Winner of the Young Doctor Award in our 2000 Doctors' Writing Contest

"All the good doctors always leave"

The author frets that she may be next. Bureaucratic hassles and lack of money have tarnished her dream.

By Kristine L. McCallum, MD
Family Physician/Chillicothe, OH

t's twilight in southern Ohio when I leave the community health center where I have worked for just over a year. Getting in my truck for the drive home, I'm filled with lingering questions: I've diagnosed Mrs. Johnson with mixed connective tissue disease, but how can I get her to a rheumatologist when the closest one is an hour north in Columbus? With my patient's unreliable car and fear of city driving, Columbus might as well be on the other side of the moon. I'm also concerned that the acrodermatitis eating away at her fingertips will travel downward. And Mrs. Johnson, like so many of the patients I see, doesn't have health insurance.

I'm also thinking about all the patients I saw today with "nerves," the local vernacular for depression, anxiety, and panic attacks. Often, these are people whose clinical conditions are exacerbated by unbearably stressful life situations—abusive spouses, imprisoned sons, money problems. Will the medications and brief counseling I offer be of any help? If not, how long will they have to wait for formal counseling?

Also on my mind are the two new patients with lower back pain who came to see me today. Without insurance, they can't afford physical therapy or the pain clinic I'd like to refer them to. On their own, they might not do the home exercises I showed them. And in any case, I'm not sure I'll ever see them again after I refused to prescribe the narcotics they requested.

But it was Mr. Williams—whom I've seen through coronary bypass surgery, depression, hyperlipidemia, and hypertension—who posed the question that troubles me most as I head home this evening. Accompanied by his wife as usual, he looked at me and asked, "Are you going to stay here, Doc? All the good doctors always leave."

I didn't have an answer for him.

Two idealists, daunted but unbowed

For years, I'd wanted to practice in just this type of setting—to doctor people who otherwise wouldn't have access to care.

I've enjoyed the challenges I've faced at the center, and generally feel I've had enough resources available to do a good job. Besides, I love the area—its foothills rolling east to the Appalachians, its secret wooded hollows. So does Scott, my husband and fellow physician. But it's proving hard to stay, just as it wasn't easy to get here in the first place.

Our third year of residency was a time of optimism. We had no doubt that Scott's background in pediatrics and mine in family practice prepared us perfectly for working with the underserved. But since our combined medical school bills totaled more than $300,000, we hoped that in return for our service, we'd receive some sort of loan repayment.

Our search for the right situation started at the beginning of that third year. We contacted the National Health Service Corps, Indian Health Service, and various state agencies that specialize in placing doctors in underserved areas. Unfortunately, many of the positions that were attractive to us clinically were unappealing personally. Some positions would have kept both of us on call every night or every other night. Others simply didn't pay enough.

One of those was a community health center system in Kentucky that we fell in love with. But no matter how many times we went over the numbers, the hard truth remained that we'd have to wait an unreasonable amount of time before we could buy a home or pay off our loans. With much regret, we declined the offer.

Meanwhile, like many of our friends in primary care, we were deluged by recruiters who claimed to know the "perfect" position for us. Certainly, the high salaries and other perks were tempting. But despite our rapidly diminishing optimism about finding the kind of job we wanted, neither of us was ready to give up our dream.

In February, finally, we heard about a community health center in southern Ohio that had positions for both of us. Though the area was no longer a federally designated health professional shortage area, the need for primary care doctors was still great, the CEO assured us. She pointed out that she planned to hire two internists, besides us.

Other aspects of the job were attractive, too. Call, for example, would be every fourth night for Scott and every fifth night for me. The guaranteed salary—though significantly below national standards—was more than sufficient for us to live on. And though we wouldn't be eligible for a federal loan repayment, we could apply to the state's program.

We were also impressed with the center, which had been around for about 20 years, and with the CEO, who was given high marks by people who knew of her. Our confidence restored, we each signed a two-year contract and began working in July. A short time later, we bought a house.

Caring for patients is the easy part

For the first several months, our new jobs were nearly everything we had hoped they'd be. Sure, things weren't as busy as the CEO had led us to believe, nor was the center as solvent as it could have been. The administration, however, was reassuring. The center had anticipated temporary losses when four new doctors were hired at what was traditionally the slowest time of the year. And since the new hires had doubled the number of physicians at the main site, growing pains and staff adjustments were also inevitable. Again, nothing to worry about.

But five months after our start, things began to look troubling. First, we learned that physician reimbursement would soon be changing from a set salary to one based on productivity. This retooling, we discovered, had been in the works before we signed on, although no one had told us. Although my contract and Scott's would keep us on a set salary for the next year and a half, the physicians whose contracts were expiring would be forced to accept the new terms.

Scott and I could live with the productivity-based pay, as long as we physicians were given some say in how things got done. But we were starting to realize how little power doctors had in this organization. We had minimal input into staffing, scheduling, or general center policy. Because no one consulted us when new clinical staff was hired, we ended up with a number of employees who didn't pull their weight.

To add to our concern, the incentive plan called for in our current contract—where doctors would receive a percentage of gross charges once we'd reached a certain amount of revenue—wasn't being honored. When we brought this up, the CEO said that the plan was still under negotiation. In fact, the CEO herself had brought up the incentive plan during our interviews, stressing that it would be part of our contracts.

Things really got bad when one of the internists hired along with Scott and me was fired after only six months on the job. "I'm sorry for the cut, but the center's losing money," the CEO explained to us. Scott and I had repeatedly suggested less drastic ways to better the financial picture, such as making sure that doctors were coding correctly. But our suggestions had fallen on deaf ears. In time, we learned that more than half a dozen physicians had left the organization over the past six years, although all continue practicing in the area. It was dissatisfaction with the administration that made them quit the center.

After the firing, Scott and I declared war on the administration. Supported by the other remaining physicians, we presented our grievances to the center's voluntary board of directors. We wanted, above all, more physician input.

Presenting our case ate up a huge amount of everyone's time. The emotional toll was especially severe on Scott and me. As the recognized leaders of the rebellion, we worried continually that we'd be next on the chopping block. On those nights when our sleep wasn't disturbed by a beeper, one of us was probably up worrying how we'd pay our $4,000 monthly loan tab if we were fired. (We had decided not to participate in the state loan repayment program because it would have forced us to remain at the center, even if things didn't improve.)

Why it's hard to stay and hard to leave

Eventually, our efforts paid off. The CEO was forced to resign recently, and the board has promised that physicians will have some say in who replaces her. The board also promised doctors more say in how things get done generally, although we haven't seen much of that yet.

Personally, Scott and I occupy a kind of limbo now. On the one hand, we're no longer afraid that we're going to get fired tomorrow. We're regarded as efficient, competent, and are well liked by both clinical staff and patients. On the other hand, the company's financial health remains precarious. For this reason, we do our best to set aside some savings each month. Also, we've delayed any major home improvements, and we aren't likely to start a family anytime soon.

Certainly, we can get jobs somewhere else. We're looking, and there are options. But this community health center needs doctors like us. We came here because we wanted to. Plus, we relish living in a small town and don't miss the urban amenities. And we don't mind getting cornered by our patients at Wal-Mart.

If my husband and I end up leaving, it will be a long time before either of us works with the underserved again. There's simply too much bureaucracy, too little physician power, and not enough monetary incentive to remain in the community health system.

A number of my patients live on the same road we do, many of them in deserted-looking single-wide trailers. As I drive past them on my way home, images of the people inside, my patients, flash through my unquiet mind.

I swing my pickup into our driveway, the question echoing gently. "So Doc, are you going to stay here?"

I don't know, Mr. Williams. I just don't know.

 

Kristine McCallum. "All the good doctors always leave". Medical Economics 2001;9:55.