June 18, 2007
Student Scene
Physician, Heal Thy Practice
Rachel Eastwood
Jason Sanders |
The nightly news tracks economic indicators such as the subprime mortgage market, the strength of the U.S. dollar, and the growth of real wages over time. The medical liability crisis sometimes makes a brief appearance, but the broader physicians’ practice environment rarely makes it to page A20 of the local paper. This is understandable, of course, given the magnitude of problems that confront our patients and society. Yet, the health of the provider system is important, too, and medical students and residents have as much of a stake in its rehabilitation as current attendings.
Running the Numbers
The Massachusetts Medical Society publishes the Physician Practice Environment
Index as a way of assessing trends in the provider space. They look at Massachusetts
as well as the rest of the United States. Think of it as you would back-page
data from the Economist or the U.S. News and World Report career
guide. It’s probably not surprising that the numbers are declining
for the 13th consecutive year in Massachusetts. The index comprises nine
factors:
• applications to medical schools
• percent of physicians over 55 years of age
• median physician income levels
• ratio of median housing prices to median physician income
• mean number of hours spent on patient care activities
• physician cost of doing business
• number of visits per emergency department
• change in average malpractice rates
• number of advertisements for physician employment in the New England
Journal of Medicine
In 2006, the key index drivers were liability costs, practice costs, and NEJM employment advertisements. This latter variable might seem a tenuous proxy, but it apparently correlates with real shortages in the physician work force. From 2005 to 2006, professional liability rates rose 5 percent; this is no one-off hike since the average annual growth rate over the past 12 years has been 7.47 percent in Massachusetts and 5.81 percent nationally. Over the past year, the cost of maintaining a practice rose 2.8 percent, comprising changes in employee wages, office space, and medical supplies. This seems reasonable in absolute terms, but over the past decade, practice costs have risen at twice the rate of inflation.
The Elephant in the Room
Physicians tend to cringe when bringing up finances, and this, in part, reflects
a deeply rooted commitment to patient healing and professionalism. Our moral
anchors keep us from confronting issues of scarcity. But while a few clinicians
choose to serve in positions of leadership on business issues, all doctors
should get involved at a baseline level. Despite disparate liability rates
among specialties, private versus academic practices, and the diverse needs
of different patient populations, we fragment broader trends at our peril.
Young doctors should take a keen interest in shaping the future of medicine
and not entirely disappear into dispersed specialty societies after medical
school graduation.
Yearly Financial Check-up
As student doctors we tend to frame our careers as blocks of time: four years
of “pre-medicine,” four years of medical school, three to 10
years of residency, and then the promised land. We bring the same perspective
toward our finances. Even debt seems to be one big fixed chunk at graduation.
Given the inability to repay interest, much less principal, during medical
school and residency, we don’t follow annual changes in the financial
markets (e.g., bond yields) as closely as we should. The near-term view of
relatively constant residency salaries numbs us to the annual cost increases
of caring for patients. Perhaps this is why medical students don’t
always comprehend the significance of yearly struggles to revise Medicare’s
Sustainable Growth Rate (SGR) formula.
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Aspiring doctors thus assume the increased responsibility to optimize the efficiency and effectiveness of their clinical services. |
Presidential candidates for 2008 presented health care plans this spring, with Senators Clinton and Obama making the biggest splash. The documents listed on their websites give special emphasis to reforming the payor system. Indeed, this is the subject that most captivates patients and the general electorate. But student doctors must not relinquish their responsibility to continue reforms in the clinic. A well-functioning payor system requires a well-functioning provider system, as can be seen from the challenges facing national health systems in other countries. While an increase in fuel costs or a longshoremen’s strike can raise the price of a gallon of milk, this is not the way things work in medicine. Aspiring doctors thus assume the increased responsibility to optimize the efficiency and effectiveness of their clinical services. Using such guides as the Physician Practice Environment Index for targeted policy changes, and continuing the interdisciplinary collegiality of medical school, student doctors can help ensure the long-term sustainability of the profession of medicine.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
Copyright 2007 by the President and Fellows of Harvard College