Bay Area Physician Overload: Shape of Future?
Dr. Lorne Rosenfield and his wife, Gina, are just settling into their apartment in the affluent Marina district here. There isn’t even a couch in the living room yet. For the moment, a pile of pillows suffices.
Even inside the apartment, Rosenfield keeps a beeper on his belt and a telephone close at hand. Packed and available to be picked up and tossed into the car on a moment’s notice is a case of medical equipment essential to his specialty--plastic surgery.
Sitting in the dining room, which contains only a newly purchased table and chairs, Rosenfield ponders these preparations for potential operations and quips, “It’s: ‘Have plastics, will travel.’ ” In his first six weeks, the beeper went off only four times.
Rosenfield is engaged in an exercise even he calls “Darwinian.” Other observers of the health care scene here are not that optimistic. Joan Trauner, a health economist and historian, sums up the chances for success of any young physician trying to establish a new solo practice in San Francisco--as Rosenfield is--in one word: “zilch.”
The word describes a brutal reality: There is one doctor in San Francisco for every 159 residents, the highest ratio in California and the fourth highest in the country. Neighboring Marin County has one doctor for every 239 residents.
These figures make San Francisco one of the world’s most over-doctored cities--a place where even top graduates of residency training programs are starting to find up to 12 qualified applicants for every job, even those at prepaid health programs like the Kaiser Plan.
A Specialist Problem
A year ago, Trauner and Harold Luft, another UC health policy analyst, published what is thought to be the first detailed analysis of what is happening here, concluding that economic pressures will inevitably force doctors to accept affiliation with large clinics and other alternatives to the traditional solo-practice. Specialists face the worst problem. Hospitals are likely to tighten requirements for membership on their medical staffs, the UC study concluded.
The glut here illustrates one of several compelling reasons why, in the view of a growing number of health economists, the American health care delivery system may well have to consider the concept of a system of national health insurance. With too many physicians available, they say, too many hospital stays occur, too many tests are performed and too much medicine is practiced as doctors struggle to survive economically.
San Francisco has 734,600 residents and 4,609 doctors, 3,853 of whom are involved in patient care.
Losing Money
Dr. Russ Granich, an internal medicine specialist, is trying to be one of them. He bought out a retiring doctor’s office on Van Ness Avenue for $45,000 14 months ago, but with monthly overhead expenses of between $5,000 and $6,000 and a workload that averages only about 30 patient visits a week, he is losing money. He had hoped at least reach the break-even point after a year in business, even allowing for taking no salary himself.
“I’ve been a little depressed about it,” he said.
To make ends meet, Granich drives an hour and 20 minutes south to Santa Cruz two days a week to work in a community hospital emergency room. He goes that far, he said, so no physician here will suspect him of scheming to steal scarce patients.
Granich says he may have to quit medicine within five years if things don’t improve. But he will leave medicine, he says, before he leaves San Francisco. “I’m not going to leave town,” he said, but “I question my decision of trying to make it as a physician.”
So intense is the attraction of San Francisco that young doctors continue to move here--or attempt to stay after they finish Bay Area residencies--and the advice of Trauner and virtually every health policy observer in the city often goes unheeded.
The doctor-population ratio in San Francisco is beaten by Manhattan (where there is one doctor for every 107 people) and Boston (one doctor per 121). By contrast, nationwide, there is one physician for every 455 people, one for every 418 statewide and one for every 373 in Los Angeles County.
Dr. R. Eugene Tolls, president of the San Francisco Medical Society, said many economically strapped hospitals face failure within the next half-decade no matter what they do and such hospital closures will inevitably spur large numbers of local doctors to search for more patients.
Bucking the Odds
Rosenfield chose to disregard these odds because he had done his general surgery training here, was familiar with the Bay Area and had contacts among established doctors he thought would refer him patients. He moved here, he said, primarily due to the same appeal San Francisco has for many.
“I like the Bay Area,” he said. “The key is you should go where you want to live. If not, you wake up five years later and, even though you may be more financially successful, you’re unhappy.”
Granich trained here, too, met and married a native of San Francisco, fell in love with the area and decided to stay on at any cost. His economic troubles are eased somewhat by the fact that his wife, a nurse, inherited a house, which substantially reduces the couple’s living expenses. Living in the city and practicing in the suburbs would be an unacceptable alternative, Granich said, because he would be too distant from hospitals where he would admit patients.
The degree to which the San Francisco experience will be repeated elsewhere remains to be seen. But most observers believe that while the Bay Area may always be an extreme of what can happen when doctors overwhelm a local population, national trends point to a widespread, if less extreme, replication of what is going on here.
“In California, we are in the mid-1980s where the country is going to be in 1990,” said Dr. Philip Lee, head of the UC San Francisco Institute of Health Policy Studies. “Although the country will never get (as bad as) San Francisco is, one would hope.”
National Health Scheme
Lee sees a direct connection between the physician supply and the possibility of a national health scheme. “As you get more physicians whose incomes are declining and the only way to assure adequate income is if you can have everybody with some payment system, there will be a significantly stronger voice within medicine for national health insurance.”
Tolls said that, though he has long realized San Francisco has a doctor supply problem, he continued to encourage young doctors to relocate here until about a year ago--reasoning that if they were persistent enough, the best of them would find a way to survive. The competition even assured that San Francisco got many of the most talented doctors, Tolls said, because less able ones either didn’t come or failed and left the area.
Last year, though, Tolls said, he changed his tactics. “It isn’t just difficult to get established here,” he said. “It’s nearly impossible.”
But still they come.
Rosenfield took his general surgery training here at a local hospital, then went onto Houston for a residency in plastic surgery. He moved back here so his wife could attend law school, and he remains upbeat despite the odds.
The couple took out a $50,000 line of credit and that, combined with some savings, may be enough to carry Rosenfield through the first year or two of the struggle to establish himself and bring in enough patients to survive. He’s renting part-time office space in San Francisco and the suburb of Burlingame and is looking to hire a part-time secretary.
“It’s Darwinian principle,” he said. “It takes a certain type of person to come here. Maybe he’s crazy or maybe it’s being well trained. Maybe I’ll play Trivial Pursuit with my secretary for a few months.”
