A question to all medical students about primary care and it's future

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DangerousDays said:

I found this interesting comment thread on reddit talking about primary care, the shortage, and what might happen to it in the near future. There were comments like these:





Are these comments accurate? I recently got into medical school and I am thinking about potential specialties, so should I avoid primary care? Thanks.
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I've been in a FM office the past 2 weeks and have had at least 5 patients specifically state that they will not see a NP/PA. The marketing from outside organizations like PPP and recently the AMA has helped keep physicians in deman in primary care. My preceptor got a very competitive salary plus loan repayment and a 9-5 no call gig. Not too bad. I personally don't think the Primary care physician is in really any danger in the near future, but if you had asked me a year ago I would have said the opposite.
 
MS2, but the relative shortage of PCPs especially in underserved areas makes this less of an issue
 
DangerousDays said:
Interesting! What made you change your opinion? Was it your personal experience?


The reddit comments said that the solution has been to move in NPs and PAs where there is a shortage and then push out physicians because you can pay NPs and PAs less.
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Lol. These concerns have gotten bimonthly threads by the same five posters for years, and serious PA/NP encroachment has yet to come to fruition
 
Do they encroach? Sure. Hospital administrators see a future where the job of the primary care physician is to supervise a pack of midlevels. That may happen in some places, but the nice thing about primary care is that you aren't tied to a hospital. There are plenty of good jobs with private practices. The skills you have as a primary care physician are portable, so you can always walk away from a bad situation.
Reddit (and sometimes we aren't that different on SDN) is the epicenter of anxious neurosis.
 
altblue said:
Lol. These concerns have gotten bimonthly threads by the same five posters for years, and serious PA/NP encroachment has yet to come to fruition
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NP schools are graduating record numbers of NP's right now, like an order of magnitude more than they did 15 years ago... I don't necessarily agree with the redditor, but I don't think it's safe to dismiss their concerns so flippantly.
 
Invasion of PAs and NPs into primary care might push IM interested MDs to other specialities.
 
rx001 said:
Invasion of PAs and NPs into primary care might push IM interested MDs to other specialities.
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The premise of this thread is a bit misguided. People aren't trying to become NPs/PAs to work in primary care, they're trying to work in highly lucrative fields like derm/surgery/anesthesia. They couldn't care less about the shortage of PCP doctors, all they care about is making the most amount of money with the least amount of effort. This idea that competitive specialties are relatively safe from encroachment needs to die; those are the fields that NPs/PAs are going to come after FIRST.
 
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COMMANDER CLOWN said:
The premise of this thread is a bit misguided. People aren't trying to become NPs/PAs to work in primary care, they're trying to work in highly lucrative fields like derm/surgery/anesthesia. They couldn't care less about the shortage of PCP doctors, all they care about is making the most amount of money with the least amount of effort. This idea that competitive specialties are relatively safe from encroachment needs to die; those are the fields that NPs/PAs are going to come after FIRST.
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Yes but those jobs are already drying up because they have so many graduates coming out. These midlevels will be pushed into pcp roles. Especially these states that are allowing solo practice for midlevels. We aren’t at a tipping point yet but it will happen
 
NicMouse64 said:
I've been in a FM office the past 2 weeks and have had at least 5 patients specifically state that they will not see a NP/PA. The marketing from outside organizations like PPP and recently the AMA has helped keep physicians in deman in primary care. My preceptor got a very competitive salary plus loan repayment and a 9-5 no call gig. Not too bad. I personally don't think the Primary care physician is in really any danger in the near future, but if you had asked me a year ago I would have said the opposite.
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Yep.

If it's the same price for them either way, patients would mostly rather see a doctor. This is especially true with the rising deductibles and copays.

Despite the higher pay, I still make way more for the hospital than the NPs - I see more patients, bill more aggressively, and hit more quality metrics.

The NPs don't usually take call so if we start replacing doctors with them the call group will get smaller which will piss off the remaining doctors.

Anecdotally, NPs seem to refer more often. It already takes weeks if not months to see the specialists so that'll get worse. Beyond that, lots of patients don't like having to see multiple doctors.

My group currently has 6 openings for PCPs, zero for midlevels. 5 of those are to replace retiring doctors. If they were trying to replace us with NPs, this would be an easy way to do it.

The huge expansion in NP schools has made their job market suck. Our group recently rolled out new contracts for them. It was a decent pay cut for all of them and basically said "take it or leave it, we can replace all of you within 3 months these days".
 
VA Hopeful Dr said:
Yep.

If it's the same price for them either way, patients would mostly rather see a doctor. This is especially true with the rising deductibles and copays.

Despite the higher pay, I still make way more for the hospital than the NPs - I see more patients, bill more aggressively, and hit more quality metrics.

The NPs don't usually take call so if we start replacing doctors with them the call group will get smaller which will piss off the remaining doctors.

Anecdotally, NPs seem to refer more often. It already takes weeks if not months to see the specialists so that'll get worse. Beyond that, lots of patients don't like having to see multiple doctors.

My group currently has 6 openings for PCPs, zero for midlevels. 5 of those are to replace retiring doctors. If they were trying to replace us with NPs, this would be an easy way to do it.

The huge expansion in NP schools has made their job market suck. Our group recently rolled out new contracts for them. It was a decent pay cut for all of them and basically said "take it or leave it, we can replace all of you within 3 months these days".
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yes. I don’t think midlevels can “take over” pcp from physicians. They just aren’t good enough. But I do see that physicians can give it up because everyone is so scared of encroachment that they choose to subspecialize. This will be a sad day for patients and a disservice.
 
VA Hopeful Dr said:
My group currently has 6 openings for PCPs, zero for midlevels. 5 of those are to replace retiring doctors. If they were trying to replace us with NPs, this would be an easy way to do it.

The huge expansion in NP schools has made their job market suck. Our group recently rolled out new contracts for them. It was a decent pay cut for all of them and basically said "take it or leave it, we can replace all of you within 3 months these days".
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This - we have been openly recruiting PCPs for 5 years, and not once have we had any midlevel PCP jobs posted. Yes the encroachment is real - there are a couple of midlevels in our clinic who arguably are "taking a job" from a physician but we can't recruit physicians into the role anyways.

And to the second comment - absolutely the same thing here. They get hired on with a letter of intent instead of a set contract, and it's well known if they want to leave over terms we can have a half dozen applicants for their job within a week. One of my colleagues SO was an NP and she ended up having to move 2 hours away further into BFE to get a job. Another could get a malignant urgent care job in town, and it was literally the only position she got an interview for after mass applying.

As I get further into medicine and see more of the business side of medicine I actually get less concerned about midlevel encroachment. I'm honestly more worried about declining Medicare reimbursements, bundled payments and reimbursements tied to quality metrics than I am about being replaced by a midlevel. Maybe time will prove me a fool, we will see.

To the OP - we are now listing a higher salary for PCPs than we are listing for hospitalists because we are having such a hard time recruiting - come to BFE adjacent and make $285k/yr + 40k guaranteed bonus.
 
One of the worst arguments when it comes to encroachment is how people will always prefer a physician over midlevel. This may be true for a small subset of patients who know the difference, but the vast majority simply do not know the difference. This is further compounded by midlevels trying to blur the line as much as possible. The number of times I have to correct patients daily when they call me Dr. even though I introduced myself as a medical student is staggeringly high.
 
DangerousDays said:
Wow. Thanks to all the physicians for clearing this up. I was kinda afraid of primary care after hearing about encroachment and even AI begging to replace us, but this helped assuage some of my fears.
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I am a PGY3 (IM) and I literally get 3-4 recruiter emails/day. We are safe for the next 10 years IMO.
 
Splenda88 said:
I am a PGY3 (IM) and I literally get 3-4 recruiter emails/day. We are safe for the next 10 years IMO.
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And this has been the common refrain for the last 30 years. That's not a guarantee of infinite prosperity of course, but my 2 cents is that barring single payer we should be OK. And even then we'll still have plenty of jobs (possibly even more if you look at physician specialty data from other countries) just slightly less money.
 
VA Hopeful Dr said:
And this has been the common refrain for the last 30 years. That's not a guarantee of infinite prosperity of course, but my 2 cents is that barring single payer we should be OK. And even then we'll still have plenty of jobs (possibly even more if you look at physician specialty data from other countries) just slightly less money.
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Is there a specific reason why single payer would affect PCPs more than specialists? I have done zero research on this, not even a google search, since preparing for med school interviews 2 plus years ago so I cant remember
 
Captain_Falcon said:
Is there a specific reason why single payer would affect PCPs more than specialists? I have done zero research on this, not even a google search, since preparing for med school interviews 2 plus years ago so I cant remember
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Only in terms of workforce need since most single payer countries have more PCPs per capita than we do.
 
DangerousDays said:
So the shortage would become even more than it is now?
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No, I think there would be incentives to get more people in primary care. Whether its negative, like cutting specialist pay more than ours so those extra years of training are less worth it, or positive like more money or loan repayment options for people who go into primary care.
 
VA Hopeful Dr said:
No, I think there would be incentives to get more people in primary care. Whether its negative, like cutting specialist pay more than ours so those extra years of training are less worth it, or positive like more money or loan repayment options for people who go into primary care.
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If you look at the extremes, orthos in the US make about 2.5x what the average PCP makes. In Germany it's 1.5x, in Australia it's 2x. Per capita, Germany and Australia both have 2/3rds as many orthopedic surgeons as the US does, with a similar rate of PCPs (Australia actually has ~1.4x as many PCPs per capita). So that's likely where reform efforts will go, regardless whether single payer becomes a thing or not (there are other ways to regulate it - if medicare lowers reimbursements for hip replacements, private insurance will follow suit).

If single-payer did pass, physicians as a whole will make less but theoretically surgeons will lose more than PCPs will. And I can't imagine that happening without midlevels also facing cuts (so long as physicians continue to stay engaged on this issue and don't let other groups monopolize the conversation). So then the question will be, do you become an MD/DO PCP and make, say, $150k/year, or do you become an NP/PA PCP and make 70-90k?
 
why are you asking medical students about the future of primary care. According to them its the 8th oval of purgatory
 
Single-payer would surely decrease reimbursements for some physicians and increase them for others, kinda like how already happens with medicare now. Tbh though, it just doesnt make sense to assume salaries would go down by half - as we know that wouldnt really do much regarding our healthcare expenditures, far more fat to be cut administratively, which is what single-payer advocates almost exclusively focus on.
 
DangerousDays said:
Yeah, I'm not planning to become a PCP, but I was just curious in case I have to go into primary care what the situation is.
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It's extremely unlikely that you would ever "have to" pursue primary care. There are plenty of specialties outside of primary care that aren't competitive at all for US MD graduates (e.g., most IM fellowship tracks, neurology, PM&R, EM, pathology, gas, DR).
 
Osminog said:
It's extremely unlikely that you would ever "have to" pursue primary care. There are plenty of specialties outside of primary care that aren't competitive at all for US MD graduates (e.g., most IM fellowship tracks, neurology, PM&R, EM, pathology, gas, DR).
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Diagnostic radiology isn’t competitive? The mean step 1 is above 240.
 
Steve_Zissou said:
Diagnostic radiology isn’t competitive? The mean step 1 is above 240.
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Nevertheless... it's a big specialty. For US MD seniors, 95.5% match rate as of Charting Outcomes 2020.
 
Steve_Zissou said:
Diagnostic radiology isn’t competitive? The mean step 1 is above 240.
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It’s not competitive. Even DOs with 220-230 match in high rates. It’s obviously competitive for top 20 programs but that’s competitive in every specialty. That’s what the AI buzzword can do to a specialty.
 
Steve_Zissou said:
And Rad Onc was 99.2%. It’s all about self-selection for higher scorers.
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Nevertheless... 91.2% match rate for those between 201-230. Idk, just doesn't seem to be particularly low chances no matter what. For the same step range, 63.6% match for derm, 52.5% match for ortho - and that's with far fewer attempts so I'd argue the real self-selection happened for those specialties. For FM, 96.8%. It's obvious that rads is far, far closer to FM than the more traditionally hyper-competitive specialties.
 
scoopdaboop said:
It’s not competitive. Even DOs with 220-230 match in high rates. It’s obviously competitive for top 20 programs but that’s competitive in every specialty. That’s what the AI buzzword can do to a specialty.
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AI has nothing to do with it. There are just a lot of programs and not much relative interest in the field, that's why DR isn't as hard to match into as other fields with a 240 or higher average step.
 
Steve_Zissou said:
Diagnostic radiology isn’t competitive? The mean step 1 is above 240.
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MD applicants to DR with Step 1 scores in the 211-230 range had an 94% match rate. The high average Step 1 is a reflection of self-selection, not competitiveness; something about DR inspires high scorers to drift toward it. It’s not a competitive specialty at all.
 
COMMANDER CLOWN said:
The premise of this thread is a bit misguided. People aren't trying to become NPs/PAs to work in primary care, they're trying to work in highly lucrative fields like derm/surgery/anesthesia. They couldn't care less about the shortage of PCP doctors, all they care about is making the most amount of money with the least amount of effort. This idea that competitive specialties are relatively safe from encroachment needs to die; those are the fields that NPs/PAs are going to come after FIRST.
Click to expand...

The pay difference for NPs/PAs across all fields is very minimal (it's the difference among physician pay that's greater) so they little incentive to go into a different field for the pay alone. They may do it more for their own interests or a work schedule that better fits them. Also, NPs and PAs still need to be officially supervised by an MDs so they won't replace MDs anytime soon. They can however decrease the overall demand for MDs to the point that we would have fewer MDs that are largely supervising PAs. This is especially more likely in primary care specialties since the learning curve and knowledge base isn't as extensive in any one area as a specialist.
 
collegestud2013 said:
The pay difference for NPs/PAs across all fields is very minimal (it's the difference among physician pay that's greater) so they little incentive to go into a different field for the pay alone. They may do it more for their own interests or a work schedule that better fits them. Also, NPs and PAs still need to be officially supervised by an MDs so they won't replace MDs anytime soon. They can however decrease the overall demand for MDs to the point that we would have fewer MDs that are largely supervising PAs. This is especially more likely in primary care specialties since the learning curve and knowledge base isn't as extensive in any one area as a specialist.
Click to expand...

the knowledge base of primary care is actually greater than specialists. That’s why midlevels work better in specialist clinics seeing follow ups. You can teach them a smaller amount of information
 
DangerousDays said:

I found this interesting comment thread on reddit talking about primary care, the shortage, and what might happen to it in the near future. There were comments like these:





Are these comments accurate? I recently got into medical school and I am thinking about potential specialties, so should I avoid primary care? Thanks.
Click to expand...


I think there's a stigma among U.S. M.D. med students that going into primary care is like having a failed career since a D.O. or Caribbean IMG could have easily done primary care. While it's true that primary care specialties remain the least competitive. And as a PCP you may feel you're at the bottom of the totem pole since you're not the expert in one area half the time you're just the patient's glorified social worker and referring them to specialists to manage any complex problems that are beyond your scope. However, the pay difference isn't as much as you think.

The true pay difference between primary care and specialists especially nowadays is much narrower than you think for several reasons:
1) You need to factor in the extra 2-4 years specialists need for training between residency and fellowship (5-7 years instead of 3 years) and in those extra years as a primary care attending you can have made an extra $500k-$1million already.
2) There are scholarships and loan repayments for primary care nowadays to even out the cost
3) You'll be in the 40+% federal tax bracket as an attending so even an extra ~$200k per year you make becomes only ~$110k per year after takes.
4) some specialists, especially in the surgical subspecialties, work much longer hours. If account for those additional hours worked per week by scaling up your patient volume as a PCP and work similar hours to the surgical specialist your RVUs and pay will be much closer.
5) Insurance reimbursements have already been more and more favoring PCPs since around 2010 and at the current rate it will only continue. For example, the proposed CMS budget for 2021 will increase outpatient primary care reimbursements even further at the cost of specialists and inpatient specialties (eg EM and hospitalist), and since the CMS needs to be "budget neutral," an increase of reimbursements in one specialty must come at the cost of decrease in reimbursements of another specialty.
 
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Medmortise said:
One of the worst arguments when it comes to encroachment is how people will always prefer a physician over midlevel. This may be true for a small subset of patients who know the difference, but the vast majority simply do not know the difference. This is further compounded by midlevels trying to blur the line as much as possible. The number of times I have to correct patients daily when they call me Dr. even though I introduced myself as a medical student is staggeringly high.
Click to expand...

I was going to say this if no one else did. My own SO can't tell the difference - and I'm a med student and I've talked to him about this stuff many times before. He went to a dermatologist recently and "the dermatologist" disagreed with what I thought (she said it was a wart; I wasn't sure exactly what it was, but I was relatively sure it's vascular in nature based on the appearance), and she froze it off. He was going on and on about how she was the doctor and I wasn't, so of course she knew better and it was going to be gone when the skin healed. It looked exactly the same after the damaged/frozen skin over it healed... surprise, surprise.

That's when I again reminded him he didn't actually see a dermatologist, which he argued about for a while... until it finally clicked that "FNP" was short for family nurse practitioner. It took a couple weeks of this for him to realize that booking an appointment with a doctor just means you're booking an appointment with someone in the office, not necessarily the doctor whose name is on the practice. :laugh:

If someone dating a med student doesn't know how to tell what education their provider has, in a relationship where this has been a household conversation in the past, do we really expect the general population to know?
 
calivianya said:
I was going to say this if no one else did. My own SO can't tell the difference - and I'm a med student and I've talked to him about this stuff many times before. He went to a dermatologist recently and "the dermatologist" disagreed with what I thought (she said it was a wart; I wasn't sure exactly what it was, but I was relatively sure it's vascular in nature based on the appearance), and she froze it off. He was going on and on about how she was the doctor and I wasn't, so of course she knew better and it was going to be gone when the skin healed. It looked exactly the same after the damaged/frozen skin over it healed... surprise, surprise.

That's when I again reminded him he didn't actually see a dermatologist, which he argued about for a while... until it finally clicked that "FNP" was short for family nurse practitioner. It took a couple weeks of this for him to realize that booking an appointment with a doctor just means you're booking an appointment with someone in the office, not necessarily the doctor whose name is on the practice. :laugh:

If someone dating a med student doesn't know how to tell what education their provider has, in a relationship where this has been a household conversation in the past, do we really expect the general population to know?
Click to expand...

Seeing anyone in a closed door room = doctor for most of the general public.
 
calivianya said:
I was going to say this if no one else did. My own SO can't tell the difference - and I'm a med student and I've talked to him about this stuff many times before. He went to a dermatologist recently and "the dermatologist" disagreed with what I thought (she said it was a wart; I wasn't sure exactly what it was, but I was relatively sure it's vascular in nature based on the appearance), and she froze it off. He was going on and on about how she was the doctor and I wasn't, so of course she knew better and it was going to be gone when the skin healed. It looked exactly the same after the damaged/frozen skin over it healed... surprise, surprise.

That's when I again reminded him he didn't actually see a dermatologist, which he argued about for a while... until it finally clicked that "FNP" was short for family nurse practitioner. It took a couple weeks of this for him to realize that booking an appointment with a doctor just means you're booking an appointment with someone in the office, not necessarily the doctor whose name is on the practice. :laugh:

If someone dating a med student doesn't know how to tell what education their provider has, in a relationship where this has been a household conversation in the past, do we really expect the general population to know?
Click to expand...
I had your SO's same experience and that was actually the thing that got me started looking into the medical field.

When I moved temporarily to a rural Oregon region, I learned a lot about the work physician's assistants and nurse practitioners do for primary and urgent care settings for rural areas underserved by the absence of specialists. Later, in a major city, I still saw it in place. I went for an urgent care visit over a sinus infection and the script writer was a PA.

I later wanted to meet with an actual OBGYN doctor over women's issues. The DNP who met with me despite my request for an MD told me that my issues were "because I had turned 30." In some respects, she is the reason why I wanted to enter the field. "You got older" is not a good enough response about major physiological changes.

I lucked out for a while after finding an IM specialist for primary care whose specialty is geriatrics but she works with younger adults. She would get to the bottom of ANYTHING. I had cat scratch fever once and she figured that one out quickly and stopped me from thinking I had lymphoma.
 
The answer is quite simple, as the issue call all be distilled into 1 issue: procedural billing. Counsel someone on using their Flovent inhaler regularly and with a spacer and reduce ER admissions and improve their quality and quantity of life and get paid nothing for it, or take a sponge out of nose or pop a pimple and make bank. Fix that issue and the rest will fall into place... or kick the can and let other providers fill the gap... whatever works.
 
I've been hearing that primary was dying ever since I was a premed. Considering I was far far far busier on PC rotations that Surgery ones I am a bit skeptical of the idea, but my N=1

On the other hand what I don't hear about is how EM is on track to be incredibly oversaturated by the time most premeds become an attending.

In the end, most people don't know what they are talking about. As a Premed, worrying about what fields are dying out seems like putting the cart before the horse's mom is even born. There are much more important things you should be worrying about in that stage.
 
ohmanwaddup said:
I've been hearing that primary was dying ever since I was a premed. Considering I was far far far busier on PC rotations that Surgery ones I am a bit skeptical of the idea, but my N=1

On the other hand what I don't hear about is how EM is on track to be incredibly oversaturated by the time most premeds become an attending.

In the end, most people don't know what they are talking about. As a Premed, worrying about what fields are dying out seems like putting the cart before the horse's mom is even born. There are much more important things you should be worrying about in that stage.
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PC will never die. There’s just too much need. Now who performs that pc is another question. Will physicians turn into midlevel managers? Hard to say. But we are no where near that yet
 
avalon10 said:
That's an idiotic statement
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I know nothing as a M3 but the NPs working my gen surgeons post op patients seemed to need to know much less than the ones working up the acute issues in the FM office.
 
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