It's easy to accuse doctors of indifference when you're sitting in a waiting room after having waited weeks to get an appointment. But doctors tell us that-with insurance and malpractice issues, difficulty in recruiting doctors to the region, and demanding, unrealistic patients-practicing medicine today is just as frustrating. Five local physicians sat down with us recently after a long day of treating patients to discuss what it's like on the other side of the examination table.
Moderated by group publisher JEFF LAWENDA.
Solo practitioner DR. MARGUERITE BARNETT is board certified in both general and plastic surgery and is president of the Sarasota County Medical Society.
DR. BRAD LERNER practiced internal medicine with First Physicians Group of Sarasota and served as the chief medical officer of the group until Oct. 1, when he left to open up his own concierge-style family care practice.
DR. CHARLES LOEWE is CEO of Center for Digestive Diseases and Center for Endoscopy and Surgery in Sarasota, which includes three physicians.
Sarasota neurologist and solo practitioner DR. J. TERRY PETRELLA is medical director of the Florida Gulf Coast ALS Centre and The Muscular Dystrophy Association of Sarasota and assistant clinical professor of neurology at the University of South Florida School of Medicine.
Bradenton urologist DR. MARK WEINTRAUB is president of We Care, a statewide program that provides medical aid to people who don't qualify for any financial assistance. He is also a delegate to the Florida Medical Association.
JEFF LAWENDA: What are your biggest challenges in running your practice?
DR. PETRELLA: Finding professional, quality-driven people who have a sense of loyalty and are willing to work in an ethic commensurate with my own. It's not easy.
DR. LERNER: The folks we generally would hire can't afford to live here. Even the physicians we would hire can't afford to live here anymore.
DR. BARNETT: I went into medicine very idealistic; I wanted to help people. The closest I've ever gotten to fulfilling that pure practice of medicine was when I was in the military. I didn't have to worry about reimbursement and collections. About six years ago, Medicare, the primary source of payment in this area, announced it was cutting reimbursements. At the same time, I have to come up with close to $50,000 just to pay my malpractice insurance. So I decided to limit my Medicare patients and gave up a good deal of my reconstructive work. And now I select patients on the basis of risk. Because we all know that bad outcomes can occur even if you've done the best job.
LERNER: The most frustrating part of running my primary-care practice is the inability to keep up with demand. Sarasota is incredibly underserved in primary care. You're seeing more patients in a day, more who are older and sicker, and [you're] doing more paperwork, while patient demand continues to grow.
WEINTRAUB: We're under attack on many fronts: the government, the insurance industry and the legal profession. We have to do so many things that have nothing to do with taking care of our patients. Once upon a time a medical record was a medical record. Now it's more a legal record. Many of my colleagues are trying to figure out how to get out of medicine early. National data shows a decreasing pool of people going to medical school. I wonder how long it's going to be before the quality of people getting into medical school is decreased.
LAWENDA: Have any of you ever thought of leaving medicine?
LERNER: I've spent the last 11 years both as a physician and as CEO of a 50-or-so physician group, and I decided I didn't want to do both. I decided I enjoyed most being a doctor, but I didn't want to be a full-time doctor in the traditional sense. So I've opened a small, concierge, boutique-type practice. It's not a solution for the masses or the industry, but it is a solution for me.
LOEWE: I'd like to be a plastic surgeon based on the reality shows now. The money is in plastic surgery, cosmetic dentistry and dermatology.
BARNETT: The grass always seems greener on the other side. You have to deal with people who come in want to see the lawyer because you've left one little crease on their cheek.
LAWENDA: How general is the level of disappointment among physicians?
LERNER: I think it is widespread. You're going to have to wait for a whole new generation of physicians who have different expectations than those sitting in this room, who probably straddle the old and the new way.
We have been searching for two physicians for the past year. Nobody's going into primary care because they work too hard and don't get paid enough. Many are going into a new field, called hospitalists, people who do shift work at the hospital and don't go into the traditional private practice. And the cost of opening up a practice and buying a house here is very expensive, particularly compared to the reimbursements. We are in a Medicare-based community. Medicare is one of our worst payers and pays worse here than on the east coast of Florida. So a new physician can move to the east coast and earn significantly more and probably spend the same or less to live.
LAWENDA: What's a typical day like?
LOEWE: Today I did 15 procedures, then saw 25 patients in the office, then did four more procedures. Now I have to go back and make rounds at three different hospitals. I do not stop for lunch. My wife dislikes it. We do not have any children because I've devoted my life to medicine. We do a lot of charity work; the community supported me, so I support the community. I work hard, but I play hard. When I go on vacation, I go off to a health spa for 10 days. And I work out every day and that rejuvenates me. But I love what I'm doing. It's intriguing, invigorating, and it keeps me running.
LERNER: My day is divided between being a doctor and being an administrator, so it's a little bit skewed. But at seven in the morning I'm either seeing patients or attending or chairing a meeting. Usually my day is meetings in the morning and afternoon and patients in between. I take at least five to 10 minutes every day for lunch. Usually I'm out of the office by 7 p.m. If I'm on call, I may go back and forth to the hospital two or three times. I may have 20 phone calls to deal with. I'm in a group and we rotate calls, so there are some weekends I don't go in at all, and other weekends that I live at the hospital. Vacation time? I haven't had much lately.
WEINTRAUB: Many doctors in Bradenton work until they're 70, retire, and six months later, die. And while I love my job, I don't want to make rounds in the hospital when I'm 70. There are other things in life. The average life expectancy in this country for doctors is significantly less than for the general population. For surgical fields, I've heard it's in the 50s.
PETRELLA: A 36-hour day would still not be enough. There are few boundaries between one's professional and personal life. It's difficult balancing being a doctor and being a person, taking care of oneself, one's family and one's health.
LAWENDA: What kind of insurance should this country have?
PETRELLA: Medicare started out as a policy for the disenfranchised and the extremely ill, and it has evolved into a sense of entitlement that most people expect no matter what their wealth at retirement age. We have a multifaceted dilemma. We have elderly people with increasing needs, increasing volumes, high expectations of living to be 100, driving their cars, playing golf, and yet, we as citizens assume somebody else must be responsible for that.
Medicare will not survive unless we make some major reformations. We consume healthcare, just as we consume cars, houses, clothes. Somewhere, somehow that has to be paid for. More than just by big government or big business.
LAWENDA: Should people shoulder the entire burden of their care?
PETRELLA: There should be some basic coverage for all people. If you need more, you get more, but you may have to pay more. If you don't need so much, maybe you don't take so much and also you don't have to pay as much. But to make an insurance company the sole determinant of what a patient gets, what tests they're allowed to acquire, what doctors they can choose is preposterous.
LERNER: There are more and more working people whose employer can no longer afford to provide health insurance. Those costs are passed on to those who have insurance. So the other insurance companies are eventually paying those fees. The hospitals are having to raise their fees to cover the uninsured. And Medicare is being subsidized by the commercial carriers as well. Somewhere along the line we're going to have to go to a payer that is more consistent, so we don't have the cash-paying patient subsidizing those who don't have insurance or who have substandard insurance.
LAWENDA: Could you see some form of socialized medicine here?
BARNETT: My big passion is getting some sort of universal access to healthcare.
PETRELLA: The major European countries have a baseline premise for all citizens. They also pay extremely higher taxes. But that sense of security for the catastrophically ill, the very old, the very poor, and the disenfranchised should be an expectation for all citizens.
WEINTRAUB: Like you said, we're consumers. "I want my MRI; I want it tomorrow. What do you mean, I have to pay for it?" They'll blow $300 on dinner and get irate about their $15 co-pay in the office. The lawyers have hugely shaped the way we practice medicine and so have the insurance companies. It is absolutely preposterous that the insurance companies are controlling the way medicine is practiced. I'd like to see it go back to the way it was 100 years ago, when you go see somebody, you get a chicken. That's probably the fairest way.
LAWENDA: Is the quality of medicine higher here than in countries that have socialized medicine?
WEINTRAUB: It's not higher in quality of care; it's higher in convenience. A patient in France or Canada or England may wait six months or more to get their total knee. Here, it's, "I want my total knee next week." People come here not because we're so much smarter and have better doctors, but because it's easier. If you've got the money to pay for it, you have it.
PETRELLA: We spend the most money on healthcare per capita. Yet our longevity is not No. 1. Today in American healthcare, so many groups of people are making a profit in record levels. Little of it has to do with wellness, longevity and health maintenance. George Bush and the drug industries are intimately involved, I'm sure, in ways that would shock most people. The federal government, even with this Medicare drug plan, does not negotiate lower prices for every citizen. The Canadians do, the Italians do, the Germans do, the French do. And we say their drugs are inferior to those made in the U.S.A. It's just not true. We have been bamboozled by the industry of illness.
LERNER: We have only recently begun to have any idea how we can measure quality and select physicians who are practicing medicine in a quality way. We need to find a way to figure out who those quality physicians and hospitals are and reward them and encourage others to get to that level.
LOEWE: In gastroenterology, we're seeing healthcare dollars misspent because of endoscopy procedures having to be repeated because of substandard quality. In every other country, patients are referred to those physicians or institution that has the highest standard of care.
LAWENDA: How high do you think our standard of care is?
LOEWE: We, the Germans and the Japanese have the highest technology in healthcare. But we [Americans] have the highest quality of care and the best overall outcome. The problem is we've got chiropractory, osteopathic and other industries that tend to take medical care down a notch. You don't find chiropractors in Germany or France.
BARNETT: I would disagree on our quality being that good. I can tell you there are populations in Sarasota I see that hardly get any care, let alone quality care.
LOEWE: There are two sides to that coin. There are individuals in the underserved population that do not seek healthcare. And then there are not enough physicians to provide that healthcare. Through Sarasota Memorial, we have spearheaded screening the underserved for colon cancer-the black population has the highest risk of that cancer. But we have to have physicians willing to do it and willing to accept those who aren't insured.
PETRELLA: Why is the cost of healthcare rising so astronomically?
LOEWE: Foreign physicians. In gastroenterology, when I started, 90 percent of the physicians were American-trained. Now 65 percent are from abroad. I went to a recent international conference in the United States in which 20,000 gastroenterologists participate. Twelve thousand of them were from India.
BARNETT: Are you saying their quality is inferior?
LOEWE: Florida has one of the largest populations of non-American trained physicians. If you look at their profiling and submission of charges and how they operate, it's a totally different world.
PETRELLA: That's a dangerous generalization.
LOEWE: Well, I'm making it, because I've researched it and analyzed it.
PETRELLA: Still, what drives the cost of business? I'm a sole practitioner who worries about paying malpractice costs and paying the light bill, the staff and the insurance for personnel. It's beyond quality of doctors or where people come from. Most of it has to do, I believe, with the fact that Americans expect everything and we want it for nothing.
LOEWE: I don't agree with you.
PETRELLA: Why is smoking not on the decline? Why is obesity higher than ever in America? We can control those issues as individuals, which would decrease utilization of healthcare in America. We serve fast food in high schools. We encourage people to be sedentary. We don't have widespread educational programs or fitness programs for senior citizens.
LERNER: There are many factors, [such as] unnecessary testing for fear of litigation. And patients have unrealistic expectations; because Medicare and co-insurance will pay 100 percent, they'll think nothing about having a series of unnecessary tests done just because they can get it done at no cost.
The other issue is technology. All these fancy gizmos and gadgets and MRIs and 32-slice CAT scans cost money. Everybody hates the drug companies, but millions of dollars go into the research and production for every one of these miracle drugs. If you have a malignancy, you're getting chemotherapy, and the drugs are incredibly expensive. They're $5,000 to $10,000 a dose instead of $5 to $10 a dose. That's the cost of technology.
WEINTRAUB: Why is it that the United States has to pay for all the R & D for the whole world? Every other country in the world negotiates better drug prices. The United States, because of politics, refuses to do that.
LERNER: I doubt too many patients in the world are getting all these chemotherapeutic drugs that we give. We give them to patients for palliation, even though there may be only a 5 percent chance it's going to help. I guarantee you, in Canada and Great Britain and other very sophisticated countries, you frequently will not get that drug.
WEINTRAUB: It's not just the outrageously expensive exotic drugs. It's every single drug out there. Why does a capsule of Nexium cost $5 in America and 90 cents everywhere else? And yes, people in Europe are getting Nexium.
LAWENDA: Why is the same medicine so much less expensive in other places?
PETRELLA: Market forces. Here in America, we turn on the TV and see ads for Celebrex and Vioxx and all these other medications that give the illusion that if you take this pill, you'll be happier, healthier and out playing Frisbee with your dog at age 85.
LAWENDA: So you're saying it's marketing?
PETRELLA: Absolutely. Wall Street and the large pharmaceuticals have no more sense of responsibility than any fast food restaurant does for your health.
WEINTRAUB: And for that matter, neither does the hospital industry or any other health-related industry. The bottom line is the bottom line.
LOEWE: You know, doctors are probably the weakest of all the lobbyists.
LAWENDA: Why is that?
WEINTRAUB: If doctors got together, they'd have the most powerful lobby in the entire country. But you can't get two doctors to agree to anything. And doctors have big egos. They don't like being told what to do by other people. Two years ago I was president of the Manatee County Medical Society and was actively involved at the state level. For every dollar the doctors spent trying to lobby for issues, attorneys spent $17. Lawyers are very well organized, and they're not afraid to put their money where their mouth is. Doctors are cheap.
LAWENDA: Do medical schools teach the business of running a practice?
PETRELLA: No. I sought out an M.B.A. because I realized my understanding of the business of medicine was so limited.
WEINTRAUB: Traditional doctors are horrible businesspeople. Years ago, medicine was treated as a mom-and-pop business, but if you treat it that way today, you're out the door. You have to treat it as a multimillion-dollar business.
LERNER: It's more difficult every day with the variety of contracts one has to negotiate with the insurance companies. Doctors are throwing their hands up and saying, "I can't do it, I don't want to do it," and are either getting out of medicine or finding somebody else to take over the business for them.
LAWENDA: All of you are still practicing. Want to share an experience that explains why?Five local physicians discuss what's ailing medicine.
WEINTRAUB: I had a middle-aged woman who came in with a big kidney mass. It was a cancer, and she had no insurance. I sat down and discussed taking out the kidney and surgery and treated her like any other patient, and went ahead and did the whole thing. She did great, and she ended up coming up with a payment plan-50 bucks a month or a hundred, something like that. After a couple of years, I just said, "OK, enough," and wrote the rest of the bill off, as we all write off lots of things.
Right after the surgery, I received a letter that made me want to cry: "You saved my life and you made me feel OK through the whole procedure, and you didn't look at your watch." I asked my partner, who's now retired, what do I do with a letter like that? She said, "You go home and put it in your sock drawer. When you have a really, really bad day, read that letter. And then you'll know why you're still doing what you do."
I still have it at home in my drawer. And it really does work.