Maybe you should wait until after law school to cure your insomnia?  Just sayin’ . . .

There’s an additional problem with primary care physicians, caused by the way many of them are reimbursed by insurance companies even for those with “good” insurance.

The doctors often get a “lump sum” for taking care of patients, which is a disincentive to treat them - the fewer visits and problems, the more profit for the doctor.

Even in the case of a doctor not paid that way there are problems. For example, I’m a middle aged woman with pre-existing health conditions. I have rather serious asthma, back problems, arthritis and a knee which has been through 7 surgeries. My doctor won’t send me to specialists - he won’t get paid for an office visit to someone else. So my asthma is not properly controlled, because he thinks it’s just a matter of writing me a prescription for Advair (which is a dicey drug to take, btw), and neither is my pain because he thinks pain meds are a bad idea.

The *only* specialist he’ll send me to is a gynecologist, because he doesn’t like dealing with “woman problems.” Even so, when I presented late last year with a problem I already understood (fibroids, not the first time I’ve dealt with them) he insisted I see him first, *and* have an ultrasound…which of course the specialist turned right around and repeated anyway. Huge waste of money. And my time - I don’t have time for two office visits when one will do.

The whole system is massively flawed.

The doctors often get a “lump sum” for taking care of patients, which is a disincentive to treat them - the fewer visits and problems, the more profit for the doctor.

I began to suspect this awhile back with my last doctor. He was really nice until I kept coming back for repeated visits (I have a really bad back, with surgery and all sorts of fun things) and then he started getting surly. It eventually got to the point where I felt that he felt that my pain was imaginary, all in my head, etc. I felt dismissed, like I wasn’t important anymore. Someone pointed out that he was probably “losing” money on me, via all my visits, and it all made sense.

Broce, the thing is that your experience makes a good case against the “family doctor” whom you regularly see: you have a set of well-known pre-existing conditions which should be handled under the supervision of specialists who know how to manage them and know your history.

I, on the other hand, don’t have any of those problems, and most any common illness I encounter is something I can manage myself… though as I get older, I’m getting sick in ways and for longer periods of time than I’m used to, and has sometimes required a doctor’s visit for something that required prescription medication. I’d be just as happy if I could get the same medication over the counter.

Broce, the thing is that your experience makes a good case against the “family doctor” whom you regularly see:

It’s the system, however, that makes him so. It isn’t just a failing of this particular doctor, who is good on the sorts of issues you cite. For example, he insists not only that I get a flu shot, but that my college age son does as well since he lives with me…and for an asthmatic, the flu can be a Very Bad Thing. On the normal day to day issues, he’s pretty good (even if he cant mind his own business about my sex life, but then I live in Fundy Central)...its just that with a primary care physician who is coordinating care *and* is a GP, he has the opportunity to step between you and the specialists you might actually need.

OTOH years ago I had an ob-gyn as my primary care and he couldnt deal with a simple case of bronchitis without having me see a specialist. I don’t suggest I have the answers, it’s just a recognition that the system is terribly broken even for those with supposedly good health insurance.

“Specialists ... who know your history”?

It is to laugh. Specialists know that they have 16 minutes to decide whether you’ve got what your primary doctor think you’ve got, or to order up a bunch more tests. And unless you’re chronically sick enough for care, you won’t be seeing them often enough for them to remember where your chart is, much less the details of your condition. Just more fragmentation of care.

Broce has an important point: even people with ostensibly good insurance don’t necessarily have a working relationship with a primary care physician. In our neck of the woods, insurance won’t pay for an office visit (for an adult) unless some actionable diagnosis comes out of it, and if you don’t see your primary physician at least once every two years you get scrubbed from their patient list (because in an HMO doctors get paid a capitation fee for every patient regardless of visits).

And yeah, it would be really nice to have one’s health records in a readily accessible form without a physician to maintain them, but the privacy hit is enormous.

Re: the milk man—we’ve got one of those around here.  http://www.maplelinefarm.com/  But then, we are special.

I would suggest people make a comparision between the situation of the primary care doctor and the neighborhood banker a la “It’s a Wonderful Life”.

We live in an era of commoditization of services, and one of the facets of that commodification is that “case by case” and “knowing your customer/patient” is a bad thing because it interferes with the broader goal of setting up a beaurocratic machinery that can handle much larger volumes of work per hour.  This process is desired because, mark this:

A beaurocratic machinery that can handle work and has fixed inputs and resolved conclusions can be over-and-underpaid for that work.

and this:

Deciding the patient’s overall health care outcomes, or the maintenance of a healthy state of being, cannot be adequately measured by beaurocratic entities in a commodified service milieu.  There is no way to tie profits from marginal accumilation to positive outcomes at the patient level.

It works largely the same way for bankers.  A local bank can have a few loan officers with a great deal of local knowlege and expertise, and they can do a great job of holding down the number of bad loans.  However, hiring and keeping good loan officers is expensive.  If one wants to be a big megacorp bank that covers multistate or national sales, then scaling up from the local bank, but with its ethos, will drastically increase labor costs.  Beyond that, *managing* so many people who are experts in their own little thing will increase costs, and more importantly, demand for truly awesome, intellegent, and capable integrators.  There are but so many of those guys.  Therefore, increasing profits by increasing size is not possible for certain services like lawyers, bankers, doctors, and other professional occupations that closely interact with consumers.  In the end, what happens for megacorps services is that they stop measuring by outcome, either by outsourcing the necessity for that (through securitization for bankers), or simply stop caring about the ultimate satisfaction of the consumer (as in medicine).

Primary care doctors decreasing in numbers simply reflects the overall commodification of health services.  If you are paid by what you do, or how long you do it, instead of patient satisfaction, then primary care doctors would be paid the least of the medical profession, and trashed on the most.  After all, what makes a good primary care doctor is his/her knowlege of the patient, empathy, and general knowlege of medicine.  Many visits may have nothing at all done to the patient, but the patient would still have been well served.  However, the beaurocracy can’t tell this from a bad outcome like they can surgeries, or anything else a specialist can offer.

Primary care doctors can only survive in a milieu where the patient is the direct customer, not anyone else.  A single payer system would work okay, but would still have many of the negative outcomes for primary care doctors.  Those can be minimized, however.

Every time I go to emergent care (because I’m not insured and never have been) I hate being asked who my regular doctor is.  Then when I say I don’t have one I get told that I “really ought to find one.”  Really, genius?  I don’t know anyone who has a family doctor.  For reference: I’m 30 years old.

I can’t imagine why med students, after giving up any semblance of a life for years and taking on crushing debt, wouldn’t opt for a low-paying, rather boring job.  Perhaps our government could offer full scholarships for med students willing to take primary care positions after graduation, but, of course, that would make sense, and this is the United States of America.

I’ve lived six different places in the past six years

In the past six years, I’ve had six different addresses in four different metropolitan areas, so I can relate.  The one time I lived in the same city for two years in a row, my doctor dropped out of my insurer’s network.  At the same time, I have a friend in a medium-sized Wisconsin city who has lived there for the same six years, and every year when she goes in for her OB-GYN checkup, she has a different doctor.  And each time, they want to run a bunch of tests to explain why her heartbeat is so fast when she’s known for decades (and has established with each previous doctor) that she simply has a fast heartbeat.  So even if you stay put (which many of us in our 20s/30s don’t get to because of schooling and/or the job market), you won’t necessarily get to establish that long-term health care relationship.

I’ve been in one place for the past 10 years, and in that time have had 4 different primary care doctors.  I’m about to embark on finding number 5 because number 4 just moved his office ten miles away (to a more yuppified suburb).  There’s no way to establish a long-term relationship with a doctor in this environment.  None.

NPR did or is doing a series a reports on universal health care systems in Europe.  I remember they just did a report on the German system, and spent a day with a young doctor who was actually being forced to make housecalls (I think one day a week).  Doctor housecalls are simply unheard of in this country.  The story also pointed out that the German system works by holding down compensation to doctors, which results in holding down prices for care; but such a solution would of course raise howls of protest in this country.

NPR’s Health Care for All series:
http://www.npr.org/templates/story/story.php?storyId=91972152

Not all specialties of doctors make oodles of money.  Pediatricians and family practice docs usually make substantially lower than say, any type of surgon (not that they are starving, but generally we are talking in the high 10s to $100,000 range, possibly a bit higher depending on managed care or urban environment).  Internal medician docs fall some place in the middle.  If you want to make the big bucks as a doctor, you do something like urology, pathology, radiology, or, like I said, any type of surgery.

The story also pointed out that the German system works by holding down compensation to doctors, which results in holding down prices for care; but such a solution would of course raise howls of protest in this country.

The only way it would be even halfway viable would be to forgive all of the medical school debt that people ran up.  When you’re looking at $100,000 to $200,000 of debt that needs to be repaid, you’re not going to take a lousy $45K a year job as a primary care physician.

PCPs are always going to be paid in the $100k range because health care professionals who work for them, like Nurse Practitioners and Physician’s Assistants are paid slightly less than that. So there’s a baseline below which you can’t really let doctors’ salaries fall below, because otherwise the incentive to be a doctor disappears.

However, primary care/family practice can be very appealing for a foreign-educated physician: the training time is short (and all foreign-educated doctors need to do a residency in the US), and the salaries, while low by physicians’ standards, are far higher than they could make in their home countries.

On the other hand, maybe we should figure out a way to manage our health care without a “family doctor.” Unless you have chronic problems or long term issues that need attending to, I really don’t see the point.

Perhaps our government could offer full scholarships for med students willing to take primary care positions after graduation, but, of course, that would make sense, and this is the United States of America.

Actually, it does. At both the federal and state levels. My wife has one from our state.  You have to agree to server as a Primary Care Physician in an under-served area to qualify for 4 years. Break that and you pay it back as a loan with a high-than-usual-student-loan rate.

Another problem is that within the medical community, Family Practice/GP is at the bottom of the barrel. The best and brightest go for higher paying or the specialties with more standardized hours. (Traditionally, FP/GP’s have their 9-5 office hours, call in the evening, rounds in the morning before clinic on any hospitalized patients. My parents were both FP’s, and even though they technically worked 3/4’s time, I would estimate they put in 50 hours/week.)  And FPs need to be bright. They need to know enough in -every- field of medicine that they can handle the basics and recognize further issues. They need to keep a working relationship with their patients, so in addition to being intelligent, they need the charisma to be able to get people to open up about some of their most personal problems and be able to get them to make changes their lifestyles (drugs, diet, exercise, etc.). Add in that it’s one of the lowest paying options for prospective doctors… No one wants to do it.

Oh, and scholarships? If you’re willing to work somewhere in need of a physician, you can usually get your med school (and possibly undergrad) loans repaid by them.

And yet, regularly scheduled maintenance checkups have been shown, repeatedly, to be cheaper long-term than not having them. It catches diseases earlier, prevents diseases from worsening, and generally will result in better health for the individual as well.

As for un/underinsured, look for a sliding-scale clinic. It may be tied with a residency or there are those that are independent, but they do provide care and will work with you on what you can afford to pay for a visit. Admittedly, these are not available everywhere.

On the insurance re-imbursement side, I’ve not dealt with HMO-style healthcare. (My parents work in the rural midwest and my wife’s residency clinic is not part of an HMO.)  What I have seen, though, is that re-imbursement is on a per-visit basis, not a lump-sum-per-patient. However, there are a number of people who abuse the systems. Medicaid patients that bring their kids in because of sniffles and skinned knees. (That said, I’m still for expanding Medicaid. I’d rather it be “abused” like this than there not be any health care available at all.)

Note: If you didn’t catch it in my comment, my parents and my wife are all MDs (Family Practice, specifically, though my dad also does ER). Thus, my perspective is somewhat biased in all likelihood.

The thing is about scholarships is that, given the choice between getting a low-paid job whose education is free and taking out loans to get a job that pays you phenomenal amounts of money, people are going to make the mental calculation and realize that having huge loans isn’t that big of a deal when your salary is huge.

regularly scheduled maintenance checkups have been shown, repeatedly, to be cheaper long-term than not having them.

Is this really true? I’ve heard the opposite: I’ve heard that outcomes are similar if you just wait until symptoms show up and see a doctor about them, so thus it just costs more to have scheduled checkups without much benefit.

I think nostalgia can be a bit blind.  While we do need a new model for front-line personal care, for every Marcus Welby there was some drunk wife-beating loser who wanted to pull tonsils for every sore throat.  If you lived in rural areas served by few doctors, it could be a real crapshoot.  Everything from very dedicated and good people doctors with flagging skills to saints and losers. Even if you lived in a well-served area, blind loyalty could get you in serious trouble with somebody who got their license immediately post-Flexner era and never cracked a journal since.

When my husband’s family FINALLY stopped seeing the “old family doctor” when said doctor beat his wife near to death with a frozen leg of lamb in a drunken rage, he finally saw a competent doctor for the first time in his life.  Turned out he had a life-threatening heart malformation that said “old family doctor” never bothered to notice or understand - beyond a past a pencil jot about a murmur in an old chart shortly after birth.  Because of new doctor, he was followed at a major medical center until he required surgery.

i lost my first post. blame the meds ;D

i accidently stumbled into this idealized relationship with one of my doctors. see, i have multiple chronic illness, and the Student Clinics (where i was forced to go as a student at OSU, because the only primary care docs covered by OSU’s insurance are those employed in the student health clinc.) iand non of the knew what to do with me, the didnt understand my aillments and didn’t get why iwouldn’t take the drugs (which fell into two categories: 1, had it a lot i knnow it doesn’t work and 2 had it alot and knew it would makeme sick) so finally finally theu collectivly give up and send me to a pain managment doctor. who FUCKING LISTENS TO ME so i am on meds that help my pain without fucking me up and he sent me to a orthopaedic who actually LOOKED AT MY LEG (instead of the common assumption that it was either all in my head, or because i am 30lbs overweight so i hurt because i’m fat. the orthopaedic found something. a HUGE something, i have me 2nd major gigantic they are cuttig off my hip surgery thursday.
my pain managment doc is now, at least between the two of us, my Primary Care.

1950s?

I have a family doctor like that - I’ve been registered with five practices since birth, and my medical records follow me around like a following thing.  Hell, in this country, you can still get home visits, if you need them.

This is the 21st century. Family doctors are only a thing of the past in the US, where you have the crappiest health care system of any developed country, which conservatives for some reason want to preserve.