DOCTORS OPTING OUT

'It was slow water torture," says Paul Ryack. That's how the 63-year-old board-certified internist describes his working life just a few years ago. With a few thousand patients, many of them elderly, he could barely find time to listen to halting explanations of their immediate complaints--let alone talk about the importance of lowering blood pressure or losing weight--in the 15 or so minutes he could allot to each. "I was unable to make the time to sit with patients, to get to know them, to help with preventive activities that we need and want," says Ryack, who practices in Santa Barbara, Calif. His costs were so high, and payment per patient so low, that taking even another dozen minutes wasn't possible. "You'd go broke," he says. The end result: a creeping sense of burnout.

Many doctors around the country are similarly frustrated. A 2001 California survey of physicians found that 75 percent of respondents grew less satisfied with practicing medicine over the previous five years. A nationwide survey by the Henry J. Kaiser Family Foundation found that 87 percent of doctors say the overall morale of the profession has gone down in the past few years, and nearly 60 percent said their own morale had declined.

Chat with your own doctor--on the off chance she has time for a conversation--and she is likely to echo those sentiments. "The practice of medicine does not offer the kinds of rewards for what you have to put into it," says Carl Getto, associate dean for hospital affairs at the University of Wisconsin Medical School, who oversees a staff of more than 1,000 physicians.

The hassle factors. Those rewards--including satisfying relationships with patients, autonomy, high status, and comparatively high pay--are increasingly outweighed by the reality of a 21st-century U.S. medical practice. In their place: reams of time-consuming paperwork that is out of proportion to time spent caring for patients, declining reimbursements from insurers, a loss of autonomy from managed care, and fear of malpractice lawsuits.

For patients, the implications of these changes are huge. Some doctors are retiring or cutting back their hours. That means fewer doctors are available. Others are opting for specialties, such as radiology, with less demanding schedules. Many are cutting out certain insurers, and thus cutting out patients who use those insurers. A handful are deliberately restructuring their practices to see fewer--and richer--patients. "It's like a casino," says Doug Farrago, a family medicine physician in Auburn, Maine, and publisher of Placebo Journal , a publication filled with the dark ironies of current medicine. "Older docs can cash in their chips, and younger ones are looking for a different game," he says. In a country that will demand more and more from its healthcare system as the population ages, this is only going to get worse--and your doctor's problems may become yours.

It's not surprising that the doctors who are most upset about how things are now are the 50- and 60-year-olds who remember how it used to be: You made medicine your top priority and reaped emotional and financial rewards. "It was the golden age of medicine when they came in--it was fee for service, and you did what you thought was the best thing for the patient," says Phil Miller with Merritt, Hawkins & Associates, an Irving, Texas-based physician search firm. But the rise of managed care and large insurers, for better or for worse, has changed things. Insurance companies may not cover the drug a doctor prefers to prescribe for a given condition. Mountains of paperwork are required to gain approval for consults or outside services. Then there is the threat of malpractice suits. Doctors in so-called crisis states have stopped delivering babies or staged walkouts in the face of climbing insurance rates; even where insurance is more affordable, doctors fear being sued. That takes a toll.


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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

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