GP burnout

[Guest Guyver03]

There is an interesting article in today's Vancouver Sun, in it, it talks about large number of GP's are having burnouts, and they either are thinking or have already left the profession. One doctor interviewed said he is leaving his family practice in Victoria and move to Vancouver to work in a walk-in clinic, as well as pursuing his interest in stand-up comedy. He explained that working in a walk-in would remove him from managing the business side of a clinic, such as insurance and claim forms. Ultimately, walk-in would provide higher a financial return than a private practice. He then goes on to reveal that he sold his private clinic for $15,000, which he bought at $46,000 in 1992. The decrease in the number of GP over the years can be blamed on two things: 1) money, and 2) the prestige of being a specialist. These two things seem to drive most newly graduated MD away from GP. Furthermore, medical schools have an inherited bias towards specialists; since most of the instructors are specialists, rarely does MD students have the opportunity to work with a GP.

 

One other thing that seems to affect GP is our dilapidated health care system. The previously mentioned doctor said that when he first started, the wait list for surgery was on average 25 people. Now, the list could be up to 250 people. He was sick and tired of telling his patients that there is nothing he can do to put people on the waiting list for surgery or to speed up the process.

 

Perhaps some of you may say: "I'd never leave my profession because of such silly reason. I'll continue to help people until I die." That is a noble cause, but it is only fantasy. No matter what, sooner or later everyone will have a burnout, and until then, young GP's will always live in their fantasy. I hope some of you will read this article, and be prepared for any obstacles that you may faced in the future.

 

Healing people is a noble act, but be prepared when reality knocks on your door. Cheers.

[Guest marbledust]

Perhaps some of you may say: "I'd never leave my profession because of such silly reason. I'll continue to help people until I die." That is a noble cause, but it is only fantasy. No matter what, sooner or later everyone will have a burnout, and until then, young GP's will always live in their fantasy. I hope some of you will read this article, and be prepared for any obstacles that you may faced in the future.

 

 

I am curious, is the above a direct quote from the article? Or did you write this? I find the tone and language a bit strange...

 

Family med does have a high burnout rate unfortunately. But any speciality or job for that matter has the potential for burnout. I've met some very burned out general surgeons, elementary school teachers, etc.

[Guest Koppertone]

It's funny that you mention this. After I was accepted into med, my family doctor said he'd "hold on to his practice and then give it to me when I'm done residency" so that he can "finally quit". The weirdest part of all was that he was serious.

[Guest Ian Wong]

The scary thing is, traditional office-based Family Medicine is so unpopular right now that it's pretty much impossible to sell your practice (which obviously has a great deal of equity invested into it), and it's pretty difficult even to GIVE the thing away. In what other professions is it this difficult to give away a free, already built-up practice?

 

There simply aren't enough new FM graduates out there, and many of those who do graduate are opting instead for locums, walk-in clinics, or Emerg Med instead of opening up their own office practices.

 

Ian

[Guest physiology]

Hello Everyone,

 

I've always been very enthusiastic towards FP, but now after reading that article, my interest towards this specialty is weaning.

 

I've always seen myself in primary care (internal, pediatrics, or FP) but with the low morale, lower pay, and extensive obligations to do paperwork/billing, it's a turn-off I must say.

 

The specialties look more and more interesting.

 

I think what the BC government needs to do is remove the "capping" that happens. I was talking to the secretary for my family doctor and she stated that my physician has a "point system." I think the maximum allowable points/day is around 60. Each visit is scored differently and once that 60 point limit is reached, he starts working for half-price. Then as the points increase, he works for free. However, he sees ALL the patients that he is scheduled to see for that day.

 

I mean this is disheartening and doesn't make any sense. It brands all FPs as cheats who provide 5 minute, super-rushed, grossly incompetent service.

 

This was the case for my former FP (the one who delivered me) but that's why we left her.

 

Anyway, FP is the backbone of medicine and they need support. I think FPs should have:

 

1) the "capping" of their points removed

2) more re-entry positions so that individuals aren't stuck in FP if they are unsatisfied

4) Loan forgiveness INCLUDING LOCs (right now, loan remission only applies to government student loans)

5) more money for their services

 

I think specialists earn enough so it's the FP who need pay raises.

 

Anyway, I also think patients should have the right to complain about their physicans if they feel the quality of the visit is compromised. I mean, I'm not referring to challenging physicians on their diagnoses, but people aren't stupid, and can easily tell when a doctor is doing a half-assed job.

 

Anyway, just went overboard on some of my thoughts!!

[Guest cracked30]

I would be careful about what you say about specialties.

 

The reason specialties earn more is because they are

on-call more. In some smaller towns, 24/7. Now, that fewer specialists, mostly surgical, are doing less call, their earning levels are dropping to GP levels.

[Guest physiology]

I disagree.

 

The specialists I see in BC (ophtho and cardiology) are NOT on call and have their own private practices with surgeries once a week. This is based on what I've seen. They rake in ~350 k to 500 k.

 

If there's a paper backing up your claim, I'd love to see it. If not, then we're both running on empirical observations.

[Guest Ian Wong]

The reason specialties earn more is because they are on-call more. In some smaller towns, 24/7. Now, that fewer specialists, mostly surgical, are doing less call, their earning levels are dropping to GP levels.

I can't agree with that statement alone. The fee schedules are heavily tilted towards the specialists, particularly the procedural ones, like GI (scopes), Cards (caths), Ophtho (cataracts), etc. Even the non-office based specialties (Path, Rads, Anesthesiology, Emerg), have a great deal on the fee schedule, because along with billing quite highly, they don't need to pay overhead! It's like getting to keep an additional 20-40% of your paycheque, not to mention all the time saved by not having to run and maintain an office.

 

Sure, that Peds Rheum guy, or the neighbourhood psychiatrist are probably making equivalent money to a family physician, but they're usually also working less hours. Call is not, nor has it ever really been a huge revenue generator, particularly seeing as most of the revenue-generating parts of the hospital are either shut down or are running at minimal levels at night (ie. OR's, endoscopy suites, fluoro rooms, etc).

 

The other perk to being a specialist is that you get to zone in on a single particular problem, and turf the other issues back to the primary care doctor. You get to bill for the short amount of time taken to address that one issue, while the family physician bills the same amount (or less) per visit, but has to disentangle all the patient's other problems, which usually takes a much longer period of time. Not a single med student or resident here hasn't heard the phrase: "Oh, that's not my area, go see your family physician about that..." at least a few times in each rotation.

 

Anyway, virtually any physician who works with, or uses hospital property in any way, needs to take call. In exchange for getting to use the hospitals resources (admitting patients, using the OR's/fluoro rooms, etc), you need to agree to provide some amount of on call coverage for the hospital.

 

The cardiologists and ophthalmologists you've seen most assuredly do take call in the hospital. The difference is that there's very few eye emergencies that need to be seen right away that night, whereas the same cannot be said of emergent cardiac conditions (usually MI's). This is why Ophtho is generally considered to be a "lifestyle" specialty, while you really wouldn't say the same about Cardiology, particularly not Interventional Cardiology. Both of these specialties have the potential to make hideous amounts of money (probably a factor in why they're so competitive), but the cardiologists certainly will need to put in more hours to achieve that.

 

The problem is that there's a fixed pool of money in the healthcare system allocated for physician salaries. In order to raise the fee schedules for Family docs, you'd need to get all the specialists to agree to cut or cap their current fee schedules, and that's just not likely to happen.

 

Ian

[Guest physiology]

Hello Ian,

 

Thanks for the insight! Could you go into ophthamology and not do any surgeries?

 

Anyway, I kinda cheat the medical health care system by getting free eye examinations (for my prescription) with my ophtho. However, I do have a contact lens allergy, so I do have a reason for seeing him. I just push for the eye exam as well

 

I hate seeing the optometrists as they seem very money-grubby. Last time, I had to pay a hidden-fee because I had previously gotten my eyes checked by the ophthalmologist.

 

Optometrists obviously don't like it when ophthalmologists infringe on their turf.

 

Anyway, didn't meanto hijack this thread.

[Guest moo]

I hate seeing the optometrists as they seem very money-grubby.

 

yeah, you see the new ads the optometrists have running now on TV? Ever since the government decided to stop reimbursing for optometry care, their business has gone way down. Don't get me wrong though. I think my optometrist is great and he's done a wonderful job with my prescriptions but at the same time, he hounds me all the time to get new contacts every time I see him, at a price of 190 bucks--per lens!

[Guest cracked30]

I guess it started with the term specialists. There are many types, and I tend to think of things like general surgery, general internal, orthopedics, pediatrics, ENT and urology in a smaller town, 20 000 to 50 000.

 

They are not paid enough for the work they do, and this is becoming evident in match rates, perhaps moreso for GSx and Ortho.

 

So when someone says specialists make too much, I think of these poor folks slogging along, working all hours, for maybe another 50K over the GPs in the same town.

 

12 people left the general surgery program at U of T last year, mostly due to the fact that remuneration for that "specialty: no longer reflected the amount of work and time away from home that is required to give good care. Two people also left General surgery in London and two left Orthopedics for similar reasons.

 

So, when someone says Specialists make too much, I think, who's going to take out your obstructing colon cancer in the middle of the night or who's going to fix your Grandma's broken hip. Very few in our generation is interested in that thing for so little money in the middle of the night.

 

I think a crisis in those two specialties is coming in Canada, they need to be paid more.

 

I totally agree about the other specialties though, no need to increase their fee schedule.

 

Sorry, I am writing this quickly.

[Guest UWOMED2005]

Cracked has a point there.

 

I just finished my Surgery rotation. The Gen surg work insane hours. . . the Orthopods only slightly less so. (I actually slept a few hours on my Ortho call.)

[Guest Ian Wong]

I think a crisis in those two specialties is coming in Canada, they need to be paid more.

 

I totally agree about the other specialties though, no need to increase their fee schedule.

I think more money will help, but only in a round-about way. What I see being the huge problem with GS is that it's in a hugely negative spiral right now. All of the old GS's in the 50-65 year demographic (which makes up a very large proportion of the practising GS's out there), are burned out, burning out, or otherwise planning on retiring sooner rather than later.

 

As soon as one member of your GS group retires, that means that the on call burden for everyone else increases proportionally, and those people in turn will retire too. It then becomes permanently impossible to hire new recruits to prop up the call pool, because they all think "Why would I want to join this 3-man group and take 1 in 4 call, when I could join with this 7-man group and take 1 in 8 call?" So, all your older surgeons are more likely to quit as the group size gets smaller, while newer surgeons are less likely to join while the group size continues to decrease. It's a vicious circle.

 

There's got to be a huge increase in the number of GS residents to keep the call burden less insane during residency and future practice. Hopefully, this will alleviate some of the manpower issues and make the currently very demanding on call schedules a bit more manageable, so our older community surgeons will continue practicing for a longer amount of time. We also have to increase funding for academic surgeons who are willing to work in the university setting, so that we have an adequate supply of staff (not to mention surgical volume) to train all these new residents. If you can recruit a staff member from the community, hopefully all of his/her old referrals will now become cases where the residents can learn as well.

 

I agree with you. I'm seriously worried about the future of General Surgery in this country. With the huge push towards lifestyle specialties by medical students today, it's not surprising that GS has dropped off the radar of many med students. A lot of those surgically-inclined students are instead going after surgical subspecialties (ie. ENT, Uro, Plastics, Ophtho, etc) or else lifestyle specialties like Emerg, Radiology, or Anesthesiology that still have the potential for lots of hands-on procedures.

 

Ian

[Guest cracked30]

Yeah,

 

The US is having real trouble with GenSX and Ortho too.

 

A really good article in the American College of Surgeons addressed this issue, especially with GenSX, Ortho and Neuro. The nighttime and weekend specialties. What I mean by that is the patient problems common to these specialties need to be taken care of when they happen, even if it is the nighttime or weekend.

 

You can't tell the ER guy to send the abdominal pain with fever, the compound fracture, or the terrible headache with positive LP to Monday's clinic. Therefore if you go into one of these specialties you will be operating at night and on the weekend.

 

Med students, understandibly so, cannot justify this kind of effort for less money than the plastic surgeon, the opthamologist, the ENT or Urology guy. SO, they are applying less and less to the nighttime/weekend specialties.

 

And those three specialties have the highest CMPA fees, after OB Gyn;

Neurosurgery $50,508

Orthopedics $29,028

GenSx $17,688

[Guest stevetilley]

Just thought I'd contribute to the discussion general practice as a career choice. To me, at least in the context of practising in St.John's, being a GP seems like a pretty good deal. I spent a couple of weeks shadowing a GP and I thought it was a pretty reasonable job.

 

For one, the 2 year redidency is short and sweet and from what I gather not too intense (perhaps except during the couple of months on surgery and internal and obs/gyn services). Secondly, once your done you can set up shop in the city and almost instantly have a busy practice (because of the shortage). The lifestyle seems ok (set your own hours, etc), and you don't HAVE to do Obs if you don't want to.

 

As a fee-for-service GP in Nfld, the fee for a partial assessment is $24 and for 12 months general checkup is arund $60 or 70.

 

Now for some math - suppose you can manage to get someone in and out and written up in 10 minutes - that works out to 6 an hour (or $144 and hour - not counting any 12month assessments). Doing that for 8 hours gives $1152 a day or $5760 for a 40-hour week. (however, any time spent doing office work etc.. obviously won't make you anything extra.) Working a net of 48 weeks a year means you bill $276,800 a year.

 

This $276k billing figure doesn't count the higher-paying 12month assessments (for which you usually do 1/year for each patient). Additionally, many GPs also do the scatttered physical assessment for private companies which usually pay around $100 for about 15 mins of work (mainly filling out forms). From what I hear, there are lots of FFS GPs billing aruound $300k total.

 

Now, you have to sutract from that everything from clinic rent, secretary salary, professional fees, insurance, tounge depressors, otoscope tips, and other office expenses. Now, granted rent in St.John's is a helluva lot less than Van or TO. For argument sake - let say expenses total about $90-100k.

 

So, you're left with about $200k before taxes, working a relatively low-stress job with reasonable hours (at least compared to something like neurosurg or gen Sx). Doesn't really seem all THAT bad to me.

 

Granted, many argue that making this kind of $$$ as a GP means you have to operate a "turnstyle" type of clinic.

 

Also, I realize the situation in the larger centres might not be as good because expenses might be higher.

 

Just thought i'd add an Eastern perspective!!

 

Cheers,

 

-Steve

[Guest everyoneloveschem]

I'd like to see any self-respective GP/FP get 6 patients through per hour, 7.5-8 hours per day, 5 days a week. Might be plausible if you are a doctor at a university health center with 99% healthy young folks, but otherwise very unlikely.

[Guest cracked30]

You would be exhausted and your patients would be pissed off.

[Guest strider2004]

35 patients is probably the max for one day, and even that's pushing it. Howwever, the $1000/day billing seems about right because you should be doing a couple of physicals each day.

[Guest icu]

I realize that this is very far off topic, but I think it requires a little clarification. A comparison of optometrists and opthamologists is on par with a comparison of apples and oranges. Although they are both involved with eye care, their roles are very different. Optometrists are focused on primary care only, whereas opthamologists undergo VERY extensive training compared to optometrists. That being said, the main role of optometrists is to identify and diagnose eye conditions and to provide refraction services. Bear in mind that the ratio of optoms to opthos is about 3:1, maybe more, and that the average age of the population is getting older. This will put considerable strain on both of these eye care providers in the future, mostly due to a limited number of trainees entering the workforce. Unfortunately, there are misconceptions in both the general public and medical community regarding the relationship between optoms and opthos and the roles that they have to play. Hopefully the strains that an aging population will soon place on the healthcare system will force optoms and opthos to work very closely together, even though there has been tension between the two fields in the past.

 

And to physiology, if you believe you're paying 'hidden-fees' you can always contact your provincial college of optoms to rectify the situation.

[Guest UWOMED2005]

Actually, I have worked with Family Physicians who do see anywhere from 4-6 patients per hour. Or at least schedule that many.