As much as the public thinks doctors are highly compensated, year after year reimbursement rates decline while there is a growing shortage of primary care (and many subspecialty) physicians in a large number of markets. Also, paperwork and other regulatory requirements keep increasing. A larger number of patients therefore exists for each doc, and in addition overhead keeps increasing because more clerical staff is required to keep up with paperwork, documentation, billing, and subsequent re-billing when the original claim is denied by insurers (who are famous for throwing out absurd denials in hopes that a medical provider will give up in disgust rather than resubmit the claim). Overall, then, many docs are forced into maximizing "throughput" via short appointment times, barely enough to make any sort of diagnosis, and long waits for new patient evaluations or even for established patient followup appointments. Is it any wonder that there isn't much time to keep up with the latest treatment recommendations or to be able to evaluate whether a treatment is working?

When you factor in the number of years docs spend in training and the cost of obtaning such training, realize that most docs don't start in a practice until an average age of 30 to 32 years old. That's 10 years beyond the average college grad, and during med school the debts accrue (educational loans from both college and med school, not to mention personal debts because you still have to live somewhere, have a car, and eat), and interest from all of these. During residency you make just enough money to live on, and most residents can't make any sort of payments against the debts they owe, so the interest keeps accruing. Into the mix, these are people in their late 20's who are starting to marry and have kids. The average debt for someone starting practice is somewhere around $150,000 (ranging up to $200K for some).

So now you're ready to start making money, right? Well, if you're a primary care doc, you either join an established practice or start your own (and the latter takes $$). Should you join someone else's practice, you make a reduced salary for a couple of years, and only then can you become a full partner with an equal share in the profits of the group. So now you're 34 or 35, and if you're lucky you MAY make $200K plus benefits -- but in many areas you'll make less -- and getting those loans paid is a real trial.

Add all this together and it's a recipe for disaster -- not enough time to spend with your patients, because your salary depends on gettng as many patients in per day as you can stuff into the schedule, and the schedule is always booked out several weeks (up to several months in some areas and some specialties). Time for continuing medical education is hard to come by and some of it is expensive to obtain. Malpractice insurance rates are rising in many markets and some specialties are essentially being driven out of business, for example obstetrics (which has one of the highest malpractice insurance rates), furthering the physician shortage and forcing the remaining docs to work even harder.

It seems to me that this is rapidly approaching crisis point: the really smart and qualified people will leave medicine early or won't go into it at all, and we'll be left with less capable docs and the few good ones who are independently wealthy such that they don't need loans to get thru school. It's already happening -- how many people reading this post are almost always seen by a physician assistant (P.A.) or a nurse practitioner (N.P.) rather than a physician (M.D. or D.O.)? These "extenders" frequently drive care with minimal input from the supervising docs, and they receive far less training (but also at less expense to themselves). Is it any wonder that the appropriate treatment and followup regimens are frequently overlooked or ignored?