I should be in Washington, DC today.

I was asked to co-chair a task force for the National Governor's Association regarding privacy in sharing medical records.  It was a great honor to be asked, and I greatly enjoyed my first two months' involvement.  It seemed that the perspective of a practicing physician was not something people were used to, and I was able to greatly help the direction of the task force - doing a task that is of utmost importance.

I had to step down.

Why?  There are several reasons for this, but one of the main reasons is that I cannot afford the time off to serve.  I was required to take 1-2 days off of my practice each month to serve on this task force.  The problem is that each day I take away from my practice, I lose money;  a good amount of money.  When overhead is tight and margins are small, missing a day or two each month is intolerable.  While this task-force would pay for my travel and some of my expenses, I had to give up an entire day's worth of income for each day I was gone.

I think that this is a fundamental problem in our system.  For policy makers to understand what is wrong with the system, they must be able to hear it from those most affected by the deficiencies in the system.  The problem is that those people who are in the most distress are exactly those who cannot afford to take the time to put forth their voice.  In general, the "physicians" who populate the committees, task forces, and advisory panels are at best only practicing part-time.  A friend of mine (who works in DC) says that often physicians on these panels introduce themselves as "recovering physicians," with a chortle from the committee in response.

This is not only a problem regarding policy makers, it is a problem in our own representative organizations.  The ACP (for internal medicine), AAFP (family practice) and AAP (pediatrics) are our representative bodies, but what practicing physician has the time for substantive involvement?  If you look at the overall makeup of the representatives within these organizations, they are generally retired, close to retirement, or academics.  Do they really understand the pain being felt "in the trenches?"  They may be sympathetic, but they don't know the weight carried by the majority of practicing physicians.

How can we expect that wrongs will be made right when those most wronged have little of their voice being heard?  How can we address a crisis when those most likely to fall as victims to this crisis are voiceless in the system?  I don't think it can happen.

My involvement in the whole healthcare reform debate has been accompanied by statements of acclaim that I am a different voice than people are used to hearing.  I am an actual practicing physician in a small practice!  Why is this so unique?  I have sacrificed some of my income and time (to the detriment of personal life as well) to be involved, but this should not be expected of other physicians.

What is a solution to this problem?  I think that our representative organizations are the place to start.  They should first realize the magnitude and seriousness of this problem.  They should focus on getting actual practicing physicians from small practices into situations where their voice will make a difference.  I have strongly urged the ACP and AMA to consider setting up a "scholarship fund" which can offer a stipend for certain types of activity.  This would, at least partially, offset the losses a physician takes when he/she becomes involved in the process.  If these organizations are serious about engaging the crisis on a meaningful level they must do what they can to get small office physicians more involved.

Historically speaking, it is normal for the most downtrodden to have the least voice.  Yet in this circumstance, the death spiral of primary care - especially in the small office - will have disastrous effects on the entire healthcare system.  Solutions need to address the real problems at hand, not just the problems an elite few decision-makers perceive as being the problems.  I again call on the specialty organizations to raise the voice of the practicing physician to where it will be heard by those with the power to make change.  Perhaps then can we have hope that things may change for the better.