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I was the thirteenth primary care physician joining (My County Hospital) to do clinic and care for inpatients in early January 2000. Of those thirteen primary care physicians, only two are still working in clinic and taking care of hospitalized patients. It concerns me than we are losing more than one per year. Why is this and what can we do to keep excellent experienced primary care physicians?

Nationwide, some doctors are quitting. They quit, they retire, they leave clinics and hospitals and do other sorts of care. I have a pamphlet for an entire three day conference on changing careers from patient care to multiple other careers. I also have a pamphlet for a writer's conference for physicians. Why are physicians unhappy?

Dr. R. is a psychiatrist who works with doctors. He told me that the Seattle primary care physicians had been driven to seeing a patient every 10 minutes. They hated it because they couldn't give good care. He said that the Seattle primary care physicians retired, quit, got sick, or changed careers until the healthcare corporations realized that it was too expensive to replace them and at last lengthened the visit times.

My brother in law is from England. He says that British physicians were driven to see more people faster. He saw a physician about his knee. The physician did not talk to him much and wrote him a prescription. My brother in law asked, "Aren't you going to examine my knee?" The physician then did examine his knee. Unfortunately he examined the wrong one. My brother in law switched doctors. He said that doctors quit and protested until they were given more time.

(My County Hospital's) administration told me in March 2009 that I had to see a minimum of 18 patients a day because Congress has set primary care a quota if the clinic is attached to a hospital that has a rural health care designation. (My County Hospital) has the rural designation. I understand that in order to survive in this economic climate, our hospital needs the extra reimbursement to stay open and that (My County Hospital) does an enormous amount of care for people with little or no insurance, but I do not think that Congress should assign me a quota. The quota makes care difficult.

Our largest demographic age group in (My County) is age 50-70. I have now been delivering babies for 18 years and my patients include pregnant mothers, newborns and every age group up to my current oldest patient, who is 104. At one point I had 6 patients over 100. I had a day in April when my youngest patient was 8 years old and my oldest that day was 92 and I saw a person from every decade in between. I love the diversity of ages, problems, people and I am happy to work with all of the wonderful surrounding specialists in town, in nearby larger towns, and in Seattle. There are specialists that I have spoken to by phone for the last 9.5 years and have never met, but still, they know who I am.

I was told that the community demanded more patient access and that that was part of the reason that I had to meet the minimum of 18 patients a day. That, by the way, is the minimum. The goal would be closer to 25. I cannot give the care that I want to give seeing 25 people a day. I also can hardly keep up with the paperwork, labs, consults, xrays, letters from other specialists, disability forms, insurance forms. I do as much as possible of the paperwork during visits, because the additional time after clinic doing paperwork is time away from my family.

Nationwide, the average primary care patient has five chronic diseases. This would include diabetes, hypertension, mild kidney failure, alcoholism, chronic back pain, allergies, congestive heart failure, coronary artery disease and so forth. Insurance and medicare payments are arranged so that three short visits pays better than one long visit. This drives the healthcare corporations to say "one problem per visit". I chose family practice as my specialty because I wanted to care for whole people, families, in their community. I cannot do that with "one problem per visit" and I cannot do the care that I want to do. Even though I would be entirely happy to have all my patients be healthy and just see each for a physical once a year, I also work well with the challenge of diagnostically puzzling and complex patients; with the minimum of 18 patients a day initiated in March 2009, I ran late nearly every day, because many visits took longer than the scheduled 20 minutes. We used to have "doctor only" visits that only we could approve. I would leave those empty to catch up. Once they were gone, I ran late. It was not fun for me, not fun for the front desk and I cannot imagine that it was worth the extra 2-3 access visits per day to the patients, because they had to wait between 30-90 minutes extra to get seen. One 20 minute visit involved calling two neurology specialists, discussion with the inpatient doctor, an admit note, orders, a call to the patients family and hospital admission. It took 70 minutes, but that was what the care required. I felt that I was working as fast as I could every day and I dropped 10 pounds in the first two weeks. After five weeks I got sick and had to cancel two days of clinic. That did not improve the access problem.

We must balance access and economics against good care. Physicians do not go in to primary care for money, since it is paid 3-5 times less than other specialties. As a nation we are frustrating our primary care physicians to the point of protesting, getting ill or quitting.

My new clinic opens in the late fall/winter 2009. Call (number)if you wish to leave a name and address for direct notification.

Lizardinlaw, MD

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