Primary care shortage exists

The combination may not yet be lethal, but a shortage of doctors in Massachusetts, coupled with more physicians practicing "defensive medicine" out of fear of being sued, is clouding the state's landmark health-care reform effort.

In a pair of reports, the Massachusetts Medical Society has concluded the shortage of primary-care physicians is now at a "critical" level, several specialties are woefully undermanned and doctors are costing the health-care system more than a billion dollars a year as they seek to avoid being dragged into what the society calls a "dysfunctional" medical liability system.

The society released its seventh annual Physician Workforce Study, and then followed that research with the Investigation of Defensive Medicine in Massachusetts.

The latter report concludes that almost 85 percent of the nearly 850 doctors surveyed reported practicing some form of "defensive medicine" out of fear of being sued, with some reducing the number of high-risk patients they saw. Those surveyed listed their primary specialty as anesthesiology, emergency medicine, family medicine, general surgery, internal medicine, neurological surgery, obstetrics-gynecology or orthopedic surgery.

In addition, the report estimates that among just those eight specialties, the annual costs in X-rays, CT scans, magnetic resonance imaging studies, lab tests, ultrasound studies and referrals or consultations ordered because of concern about potential legal liability is nearly $300 million. The report states that the calculation excludes the cost of unnecessary hospitalizations, which was estimated at $1.1 billion, bringing the combined total to about $1.4 billion.

That, says Dr. Alan C. Woodward, a past society president, is just a fraction of the cost of "defensive medicine."

"It's really just the tip of the iceberg," said Woodward, co-author of the "defensive medicine" report.

The society is pushing for a transformation of the legal system in which cases typically take several years to resolve, with one alternative calling for an apology and offer of "fair and timely economic compensation" in the case of avoidable injury and that disputes be resolved through mediation or arbitration.

The current tort system would be used rarely.

"You use tort as a last resort. It's an adversarial model," said Woodward, who also called the existing system "slow, inefficient, inequitable."

Frank J. Riccio, co-chairman of the Massachusetts Bar Association's Health Law Section, said the vast majority of medical malpractice claims simply cost too much to take to court. Riccio, a practicing dentist for several years before becoming a medical malpractice lawyer, said the average cost when he brings a case is $20,000 to $100,000, including investigation and depositions. "If you take on a case, you better be pretty sure there is a case," Riccio said.

No matter what the system used in handling medical malpractice cases, though, "it's always an adversarial system at some point," Riccio added.

While many doctors have become defensive practitioners, the ranks of primary-care physicians are being greatly tested as hundreds of thousands of people have been added to the rolls of the medically insured in the state since health-care reform was signed into law in 2006.

Having enough primary-care doctors is critical, said state Rep. Christopher J. Donelan, D-Orange, who wrote part of another health reform bill passed by the Legislature last summer. Primary care is the least expensive care because it stresses prevention and early detection of medical problems, he said. "This is where health-care reform in Massachusetts makes it or doesn't," Donelan said.

Older primary-care physicians are winding down their careers and more medical school residents are becoming specialists who can make more money and not have to deal with the avalanche of paperwork that is part of being a primary-care doctor, according to Dr. Barry Z. Izenstein, of Springfield, governor of the Massachusetts Chapter of the American College of Physicians. "I don't think patients hold them in less regard," Izenstein said of primary-care doctors. "I think the residents and medical students do."

A very real consideration for medical school students is debt. In a medical society survey, medical students said they would have debt ranging from $150,000 to more than $250,000.

Donelan fashioned language in the new health care reform law that includes loan forgiveness for University of Massachusetts Medical School students willing to work as primary care physicians in underserved areas. Donelan also said some primary care doctors have told him more pay is a necessity.

"They've told me that they have to make more money in order to pay the bills," he said.

Dr. Robert M. Fishman, who has been a primary-care doctor in South Hadley for 20 years, said primary-care physicians need to be able to afford to hire an assistant, and that electronic medical record keeping is needed to ease the paperwork load. Fishman also said internists, who often provide a patient's primary care, make $150,000 to $180,000 on average in Massachusetts compared to cardiologists earning about $300,000 or more annually.

Still, whatever happens, time is most definitely a factor in addressing the shortage of primary-care doctors. There is no quick fix, Fishman said, because it takes years of education and training to become a doctor. "You can't create a primary care physician overnight," he said.

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