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The Doctor is Out

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When Lawson looked around, she saw "doctors leaving, doctors retiring early. Every few months there would be somebody who closed a practice." Meanwhile, in hospital OB/GYN meetings, the topics were changing. "We used to talk about when to initiate antibiotics when a woman has ruptured membranes, or how to manage an ovarian cyst. Now we talk about financial issues, managed-care contracts, how to minimize care to the patients. Can you decrease the number of prenatal visits? The number of times someone needs a Pap smear?

"One hospital trained janitorial staff to answer patient bells," says Lawson. "If I'd call about a patient, I'd have a hard time finding the nurse, and it'd take her a while to get oriented; she wouldn't know them by name." One day, Lawson called to check on a patient and was told, "Oh, her baby's doing fine." Whereupon she dryly reminded the nurse that Mrs. Smith had just had a hysterectomy.

Another time, a colleague was paged while talking with Lawson. A patient was undergoing ultrasound, and it looked as if she had ovarian cancer. Trying to swiftly schedule the patient for surgery, the other physician groaned, "Oh, I'm going to have to get a resident." When Lawson said that that should be easy, her colleague said, "No, they don't like to operate. They want to go home on time."

Granted, residency used to be a ring of Dante's Inferno, and the new regulations limiting work hours are a welcome reprieve. But in Lawson's opinion, attitudes are turning a little too 9-to-5. "You are producing a new generation of doctors whose expectations are different," she warns. "They don't expect to make as much money, and they don't expect to work hard.

"But you get what you pay for."

It's Just Not Fun Anymore
Every doctor has flashes of discontent, hints that the practice of medicine isn't what it could be. Today, more doctors are heeding them. Unable to reconcile themselves to managed care, they're leaving the frustrations of clinical practice for jobs as health-care executives and consultants; retiring early on disability; leaving medicine altogether.

In California, where managed care soaked in like cocoa butter, a 1995 survey showed 21 percent of office-based physicians over 50 wanting to retire or sell their practices within the year. A San Francisco survey of mental-health practitioners found 43 percent considering leaving the field. Last year's American Medical Association focus groups identified work pressures and job insecurity as leading causes of dissatisfaction with physician careers. The most recent Family Practice Management journal reports that nearly seven of 10 physicians consider themselves anti-managed care.

Then there are the articles: "You Don't Have to Plug Along," in Dermatology Times. "Changing Courses" in American Medical News. "Thinking About a Career Change?" in the Health Care Almanac. "Goodbye Hippocrates! Yes, There Is Life Away from Medicine" and "Which Doctors Are Quitting Medicine?" in Medical Economics. These articles give tips about administrative and pharmaceutical jobs; they tell stories about a psychiatrist now selling real estate, a neuroradiologist designing Web pages, a cardiologist teaching tennis. (There's even an ophthalmologist who started the Managed Care Blues Band, recording "You Picked a Fine Time to Leave Me, Blue Shield.")

Finally there are the career counselors and management recruiters, who say physicians are littering their doorsteps ... for the first time ever. Susan Cejka, president of Cejka & Co., a St. Louis-based firm that conducts physician and health-care-executive searches, calls the departure from clinical practice "a major trend. It generally happens around age 40. About 80 percent become disenchanted; 10-15 percent actually leave."

The renunciation isn't always dramatic. "What you are seeing," explains Cejka, "is a tremendous rise in physicians who become managers and consultants." She does acknowledge the "hassle factor" of managed care but puts more emphasis on the end of loyalty. "Patients no longer revere physicians," she says gently. "I think it was the patients that held the physicians in place. They couldn't bear to leave their patients. And now, for a $10 change in co-pay, your patients leave you."

After hours of listening to her clients' wails, Navarro describes the shift in terms of trade-offs. "There's a huge gap between doctors' expectations and today's reality," she observes. "They expected a huge educational debt, long hours, lots of responsibility and, in return, a lot of independence, money, job security and a chance to do good in the world. The reality today is that their freedom to practice medicine is curtailed by insurance companies; their compensation is declining relative to the cost of living; the possibilities of self-employment are limited or nonexistent, because insurance companies are reluctant to contract with individuals; and job security is shaky."

Navarro patiently guides clients through an inventory that forces them to "reach down into their guts and their souls." Sort of like exploratory surgery -- without anesthesia. "It's gut-wrenching," she admits. "They look at three to eight different ideas before they can hone in on what is right for them." Then comes a job hunt or more education, "which is mind-boggling, considering how much education these folks have.

"Sometimes," she adds, "they just decide to play their cards differently, define a niche, position themselves. Today's physicians have got to earn their keep; they've got to show revenue. They can't just be brilliant anymore."

Time Is Money
It's hard to muster pity for overpaid, overadulated demigods who've scraped their knees on what, for most of us, are everyday demands to be more useful than brilliant. According to a Medical Group Management Association survey, specialists' income increased by 6 percent between 1993-1997. The consumer price index rose 11 percent. Suspicion lurks: Is all this Hippocratic bitterness just the result of thinned pocketbooks? And if so, why should the rest of us commiserate?

The answer's simple. If time is money, money is time, and the change in physician compensation is also changing the amount of time physicians have to spend on us. HMOs pay them not by the amount of work they do but by the number of patients on their panels. Quantity's what counts. And unless you're a Houdini who can listen thoroughly and make a patient feel heard in five minutes, the physician-patient relationship suffers the consequences.

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