tell you, it may be a cookbook, but it's written by a gourmet chef.
"Medical practice is becoming a business," continues Rathert, "and it has to be managed like a business. You get paid for the number of patients in your panel, not the amount of work you do. One of the hardest things for a procedural specialist, like a surgeon, to understand is that now, if you do lots of procedures, you cost the organization.
"The bottom -- " he catches himself. "The fundamental thing is that managed care is not a bad thing. What it's trying to do is ensure that what is done is appropriate and of the highest quality." What about the gynecologist who hated herself for sending her patient to the ER? "Well, did she enjoy the time she spent with her family?" Rathert retorts. "If the lady got appropriate care that solved her problem, she should feel a little less bad about it."
"My father and grandfather were both physicians in rural Wisconsin," he says later. "I went to engineering school a couple years first, but with a background like that, it's hard to avoid medicine. And it's a great line to be in; it's a great business." Yet for his dad and grandfather, it wasn't a business. "I'm sure my grandfather would have disliked managed care," Rathert admits freely. "He was his own person. And my dad practiced until he was 90; he'd see anybody that came in the door. On the other hand, they had (bill) collections of 50-60 percent. The benchmark for a good practice is above 90 percent."
Isn't something being lost in the switch to a punched-clock, cookbook-regulated system? "Medicine's much too complex now to be done that way," replies Rathert. "What is available is astounding, in terms of the ability to prevent, diagnose and treat disease. There is still a lot of caring, but there are also fabulous technologies, and it's necessary to manage all that more tightly. You can't continue losing money in a medical practice -- you don't stay in business."
Younger doctors know that better than their elders, he adds. "I identified myself by my job; I'd say, 'I am a pediatrician.' They are lifestyle-oriented. They want to have regular hours, time off, vacations with their families. My dad was on call 24 hours a day, seven days a week, and the phone would ring all hours of the day and night. That's not what people want."
Unfortunately, it's still what their patients want.
The Call of the Tame
The field of medical executives is rising fast: The American College of Physician Executives now has 13,600 members, more than double the 5,711 they had in 1990. "The group of wannabes is huge," sighs search consultant Lyons. "When health care was in its time of largesse, peaking 7 to 10 years ago, being CEO of a health-care system was like being Ike when he was president: You just had to be smart enough to not do anything stupid. Now, on the health-care-executive side, the adults are being separated from the children as we speak."
The move into management isn't all peaches and perks, though. "You lose collegiality with other physicians," says cardiologist Palank. "They see you as a suit, not a white coat. We have lived medicine all our lives as clinicians. There is an emptiness, a void." There's also a lot of maddeningly protracted committee work. "Seeing patients is terrific," sighs Palank. "Diagnosing and correcting a problem. Projects I'm in now may take a year to complete."
If Palank were suffering with chronic pain or disability, he might not bother adjusting. Now that they're mere mortals, physicians have begun claiming disability so freely their insurers have lost money on the payouts. "Physicians used to be like Marcus Welby, delivering a baby that morning and dying that afternoon and enjoying the profession right up to that minute," remarks James D. Johnson, spokesman for Provident Life and Accident Insurance Co., one of the disability biggies. "But with managed care and large group practices, physicians are feeling and acting much more like employees than professionals. Starting in the '80s, we saw an increase in their disability claims. They went from being the best risk to being average. Plus, they had policies to fall back on that became more windfall than safety net."
What he means, according to disability consultant Arthur L. Fries, is that physicians' policies used to be worded broadly and priced generously. Insurers considered them "prime prospects, because they had big needs, big lifestyles and big earnings, and they had an attitude of, 'You work until you drop.'"
Fries used to sell disability insurance himself; now he consults with physicians across the nation who are trying to go on disability. He cites recurring factors: "Increased paperwork, disrespect, unhappiness and managed care telling them when to go to the bathroom." Not to mention salary reductions that provided "quite an encouragement to lean into a disability claim."
The New Generation
Physicians have long been ill-distributed, clambering over each other in metropolitan areas and leaving tiny towns unserved. Now, rumors are flying that we'll soon have a surplus of physicians. So maybe this slight hemorrhage of practicing physicians is just Darwinian necessity?
Medical-school applications are down nationwide, so markedly that the Association of American Medical Colleges is polling its participants to learn why. Applications to St. Louis University School of Medicine dropped from 7,215 in 1997 to 6,206 in 1998. Applications to Washington University School of Medicine dropped from 5,823 to 5,143, and the dean expects them to decrease again in 1999.
Applicants still wildly outnumber the small pool that's chosen, though, and deans insist that the caliber of those students hasn't dropped. Outsiders wonder whether they know what they're getting into. Med students gain their clinical experience at teaching hospitals that see the most serious and complex cases; in that world, managed care has far less say. As for classroom experience, academic medicine's pretty sheltered. Some faculty members do maintain clinical practices, and do moan about the higher patient loads and paperwork rigamarole of managed care, but their malpractice insurance and salaries are paid by the school and their managed-care contracts are negotiated collectively.
Still, even med students absorb a bit of the real world by osmosis. And they do read. "Physicians Enter the Job Market," a recent article in the Medical Student Journal of the American Medical Association, opens with the warning, "The model of the past, when medicine was a reliable field in which hard work was rewarded by a stable and comfortable lifestyle, no longer holds true."
Asked whether students are prepared for the new paradigm, Dr. Alberto Galofre, associate dean for curriculum at St. Louis University School of Medicine, scrawls three rectangles on a yellow pad. He labels the first "medical school," the next "graduate medical education" (residency) and the third "real life." "I deal with here," he explains, pointing to the first rectangle. "When they graduate med school, they go into hospitals for three more years of education. Then real life. And that is where you have the problems.
"We've had these discussions: How much should we do for real life?" he continues. "They should know what managed care is. But shouldn't we prepare them in such a way that it doesn't matter what system is in place tomorrow?"
Students aren't sure. Nationwide, almost 61 percent of graduating medical students say they received inadequate instruction about managed care, according to the 1998 Medical School Graduation Questionnaire just released by the Association of American Medical Colleges. In a 1995 survey, SLU med students complained they'd received insufficient information about managed care and insufficient experience with its offshoots, family medicine and outpatient care. (Now SLU includes a section on managed care in one of its required courses, although it hasn't gone as far as, say, the University of British Columbia, which rewrote its goals for medical students to include the ability to "consider the cost and societal implications of their approach to providing health care.")
"Have we had a huge change in the amount of time we spend teaching managed care? No," says Dr. Alison Whelan, associate dean of Washington University School of Medicine. "But we have begun to increase the amount of teaching about the practice of management. Students receive at least a couple hours of lectures about the business aspects, and we've started a biannual managed-care symposium.
"Students see the way the practice of medicine is altered by the way health care is managed," remarks Whelan, "the amount of time physicians spend on paperwork, the office personnel required to submit it all. They see that as part and parcel of the care of the patient." They also spend more time learning to plan for discharge, she adds, because patients go home less well.
Whelan doesn't see students fretting about the increased business aspects of clinical practice, but Navarro has seen just how unprepared some of her clients are for those challenges. In her opinion, "it's not bad for them to get a couple courses in accounting, marketing, strategic thinking. And they have to have the capacity for teamwork, the capacity to manage bureaucratic politics."
Ask Galofre whether students are taught teamwork, and he shrugs genially. "Teamwork -- that is a tough one. It deals with being socialized to the profession, which happens gradually. We can teach our students how certain things should be done, but what really changes them is when they go into a clinical situation and see it done differently. What I hear from our students is that some areas are better for teamwork; in others, people say, 'Look, I am the one who is responsible, so I will say how it should be done."
Galofre thinks "today's students are going to be much better adapted" than physicians of his own generation, which he dubs "the Romantic period of medicine. You did everything you could for the patient, and you were treated as a god." He adds candidly, with a Latin twinkle, "I would think twice to go into the system we have now.
"Is there going to be a difference in the interaction between patient and physician?" Galofre asks abruptly. "In some ways, that is what we are seeing. But I hope in other areas it will be even better. An HMO in the long run cannot tolerate bad medicine, because the patient comes back and back and back. So good medicine should prevail."
Search consultant Lyons travels the country, looking for signs that it will prevail. "I hear scarily few success stories," she admits. "Where good things are happening, the single common denominator is the presence of a positive physician culture. Physicians understand why they are there, what their role is. They are committed to providing the best possible care." She pauses. "That describes very few health-care forums. It does describe a large number of physician-driven group practices, because physicians feel very empowered in those settings. I also found it at a hospital where seven of the eight board members were physicians."
Does this mean physicians need the reins back? Maybe so, but Lyons warns that they won't each get their own sets. "Physicians are more powerful than ever, but not on their own," she remarks. She's weary of their individual "bellyaching, the spiral of negativity that siphons off energy year after year." Her voice brightens temporarily. "You could send them all off to a career consultant ... but I don't know that there are enough career consultants.
"Physicians really have to do some soul-searching," she concludes. "If they absolutely must have autonomy, then they need to get out of medicine.
