What’s it like to be a doctor these days? And what might patients want to know about that? I met a doctor in an online group and we struck up a conversation. Her views were so interesting that I asked her to join me in a series of conversations for ClearHealthCosts. She is a D.O. (Doctor of Osteopathic Medicine) in private practice who also has a leadership role in obstetrics and gynecology at a Midwestern hospital system. She spoke on condition that we not use her name. Here is our first conversation, lightly edited for length and clarity.
Jeanne Pinder
What does the average patient not know about medicine now versus medicine 15, 20 years ago?
Dr. X
Little things like access to your doctor. You have to jump through hoops — it’s harder to get an appointment. It’s harder to get established with the primary care doctor because they’re so overrun. It’s easier to get sent off to an advanced practice nurse or a physician assistant.
I was reading something today on a Facebook group for private practice physicians. A lot of these primary care doctors don’t refer a lot to dermatologists, but instead you’re referring to an advanced practice nurse or a physician assistant — who biopsies way more than a physician does, because they don’t know as much. They’re not nearly as educated as a physician is – they don’t have as much training. People are clueless about that stuff.
We have advanced practice nurses in our practice, because there’s no way a doctor can see you for everything. It’s just impossible. They have half of the education. But people have no idea that they are seeing a nurse — even though she has introduced herself, ‘Hi, I’m K.B.,” and the response is ‘Oh, Dr. B.” They have no idea.
What should we do?
JP
Maybe a lot of people have experienced this. It’s hard to get to a doctor for primary care. What should a patient do? Should a patient insist on seeing a doctor, or wait for a doctor rather than seeing a nurse practitioner or physician assistant?
Dr. X
Not necessarily. I totally grappled with this when we started.
We had midwives working for us for a long time. And then two of them retired, and one moved. These were like really great midwives who were just phenomenal clinicians. And when we knew that we couldn’t replicate that, we ended up just hiring a couple more APN’s — advanced practice nurses — to see patients.
There’s some things that they can see — your run-of-the-mill STD exposure, vaginal discharge, upper respiratory infection in pregnancy — easy pregnancy stuff. But for something more complicated — like a lesion on the skin, if you’re a dermatologist, does that person need to be biopsied? Or can they wait?
I don’t know what the answer is to that. Because there’s such a benefit to somebody having experience and having a great amount of training, and it just doesn’t happen with nurse practitioners.
Caution over urgent care
JP
We’ve written a couple of stories about how hard it is for people to be seen, both by a general practitioner and by a specialist. It’s almost like we need to have a whole different way of thinking about our health. Is this so urgent that I should go to the urgent care center? Is that really a solution? We wrote a story about urgent care being kind of a crapshoot, shall we say?
Dr. X
I hate it. I hate it. Oh, my God.
JP
Tell me why?
Dr. X
I because it’s a crapshoot. Because you may get somebody who’s decent and you may get a total hack.
For an example: One of my dearest friends, who nannied my kids for 15 years, died last year because she had strep pneumonia that was not diagnosed properly.
About two weeks after her death, the urgent care sent me a copy of the chart note. They didn’t even listen to her lungs.
You know, what the hell? She has an upper respiratory infection, and you don’t listen to her lungs. She had strep pneumonia.
The physician shortage
JP
From the patient’s perspective, none of the answers are correct. Wait for an appointment? Go to urgent care? Go to the emergency room? Try telehealth? For patients, we’re out here kind of struggling. I imagine for doctors, you’re struggling too. That story that you just told me it’s heartbreaking.
Dr. X
Take it a step back — why is there a paucity of physicians? It’s because there are not enough [Centers for Medicare and Medicaid Services]-funded residency positions. There’s more medical students coming out of school than there are residency positions. Does that make any sense to you?
These for-profit medical schools are opening up? Fine, I mean, that’s fine. But there’s no residency positions to train them. The residency positions have not increased appreciably in decades. And yet our population is aging, there’s much more of a strain on the healthcare system. Doctors are retiring earlier, because everybody’s burned out. So where does this start?
JP
What else do patients not know? I mean, we know that we can’t get an appointment. Do we not know how much time you’re spending on the phone with the insurance company?
Dr. X
Yes, people in my office are spending a lot of time doing prior authorizations, because care is being denied by insurance companies. For stupid things.
In my practice, there’s one drug that I have to use for something that’s very old school. It’s the only thing that works. It works well. And it’s cheap. And probably a couple times a week, insurance companies will deny cheap ointment that takes care of the problem. It’s just to throw up a roadblock to make somebody have to work harder to get the patient coverage.
Or vaginal estrogen. My God, how many times a week do we get a call from a patient saying, “Oh, I can’t use that because it’s $200. And my insurance doesn’t cover it.” For vaginal estrogen?
Insurance appeals
JP
So in that case often it’s somebody in your office who will appeal to the insurance company?
Dr. X
Somebody in the office will appeal to the insurance company for most of the stuff.
Every once in a while, for the big ticket drugs, you have to do a peer-to-peer, where I have to talk to a doctor at the insurance company.
They have to set up a time. You can’t talk to somebody right away, you have to set up a time, and you have to give them three different times that possibly you can talk to them about the care of the patient. And don’t be thinking that it’s a person in your specialty, who knows what the heck you’re talking about. It’s just any kind of random physician.
A lot of times it’s physicians who have lost their licenses, who can’t get jobs somewhere else. They’re the ones who are doing the peer-to-peer reviews. And they’re just denying things.
JP
If you stand back and look at that, it almost seems like denying a common inexpensive treatment to a patient will then result in them getting sicker. So what’s the end game in the denial? I guess the insurance company might think that they’re saving money by refusing to pay. But don’t the small problems then become big problems?
Dr. X
A lot of times, they can, but I honestly don’t think that they think that far. I really don’t. There’s federal legislation. I don’t know where it is in the whole scheme of things. But there is federal legislation to address prior authorizations and the burden that physician offices are under for that.
Working in a hospital
JP
What else do we not see, as patients? Are we not aware of regulations that you have to follow, or about practicing inside of a hospital?
Dr. X
I do surgery at the hospital, and I deliver babies at the hospital. And then I have my office where I see patients.
With regulations, it’s interesting. I had a meeting yesterday with the medical executive committee — hospital administration, the chairs of all the departments in the hospital. And the marketing guy came in. He was talking about how we just recently joined forces with a premier institution. And they own part of our hospital. It’s been over a year, and they’re dragging their feet about marketing.
People need to know that this is an added benefit, but they’re not marketing to women and children right now, which is a big driver of health care. Women dictate where families go for health care, typically. They’re not doing that much.
The medical staff president, who’s an independent physician, and business-savvy kind of guy, said, “You’re talking about all this stuff with and as it relates to the hospital, quote, unquote, the employed physicians, and 40% of the medical staff is independent. What are you doing to promote our businesses and our practices?”
And he’s like, “Well, you know, we really can’t do much because of Stark laws [which prohibit self-referring among doctors].”
So I think to myself, that is such B.S. – they’re touting the hell out of those employed physicians, and the physicians that are independent, even like the “Find a Doctor” thing on the website – for the longest time, they didn’t have independent doctors on there.
We said something like, “This is ridiculous. You know, we’re a part of the medical staff.” And, you know, that’s a regulation, quote, unquote, that we need to supposedly adhere to. I don’t know if there’s that many regulations – you know, HIPAA, things like that.
Certainly in places where abortion care is not legal — that’s a whole nother ball of worms.
Telehealth and abortions
JP
Maybe I should ask you about abortion care. Have the changes in legislation resulted in more people coming to Illinois from other states?
Dr. X
Yeah, a lot more. And, you know, telehealth — I’ve done a couple of medical abortions for people who are out of state, kind of under the table, because you’re really not supposed to do telehealth unless both of you are in the state of Illinois. It’s patients you know — patients that are away at college and need to have a medical abortion.
It’s terrible, what it’s doing. There was a piece in The New York Times today, about where people have had to travel for abortion?
I have a friend who works for Planned Parenthood. And she said, it’s just crazy. And the women who are training to be OB-GYNs in states that restrict care, they’re having to come to Illinois or to New York to learn how to do abortions. Extra costs, and logistically, it’s kind of a nightmare.
JP
As a patient, you brought up the topic of things that we don’t know — but I kind of don’t know what I don’t know. What else?
Dr. X
The burnout that a lot of physicians are facing — the fact that so many physicians are very unhappy with their state in life.
I mean, think about it: You go through all this training, you’re at the top of your class, you’ve worked super hard. And then you hate your job, because some administrator is telling you, “You know, you’re not doing enough, you’re not billing enough. You’re not — whatever.”
A lot of people are really burned out, and patients are super demanding – I think more so than I have seen in this work for 30-plus years.
‘Everything costs more’
JP
Is there anything that we don’t know about supply-chain issues?
Dr. X
That’s for sure. Everything costs more.
It was funny because I was talking to my husband a couple months ago about this – about raises for my staff and how much things are costing.
He’s like, “Well, just raise your prices.” I’m like, “I can’t raise my prices.”
Everything is costing more. And as a business owner, we run super lean. But we look at everything. Could we do with one less staff member if somebody quits? Can we absorb their job, somehow? We’re certainly not immune to the cost, the price hikes, but we can’t raise our prices.
JP
A question about drug shortages. I was speaking with a pediatrician who said she’d like it if her daughter would get pregnant, but pitocin is on short supply, the medications for an epidural are on short supply, some of the micro-nutrients for preemies are on short supply. Can you talk a little bit about how drug shortages affect you? And maybe as patients, we wouldn’t see that, maybe you would do something behind the scenes to alleviate a problem like that.
Dr. X
Yeah, at one meeting, we have a group of pharmacists there to kind of talk about what’s going on in the pharmacy world. We’ve been able to pivot. When the pitocin shortage was a thing, he’s like, “We’ve got a lot stockpiled.” I think they’ve been really good at procuring drugs.
What we did have that was crazy: A lidocaine shortage. You couldn’t get lidocaine in our office. To do a biopsy, you use lidocaine with epinephrine. So we ended up having to get it and it was way more expensive. Then we checked, every supplier was out.
We did two things. We got really expensive lidocaine that dentists use – we found a couple packages of that.
Also, when you do a circumcision, you inject lidocaine, and there’s usually four or five CC’s left over. So with all of my partners, we would pocket the extra and bring it to our office. Even though it didn’t have epinephrine in it, it was still better than nothing. So yeah, liberated it. I guess it would not have been used anyway.
JP
One of the stories I heard was about people who were unable to get saline. So they bought saline from a veterinary hospital.
Dr. X
Oh, gosh.
Other drug shortages
JP
Anything else about drugs?
Dr. X
With the Puerto Rican hurricane, there were a lot of drug shortages stemming from that because there was a lot of drug manufacturing in Puerto Rico. Sometimes people would be sourcing stuff from India, and it’s not as regulated there as it is in the States. It was kind of questionable.
There was a shortage of RhoGAM for Rh sensitization. But there are other manufacturers, so they just went to the other manufacturer, and now it’s OK.
JP
We’ve been hearing a lot lately about the shortages of ADHD medications, but that doesn’t affect you, right?
Dr. X
My son is on ADHD medication, my youngest. I asked him, has that been a problem? He said, “Yeah, it’s a problem. But I stockpiled it — or I don’t take it on the weekends. If I’m not really needing to hunker down and study, I’ll take a half of a dose.”
It’s a real problem. Especially for young kids.
JP
When we first wrote about it, we also heard about doctors who can’t practice because they’re not medicated properly.
Dr. X
Yeah, I believe that.
Also, so many women have been under diagnosed with ADHD. And now I am taking care of pregnant women who are on these medications, which is super helpful. But you don’t necessarily want them to take it all the time during pregnancy, because it’s an amphetamine.
You kind of have to have that conversation: “OK if you’re just going to be on Zoom calls for your job, and it’s going to be pretty easy, how about you don’t take it? But if you have to, sit down and you know, grind out some financial data or whatever, then take your Adderall.” It really helps to game plan it out with them. And they are really hesitant because, you know, you’re judged on the quality of your work.
JP
Let’s close out here and talk again next week, is that OK? This was really interesting. Thank you so much.
Dr. X
Thank you! I feel like there’s so much to talk about.
