I'm currently a categorical IM resident. For a while I was seriously entertaining the idea of going into primary care, but that desire has died a slow death. I'm interested in what other IM residents or practicing primary care physicians think about this issue and if anyone else has reached similar conclusions. I listed some reasons I thought I'd like primary care and the "realities" as I see them now.

1. I wanted to be someone's overall doctor, not just the guy who knows about the kidneys/heart/skin, etc
... This is now impossible in the current climate of healthcare. At the very least, you can be marginally competent in everything and perhaps pick an interest, like derm lesions or cardiology, where you can make a point to learn more. However, if you pick up any serious pathology, standard care now is to refer. Have RA? See rheum for the latest treatment! New a-fib? Better refer to cards! Scar pain? Have to see derm! That's not being someone's doctor, it's just directing traffic.

2. I wanted to go into a profession where I could apply my MD training and be well compensated for all the hard work up to this point.
... After all this work, as a primary care doctor I'll have the same job and earning only marginally more than our NP/PA collegues (we may see sicker pts as an MD but the day-to-day activities of seeing clinic patients are very similar). Starting salary for a primary care doctor is about 150K, wheras midlevels can make about 80-100K. One review article I read estimated that 60-70% and up to 90% of primary care office visits can be "adequately attended" by midleves. That means I went to med school and incurred 180K of debt in order to be able to deliver the same service as someone with much less training. One response to this might be "who cares what other practitioners do/make?", but it does matter to me... I want to apply all this wonderful and expensive education somewhere, and appearently it's not required for primary care.

Could go on, but that's enough for now. Any thoughts?

wow...you make a good point, but unfortunately healthcare seems to evolving into a newer era...especially with insurance companies and lawyers keeping a watchful eye out to daily activities of practitioners... it actually is still a work in progress....

My debt is about $400K-- $200 from a mortgage and the other is education.... and I wonder everyday how can life be managed when prices are going up on basic neccessities and trying to provide my son with a "better" opportunity in life then myself... I don't think it will be easy at first for any physicians...but I know it will get better...just by speaking with practicing physicians...just be patient and believe me, your knowledge will serve many people well-- more then a "midlevel"

And, there is always plenty of work-- more than enough for a practicing physician.. that you will probably want to hire a "midlevel"...just to help out with the load...so you can have some "life" outside the office/hospital..

I'm currently a categorical IM resident. For a while I was seriously entertaining the idea of going into primary care, but that desire has died a slow death. I'm interested in what other IM residents or practicing primary care physicians think about this issue and if anyone else has reached similar conclusions. I listed some reasons I thought I'd like primary care and the "realities" as I see them now.

1. I wanted to be someone's overall doctor, not just the guy who knows about the kidneys/heart/skin, etc
... This is now impossible in the current climate of healthcare. At the very least, you can be marginally competent in everything and perhaps pick an interest, like derm lesions or cardiology, where you can make a point to learn more. However, if you pick up any serious pathology, standard care now is to refer. Have RA? See rheum for the latest treatment! New a-fib? Better refer to cards! Scar pain? Have to see derm! That's not being someone's doctor, it's just directing traffic.


just because that's the way you see things being done, doesn't mean that they need to continue. in a way, when you're done with residency, it all depends on how comfortable you feel with managing certain diseases. you can always refer for an opinion (send the request for consult as a consult only, not a consult and follow jointly), and then continue to see the patient.


however, i do realize that much of medicine these days deals with your place within medicare/medicaid/hmo/epo/ppo! :laugh: depending on the type of ra and the type of treatment requested (say one of the new biologic infusions), it would likely require a visit to the rheumatologist. but, the patient doesn't necessarily have to continue to see the rheumatologist for that problem.

in a way, part of the problem is that those before us brought the problem of volume. i.e., the physician/group gets paid each month depending on membership. for medicaid, it's roughly 10 dollars per member per month. so, if you have 1000 members on your roster, that's 10k a month right there without seeing anyone. thus, many docs want to get that member roster up in order to get more money per month without lifting a finger! the problem comes in where statistics show that roughly 25% of your roster will come in during the month. so, 1000 patients on the roster mean 250 patients coming in.

some of the rules are changing in regards to primary care and reimbursement:
physicians are figuring out how to bill to the highest degree (billing for diabetes type 2 gets a lower reimbursement than diabetes type 2 associated with peripheral neuropathy; history of stroke gets a lower reimbursement than history of stroke with residual left arm and left leg weakness).
some insurances are looking at rewarding preventive care. keeping your diabetics with good glucose control (by keeping tabs on a hemoglobin a1c a few times per year), keeping your hypertensives under good control, keeping your patients with multiple medical conditions out of the hospital.




2. I wanted to go into a profession where I could apply my MD training and be well compensated for all the hard work up to this point.
... After all this work, as a primary care doctor I'll have the same job and earning only marginally more than our NP/PA collegues (we may see sicker pts as an MD but the day-to-day activities of seeing clinic patients are very similar). Starting salary for a primary care doctor is about 150K, wheras midlevels can make about 80-100K. One review article I read estimated that 60-70% and up to 90% of primary care office visits can be "adequately attended" by midleves. That means I went to med school and incurred 180K of debt in order to be able to deliver the same service as someone with much less training. One response to this might be "who cares what other practitioners do/make?", but it does matter to me... I want to apply all this wonderful and expensive education somewhere, and appearently it's not required for primary care.

Could go on, but that's enough for now. Any thoughts?

now you're talking more about the business model and economics of medicine, rather than medicine itself. :laugh: under the current set up, if you want to make more money in the office, you need to see more patients... or develop other streams of revenue via x ray, labs, public notary, copy services, medical spa, etc.