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

[DO2015CA]

That's an idiotic statement

Primary care is a vast amount of knowledge. They can and do walk in with anything. Specialists are harder in the terms of managing but have a finite amount of subject matter. That’s the problem with primary care as it stands. We are learning so much about medicine that it’s hard to be a great pcp. I will do a subspecialty for that reason. I would prefer to be very knowledgeable about a little than know a little about a lot.

---

Members don't see this ad.

 

[DO2015CA]

If you're an MS3, then you're correct- you know nothing.

That’s been my experience with all of our subspecialty midlevels in our health system as well. They do a fine job in subspecialty clinics because they are seeing things routinely everyday. The ones doing pcp flounder and have inappropriate admits to our service. There is just so much variety

 

[avalon10]

That’s been my experience with all of our subspecialty midlevels in our health system as well. They do a fine job in subspecialty clinics because they are seeing things routinely everyday. The ones doing pcp flounder and have inappropriate admits to our service. There is just so much variety

That doesn't mean that "the knowledge base of primary care is actually greater than specialists."

THAT is the part I was referring to as idiotic.

 

[DO2015CA]

That doesn't mean that "the knowledge base of primary care is actually greater than specialists."

THAT is the part I was referring to as idiotic.

*shrug* this is where we disagree and that’s okay.

 

[trapperjohn4077]

If you're an MS3, then you're correct- you know nothing.

The scary part is that you are an attending and yet somehow the MS3 knows more about how medicine is practiced than you do! Perhaps you are actually a premed in attending's clothes? That would also explain the immaturity.

 

[avalon10]

The scary part is that you think that you can make that conclusion based on a few sentences written by strangers. Perhaps you actually have ESP?

 

[Tangerine123]

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)

As a wierd fact. Ortho isn't that sought after in Germany. When interviewing last year medical stidents, a nation-wide census found that the most desired specialties are (in order)

1) Internal Medicine
2) Peds
3) Family Medicine
4) Anesthesia
5) General Surgery
6) Ortho

Only 1% wanted derm.

Probably because salaries are standarized and the difference in private practice isn't as big as in other countries. So people follow what they like.

 

[Matthew9Thirtyfive]

How about we keep the thread professional and not resort to name calling? Keep it on topic and professional.

 

[Matthew9Thirtyfive]

*shrug* this is where we disagree and that’s okay.

I’ve had a bunch of specialists tell me they decided against primary care because of the knowledge base required. *shrug*

I think every specialty requires a vast amount of knowledge, it’s just whether you’re going down to the Mariana Trench in one area or you’re doing the whole ocean but only a couple hundred feet down.

 

[Lexdiamondz]

That doesn't mean that "the knowledge base of primary care is actually greater than specialists."

THAT is the part I was referring to as idiotic.

"Greater" may not be a great adjective here but being a good generalist definitely requires, at least, a broader knowledge base than most specialists need.

To be a decent PCP and not be a referral-monkey you need to have a pretty firm knowledge of IM, OBGYN, Neuro, Psych and (if you see kids) Peds, plus enough knowledge of the surgical subspecialties to know when to refer your patient for evaluation and possible operative management. Almost no subspecialist requires this broad a knowledge base for their day to day practice.

Furthermore, depending on where you practice, you may not even have access to timely subspecialist referrals and may end up managing a great deal of pathology on your own that would have otherwised been referred out.

No need to call a med student "idiotic" - uninformed sure, but idiotic just sounds petty and mean.

 

[DO2015CA]

"Greater" may not be a great adjective here but being a good generalist definitely requires, at least, a broader knowledge base than most specialists need.

To be a decent PCP and not be a referral-monkey you need to have a pretty firm knowledge of IM, OBGYN, Neuro, Psych and (if you see kids) Peds, plus enough knowledge of the surgical subspecialties to know when to refer your patient for evaluation and possible operative management. Almost no subspecialist requires this broad a knowledge base for their day to day practice.

Furthermore, depending on where you practice, you may not even have access to timely subspecialist referrals and may end up managing a great deal of pathology on your own that would have otherwised been referred out.

No need to call a med student "idiotic" - uninformed sure, but idiotic just sounds petty and mean.

Good elaboration. More or less what I meant in more elegant terms

 

[Sleepingdoc]

Great thing about primary care, especially in FM/IM, you can do whatever you want... you can set up your own clinic if you want....
Unlike what is the medschool craze about how everyone wants be be a specialist, specialist will come knocking at your door to ask you to refer the patients to them..
NP's and PA's need to stop calling themselves doctor in a clinical setting though.

 

[mvenus929]

PCPs require a greater breadth of knowledge but not as much depth--they can handle the routine stuff but need to know when it's appropriate to refer. And each is going to have a different threshold based on their patient mix and experience. In the endocrine world, some people are perfectly comfortable managing and titrating thyroid hormone medications. Others don't have the experience to know what to do with those labs, so refer out, but may learn those skills over time as they refer patients to the endo.

NPs in the specialists clinics tend to focus on one or two disease processes, rather than the full spectrum of specialty care. As a fellow, I see anything that gets referred to clinic, simple or complex. One of our NPs only sees type 1 diabetes (and sees them only in follow-up, after they've seen a physician for their initial visit). Another sees growth (which I disagree with, but I'm not the boss), and another sees kids in multidisciplinary settings with the oversight of an attending (essentially acting as a perpetual fellow). Our nephrology clinic has an NP who sees nocturnal enuresis consults. In the ED, they see the low-acuity patients. They are working at the top of their license, but working at the bottom of a physician's scope of practice in whatever specialty.

 

[Rusino]

If you are not in med school already, you should think very hard about going to med school to become a PCP...

Well, I start med school in July and I want to do rural med, so FM seems like a good option. Hopefully I'm not gonna screw myself over....

 

[Splenda88]

Well, I start med school in July and I want to do rural med, so FM seems like a good option. Hopefully I'm not gonna screw myself over....

What will be your student loan balance at the end of this endeavor? I think I was somewhat wrong on that post. As it stands right now, I think med school is almost a sure path to make in the top 3% financially in the US...

 

[Rusino]

What will be your student loan balance at the end of this endeavor? I think I was somewhat wrong on that post. As it stands right now, I think med school is almost a sure path to make in the top 3% financially in the US...

So, I'm aiming to get a particular scholarship for rural med at my school and if I get it, my student loan balance will be $0. If I don't get it, probably in the vicinity of $90K. State school, quite affordable.

 

[Splenda88]

So, I'm aiming to get a particular scholarship for rural med at my school and if I get it, my student loan balance will be $0. If I don't get it, probably in the vicinity of $90K. State school, quite affordable.

Either way, you have won the lottery...

 

[MedicineZ0Z]

What will be your student loan balance at the end of this endeavor? I think I was somewhat wrong on that post. As it stands right now, I think med school is almost a sure path to make in the top 3% financially in the US...

Adjusted for age, an attending FM making 260k is well deep into the top 1% for their age. Making just 100k is very high up there for a 30 year old. Plus, working more hours (or just more efficiently during your active hours) and you can make 300-350k+.

 

[Lem0nz]

Found this thread actually fairly enlightening from the normal mid level slug fest we have.

It speaks a lot to the question I always have which is: how big of a problem is this actually? If PCPs are not having trouble finding jobs, and they aren’t having trouble finding patients, and midlevels are still seeing a huge amount of patients, the Reddit boogeyman seems much less scary. Independent practice may be a huge threat one day, but we’ll probably have an army of malpractice lawyers to fight it by then too...

Also thought the salary numbers being thrown around were super interesting for primary care. Completely agree that if you adjust for hours of work and RVUs, primary care can come close (and maybe even pass) starting surgeon salaries for the general surgery tracks. We probably have a higher ceiling, but it’s actually pretty encouraging for our PCP colleagues that this is the case. I honestly thought you guys made less. That’s cool.

 

[Splenda88]

Adjusted for age, an attending FM making 260k is well deep into the top 1% for their age. Making just 100k is very high up there for a 30 year old. Plus, working more hours (or just more efficiently during your active hours) and you can make 300-350k+.

But the market is starting to get tight... I am not yet able to find a hospitalist that will pay me 270k+ plus benefits in a nice suburbia. I guess it's first world problem.

 

[MedicineZ0Z]

But the market is starting to get tight... I am not yet able to find a hospitalist that will pay me 270k+ plus benefits in a nice suburbia. I guess it's first world problem.

Little trickier for hospitalists as the base pay is higher than outpatient but the ceiling can be a bit lower.
You can do some extra noninpatient work on your weeks off as well?

Medicine allows for additional work on top of your main job. Other careers don't effectively do that. Doesn't even have to involve patient care but things like medmal work or even clinical research can pay really well.

While there's the occasional 30 year old making high 5 figures to 100-120k, it's fairly rare. And those making higher 6 figures are often in business and have to take huge loans with massive risk.

 

[Splenda88]

While there's the occasional 30 year old making high 5 figures to 100-120k, it's fairly rare. And those making higher 6 figures are often in business and have to take huge loans with massive risk.

I agree with you on that. It's only in SDN you hear: "Don't go into medicine for the money because there are easier way to make money". One of my best friends has been a civil engineer for over 10 yrs and has not been able to crack 6-figure salary. The guy is always petrified whenever there an economic downturn.

 

[MedicineZ0Z]

I agree with you on that. It's only in SDN you hear: "Don't go into medicine for the money because there are easier way to make money". One of my best friends has been a civil engineer for over 10 yrs and has not been able to crack 6-figure salary. The guy is always petrified whenever there an economic downturn.

Absolutely. I owned a small side business through undergrad and I'm still involved in finance. It's a brutally competitive world to make money in. To truly be successful and outearn a physician in the world of business or finance, you have to work more than a neurosurgery resident (while making less than a resident). The only problem is there is a very significant risk of failure involved.

Other professions outside the business world do not make as much money as medicine, period. (dentists, engineers, etc.) And while some midlevels do make 150-200k range and some CRNAs make more, a family doctor can also choose to work 80 efficient hours a week and make >500k for example.

 

[Rusino]

Absolutely. I owned a small side business through undergrad and I'm still involved in finance. It's a brutally competitive world to make money in. To truly be successful and outearn a physician in the world of business or finance, you have to work more than a neurosurgery resident (while making less than a resident). The only problem is there is a very significant risk of failure involved.

Other professions outside the business world do not make as much money as medicine, period. (dentists, engineers, etc.) And while some midlevels do make 150-200k range and some CRNAs make more, a family doctor can also choose to work 80 efficient hours a week and make >500k for example.

Could you please elaborate on how exactly an FM doc would find 80 hours of work a week for that $500K? What kinds of opportunities would have to be available in the area? Salaried side work or some kind of private practice stuff? I assume it's not possible to do that everywhere.

 

[MedicineZ0Z]

Could you please elaborate on how exactly an FM doc would find 80 hours of work a week for that $500K? What kinds of opportunities would have to be available in the area? Salaried side work or some kind of private practice stuff? I assume it's not possible to do that everywhere.

You get a reasonably flexible job working full time hours with production bonuses. Then you can do additional work (urgent care, ED shifts if you have the skills, hospitalist coverage etc.) on other days +/- add evening hours to your current job or work evening hours in a walk in type setting. Essentially, you're stretching out your clinical hours.
Medmal work, non-clinical work opportunities are also available and a lot of it has highly flexible scheduling.

The above is pretty much possible anywhere really. I'm sure being in Manhattan or the heart of LA won't make it easy but generally speaking most markets would be favorable to such a setup.

It's also not rare to make >400k as a family med doc. Seeing more patients gets you there. So if you're doing all of the above, you're going quite a bit over half a million. The reality is, a lot of the personality types found in family med are unlikely to do that. But the option to choose to do it is there.

Now if you're an engineer, you can't simply choose to work double the hours.

 

[Rusino]

You get a reasonably flexible job working full time hours with production bonuses. Then you can do additional work (urgent care, ED shifts if you have the skills, hospitalist coverage etc.) on other days +/- add evening hours to your current job or work evening hours in a walk in type setting. Essentially, you're stretching out your clinical hours.
Medmal work, non-clinical work opportunities are also available and a lot of it has highly flexible scheduling.

The above is pretty much possible anywhere really. I'm sure being in Manhattan or the heart of LA won't make it easy but generally speaking most markets would be favorable to such a setup.

It's also not rare to make >400k as a family med doc. Seeing more patients gets you there. So if you're doing all of the above, you're going quite a bit over half a million. The reality is, a lot of the personality types found in family med are unlikely to do that. But the option to choose to do it is there.

Now if you're an engineer, you can't simply choose to work double the hours.

That makes a lot of sense. My personality type is exactly the type to do all that stuff haha...

But what about a very rural environment? Only one practice in the area, no ED, no hospital, just a clinic.

 

[Splenda88]

That makes a lot of sense. My personality type is exactly the type to do all that stuff haha...

But what about a very rural environment? Only one practice in the area, no ED, no hospital, just a clinic.

No hospital or nursing home w/in 30 minutes of where you want to practice! Some docs cover nursing home because of the flexibility (you pretty much can show up at any time).

 

[Redpancreas]

Specialties are completely invaded by midlevels. Primary care has the patient relationship factor that can provide some leverage.

This is a good point that's never brought up. In specialty clinic, there's much less variability assuming the referral is legitimate and the history/exam consists of a limited set of questions/manuevers that a midlevel/PA can master with experience. On the other hand, primary care requires an extremely broad knowledge base with fundamental understanding of medicine/critical thinking skills that midlevels lack.

The reason why everyone's neurotically gunning for specialties over primary care is because the proprietary nature of the surgical or other element.

 

[Redpancreas]

It's true.

Briefly as to not derail OPs thread, what happens when students interested in EM realize this and stop applying reversing the saturation? Will the pendulum swing? What I've noticed as an SDN regular is the amount of attention EM got in 2016-2018 compared to now is night and day. Literally every other thread back then was about SLOEs, Aways, EM salaries, etc. When did EM die?

 

[Rusino]

This is a good point that's never brought up. In specialty clinic, there's much less variability assuming the referral is legitimate and the history/exam consists of a limited set of questions/manuevers that a midlevel/PA can master with experience. On the other hand, primary care requires an extremely broad knowledge base with fundamental understanding of medicine/critical thinking skills that midlevels lack.

The reason why everyone's neurotically gunning for specialties over primary care is because the proprietary nature of the surgical or other element.

Could you elaborate on what you mean by proprietary nature, please? Unclear to me.

Also, as a side note, I'm pretty neurotically gunning for primary care, but I guess I'm weird haha...

 

[Redpancreas]

Could you elaborate on what you mean by proprietary nature, please? Unclear to me.

Also, as a side note, I'm pretty neurotically gunning for primary care, but I guess I'm weird haha...

I don't think NPs/PAs can do surgery. Some see that as insulation to midlevel creep.

 

[slowthai]

Briefly as to not derail OPs thread, what happens when students interested in EM realize this and stop applying reversing the saturation? Will the pendulum swing? What I've noticed as an SDN regular is the amount of attention EM got in 2016-2018 compared to now is night and day. Literally every other thread back then was about SLOEs, Aways, EM salaries, etc. When did EM die?

They say that it takes about 5 years for the current job market to translate to current M4s, so by then it'll be far too late, which it already is.

These HCA residencies are expanding with no end in sight. The damage is already done.

I think it died sometime last year, lol. I don't know; I just know that it's about to be rad onc jr

 

[altblue]

They say that it takes about 5 years for the current job market to translate to current M4s, so by then it'll be far too late, which it already is.

These HCA residencies are expanding with no end in sight. The damage is already done.

I think it died sometime last year, lol. I don't know; I just know that it's about to be rad onc jr

Ahhh rad onc, where getting a job 30 minutes outside Kansas City is a success