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 second conversation, lightly edited for length and clarity.
JP
So you graduated in what year?
Dr. X
1989.
JP
And when did you start practicing?
Dr. X
In ‘93, I finished residency, and got a job working for one other person. We added a third. Then the two of us knew two other people in another practice who were dissatisfied with their business situation. So we had meetings, and we made our business plan. And then we left our respective practices and built this private practice, the four of us. It’s been 24 years now, and it’s going strong.
Physician dissatisfaction
JP
So when you look back to the beginning, from this vantage point, what’s the one biggest change, or two of the biggest changes?
Dr. X
Probably overall physician dissatisfaction.It plays a huge part in medicine today.
People are very disenchanted. It’s rare that somebody’s not. People are quitting, and they don’t have autonomy. That’s probably the biggest.
Also, access to care has changed a lot for patients. Part of it, I think, is there’s not enough physicians, and part of it is that health insurance is no longer covering what it needs to cover.
I was just talking to someone the other day who was saying she was supposed to go to physical therapy three times a week to rehab a knee. It’s $50 a session for physical therapy. She said, “I can’t afford that.” She has hospital insurance. She’s one of the hospital charge nurses.
We hear this time and time again. Access to care is limited everywhere. And I’m in a major metropolitan area. Go to downstate Illinois, and the issue is so much worse.
JP
And what is the eventual result of that? If people don’t have access to care, then that means their health gets worse, right?
Dr. X
Yeah. People get sicker before they go.
JP
So, we talked last time also about access to medications, which is limited. I imagine that’s another change from when you started.
Dr. X
It kind of comes and goes. And it’s, you know, very piecemeal, the shortages.
The other thing is the prior authorizations, It was bad 10 years ago, it’s exponentially worse today. I don’t think patients realize that until they’re kind of in the thick of it — the roadblocks that are routinely put up for them.
Corporatized medicine
JP
Yeah, I think you’re right about that. What about things like — increasingly, I think you’ll agree with me, patients are going into larger, more corporatized environments for a lot of their medical care. Is that true?
Dr. X
Definitely. Yeah. And what does that look like from a patient’s perspective? I mean, it’s been kind of a gradual change. It’s not a sudden thing.
JP
It’s sort of like boiling a frog, right?
Dr. X
I was thinking the same thing. My mom is an example. Her primary doctor is with one of the big private equity groups. I had to reschedule the appointment for her Medicare annual checkup. They were saying that if I was going to cancel that appointment, the next available appointment was in five months.
Actually, my primary care is also with a private equity group. Same thing: I had to call her and say, “Can I get in before November?” This was in April.
There are barriers: You don’t talk to the doctor’s nurse, or even the receptionist, a lot of the time they’re calling a call center in the Philippines or something. The receptionist doesn’t know how to manipulate the schedule.
I’ve had patients comment positively on our practice, because in our practice, you do talk to somebody, and there is a triage nurse there to ask questions. And if she can’t answer it, she comes to one of us who’s working — so they get a level of care that I just don’t think that you get from a corporate medical center.
Call centers overseas
JP
I’m sort of getting twitchy here thinking about my experiences with corporate support in the Philippines, over my computer or my phone bill. Do people really have a call center in the Philippines for medical care?
Dr. X
Oh, my goodness, yes. And also there’s this new thing called virtual assistants, A lot of physicians who are in private practice have virtual assistants. And there are people in the Philippines who have access to your computer system. I’m not exactly sure how that works from a HIPAA standpoint. They literally cost $6 an hour.
As business owners, you’re always trying to run leaner. Now, I don’t want to do that. But boy, if you could offload prior authorizations and some clerical stuff to somebody and pay $6 an hour – at my work, we don’t do that, but it’s available. And definitely a money saver.
JP
You may have seen the news report recently about Amazon’s One Medical — not virtual assistants. Is that a different end of the same horse? They were using people to do phone intake who weren’t able to assess somebody for a serious problem like chest tightness. Because it was somebody who just didn’t have the training.
Dr. X
Oh, yeah. We have very strict guidelines in our office, like the protocols for the receptionists and the nurses so they are clear on what they can handle and what the physicians need to be consulted on.
Usually, if somebody needs to get in from an emergency, there are guidelines of what exactly warrants an emergency visit that needs to go to the hospital. Or can they come to the office, and we can squeeze them in?
I could definitely see how people who aren’t medically aware could not realize the importance of triaging those patients appropriately. I didn’t hear about that with the Amazon stuff, but it doesn’t surprise me.
Virtual visits
JP
Can you tell me more specifics? I’m horrified that your mom is unable to get seen for five months. Are there other things that you have heard of that are similar examples of this virtual assistant? Or maybe a chatbot? Or a person?
Dr. X
I don’t know about chatbots. But insurance companies — I know Blue Cross Blue Shield has a thing that you can go on their website and have a virtual visit. It’s like a $20 copay or whatever. It takes money away from the physician, and that’s a lower level of care.
I think that’s happening, because insurance companies are trying to keep costs down. I think it’s an actual person, a nurse practitioner, or a PA. I don’t know if they have chatbots, but it wouldn’t surprise me either.
JP
Let’s talk about other things that have changed. For example, you as an OB-GYN might be able to tell us how childbirth or prenatal care has changed from the beginning of your career to now.
Dr. X
Prenatal care — there’s so many more tests that we can do that weren’t available 30 years ago, with genetic testing that can be done on maternal blood. That, to me, is kind of Star Trek-y. We do so much more testing.
For people with high risk situations, it’s best to be monitoring the baby either once or twice a week. There’s definitely a level of care that is elevated versus what we did 30 years ago.
People also have — I don’t know how to put this in some neutral way. People think they know just as much as we do, they really do.
I’m all for making decisions with a patient. But there are so many patients — we’re in a higher socioeconomic area here. So we have that kind of strata of patients. It’s amazing, kind of the pushback I get from people who know better than I do. My gray hair is of benefit to me, because I can kind of give them the motherly look down my glasses and be like, “Look, I’ve been doing this for over 30 years, you know.” But they’re very opinionated.
And it’s all social media.
‘Curb-walking’ and dates on TikTok
JP
For example, somebody who’s talking to you about childbirth facts that they learned off of TikTok? Tell me more.
Dr. X
Let me think … Sometimes, you’ll have a bunch of patients that will ask you the same thing. I’m like, this has got to be a TikTok thing.
Like curb-walking to start your labor. You do curb-walking, which is — you have one foot on the curb and one foot on the street and kind of go up and down, up and down. And that’s got to be a TikTok thing.
Dates, you know, people eat a lot of dates to bring them into labor. And I’m like ‘I don’t know if it brings you into labor. I don’t think it really does. But it’s really, really good fiber. So you’re not gonna be constipated.”
The list goes on and on. We saw it so much with the Covid vaccine. It was out of control. That was very tiring after a while. It’s like, if you don’t listen to the science, what can you do?
‘How long will labor take?’
JP
Tell me more.
Dr. X
I had one guy who came in last week with his wife. He’s kind of what we would in the 80s call a yuppie. He said to me, “So how long is her labor going to take?” And I said, “Well, I don’t know. Everybody’s different.” He goes, “Well, isn’t that something that you should know?”
I looked at him and I wanted to say, “You know, maybe you should have listened in biology class.” He actually was serious.
Labor has changed a lot. A lot more people get epidurals. A lot more people talk about Instagram. We’ve got a couple of people who are influencers in our practice. It’s unbelievable. You look at their Instagram page, and then you look at who they really are and like, oh, man, there are some filters going on there.
Everybody thinks it should be all perfect, but labor and delivery is much less than perfect.
JP
This may be a silly question, but do people ask you to adjust the lighting in the delivery room so that their Instagram is perfect?.
Dr. X
No, but boy, but when they do their pictures the day after, there’s a professional that comes in to do their pictures. When my kids were born, they got the pictures in the hospital labeled kind of like mug shots. But now there’s the service that comes in. They really do a very, very nice job.
Everything is curated in our culture now. But I can think of nothing less curated than childbirth and delivery.
Newborn care
JP
So what about the care of an infant after birth? I mean, that has to have changed dramatically, right, in the 20 or 30 years since you’ve been practicing?
Dr. X
As far as newborn care, there’s more testing. Probably if you talk to a pediatrician, I think that they would probably mirror the same things that I’m saying as far as patients being so much more hands on and so much more like helicopters. They kind of have been for a while now.
JP
Over the trajectory of your career has the administrative burden changed, either from the hospital, or from the insurance company or from government?
Dr. X
We’ve always had administrative burden, just because we run our own practice. I think that’s what a lot of physicians who sold out to private equity have been trying to get away from. But I think, to a person, they’re realizing that it’s at a very high cost. Private equity is not doing this for free.
We have billers that work in house. We don’t outsource them because we want people to be accountable — making sure that we’re getting every penny that we deserve. It’s hard to say — I don’t think it’s any more from the paperwork. But it’s not something that I really have to deal with. Because I have people that do that and they are very skilled.
We have three, actually, two and a half, like two and a half. One worked for us for 24 years. And one’s worked for us for 14 years.We’ve had them around for a long time, and they really work hard. And get the job done. We audited them maybe about a year and a half ago, which is interesting, but because I think one person was not doing what she should have been doing. And that kind of was a rude awakening for everybody. But as a physician, if you don’t run the practice and pay attention, the practice will go under.
JP
I have heard people say they have, like, doubled their billing staff because of preauth and all the other hurdles for payment. But you haven’t done that?
Dr. X
We have not done that. We do have somebody who does [Family and Medical Leave Act] papers, short-term disability papers. We charge for it now. We used to do it for free.
Personal care is lost
JP
What have we not talked about that leaps to mind as something that has changed dramatically since you first started practicing vs. practicing now?
Dr. X
Probably the biggest thing that as medicine writ large, the personal care of people, is just lost. It’s absolutely lost.
It’s so much more impersonal than it ever was.
I’m such an outlier. So I’m probably not a good person to talk to on that front. Because the average doctor thinks that she’s going to work in a job for five years, and you don’t get to know your doctor. I hear it all the time, “Oh, yeah, I had a primary care doctor. She was good.” But the person who replaced them, they’re not thrilled about it. It happens all the time.
You don’t have continuity. There’s a lot of benefit to the continuity.
As a physician, I can look down my list and know these people and know a lot of their history just by seeing their name. From a patient safety standpoint, that’s good, because I have a history with them. I know these patients, and I know what their issues are. And of course, there’s the medical record, but it takes less of an intellectual toll on you too. When I know their health problems, and I’m not trying to garner trust, because I already have it, because I’ve known this person for a decade. That’s a huge difference.
Also, people are just really dissatisfied. I hate to be so negative about it, but it could be so much better. The whole private practice piece: It does make a difference. There are studies to support that.
