Primary Care Doctors Struggling to Survive

Brian Vander Brug / Los Angeles Times

Dr. Tanyech Walford takes blood from patient Gwendolyn Wood during Wood's check-up on Tuesday. Walford is closing her Beverly Hills practice after struggling to stay financially afloat.

Relatively low earnings, rising overhead and overwhelming patient loads are sending veteran physicians into early retirement and driving medical students into better-paying specialties.

By Lisa Girion
December 15, 2008

The morning's last patient, a disabled woman on Medicare, trails her doctor into her office and confides that she doesn't have money for lunch. Tanyech Walford pulls out her billfold and hands her $3.  It's money the doctor really doesn't have.

"I tell patients I'm broke, and they just chuckle," she said. "They don't believe me."

Walford's fashionable medical suite in a sleek black-paneled building in Beverly Hills was hiding a grittier reality: She spent much of her lunch hour that day in her office opening mail -- hoping to find payment checks to help fill the gap between her expenses and her revenue.

She hadn't drawn a paycheck for herself since February. On top of that, her practice has cost her $40,000 in personal savings and left her with $15,000 in credit card debt. Walford, 39, also owes $80,000 in medical school loans. She shops at Ross and other discount retailers, and rarely eats out or takes time off.

"I'm totally stressed out," Walford said. "How can I take care of my patients when I'm that stressed?"

Walford is not alone in her struggle. Relatively low earnings, rising overhead and overwhelming patient loads are sending veteran primary care physicians into early retirement and driving medical students into better-paying specialties, creating what the New England Journal of Medicine recently called a crisis.

Primary care doctors "should be able to leave work thinking not of their income, or of unanswered phone calls, or of test results that they might have overlooked," Boston physician and associate journal editor Thomas H. Lee wrote in the Nov. 12 issue. "They should go home thinking, 'This is what I was meant to do.' "

But after five years, Walford couldn't hang on any longer. She closed her office nine days ago.

"It's sad," said Walford, who has shoulder-length wavy black hair, a cherubic smile and a slight lilt that betrays her Jamaican roots. "I worked really hard. It's a tragedy."

The loss of a single physician thrusts hundreds of patients into medical limbo. But the effect is far broader. Experts say the pool of primary care physicians is insufficient to meet the needs of an aging population. Already, shortages make it difficult to see physicians in swaths of northern and rural California, as well as neighborhoods in South Central Los Angeles and other urban cores.

Much of the problem lies in an endangered business model: the one- or two-physician general practice. Such practices are particularly difficult for primary care physicians to maintain because of their relatively slim and declining margins.

In her best year, Walford grossed about $360,000, more than enough to cover her overhead and take home a tidy income. That stands in sharp contrast to this year, when her practice slid into the red.

Small general practices afford doctors autonomy to practice medicine as they see fit and can produce strong doctor-patient bonds. But these physicians have little or no clout to leverage better payments with insurers; they have no economy of scale, which makes overhead more burdensome.