Robert A. Levine 6-4-14
What has been seen as a serious problem with the care given at our Veterans Administration hospitals is not really a V.A. problem, although the Veterans Administration is being battered by the media and politicians seeking publicity. The vast majority of veterans are quite content with the care they receive at the V.A. and the quality of the physicians. Their main gripe is the time they have to wait in order to get to see their physicians.
I am a Vietnam veteran who developed lymphoma. I am being followed by a primary care physician and oncologist at the West Haven V.A. in addition to being in an experimental trial being conducted at Weill Cornell Hospital in New York that has arrested my disease. My local oncologist also participates in my care. However, the care I have received at the V.A. is top-notch and I have obtained all my medications (16 different pills) from the V.A. in a timely fashion over a number of years.
There seems to be little question that some data regarding appointments and waiting times were falsified by administrators (and possibly some physicians) at certain V.A. facilities to hide the inadequacies at these hospitals and bolster their standings. However, the vast majority of V.A. physicians were not involved in this deception.
The problem being seen at the V.A. regarding appointments is actually systemic in origin involving medical care in general and has been going on for years. There are just not enough primary care physicians to service the American population (as well as veterans) and they are not being paid adequately. Because of this, the number of primary care physicians will continue to decrease relative to the population in the future. And the Affordable Care Act will only exacerbate the situation as more Americans who were previously uninsured will now have coverage and can seek medical care.
A survey on medical compensation conducted by Medscape in 2013 showed orthopedists at the top of the heap with an average annual salary of $413,000. Other well-paid specialties near the top included cardiologists, urologists, gastro-enterologists, radiologists, and dermatologists. Primary care physicians, who work long hours as the main caregivers and are the bulwark of the system, are among the most poorly paid physicians. The average annual pay for an internist is $188,000 and for a family medicine doctor is $176,000. Not surprisingly, a large number of these physicians feel they are not being fairly compensated.
57% of internists spend more than forty hours per week in patients care and another 5-9 hours or more in paperwork and administrative tasks. The majority of PCPs spend 13-20 minutes with each patient they see.
So the problem is not because there are not enough primary care physicians at the V.A. but because the nation does not have enough of them overall. And the situation will only deteriorate further unless profound changes are made is the system of remuneration for physicians. There is no reason why orthopedists and other subspecialists should be making more than twice as much as primary care physicians when the latter provide just as valuable a service (if not more so) in the medical care which they provide.
Interestingly, when asked whether they would choose medicine again as a career, internists were at the top with 68% saying they would make this choice. However, they were at the bottom in saying they would choose a different specialty than internal medicine and were also near the bottom in affirming their overall career satisfaction.
While compensation may not be the main reason medical students choose internal medicine as a career, they have families to raise, loans to pay off, college costs for their children to consider, and so forth. If America wants to guarantee a steady supply of primary care physicians in the future for general care as well as for the V.A., the way we pay our doctors must be transformed dramatically.
So don’t blame the long waits for care at the V.A. on the physicians there. There just aren’t enough of them. (Congress could fix this situation quickly by increasing PCP pay at the V.A. and allotting funding to recruit more doctors. Don’t hold your breath waiting for this to happen.)