10 things your primary care physician won't tell you

From Smartmoney.

1. "They should put me on the endangered-species list."
A good primary-care doctor — someone to coordinate your health care, help choose your specialists and be the first to diagnose just about any problem — is the key to good medical treatment. But they're getting harder to come by. According to a 2007 study, it took new patients in Massachusetts an average 26 days to land an appointment with one. Why? Fewer med students are going into primary care: Interest is so low that the number of primary-care internal medicine residency positions dropped by more than 50% in the past decade. "We're not really getting the best and brightest in primary care," says Kevin Pho, a Nashua, N.H., physician who writes the blog Kevin, MD. "And that's where they're needed."

Cherrie Brunner of Syracuse, N.Y., knows this all too well. She had such trouble finding a new doctor that she stuck with her old one despite problems — when she had blood in her urine, for example, she had to wait a week for an appointment, and the office then tried to cancel. But find a new GP? "I want to," says Brunner. "But when friends say, 'my doctor's great,' he won't take new patients." (Brunner's doctor had no comment.)

2. "I'm the pauper of my profession."
One big reason fewer medical students are specializing in primary care is pure and simple economics. In 2006 primary-care doctors earned an average of $171,519. That might sound like a lot to most working people, but it's less than half of what dermatologists made that same year. And the call of more-lucrative specialities is only likely to get louder for today's residents: According to one study, the income of primary-care doctors, adjusted for inflation, actually fell by 10% between 1995 and 2003. "Students are not dummies," says Pho. "They graduate with $130,000 in debt; why should they go into primary care?"

The income of primary-care doctors is under such pressure these days because general practitioners are paid roughly $30 to $70 for each patient they see regardless of how long the individual visit. That scale, based on Medicare reimbursements, has changed little since 2000. "Reimbursement for primary care is lousy," says John Ford, an assistant professor at the David Geffen School of Medicine at UCLA. "They put a premium on volume, not on spending time with patients."

3. "Sorry, your 12 minutes are up."
These days it seems like a visit to the doctor involves little contact with an actual doctor. Instead, most of the time is spent explaining problems to assistants and having blood drawn by nurses. Indeed, doctors have been beefing up their support staff — physician's assistants and nurse practitioners — to help them squeeze in more patients. They say this assembly-line approach is necessary because they get paid about the same for each patient no matter how long it takes. It certainly has been effective; some doctors are able to see 40 patients a day. That's one every 12 minutes. And it doesn't show signs of slowing: According to one survey the average number of patients doctors saw grew by 7.5% from 2004 to 2005.

While this system isn't inherently bad, it can be abused, says Ford. Assistants may have a different philosophy from the doctor, leading them to treat problems differently as well. Communication can break down, causing confusion about medications, and a misdiagnosis by an assistant is always possible. Some doctors do take things to the extreme: In the Massachusetts study, 41% of patients had an appointment during which they never saw the doctor.

4. "I hawk for Big Pharma in my spare time."
Your physician relies on his best judgment when deciding what drugs to prescribe. And influencing that judgment is big business. Market-research firm IMS has found that the pharmaceutical industry spends $7.2 billion a year targeting doctors with ads and sales representatives. That translates into $8,000 in marketing money spent on each of the 900,000 doctors practicing in the U.S. today. "The introduction to pharmaceutical representatives starts as early as medical school, and it never really stops," says Pho.

The real amount is certainly much higher, since these figures include only journal advertising and salaries of sales reps, not their expenses. Drug reps give away pens, cups, hats and shirts, and buy office staff lunch, all in hopes of nabbing time with the doctor. But that's just the beginning — drug companies know doctors are more likely to take their cues from other doctors, so they sponsor weekend seminars at expensive resorts featuring presentations by physicians. Drug companies pay these docs to give informative talks about medical conditions — for which the company's drug gets pitched as the best remedy.

5. "Sore throat? You might be better off going to the mall."
When Mary Furman got a call from her daughter's school at 10 a.m. one day last year, she was sure it was strep throat, but her pediatrician couldn't see the girl until 4. Furman decided to try a new clinic she'd noticed at a nearby Wal-Mart; they were in and out with a prescription in under an hour.

Walk-in clinics are springing up across the country. They're run by nurse practitioners, who diagnose simple maladies, like strep throat or flu, and provide prescriptions, medical advice or referrals if the problem is beyond their scope. These clinics have caught on in part because they're fast and don't require an appointment, says Steven Cooley, a physician and CEO of SmartCare Family Medical Centers in Denver. They're also cheap — $40 to $60 a visit, versus $150 for a doctor or $300 for an ER visit — and many take insurance.

Today there are about 460 such clinics, but analysts expect the number to jump to 4,000 by 2009. When visiting one, says Jim King, president of the American Academy of Family Physicians, ask to have your records forwarded to your doctor, and be sure to tell him about any medication prescribed at the clinic.

6. "I hate technology."
It's almost impossible to imagine anyone doing his job these days without a computer — except your doctor. Although billing and other systems may be computerized, when it comes to medical records, many GPs still prefer pen and paper. New electronic medical-record systems can print out clear prescriptions that are cross-referenced with medical databases to avoid incorrect dosages or dangerous drug combinations; hospitals can access patient histories in case of emergency; and care can be better tracked over time. But as a group, primary-care physicians have been slow to adopt the technology: A recent study found that only 28% use these systems. Why? They can cost up to $70,000, and cash-strapped GPs see little payoff.

For most patients the benefits of the technology are huge. It eliminates prescription errors due to illegible handwriting. It ensures that patients get the right dosage. Records won't get lost. It reminds doctors when they need to monitor their patients. And specialists and others can easily forward electronic records to your GP. "I'd seriously consider changing doctors if he didn't have an electronic records system," King says.

7. "Your insurance company is calling the shots."
these days doctors have more freedom to send you to a specialist or order expensive tests than they once did under managed care. But that doesn't mean the system is fixed. For starters, your insurance provider's pool of doctors may lack, say, a great cardiologist, King says. And with increased deductibles, it's often the patient who foots the bill for a referral or an expensive test.

Insurers also still wield the power when it comes to hospital stays, says Jerome Epplin, a geriatrician and clinical professor at the Southern Illinois University School of Medicine; he has recommended that a patient spend four days only to have the insurance company overrule him, refusing to pay for the last day and sticking the patient with the bill. "We are powerless over it," Epplin says. "It's incredibly frustrating." Mohit M. Ghose, spokesperson for America's Health Insurance Plans, an industry trade group, says, "When I hear physicians speaking like this, it tells me that physicians need to be working more closely with plans to understand what the guidelines are."

8. "My legal history is none of your business."
Today's insurance plans give patients a wider range of doctors to choose from, but patients don't have any more information to help them decide. "If insurance companies really wanted to bolster patient choice, they would give patients the ability to make informed choices," says Peter Lurie, deputy director of the health research group at Public Citizen. The best information about doctors is off-limits to patients. It's the National Practitioner Data Bank, which state medical boards and hospitals use to do background checks, and it includes information on disciplinary actions and malpractice payments.

To find out if your doctor has been sued, you'll have to go down to the local courthouse, but if your doctor has moved around, you'll get only part of the picture. The best publicly available information is tracked by state medical boards, many of which publish this information on their Web pages. If yours doesn't, you can pay $9.95 for a report from DocInfo.org, a site run by the Federation of State Medical Boards.

9. "If you're over 65, don't bother me..."
As troubling as things are in primary care, the situation is worse when it comes to treating elderly patients, especially those on Medicare. Doctors who specialize in geriatrics are certified by the American Board of either Family or Internal Medicine, and they're increasingly rare. Right now there is just one geriatrician in the U.S. for every 5,000 seniors, about half of what we should have, according to the American Geriatrics Society.

The problem is that fewer medical students are choosing this subspecialty: Last year only two-thirds of geriatric fellowship programs were filled. That's because treating older patients who have multiple, often complex problems is about the worst way a doctor can make a living. Medicare doesn't compensate much more for a 45-minute appointment with a patient with dementia, hearing loss and a half-dozen other maladies than it does for seeing someone for a simple checkup. "It is fiscal suicide to go out there and say, 'I am a geriatrician,'" Robinson says. "You get the patients that require the most time that pay the worst."

10. "...unless, of course, you're willing to pay extra."
unfortunately, the shortage of geriatricians is worsening. As med students shy away from geriatrics, the number of people over 65 is set to grow faster than ever as boomers retire. The American Geriatrics Society estimates that by 2030, there will be a shortage of about 36,000 geriatricians in the U.S., up from 7,000 today.

Though the situation seems dire, there are ways to guarantee qualified care. One approach is to see a good primary-care doctor who is also a geriatrician long before you need one. Epplin says that in southern Illinois, not many doctors accept new Medicare patients, but when their existing patients go on Medicare, they keep them. Other approaches can be costly. In Sarasota, Fla., where Robinson practices, many doctors provide "concierge" service: Patients pay an annual retainer of about $4,000 in exchange for their doctor's cell number and upgraded access. Other physicians in Florida have begun asking patients to pay an annual administrative fee of about $200 or $300 to help them continue to provide individualized care. These pricey options aren't what most people have in mind when they think of health care reform, but they may be the only way to maintain ready access to a good doctor.