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The Boston Tea party happened prior to the American Revolution due to a very small tax imposed by the British government on the tea that the colonists were buying. To show outrage over this tax, the colonists dumped tea into Boston harbor.
The major issue for the colonists was that the government imposed taxes on them without having fair representation for the colonies in that government. The reaction of the British government to the resistance in the colonies is what precipitated the Revolution. They felt that the colonists should be grateful for the benefits being part of the British Empire brought.
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Yet the idea of people having the right of self-determination was so important to many in the colonies (that is why they left Europe in the first place) that they were willing to give up all of the benefits of being part of the empire for the sake of being their own boss. They felt that the individuals governed had the right to have a say in that governing. This is the foundation of the American mind-set.
In the light of this, I make the following statement: the majority of primary care physicians in our country are treated in an entirely un-American way.
Most internists, pediatricians, and family physicians work in small practices. A small practice is basically a small business with the commodity sold being care of the patient. A practice must be a successful business first for medical care to be possible. The best medical care, however, does not guarantee success as a business (in fact, the opposite is true, but that is not what this post is about). To be able to offer any medical care, there must be a enough revenue to offset expenses.
This makes it very unlikely that PCP\’s that work in a private practice setting can spend much time advocating for themselves. When I spend time away from my office, my business loses one of its main sources of income: me. My time off is always deducted from my salary; there is no such thing as paid time off.
![\"Alice](\"http://distractible.org/wp-content/uploads/2008/04/aliceteapartysmall.png\")
This is true to a lesser degree for other private practice physicians, such as cardiologists and surgeons, but the margins are far smaller for primary care and the greatest dysfunction in our system lies in our offices, not those of the specialist (which is why so many medical students are becoming specialists, and not PCP\’s). They too lose money when the take time off, but it is not nearly as common for most specialists to run in the red as primary care physicians.
Instead of having private-practice physicians as representatives, we have either academic doctors or employed physicians – both of whom can more afford to take the time off. The problem is, few of these physicians really understand the reality of what it is to work in private practice during this very difficult time. They do not know what it is to have to lose staff because you can\’t afford to pay them as much as hospitals or specialists. They don\’t know the constant emotional burden it is to have to be the one running the business, when you weren\’t really trained to do so. They have not faced the conflicts of interest that we face on a daily basis:
- Do you spend less time with patients so you can make more money?
- Do you order more tests in your lab so you can increase revenue (despite the fact that it may not really be necessary)?
- Should you down-code so that you don\’t trigger an audit of your records?
![\"8300_1\"](\"http://distractible.org/wp-content/uploads/2008/04/8300-1-thumb.jpg\")
Do you drop Medicare and Medicaid because they don\’t pay you well enough, when doing so would be losing the opportunity to serve the elderly and poor?- Do you do cosmetic procedures to subsidize the medicine you really enjoy practicing?
- Can you stay in business if Medicare cuts go through?
- Do you document more so you can bill more, or do you just document for the care you actually give?
![\"8300_1\"](\"http://distractible.org/wp-content/uploads/2008/04/8300-1.jpg\")
No, the only ones who really understand what it is to be a primary care physician in private practice are others in the same situation. Yet the simple fact that the situation is so difficult makes it nearly impossible for us to have representatives that truly advocate for what we need. Instead, we have folks who think that the private docs are of poorer quality than the academic docs as our representatives. Decisions are made about our livelihoods and our practices without understanding of how it would really impact us. I don\’t think their intent is ill, I just don\’t think they offer us adequate representation.
![\"tea](\"http://distractible.org/wp-content/uploads/2008/04/tea-party.jpg\")
Our medical societies are partly to blame for this. They collect dues from us but do not assure adequate representation. I was recently asked to be a co-chair for a national task-force on medical information privacy issues. The problem was that the government did not give any stipend for me to do this. I had to be gone for two days every other month to be on this committee, not to mention the phone conferences and e-mails. But I lose significant income when I am gone. My business doesn\’t really go on without me; it simply stops generating income for me when I am gone. I suggested to my professional society that there should be a fund to offset this loss set up by the society. Since that society, however, is made up mainly of academic doctors who don\’t understand, the idea wasn\’t felt to be worth it.
So what is our tea party? What can we do to start the move toward adequate representation? How can we rise up and make ourselves heard without costing us our businesses? Am I talking about revolution? No! Are the other doctors evil? No. The fact is simply that we are in the eye of the healthcare crisis and are possibly the key to fixing it – yet we don\’t really have a voice. This is not right.
Help me Dinosaur, Anonymous, Smak, Solo Doc, and any other private-practice primary care physicians out there (there aren\’t many who can afford the time off to blog)! What can we throw into Boston harbor to make our point? How can we fight the injustice of inadequate representation? If we don\’t raise our voices now, others will speak in our place. Those others are probably very content to keep us as colonies, rather than as independent powerful voices.
“They don’t know the constant emotional burden it is to have to be the one running the business, when you weren’t really trained to do so.”
Maybe that is part of the problem. If you said the same thing about any other business most people would suggest you either get the training or get out of the business and become an employee. Leave the business end of the practice to those who are most capable of doing it and let those with who are primarily interested in providing clinical care do what they are best at doing. Just a thought.
“They don’t know the constant emotional burden it is to have to be the one running the business, when you weren’t really trained to do so.”
Maybe that is part of the problem. If you said the same thing about any other business most people would suggest you either get the training or get out of the business and become an employee. Leave the business end of the practice to those who are most capable of doing it and let those with who are primarily interested in providing clinical care do what they are best at doing. Just a thought.
Unfortunately, there are not many good employers. I worked for a hospital when I first started, and the amount of money our practice earned was not important to the hospital – so it was not important for them how well (or poorly) our practice ran. We are small-businesses. Are you suggesting that small businesses should sell off to large corporations? Remember – a non-physician cannot own a medical practice individually.
I would also add that my practice is actually quite profitable and doing quite well. This is not a rant out of the desperation of my own situation. My income went up by 30% last year. I am not just a bitter person who can’t run a business. I am just frustrated at the poor way in which my interests are put forth.
Unfortunately, there are not many good employers. I worked for a hospital when I first started, and the amount of money our practice earned was not important to the hospital – so it was not important for them how well (or poorly) our practice ran. We are small-businesses. Are you suggesting that small businesses should sell off to large corporations? Remember – a non-physician cannot own a medical practice individually.
I would also add that my practice is actually quite profitable and doing quite well. This is not a rant out of the desperation of my own situation. My income went up by 30% last year. I am not just a bitter person who can’t run a business. I am just frustrated at the poor way in which my interests are put forth.
In my opinion, the uprising does not need to come from physicians. The ONLY way things will change is if physicians can get the assistance of our patients – preferably those patient who vote and who are politically active.
A physician strike is not going to work. Docs going off of medicare is not going to work. Primary care docs have let specialists intrude on our scope of practice through the years. Docs in general have let mid level providers intrude on the scope of practice of primary care docs. Med students no longer find primary care a viable career choice.
Unfortunately, I think the only solution is through legislation and primary care docs don’t have the financial resources for political action committees that other groups do. They don’t have the time or patience to educate our patients. And, some primary care docs are just going through the motions waiting for the right financial time to retire.
Don’t get me wrong. I’m still fighting the good fight here. You may be surprised, but I’m more upbeat than this comment portrays. This is just the frustrations that I run into when I talk to docs around here.
In my opinion, the uprising does not need to come from physicians. The ONLY way things will change is if physicians can get the assistance of our patients – preferably those patient who vote and who are politically active.
A physician strike is not going to work. Docs going off of medicare is not going to work. Primary care docs have let specialists intrude on our scope of practice through the years. Docs in general have let mid level providers intrude on the scope of practice of primary care docs. Med students no longer find primary care a viable career choice.
Unfortunately, I think the only solution is through legislation and primary care docs don’t have the financial resources for political action committees that other groups do. They don’t have the time or patience to educate our patients. And, some primary care docs are just going through the motions waiting for the right financial time to retire.
Don’t get me wrong. I’m still fighting the good fight here. You may be surprised, but I’m more upbeat than this comment portrays. This is just the frustrations that I run into when I talk to docs around here.
i think it is a little simplistic to say that cardiologists and surgeons can spend more time representing themselves. they organize and they make the time to do it. certainly their margins are higher, but also their lifestyle is (usually) more demanding and subject to the whims of emergencies. rather i think that there is a divide among primary care physicans-fp may have different interests and goals than internists and pediatricians. furthermore, my anecdotal experience is that primary care docs have an independent streak or nature which limits their desire to form mega groups and give up autonomy. lastly, there are probably more women in those fields which currently means more people who have family and other focuses that may encourage them to be part time or at least not involve themselves in these ‘extracurricular’ activities. lastly, i think the people going into primary care have a personality which is one of complaisance-of trying to please everyone. they need a negotiatior who can be just as much a shark as anyone are when it comes to dealing with business issues. unfortunately they can’t afford it unless they merge practices. ymmv.
agree with dr a that a physician strike is not going to work. the situation is desparate–the sgr cannot be allowed to persist–too much energy is diverted to dealing with that every year or now even every six months.
i think it is a little simplistic to say that cardiologists and surgeons can spend more time representing themselves. they organize and they make the time to do it. certainly their margins are higher, but also their lifestyle is (usually) more demanding and subject to the whims of emergencies. rather i think that there is a divide among primary care physicans-fp may have different interests and goals than internists and pediatricians. furthermore, my anecdotal experience is that primary care docs have an independent streak or nature which limits their desire to form mega groups and give up autonomy. lastly, there are probably more women in those fields which currently means more people who have family and other focuses that may encourage them to be part time or at least not involve themselves in these ‘extracurricular’ activities. lastly, i think the people going into primary care have a personality which is one of complaisance-of trying to please everyone. they need a negotiatior who can be just as much a shark as anyone are when it comes to dealing with business issues. unfortunately they can’t afford it unless they merge practices. ymmv.
agree with dr a that a physician strike is not going to work. the situation is desparate–the sgr cannot be allowed to persist–too much energy is diverted to dealing with that every year or now even every six months.
Hi Rob,
I think the tea party you look for is what you already described as currently happening. Rather than one big event (such as the Boston Tea Party was), it is more like thousands of tiny little tea parties.
Every time a medical student says “Screw primary care, I’m going into radiology or dermatology,” that is a tiny little tea party.
Every time a primary care doc says “Screw Medicare and Medicaid, I’m dropping that cash losing bureaucratic mess,” that is a tiny little tea party.
Every time a primary care doc says “Screw the intrusive demanding costly third party payers, I’m going cash only,” that is a tiny little tea party.
Every time a primary care doc says “Pay for performance? Screw that, I’m firing all my non-compliant diabetics with out of control HgbA1c’s,” that is a tiny little tea party.
Every time a primary care doc says “This sucks, I’m opening a weight loss clinic or a botox boutique,” that is a tiny little tea party.
I could go on and on, but you get the point.
Eventually, when the effect of all of these tiny little tea parties begins to really be felt in the form of increasingly limited access to care, skyrocketing health care costs, etc…
Wait a second, did I say “Eventually, when…”?
I meant “Right now”…we are seeing the effects of all these tiny little tea parties and it will only accelerate over the next several years.
Eventually (as in maybe almost right now) some politician is going to come forth and promise universal health care and their solution to that will be something along the lines of further tightening the screws of bureaucracy on primary care docs.
They will perhaps try to make it illegal for docs to work outside of their system, make it illegal for docs to go cash only, etc.
That will be like a tiny little Boston Massacre.
At that point, the primary care docs will either roll over and urinate on themselves in submission (which is what I think our “representatives” in AAFP, AMA, etc would like us to do) or they will act like they have a back-bone and you will see a true revolution. It will not be pretty in either case.
As for me, I’m busy planning a little tea party.
Hi Rob,
I think the tea party you look for is what you already described as currently happening. Rather than one big event (such as the Boston Tea Party was), it is more like thousands of tiny little tea parties.
Every time a medical student says “Screw primary care, I’m going into radiology or dermatology,” that is a tiny little tea party.
Every time a primary care doc says “Screw Medicare and Medicaid, I’m dropping that cash losing bureaucratic mess,” that is a tiny little tea party.
Every time a primary care doc says “Screw the intrusive demanding costly third party payers, I’m going cash only,” that is a tiny little tea party.
Every time a primary care doc says “Pay for performance? Screw that, I’m firing all my non-compliant diabetics with out of control HgbA1c’s,” that is a tiny little tea party.
Every time a primary care doc says “This sucks, I’m opening a weight loss clinic or a botox boutique,” that is a tiny little tea party.
I could go on and on, but you get the point.
Eventually, when the effect of all of these tiny little tea parties begins to really be felt in the form of increasingly limited access to care, skyrocketing health care costs, etc…
Wait a second, did I say “Eventually, when…”?
I meant “Right now”…we are seeing the effects of all these tiny little tea parties and it will only accelerate over the next several years.
Eventually (as in maybe almost right now) some politician is going to come forth and promise universal health care and their solution to that will be something along the lines of further tightening the screws of bureaucracy on primary care docs.
They will perhaps try to make it illegal for docs to work outside of their system, make it illegal for docs to go cash only, etc.
That will be like a tiny little Boston Massacre.
At that point, the primary care docs will either roll over and urinate on themselves in submission (which is what I think our “representatives” in AAFP, AMA, etc would like us to do) or they will act like they have a back-bone and you will see a true revolution. It will not be pretty in either case.
As for me, I’m busy planning a little tea party.
First off, I am in no way advocating a strike. The point of this whole post is to point out that the decision-makers are making poorly-informed decisions because the most important parties are not at the table (us). When I say “have a tea party” it is definitely metaphorical – and I am not sure what the metaphor represents. We simply need to rise up and make our voice heard. It does not need to be angry as hell, or anything like that.
Check out the differences, by the way, of PCP salaries and specialists. The margin difference is enormous. Most of their work is done in the hospital, so they have no overhead there. We carry all of our overhead.
Sam – I can’t disagree. Wouldn’t it be better if we were at least somewhat organized?
First off, I am in no way advocating a strike. The point of this whole post is to point out that the decision-makers are making poorly-informed decisions because the most important parties are not at the table (us). When I say “have a tea party” it is definitely metaphorical – and I am not sure what the metaphor represents. We simply need to rise up and make our voice heard. It does not need to be angry as hell, or anything like that.
Check out the differences, by the way, of PCP salaries and specialists. The margin difference is enormous. Most of their work is done in the hospital, so they have no overhead there. We carry all of our overhead.
Sam – I can’t disagree. Wouldn’t it be better if we were at least somewhat organized?
Dr. Rob,What I’m suggesting is that some physicians may be better trained to handle the business end of the practice and some are better trained to handle the clinical end of the practice. There are a few in solo private practice who have the training to do both very successfully. For those that aren’t trained or interested in the business aspect it makes sense to partner with those who are. This doesn’t mean they must become an employee. It may come in the form of a group of physicians who employ a professional business manager. Sure it comes at a price, but the trade-off is shrugging off the “constant emotional burden” and focusing one’s energy on optimizing the clinical end of the practice.
Dr. Rob,What I’m suggesting is that some physicians may be better trained to handle the business end of the practice and some are better trained to handle the clinical end of the practice. There are a few in solo private practice who have the training to do both very successfully. For those that aren’t trained or interested in the business aspect it makes sense to partner with those who are. This doesn’t mean they must become an employee. It may come in the form of a group of physicians who employ a professional business manager. Sure it comes at a price, but the trade-off is shrugging off the “constant emotional burden” and focusing one’s energy on optimizing the clinical end of the practice.
Terry:That is Actually what we do in our practice. Division of labor is important and our practice is quite profitable for primary care. We are definitely in the to 10%. That still does not answer, however, the fact that we are not represented well (which is why I wrote the post)
Terry:That is Actually what we do in our practice. Division of labor is important and our practice is quite profitable for primary care. We are definitely in the to 10%. That still does not answer, however, the fact that we are not represented well (which is why I wrote the post)
[…] Primary Care Tea Party (Musings of a Distractible Mind) […]
Hi Rob,
Yes, I think it probably would be better if we were better organized and/or represented by organized medicine.
I think you have fairly well outlined the reasons that seems unlikely to happen.
Private practice PCP’s are simply too busy/financially strapped to get too involved with organized medicine, and even if they weren’t, most of them tend to have that solo independent streak that makes them not very inclined to be “joiners.”
I have to admit that I have that characteristic myself. I think it comes from my Southern/Scots-Irish cultural background.
I think most PCP’s, like myself, mostly just want to be left the hell alone and alowed to practice medicine without a lot of outside interference. It just naturally rubs us the wrong way and gets our “Ire” up when some bureaucrat from D.C. or the state capitol starts telling us how we have to do things, etc.
I think the AAFP, AMA, etc are very top-heavy with people who don’t share these tendencies and just don’t understand them. They think if they can just convince these idiots in private practice to embrace their guidelines, their rules, their maintenance of certification, their JHACO standards, their utopion goals for universal healthcare, etc., etc., well then everything would just be peachy.
They don’t get it. The folks in the trenches of private practice understand the concept of “Less is More” when in comes to bureacracy and rules and government and control.
To our “representatives” in organized medicine this is a totally foreign concept.
About the only organization that I’ve seen that sort of seems to get it is the Association of American Physicians and Surgeons.
I’m not a member of this organization (see my comments about the independent streak thing above), but I often contemplate sending them a check and joining their ranks.
Maybe I will.
For now though, I’m still preparing for my little tea party.
Hi Rob,
Yes, I think it probably would be better if we were better organized and/or represented by organized medicine.
I think you have fairly well outlined the reasons that seems unlikely to happen.
Private practice PCP’s are simply too busy/financially strapped to get too involved with organized medicine, and even if they weren’t, most of them tend to have that solo independent streak that makes them not very inclined to be “joiners.”
I have to admit that I have that characteristic myself. I think it comes from my Southern/Scots-Irish cultural background.
I think most PCP’s, like myself, mostly just want to be left the hell alone and alowed to practice medicine without a lot of outside interference. It just naturally rubs us the wrong way and gets our “Ire” up when some bureaucrat from D.C. or the state capitol starts telling us how we have to do things, etc.
I think the AAFP, AMA, etc are very top-heavy with people who don’t share these tendencies and just don’t understand them. They think if they can just convince these idiots in private practice to embrace their guidelines, their rules, their maintenance of certification, their JHACO standards, their utopion goals for universal healthcare, etc., etc., well then everything would just be peachy.
They don’t get it. The folks in the trenches of private practice understand the concept of “Less is More” when in comes to bureacracy and rules and government and control.
To our “representatives” in organized medicine this is a totally foreign concept.
About the only organization that I’ve seen that sort of seems to get it is the Association of American Physicians and Surgeons.
I’m not a member of this organization (see my comments about the independent streak thing above), but I often contemplate sending them a check and joining their ranks.
Maybe I will.
For now though, I’m still preparing for my little tea party.
Dr. Rob,
Actually, I’m an employee. I’m not sure my ovaries are big enough for me to go into private practice. For me, being an employee works well. My paycheck is predictable, I can go on vacation without thinking about the opportunity cost, and the whole hiring/firing staff headache is someone else’s. Of course, I lose some autonomy, and some income. Working for an FQHC, the bottom line is important, but not the most important thing. I’m the rare bird who is an an employee but who isn’t harassed to see more see more see more patients.
I think your point that good primary care is the key to our nation’s health care woes is entirely accurate. But we have an image problem. Once John Q. Public, with a salary of $50K per year, hears what amounts to “But we only make $160,000 a year! The cardiologists make double that!” we look like a bunch of ninnies.
Personally, I think I make plenty for the work I do. But the damn urologist doesn’t deserve $375K a year. Geesh.
At the risk of raining on a historic, distinguished, and important solo doc parade, maybe the mom and pop grocery store just isn’t suited for the post-WalMart era.
This is a political issue, and needs a political solution. We need some good lobbyists, if anything is going to change.
Dr. Rob,
Actually, I’m an employee. I’m not sure my ovaries are big enough for me to go into private practice. For me, being an employee works well. My paycheck is predictable, I can go on vacation without thinking about the opportunity cost, and the whole hiring/firing staff headache is someone else’s. Of course, I lose some autonomy, and some income. Working for an FQHC, the bottom line is important, but not the most important thing. I’m the rare bird who is an an employee but who isn’t harassed to see more see more see more patients.
I think your point that good primary care is the key to our nation’s health care woes is entirely accurate. But we have an image problem. Once John Q. Public, with a salary of $50K per year, hears what amounts to “But we only make $160,000 a year! The cardiologists make double that!” we look like a bunch of ninnies.
Personally, I think I make plenty for the work I do. But the damn urologist doesn’t deserve $375K a year. Geesh.
At the risk of raining on a historic, distinguished, and important solo doc parade, maybe the mom and pop grocery store just isn’t suited for the post-WalMart era.
This is a political issue, and needs a political solution. We need some good lobbyists, if anything is going to change.
I have a ton of friends in the same “boat”. If you assume that an uprising is unlikely because even if underpaid you’re still in the top 5%, you better look for other solutions. I think the best one is group practice. In our own practice, it’s made it easier to take holidays, manage the business and recruit new partners. It’s also improved service to our patients with lower wait times. I think a lot of practitioners forgo group practice to maintain control. But in the end, it’s harder to work alone than compromise. I suspect the solo-doc practice is likely to die.http://waittimes.blogspot.com/2008/04/high-stakes-email.html
I have a ton of friends in the same “boat”. If you assume that an uprising is unlikely because even if underpaid you’re still in the top 5%, you better look for other solutions. I think the best one is group practice. In our own practice, it’s made it easier to take holidays, manage the business and recruit new partners. It’s also improved service to our patients with lower wait times. I think a lot of practitioners forgo group practice to maintain control. But in the end, it’s harder to work alone than compromise. I suspect the solo-doc practice is likely to die.http://waittimes.blogspot.com/2008/04/high-stakes-email.html
whoops sorry — wrong linkhttp://www.waittimes.blogspot.com
whoops sorry — wrong linkhttp://www.waittimes.blogspot.com
No, the fact is that primary care is dying. Even though we do earn a good salary, many physicians do not. We may be on the top of the bubble, but what happens when the bubble bursts? Yes, I am doing well (quite well, actually), and I don’t want the same salary as the cardiologist. Those of us who do well, however, either are exceptionally efficient in our care, or offer bad care by not spending much time with our patients. Hospitals can pay docs well because they are loss-leaders so they can get on insurance plans. Plus, you make a whole bunch of money from the ancillaries you order. Yet I found that the amount of time I spent frustrated with how poorly they managed my practice.
By the way, if 40% of all primary care physicians are in solo practice, won’t the system die if solo practice dies? The fact is, there is plenty of money in the system – enough to fund the solo docs many times over – but it is just going to the wrong hands: insurance industry and overpaid specialists. Neurosurgeons deserve big salaries, but the ones in our area are earning over $1 Million. That could keep several solo docs in practice and still leave them quite comfortable.
No, the fact is that primary care is dying. Even though we do earn a good salary, many physicians do not. We may be on the top of the bubble, but what happens when the bubble bursts? Yes, I am doing well (quite well, actually), and I don’t want the same salary as the cardiologist. Those of us who do well, however, either are exceptionally efficient in our care, or offer bad care by not spending much time with our patients. Hospitals can pay docs well because they are loss-leaders so they can get on insurance plans. Plus, you make a whole bunch of money from the ancillaries you order. Yet I found that the amount of time I spent frustrated with how poorly they managed my practice.
By the way, if 40% of all primary care physicians are in solo practice, won’t the system die if solo practice dies? The fact is, there is plenty of money in the system – enough to fund the solo docs many times over – but it is just going to the wrong hands: insurance industry and overpaid specialists. Neurosurgeons deserve big salaries, but the ones in our area are earning over $1 Million. That could keep several solo docs in practice and still leave them quite comfortable.
Being the outsider looking in, it seems to me that the biggest problems lie within and not from outside forces (though I do not deny they are there, but they can not be or are difficult to address for this reason).
I have commented here before on this (in different context, but to reiterate) … take a gander around “The Tubes” of the Internet, when Sen. Stevens and the others challenged law providers peek out from their little domes, what do they see? They see people (like me) complaining about the lousy state of affairs, not only of insurance, and payment issues, but of care provided by far too many Primary Care Physicians that are not “doing it right” such as you and some of your colleagues here. Which leads to one nasty perception problem.
How many stories can you find about people complaining about being treated like a part on an assembly line? Of doctors that don’t even take the time to actually listen to the problem before writing a script for the medication of whatever drug representative happened to be in the office last? Ask a person about whether doctors are underpaid, and they think “He billed XYZ Insurance $100 for a six minute visit, where I got weighed, listened to my chest, wrote me a script” again, perception problem.
So, in short it looks to me that before this situation can get better that perception has to change, and the question becomes, is how to weed out the bad apples that are causing this perception issues.
Being the outsider looking in, it seems to me that the biggest problems lie within and not from outside forces (though I do not deny they are there, but they can not be or are difficult to address for this reason).
I have commented here before on this (in different context, but to reiterate) … take a gander around “The Tubes” of the Internet, when Sen. Stevens and the others challenged law providers peek out from their little domes, what do they see? They see people (like me) complaining about the lousy state of affairs, not only of insurance, and payment issues, but of care provided by far too many Primary Care Physicians that are not “doing it right” such as you and some of your colleagues here. Which leads to one nasty perception problem.
How many stories can you find about people complaining about being treated like a part on an assembly line? Of doctors that don’t even take the time to actually listen to the problem before writing a script for the medication of whatever drug representative happened to be in the office last? Ask a person about whether doctors are underpaid, and they think “He billed XYZ Insurance $100 for a six minute visit, where I got weighed, listened to my chest, wrote me a script” again, perception problem.
So, in short it looks to me that before this situation can get better that perception has to change, and the question becomes, is how to weed out the bad apples that are causing this perception issues.