If we are going to make rational decisions about health care reform, it helps to understand the medical economics of a primary care practice.

I was ten years out of medical school by the time I joined Narragansett Bay Pediatrics, a group practice in southern Rhode Island, and I was earning a salary of $48,000 for my “part-time” position. I worked in the office 24 hours per week, and covered nights and weekends. The hours on call were long and exhausting, but generated very little income.

A pediatrician could stay up all night answering phone calls, and not earn a dime. Or she could trek into the ER at 2 AM to see a worrisome child who turned out only to have a cold, and have the reimbursement denied because of the final diagnosis; colds shouldn’t be seen in the ER. Or that pediatrician, the Rodney Dangerfield of medicine, could spend a half hour doing a spinal tap on a sick infant in the middle of the night and get paid $40 for it, as opposed to her husband, the neurologist, who could do an elective spinal tap in his office in a regularly scheduled time slot and get paid $120 for it, because his patient was an adult.

I understood that the more money the practice made, the more my salary would increase. The key was in finding ways to be more efficient without compromising patient care. How much emphasis a doctor puts on either side of this seesaw shapes her practice as much as her expertise will.

Shortly after I joined the practice so did a young infant of a drug-addicted mother. Josh’s foster mother brought him in, along with a room full of her own children. I was confused when I looked for the names of the siblings in the chart. None were listed.

“Oh, that’s because they aren’t seen here.” Mom started her explanation matter-of-factly, but grew more uncertain as she went on, as if the callousness of the situation hadn’t occurred to her until she described it out loud. “They see Dr. X, in East Greenwich, but, well, he doesn’t take Medicaid, so I have to bring Josh here.” Perhaps the stunned look on my face helped move her thought processes along. In any event, the entire family of children eventually transferred over to our practice.

The best way to make money as a pediatrician is to see as many outpatients with really good insurance as possible. Obviously, to see a lot of patients, you have to see them quickly. The easiest way to do that would be to give the parents exactly what they think they want – often antibiotics. That means writing the prescription for the over-priced broad-spectrum antibiotic before Mom has even settled in to her chair, congratulating her for bringing her child in so soon.

“That ear drum looked like it was about to burst!” Doctor to the rescue.

It means treating any unexplained ache or fatigue as Lyme disease.

“Fortunately, we caught it so early.”

“Oh, thank you doctor,” gushes Mom, ushered out of the room six minutes after the doctor swooped in, relieved at the decisive action. A deeper conversation to tease out the vague symptoms and a recommendation for watchful waiting would have taken much longer, and, in all likelihood, a much less satisfied mom would be making her way to the check out window.

Quick patient turnover means telling stressed out nursing moms to just switch to formula.

“You’ve done everything you could. Some women just can’t breastfeed. Let’s get you a free sample case of formula.”

What else is good for rapid patient turnover? Vitamins as the quick solution for a picky eater, cough syrup with codeine for colds and knee jerk Ritalin for out of control kids. The child’s condition will follow its natural course mostly unaffected by the intervention, and eroding reimbursement rates will be more than offset by the healthy volume of well-insured patients. On top of the financial disincentives to doing the job right, no one should underestimate the pressure pediatricians feel not to disappoint parents, or how seductive it is for a pediatrician to be seen as coming to the rescue.

Being conscientious has its price.

“This is a viral infection. You need to understand why antibiotics won’t help, and may actually cause resistance…” or

“We have a lot of experience with Lyme disease here, and I don’t think this is it. Why don’t we follow this closely over the next few days. Call me if…” or

“Why don’t you go ahead and breast feed your baby now, so I can get a firsthand look at how he’s doing….”

Insurance companies don’t pay for “…,” and there is the very real risk that parents will leave the office quite annoyed that they wasted their time and money. Practicing good pediatrics is a moment-by-moment struggle. Most of the heroics in modern pediatrics are found not in the delivery room or the ER, but go unnoticed, and unrewarded, in the tiny little decisions of everyday care.

Maggie Kozel is the author of The Color of Atmosphere: One Doctor’s Journey In and Out of Medicine and blogs at Barkingdoc’s Blog.

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