Money woes limit doctors

While many academic physicians have the chance to research the cure for cancer or to try to solve the plaguing problem of the common cold, this image of them may no longer be the complete picture.

A new study published in the January issue of the journal Academic Medicine concludes that more and more academic physicians are suffering from growing pressures in the workplace. This rising stress, according to the study, can be traced back to falling physician reimbursement rates for medical care from insurance companies and the government.

School of Medicine faculty members said they agreed that this general trend applies at Yale. More ominously, they said, the problem will likely have an impact on recruiting physicians to train the next generation of doctors.

Declining reimbursements are not limited to academic medicine, as physicians across the field receive payment in reimbursement form. But academic physicians are particularly at risk, according to the study. While private practice physicians only see patients, School of Medicine Dean Robert Alpern said academic physicians generally also conduct research and teach medical students, residents and fellows.

“In private practice [lowered reimbursement] means longer hours; in academics you need to see more patients instead of research or work longer,” he said.

Besides needing to devote more time to patient care, some academic physicians said they are also forced to spend less time with each patient, assistant professor of surgery Dr. Robert Bell said.

“You give them the Reader’s Digest version and move on,” he said. “It absolutely happens.”

But, Bell said, maintaining standards of patient care is still a priority. Because of the need to ensure adequate care, Bell said the extra time spent teaching now needs to be devoted to patients. Previously, medical students or residents would first see patients on their own, then discuss the case with the teaching physician. Now, Bell said, he tries to teach the students in front of the patient due to time constraints.

As medical students witness their teachers pressed to expand their clinical practices at the expense of research or teaching, many are turning away from the field, professor of vascular surgery Dr. Richard Gusberg said. Surveys of medical students have increasingly shown that the students take financial and lifestyle considerations into account when choosing their specialties, Gusberg said. He added that most medical students graduate with a significant amount of debt, which he said may prevent some from pursuing the lower-paying — and more stressful — academic path.

Eliminating medical school debt seems an unlikely method of attracting more students to academia. Tuition does not cover the costs of medical education even now, Alpern said, with the remainder of the costs coming from already-squeezed clinical revenue. One alternative Alpern suggested is to increase the endowment of the School of Medicine to support teaching time, something he said is being attempted.

Dr. Barbara Schindler, lead author of the study and vice dean for educational and academic affairs at Drexel University College of Medicine, said medical students are now less likely to want an academic career for another, perhaps less obvious, reason.

“There’s a generational gap,” she said. “Baby boomers were willing to work 24/7 without being discouraged. It’s the junior faculty who are having the hardest time … [And] they’re the ones who spend the most time with trainees.”

Another factor discouraging medical students from entering the ranks of the medical school faculty is that in many cases most of their salaries will come from their clinical practices regardless of how much research they publish, said Dr. Richard Antaya, assistant professor of pediatric dermatology at the Yale School of Medicine.

There is little consensus as to whether or not the worst of the financial pressures has already passed. The latest federal budget reduced Medicare reimbursements by 4.4 percent, and Gusberg said Congress plans to cut Medicare payments another 5 percent each year for the next five years. David Leffell, deputy dean for clinical affairs at the Yale School of Medicine, said he thinks managed care companies will continue to put pressure on the School of Medicine with lower reimbursement rates. But Alpern said managed care is sufficiently prevalent to ensure a stabilization of cost-cutting measures.

But some say the problem is not that simple, and that not all the blame can be put on the insurance companies and government agencies that set reimbursement rates.

“We have a richer society that wants medical technology to be used even if it doesn’t buy them greater health outcomes,” said Dr. Howard Forman, a professor of radiology and an economics lecturer. “It puts more pressure on insurance companies.”

And as reimbursements have fallen, malpractice insurance rates have been rising, Leffell said. Certain specialties such as surgery, obstetrics and gynecology face particular financial pressures in this area, he said. Here, the toll varies by specialty. Adding to faculty members’ difficulties is a recent move intended to improve patient care. Residents are now restricted to an 80-hour workweek, and Schindler said the faculty has had to pick up the slack, working more to replace the time previously put in by the physicians in training.

Further complicating the situation is the variety of fields present in medical academia. Not every academic physician even attempts to balance clinical practice, research and teaching. Research can be an alternative to clinical practice, since grants received for research projects, on a financial level, can substitute for seeing patients. But physicians who only conduct research are not the best at training the next generation of physicians, many of whom will go on to private practice and not research, Antaya said.

Academic medical centers could not abandon seeing patients either, Leffell said.

“We deliver the majority of care for the underinsured and uninsured,” he said. “Community physicians are much less likely to see them and will refer them to [the] Yale medical center.”

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