MS. WEISS is a Senior Editor for Medical Economics magazine.

Gail Garfinkel Weiss

A rough year for the US economy had little negative impact on the income of physicians, according to the results of 

' 2009 Exclusive Survey. (For details about survey methodology and basic demographic data on respondents, go to 

). As the recession took hold and third-party payers tamped down on reimbursement, physician income scarcely budged from 2007 to 2008. 

According to the survey, which was administered in April and May to more than 100,000 office-based MDs and DOs in more than 16 specialties, median earnings for family physicians, internists, general practitioners, pediatricians, and ob/gyns remained roughly the same in 2008 as they were in 2007. Among them, ob/gyns were the top earners, posting a median income of $237,500. 

Pediatricians averaged $187,500, followed by FPs, GPs, and internists at $162,500. 

"I have had more calls in 2009 than I did in 2008 from physicians who say their patient load has decreased," she says. "Due to the recession, patients have been more selective about going to physicians, and primary-care practices are seeing a slowdown in their appointment schedules-not only with regard to new patients, but established patients as well." 

Sage notes that there was very little upward change in fee schedule reimbursement from Medicare and other third-party payers in the past year, thus adding to the challenge. 

The equation is balanced to a degree, she says, by a rise in practice startups in urban and rural areas that have long experienced physician shortages, particularly in primary care. In general, she believes, "Physicians recognized the recessionary trend early and were judicious about keeping their costs under control as much as possible to avoid a loss of profitability." 

Soon, she'll be joining a new practice that offers her a partnership opportunity-though it comes with the tradeoff of lower starting pay. 

"A partnership is more important for me and my future," says Abernethy. "The opportunity for more money will come." 

Jeffrey B. Milburn, a Colorado Springs consultant with the Medical Group Management Association, says that physicians who earned more or roughly the same in 2007 and 2008 probably did so the old-fashioned way: by reducing expenses and increasing productivity. He adds, however, that the "ripple effect" of increased unemployment-with expiring healthcare benefits and less discretionary income-bodes poorly for physician earnings in 2009. 

Survey respondent Ralph Boling, MD, knows this feeling well. The ob/gyn from Kirksville, MO, saw his income decline between 2007 and 2008 despite workweeks of up to 60 hours. 

Articles

A rough year for the U.S. economy had little negative impact on the income of physicians, according to the results of Medical Economics' 2009 Exclusive Survey.

2009 earnings survey: How do you compare?

You were warned about them in med school: the patients who make threatening noises about lawsuits at the slightest provocation. The folks who know exactly what's wrong with them and how you should treat it. People who make you wonder why you didn't listen to Uncle Fred and become an actuary.  

Yes-disagreeable, noncompliant, arrogant, and anxious patients come with the territory. But that doesn't mean you have to grit your teeth and put up with them. Most veteran physicians have developed ways of handling troublesome patients-although "handling" sometimes means showing hard-core irritants the door. So the next time you're on the receiving end of a patient's diatribe, don't get angry-get serious about determining what the trouble is and taking corrective action. 

Here's a look at four patient "types" every clinician will recognize, along with tips from your colleagues on how to deal with them. 

Urologist Stephen Leslie of Lorain, Ohio, once sparred with a 65-year-old man who wanted a testosterone gel that had just been approved by the FDA. Leslie demurred, because he hadn't received official prescribing information, and no local pharmacy had the gel in stock anyway. With that, the patient erupted. 

"He ranted and raved in the exam room and out in the hall," Leslie says. "He accused me of malpractice and threatened me with legal action, including letters to the state medical board and anywhere else he could think of. This was the only time in 19 years of practice that I had to call the police about an unruly patient. Fortunately, the man left before they arrived." 

As Leslie acknowledges, experiences like the one he describes are atypical. Most irascible patients are open to reason, and will come around if you push the right buttons. For example, neurosurgeon Michael-Gerard Moncman of Altoona, Pa., turned a cantankerous fellow into an ally by getting a staffer to run interference. 

"He gave me a particular history, I operated on him, then he changed his history and sought care elsewhere while continuing to see me," Moncman says. ["I learned that in treating this man and people like him, sometimes the best strategy is to figure out who in the office they best interact with and use that person as a buffer."] 

"So whenever this man called, we put his favorite staff member on the phone. That way, some of his hostility got defused and we were able to get through the situation very nicely. When all was said and done he admitted, grudgingly, that we had treated him well." 

How is the intermediary selected? "Sometimes patients pick them for us," Moncman explains. "They'll call specifically to speak with a certain individual, or they'll express disappointment if someone is out of the office that day. When the intermediary isn't obvious, I may bring up a problem patient during a staff meeting and ask, 'Does anyone have a good relationship with this guy and can reach out and touch him better than I can?' Obviously, I bear ultimate responsibility for the relationship, but if I have someone who can intercede for me, it's a big help." 

E. Gene Burns, Jr., a family practitioner in LaPlace, La., sometimes wins over quarrelsome patients by agreeing with them on some point. One of Burns' patients was frustrated about having a procedure denied by an HMO. "Most patients in this position initially show their anger to the physician instead of the HMO," Burns says. "This man, however, was stunned and apologetic when I gave him a copy of a letter I had already sent to the HMO on his behalf." 

San Francisco internist Gary G. Kardos remembers a 55-year-old auto mechanic who, upon meeting the doctor, barked, "Just give me a checkup so my wife will get off my back!" Kardos performed a complete physical, then referred the man for several screening tests.  

Your colleagues share their secrets for defusing hostility, coaxing compliance, and allaying anxiety.

Gail Garfinkel Weiss

Articles

2009 earnings survey: How do you compare?

Taming the difficult patient