Thursday, September 6, 2012

Family Medicine: Replacements are Lacking for Aging Docs

OK, I'm creeping toward retirement in a few years.  My hospital(s) have committed verbally to help recruit a replacement Family Physician and another and maybe another to help us grow to three physicians.  Eight years ago we were included in their search process.  My replacement hasn't shown up, though.  One candidate did interview and agree to work with me as a full time Family Physician seven years ago.  She called a week later and apologetically withdrew her acceptance of the position because the job she really wanted had suddenly come available.  I agreed with her that she had to go with her heart and wished her well.  Oops!, she said when she called back a week later saying she made a mistake since the "dream job" she went to finalize wasn't exactly what she thought it was.  And... was the position in my office still open for her.  I reaffirmed that I thought her heart had spoken to the effect that she really wasn't supposed to be coming into my practice and something else would be the real "Dream Job".

Six months later, a very good Family Physician interviewed with me as a result of the system ad.  She was about to deliver her second child and wanted to work three days weekly.  She started a few months later and is still in the practice, along with a part time Family Nurse Practitioner, who just got a four day a week job in a geriatric house call company and will reduce her work at our practice to one day weekly.

Since then (five years), no other qualified applicants have been identified by the search process being used by my hospitals.  Eight Family Physicians have left our county and two have been replaced, one in a hospital owned practice and one in a large group practice.

I met with our hospital physician recruiter today.  It looks relatively hopeless for them to recruit another physician to our practice.  The only persons responding to their ads in Family Practice journals and online want a permanent employed position with a fair amount of security, not a small private practice, such as ours.

We are "Family Fanatics".  We only take families as patients (entire households).  It's been fun for me these last 32 years and I suspect that it would appeal to another Family Physician, as it has to the woman practicing with me.  We also just started a Direct Family Medicine track for uninsured new patients who want a "Medical Club".  They pay $80 to enroll, $60 at the end of each month and $20 per visit for basic Family Medicine (in office acute, chronic and preventive care with flu shot included, but there's a separate fee for other immunizations, outside laboratory tests and surgical procedures).

I've posted before about the inadequate number of medical students selecting Family Medicine for their specialty training.  Also, I've posted about how the two flagship hospitals for the two local hospital systems both closed their Family Medicine Residency Training Programs.  They don't even train primary care internists in my hospital system, even though they have several residency programs in several specialties.  Overall, the primary care base for the health care non-system is shrinking.  Duck.  Here come the wrong specialists to provide your primary care services.

I wonder if we are too much of a fossil practice to get a young Family Physician to join us?  I wonder if we have to find our own recruit since we're possibly lumped in with the wrong group of practices seeking another physician (hospital and large group)?

What do you think?


  1. The "system" is obviously letting you (and us) down. I imagine the cause has a mixture of ignorance and maliciousness involved. I hope that you opt for or include your own search for the right person(s) to join your practice. I will pray for your success. The community and I will benefit. Thanks for hanging in there.

  2. I certainly hear your concerns. As a young doctor in the middle of residency I feel torn between two imperfect options if I go home to practice. 1) a hospital system that would restrict me to a narrow, office based, high productivity model of practice (for which I certainly didn't need to spend my time training as a family doc with skills to practice in multiple settings) and they have no plans to compensate me for the loss of skills (and morale) that would develop over a few years in such a setting or 2) starting up my own practice since finding any private practitioners who haven't already made plans to sell to the hospital system is difficult and I am already working through education debt that would make acquiring a business loan difficult (and risky).
    Turns out I left home to train for a job that may not exist a decade later now that I'm ready to come back.

  3. You're going to keep spinning your wheels trying to recruit a doc (and family) to an out of the way area if you and the hospital do not incentivize--what docs and the family that goes with them look for is lifestyle and money. Pay them right (over 300k) and don't make em work as hard and long

  4. This is a big problem. It is especially a big problem in primary care. My former physician boss in Congress is a Family Practitioner and his name is Dr. Tom Coburn (R-OK). He and several other physicians in Congress wrote provisions into the healthcare law that will give primary care a mandatory 12% raise in reimbursement and also forgive student loans for those who decide to go into primary care. These two provisions were wanted specifically by the AAP, ACP, and AAFP. Dr. Coburn worked hard to make sure this happened when he and his congressional physician colleagues wrote the provision into the law in 2008. These two provisions should help improve the situation.

  5. Thanks for the great comments. Rex, I appreciate your prayers and encouragement. The confluence of many phenomena set up an upside down health care system. We have too many expensive pieces and "Market Medicine" as the umbrella for the Medical Industrial Complex. The front lines are collapsing with financial non-support, but I'm optimistic that the creative spirit in America will squeak through eventually with a right side up way of promoting health and wellbeing and treating acute and chronic problems.

    Anonymous resident in training. Your comment might be better than my blog post. Your message is a voice of reality. Your training on "Family Medicine Island" where you're learning to care for individuals, families and communities with a broad skill set prepares you to respond to more human need than most people, including those non-physicians, who hire physicians can imagine. The threat of such a physician who prevents ER visits, admissions and the use of expensive technology on hospital budgets can be eliminated by hiring you into the hospital position you mention. Once they load you into inadequate time to effectively interact with your patients (who they "own") you will ethically refer a lot more to the hospital owned sub-specialists and facilities, filling the coffers of hospital service lines and pleasing the non-physician owners. However, I believe that your real dream can be achieved. I'm intrigued by the Direct Primary Care business model used by many, but most notably Qliance in Seattle. I believe there is still room for those who want to use their skills and live their dream. Your formula will be one of a kind, like mine and others.

    Anonymous #2 It does feel like spinning wheels at times. My location is 400 yards from a brand new hospital (Feb 2012) and I am the only Family Physician with admitting privileges so far, so I'm not in an "out of the way area". The lifestyle and money depend on the individual and their family. The anonymous resident physician above has a big debt, but a big heart. Career satisfaction is a big factor for many FP's, too. $300K won't be happening around Dayton, Ohio for FP's.
    Matthew, thanks for your encouraging words. Your contributions on Linkedin are also good information for physicians. Congress is aware of the plight of primary care, but less aware of the dwindling capacity for patients to find a family doctor.
    This is a time of immense transformation, with benefits and harms abounding. Onward. apj

  6. @Anon: Not sure where you're interested in moving, but my family physician has no intention of selling to a hospital. He still has hospital privileges, and still sees patients in nursing homes. Last year, a number of the private practice doctors in the area looked for a way to stay independent and joined together for the advantages of a large practice, with the understanding that they all get to stay independent and run their offices how they wish (as nearly as I understood how my dr explained it). I think my dr is still looking to hire help, too, if that sounds like something you'd like to investigate.

    @Dr. Jonas, the way you describe your practice & caring is exactly what patients want. I sincerely hope that we don't run out of doctors in your specialty before those who do the training & write the payment schedules figure out that they have a huge problem to fix. Best of luck recruiting new physicians to your practice.

  7. Thanks, warmsocks. We live in interesting times. apj