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Becoming relics of the past "Local primary doctors are leaving the area, or retiring early, or going broke."

Primary care physicians are fleeing the field.

The system is actually on the verge of "collapse," according to The American College of Physicians (ACP), the professional organization representing specialists in internal medicine. And many people are having trouble finding primary doctors.

Family physicians -- apart from internal medicine are the other main providers of primary care to adults -- seem to maintain a more optimistic stance, possibly because they see children as well, who tend not to come to the office with seven chronic medical conditions and five separate medical concerns of their own. The ACP statement was actually amusing to me. I've been saying it for years, and I get a glaring lack of sympathy for my complaints.

I left, and now I work in a hospital. I can't handle it.

By way of pre-emptive denial, let me say I'm not weak, and I do understand and love the humanity and beauty of primary care. That's what I was trained to do, by choice. I just don't want what happened to Dr. Mike Pelechaty to happen to me.

Pelechaty, a primary care doctor, currently is closing his West Seneca practice after three years. His patients love him and are devastated. But after paying his staff and overhead, last year he made $30,000. He can't live on that.

"I gave it my best shot," he said. "I thought I was a good doctor. But financially, the well ran dry." And the trend is continuing across Western New York. It's a common topic of conversations in the hospital where I work: How local primary doctors are leaving the area, or retiring early, or going broke.

Another primary doctor, asking for anonymity due to the politics of leaving a group practice, told me, "the reimbursement for the type of work that I do, which is preventive medicine, is so low that I really can't make ends meet -- I can't make the overhead.

"In effect what's happening is that people like me, who take time and try to do quality care without a lot of referrals, are leaving the field," this doctor said. "What you're left with are the people are willing, or by some miracle of talent are able to do (a quality visit) in eight minutes," which is what you need to do to stay in business.

"I have refused to crank through patients at the rate that is required, so I'm going bankrupt. I'm moving on."
Pelechaty says he started his solo practice three years ago, and had tremendous growth since then. Still, after doing the math, he figures that he needs to see 28 to 35 people a day to stay in business.

But that makes visits so short that you can't deliver quality care. And if you try to break up the preventive medicine in multiple visits, the patients have to pay multiple copayments, and they resent that. The core of the financial problem is that Medicare, and by a follow-the-leader process all other insurance carriers, reimburse "evaluation and management" services at low rates. This is the brain work of medicine -- taking a history, doing a physical, gathering and coordinating information, ensuring that medications are straightened out, preventing major illnesses where possible.

As a rule, the closer doctors are to machines, the more money they make. So you see radiologists paid more than endocrinologists, and cardiothoracic surgeons paid more than family doctors. You need a machine to make a living, but machines don't do everything.

And just about everything else is dumped onto the back of the primary doctor -- ensuring that the right heart failure medications are in place, ensuring diabetic foot exams, screening for domestic violence, treating mild depression, doing screening skin exams, and so on in a very, very long list.

"More and more things were being bundled into what the primary care physician had to do to meet the requirements of the insurance company, without extra reimbursement," Pelechaty says. "One insurance company director told me, 'you're a dinosaur and you're going to go extinct,' " -- the dinosaur meaning a solo practice.

"My internal belief is that the health insurance companies are placing forces upon primary care to take it away from the physicians hands and to place it into the physician extender community," Pelechaty says. That is, probably soon you'll only get to see nurse practitioners and physician assistants in your primary care office. If you get profoundly sick, then you can see a doctor.

If that's true, it's too bad, because general medicine is not an easy thing to do. It is, perhaps, the most pure inheritor of the intellectual tradition of medicine. It's complicated.

If you don't believe me, I invite you to go through the training and try it.

See you in seven or eight years.

Dr. Mike Merrill is an internist practicing in Buffalo. His column appears once a month on this page. E-mail your comments to him at driconoclast@yahoo.com.

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