Declining Primary Care Popularity -- $$'s related?

[OncoCaP]

The number of U.S. Medical Graduates going into Family Practice residencies has been steadily decreasing, from ~2300 in 1996 to ~1200 in 2006. I'm curious as to whether this is based solely on pay or there is more to it. If primary care paid the same as a specialist, would you go into it? What about if it paid more than a specialist wage? For me, it wouldn't be my first choice even if it paid more than a specialist wage, but I'm curious as to what others think. For the purpose of this poll, I consider Family Practice, General Practice, Internal Medicine (non-specialist), Pediatrics, and OB/GYN.

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[sunnyjohn]

If the lifestyle/hours improved along with the money, it probably would attract more people.

That is sad since an increase in primary care doctors (esp. one's trained in nurtion, diet and exercise) would be a boon to the medical bottom line.

Some smart person will figure out how to cash in on primary care medicine and we'll all be kicking ourselves.




EM is primary care (for poor people), right?

 

[Critical Mass]

Pay is part of the equation, but it's also a little bit more about liability and scope of practice. Family docs in my area no longer deliver babies, for instance, and insurance companies have become more ruthless about referring out for basic procedures. The last family doc I shadowed said he doesn't even remove moles anymore.

I don't want to start a dicussion about midlevels over here, but a lot of folks feel like PA's and NP's are competing with primary care docs; and insurance companies may soon favor them in the interest of cost control.

As to the pay, most people have realized that a primary care doc has to see a lot more patients today than years back to get paid the same due to dropping reimbursements.

The last family doc I was with didn't look like he had a very exciting job--something fell on your foot? X-Ray and refer to ortho if abnormal. Blood pressure? Here's what the drug rep told me to give you. Infection? Levaquin for everybody! (They have the coolest pens aside from Viagra). Refer, refer, refer. I was interested in primary care before med school. Now I've ruled it out.

 

[msl2007]

I think that it has more to do with exposure and the current competetive nature of med school..we compete so hard to get in, it becomes natural to "compete" as doctors and try to get the hardest/most exclusive/most improtant (however you see it) specialty, and primary care isn't considered to be one of these, regardless of its challenges and importance. The specialties also have a more competetive feel (ie surgery) than do the primary care fields, wherever is usualy nicer and more helpful, so maybe med students don't feel right being treated like humans?

It is possible that money has something to do with, but everyone sees this in a differnt way- $140k (peds) might be great for some, while others need $350k. Individual differences.

I think that the media might influence choices as well. Most patients love their primary docs and cringe at the thought of going to the academic hospital to see a specialist, but the news, tv shows, etc all glamourize the NIH super subspecialists and ignore the internist down the road.

 

[OncoCaP]

If the lifestyle/hours improved along with the money, it probably would attract more people.

That is sad since an increase in primary care doctors (esp. one's trained in nurtion, diet and exercise) would be a boon to the medical bottom line.

Some smart person will figure out how to cash in on primary care medicine and we'll all be kicking ourselves.

EM is primary care (for poor people), right?

Yeah, well, EM isn't supposed to be primary care, but now that you mention it ....

Some PC physicians are turning to cash-only practices and a few are experimenting with very low overhead practices in an attempt to turn things around. My guess is that unless our healthcare system is reformed, primary care will be increasingly served by foreign medical graduates and mid-level providers. Maybe everything will work out, but the declining number of U.S. medical graduates choosing primary care has many experts worried about the quality of primary care in the U.S. and our overall health in the future.

 

[jsnuka]

EM is primary care (for poor people), right?

De facto, but it is not de jure.

There is a push, it seems, to get EM calssified as Primary care. I doubt it will ever happen though.



What does money have to do with it?

No matter what you do your residency in these days, you will come out making 2-10 times what your typical patient is making.

Is money REALLY that important?

 

[baylormed]

Mmmm...it's a hard thing to decide before going into medical school. I think most of us are shooting for "lifestyle" specialties, no one except a few are really hoping to work bad, long hours for a low pay.

However, I do know some primary care doctors that work 8-5, five days a week, while making ~150,000/year. It doesn't really sound that bad, and the job isn't stressful, because you see a lot of minor things and you see them over and over again.

Being female and maybe one day having a family, it might not be completely out of the question for me...I certainly don't want to raise my children on nannies, but that is just a personal choice.

However, I will just base my decision on doing something I enjoy and that allows the best lifestyle possible. I'm looking (as of now) into internal medicine and its subspecialties, there is plenty of room within that specialty for subspecialization on many different areas that pays very well.

 

[Critical Mass]

Is money REALLY that important?

Most people say yes after feeling tortured throughout med school.

 

[sunnyjohn]

...

Is money REALLY that important?

I gotta whole lotta folks just waitin' for me to break them off their two-fity'!

 

[OncoCaP]

I think that it has more to do with exposure and the current competetive nature of med school..we compete so hard to get in, it becomes natural to "compete" as doctors and try to get the hardest/most exclusive/most improtant (however you see it) specialty, and primary care isn't considered to be one of these, regardless of its challenges and importance. The specialties also have a more competetive feel (ie surgery) than do the primary care fields, wherever is usualy nicer and more helpful, so maybe med students don't feel right being treated like humans? ...

That's probably true as long as pay was more or less the same. If you stand to make $120,000 in family practice vs $190,000 in some type of IM speciality, money probably does become a factor.

I'm just not sure that decreasing the number of family practice residencies would make more medical students want to go into that field. If anything, I would expect the number of family practice physicians to decrease even more.

 

[jsnuka]

Forget Family Medicine, look into Med-Peds. The ultimate in flexibility AND exclusivity.

 

[lilnoelle]

I wanted to do primary care before going to med school.... now I'm not all that interested in it. I think the big reason is that I would like a more focused practice with a smaller set of diseases or more definitive diagnosis. I.e. Radiology or pathology, pretty clear cut diagnosis, Surgery, you get in and solve whatever the problem is, Anesthesiology, you give anesthesia and have an immediate result, EM, you take care of whatever is life threatening or the critical complaint and leave the rest for their primary care doc or admit if the patient needs longer term care.

The shadowing I've done in primary care, it feels like we're just guessing, trying different meds to see if they work, etc, but it takes a long time to actually decide what is wrong with the patient. That would get frustrating to me. I want more immediate results.

 

[DropkickMurphy]

I wanted to do primary care before going to med school.... now I'm not all that interested in it. I think the big reason is that I would like a more focused practice with a smaller set of diseases or more definitive diagnosis. I.e. Radiology or pathology, pretty clear cut diagnosis, Surgery, you get in and solve whatever the problem is, Anesthesiology, you give anesthesia and have an immediate result, EM, you take care of whatever is life threatening or the critical complaint and leave the rest for their primary care doc or admit if the patient needs longer term care.

The shadowing I've done in primary care, it feels like we're just guessing, trying different meds to see if they work, etc, but it takes a long time to actually decide what is wrong with the patient. That would get frustrating to me. I want more immediate results.

You'd have to pay me double what I could make in an interesting specialty to get me to be a primary care doc.

 

[OncoCaP]

If pay is the main issue keeping students out of primary care, perhaps some enforced pay parity would correct the issue. One radical idea might be requiring insurance companies would be required to have a certain percentage of their reimbursements (33%? 25%?) be to primary care or be fined 2X the difference; this would force them to negotiate harder with specialists and avoid driving down primary care wages. A variant would be a state-mandated minimum charge for certain primary care services and that all insurance plans in the state cover certain types of care @ 90%. Maybe someone has a better idea. There are a lot of arguments that more of our money should be in primary care for the sake of the overall health of the population. Major U.S. health issues like obesity, which affects at least 30% of our population are probably best handled at the primary care level.

Judging from the very early poll results, we could easily double the number of new primary care physicians if the pay parity issue was addressed.

 

[THE armada]

There's money to be made in primary care. Rural areas are desperate for these doctors.

 

[spicedmanna]

I wanted to do primary care before going to med school.... now I'm not all that interested in it. I think the big reason is that I would like a more focused practice with a smaller set of diseases or more definitive diagnosis. I.e. Radiology or pathology, pretty clear cut diagnosis, Surgery, you get in and solve whatever the problem is, Anesthesiology, you give anesthesia and have an immediate result, EM, you take care of whatever is life threatening or the critical complaint and leave the rest for their primary care doc or admit if the patient needs longer term care.

The shadowing I've done in primary care, it feels like we're just guessing, trying different meds to see if they work, etc, but it takes a long time to actually decide what is wrong with the patient. That would get frustrating to me. I want more immediate results.

Very thoughtful post. I just wanted to add the counter perspective. For me, it seems that I thrive off of the long-term aspects of patient care, i.e., the idea of being able to follow my patients throughout their life. I also like the detective work and management process involved in primary care, particularly in IM. I like scrubbing the patient's history and records and getting to know them in depth. It's like an endless puzzle of actions and interactions, and it seems like you need to view everything in context. The researcher in me really loves that. I also like being involved in teaching my patients how to take better care of themselves. On the other hand, I haven't tried my hand in this yet, so perhaps my views will change as I delve into medicine. We shall see.

 

[DropkickMurphy]

It would also help if primary care wasn't so dull.......

 

[DropkickMurphy]

There's money to be made in primary care. Rural areas are desperate for these doctors.

Yeah, but the pay is still trumped by what you can make in EM or one of the IM subspecialties......

 

[spicedmanna]

Forget Family Medicine, look into Med-Peds. The ultimate in flexibility AND exclusivity.

Yeah, I'm thinking about a dual residency, IM/Peds, myself.

 

[jsnuka]

How is money an issue--A REAL issue, when you have loan payback programs that the other specialities (non PC obviously) will no/never have access to?

If you lookat money ina vacuum and just your salary and not the "benefits" then certain specialities may preclude your interest. However, if you sit down and REALLY look at it, it is not bad at all.

Either way you are making 2-10 times more than your typical patient....at a minimum.

 

[DropkickMurphy]

How is money an issue--A REAL issue, when you have loan payback programs that the other specialities (non PC obviously) will no/never have access to?

If you lookat money ina vacuum and just your salary and not the "benefits" then certain specialities may preclude your interest. However, if you sit down and REALLY look at it, it is not bad at all.

Either way you are making 2-10 times more than your typical patient....at a minimum.

It's not so much a matter of the amount you're making in regards to debt, but being paid commensurate with the level of bull**** you have to put up with and the drudgery of the job you're being asked to do.

 

[TheCybermen]

It would also help if primary care wasn't so dull.......

there isn't a great deal, at least as i see it, of opportunity for research in primary care, whether it be basic science/translational research or healthcare outcomes research. this may not be true at all, but to many the research facet(s) of primary care require more digging and are not immediately perceived as a consequence.

ultimately, any job has the potential to get dull after 18 - 24 months, no matter how exciting at the outset. the challenge (and ultimately what makes a job more than just a job) is to find a way to circumvent this, and it usually involves a daily commitment to seeking out new bounty -- i.e., how are you going to combat seeing the same patients year after year, telling them: sleep more, exercise more, eat healthy, stop smoking...? many physicians answer this by playing a more active role in research, sitting on scientific or healthcare advisory boards, contributing to or serving on peer review/editorial staff of healthcare journals, etc.

that then, seems to be part of the trouble with primary care. many doctors these days want more than patient-physician relationships, and that's really all that primary care seems to provide, at least on the surface.

 

[Law2Doc]

If the lifestyle/hours improved along with the money, it probably would attract more people.

Agree with this - what has been hit harder than the money (which has declined about 10% over the past decade) is the hours you need to work to earn that income. Many primary care docs are finding they have to work substantially longer hours for the same money they earned just a few years back, and are facing an enormous amount of paperwork these days. Such is the nature of a reimbursement driven business. When you combine low end salary with long hours, it ceases to be a lot of people's first choice. That and the fact that it is perhaps not as intellectually stimulating as some of the high tech specialties, and not as hands on as some of the surgical/procedural specialties. But as med schools increase their class size and residency slots have not been increased correspondingly, you are going to see a whole lot more US med students getting pushed into primary care in the near future (bumping out some of the offshore crowd).

 

[sirus_virus]

This is exactly what is wrong with the american system. Primary care is supposed to be the anchor of the entire system, but nobody(including myself) really likes primary care anymore. It will also help if they payed primary care physicians good money.

 

[jsnuka]

It's not so much a matter of the amount you're making in regards to debt, but being paid commensurate with the level of bull**** you have to put up with and the drudgery of the job you're being asked to do.

That begs the question of are you becoming a doctor for yourself or to help people?

EVERY job has some "drudgery and Bulls**t" that comes with the territory.

 

[sirus_virus]

That begs the question of are you becoming a doctor for yourself or to help people?

EVERY job has some "drudgery and Bulls**t" that comes with the territory.

I don't know about dropkick, but I am doing it for myself. If I help someone in the process then great.

 

[Law2Doc]

That begs the question of are you becoming a doctor for yourself or to help people?

Ideally you do both. Only on SDN is such a question either or.

 

[jsnuka]

I don't know about dropkick, but I am doing it for myself. If I help someone in the process then great.

Gee, that sounds like a pretty good interview answer.

I bet that one never came out in an interview or will come out.

 

[sirus_virus]

Ideally you do both. Only on SDN is such a question either or.

The wise one has spoken.

 

[spicedmanna]

This is exactly what is wrong with the american system. Primary care is supposed to be the anchor of the entire system, but nobody(including myself) really likes primary care anymore. It will also help if they payed primary care physicians good money.

Yup, I agree. Although I do want to become a PCP, I think a lot of people hold your opinion. Heck, who am I fooling? I wouldn't mind making more money, if it were available. It's not my primary motivating factor, but it certainly would be nice on top of everything else.

 

[lilnoelle]

That begs the question of are you becoming a doctor for yourself or to help people?

EVERY job has some "drudgery and Bulls**t" that comes with the territory.

But one does not realize the amount of drudgery and BS until one gets into a inner city clinic/ER. Yes, one could potentially realize this with shadowing/volunteer work, but you don't realize the amount of sacrifice and work required in med school until you are in the midst of it and then, when your working in the clinic, etc, you think "I'm working this hard for this long to do THIS? And on top of that, I'm gonna be paid how much, work how many hours, and be in how much debt when I graduate? Forget it."

 

[jsnuka]

Ideally you do both. Only on SDN is such a question either or.

I get what you are saying, but I see it as you choose a career, a profession, a vocation because you TRULY LOVE IT. The fact that you get paid to do it is a nice side benefit.

 

[sirus_virus]

Gee, that sounds like a pretty good interview answer.

I bet that one never came out in an interview or will come out.

Why would I say something like that in an interview. Especially since I was competing with guys like you who already donated a kidney to a somalian orphan.

 

[DropkickMurphy]

Ideally you do both. Only on SDN is such a question either or.

Thank you....you kept me from having to point that out.

 

[zimmie256]

Gee, that sounds like a pretty good interview answer.

I bet that one never came out in an interview or will come out.

Definitely came out in my interviews (that led to acceptances), albeit not phrased as the previous poster did. When asked why medicine I talked about lots of areas of the field that appealed to me that I thought I would enjoy or be good at that were not directly related to 'helping others'.

You don't need to shovel as much bs during interviews as you think you do...

Ultimately it is your career, not your patients'. So you need to find a job that will make you happy and fit in with your life goals. If for you that's helping people, then awesome, but it's not the only answer. And in the end you need to choose your career based on what is best for yourself.

 

[DropkickMurphy]

Why would I say something like that in an interview. Especially since I was competing with guys like you who already donated a kidney to a somalian orphan.

"So Mr. Murphy what have you done to take care of poor Africans?"
"I started an organization to spay and neuter a whole frickin' mess of them."

 

[jsnuka]

But one does not realize the amount of drudgery and BS until one gets into a inner city clinic/ER. Yes, one could potentially realize this with shadowing/volunteer work, but you don't realize the amount of sacrifice and work required in med school until you are in the midst of it and then, when your working in the clinic, etc, you think "I'm working this hard for this long to do THIS? And on top of that, I'm gonna be paid how much, work how many hours, and be in how much debt when I graduate? Forget it."

Once again, I say LOAN REPAYMENT PROGRAMS.

I mean, hey, if you are dead set against PC b/c of its inferiority to other specialities (in some circles) or the pay issue or the fact that you may not be the people person you thought you were, then so be it.

There are numerous opportunities for people in PC and someone has to fill them.

 

[OncoCaP]

there isn't a great deal, at least as i see it, of opportunity for research in primary care, whether it be basic science/translational research or healthcare outcomes research. this may not be true at all, but to many the research facet(s) of primary care require more digging and are not immediately perceived as a consequence.

ultimately, any job has the potential to get dull after 18 - 24 months, no matter how exciting at the outset. the challenge (and ultimately what makes a job more than just a job) is to find a way to circumvent this, and it usually involves a daily commitment to seeking out new bounty -- i.e., how are you going to combat seeing the same patients year after year, telling them: sleep more, exercise more, eat healthy, stop smoking...? many physicians answer this by playing a more active role in research, sitting on scientific or healthcare advisory boards, contributing to or serving on peer review/editorial staff of healthcare journals, etc.

that then, seems to be part of the trouble with primary care. many doctors these days want more than patient-physician relationships, and that's really all that primary care seems to provide, at least on the surface.

One of my interviewers at UNT TCOM was doing FP research, and he had a very active research program (he was a young guy as well). I dare say he was one of the sharpest people I spoke with in all of my interviews at Texas schools and he had absolutely no lack of work. He knew quite a few heart medications (at least as far as a pre-med can tell -- not exactly an expert, I know), including their retail prices. When he developed a treament plan, he not only considered what was effective based on clinical studies but also factored in cost of the medications as a critical component of compliance. A lot of serious issues (obesity, heart disease, etc.) have primary care components and from what I could tell, there are research dollars available for that.

On the flip side, I know there are FP's who have gone bankrupt because of a combination of factors, such as unwise EHR software purchases ($120K+) and trying to increase their patient base by accepting more Medicaid and Medicaid patients (most FP physicians I have spoken to have a cap of ~25% of patients they will accept from those programs). It seems to me that Primary Care physicians need to be particularly sensitive to the business side of their practice, at least compared to other specialities that have greater compensation and thus a bit more room for error.

 

[sirus_virus]

Once again, I say LOAN REPAYMENT PROGRAMS.

I mean, hey, if you are dead set against PC b/c of its inferiority to other specialities (in some circles) or the pay issue or the fact that you may not be the people person you thought you were, then so be it.

There are numerous opportunities for people in PC and someone has to fill them.

Yes, and that is where you come into play.

 

[Law2Doc]

You don't need to shovel as much bs during interviews as you think you do...

Agree. Adcoms can tell what's BS and you get no points for giving insincere lip service. Honesty about your interests and goals tends to get you into med school more.

 

[TheCybermen]

One of my interviewers at UNT TCOM was doing FP research, and he had a very active research program (he was a young guy as well). I dare say he was one of the sharpest people I spoke with in all of my interviews at Texas schools and he had absolutely no lack of work. He knew pretty much every heart medication (at least as far as pre-med can tell), including its price. When he developed a treament plan, he not only considered what was effective based on clinical studies but also factored in cost of the medications as a critical component of compliance. A lot of serious issues (obesity, heart disease, etc.) have primary care components and from what I could tell, there are research dollars available for that.

i'm so glad you could actually attest to this -- and i'm sure everyone on this thread is grateful as well. i mean this is clinical investigatorship at its finest, and there's ample opportunity for it in FP. it's a stereotype -- and a common one -- that this kind of opportunity is limited and the demands of one's clinical/fiscal responsibilities preclude clinical investigation. thx, oncocap.

 

[jsnuka]

Sure, it is insincere if you have absolutely no track record to back it up.

Helen Keller can see and hear that.

 

[spicedmanna]

Even though I want to be a PCP, please do not let me become like one of the FP's I shadowed. The guy looked like if he saw another "generalized" sniffle, gave another flu shot, or indulged another person asking to be prescribed something he saw on TV, he'd run into the street screaming like a madman. Yes, there are minuses, folks; plenty of minuses. That's why it's hard to choose what you want to do until you try it.

 

[lilnoelle]

Once again, I say LOAN REPAYMENT PROGRAMS.

I mean, hey, if you are dead set against PC b/c of its inferiority to other specialities (in some circles) or the pay issue or the fact that you may not be the people person you thought you were, then so be it.

There are numerous opportunities for people in PC and someone has to fill them.

And I had one until recently. But in order to get the good ones, you have to make a commitment before attending med school. Thats not exactly a wise decision to make because you might change your mind.

So I thought "I'll cancel it, and make a commitment after residency" I sent some emails around, looked at various websites, and found numbers like $30K a year for underserved primary care. Because of circumstances, my loans will be large enough that $30K a year will cover little more than my interest. If I'm also making decent money in that underserved primary care field, its probably doable (30K plus putting in my own 30K a year will take care of my loans in around ten years). However, using my current program would leave me with less than $100K when I leave residency, is therefore a much better program to be involved in, but I'm not willing to take the risk that I will decide to do something other than primary care. (especially concerning my previous statement as to why I like other fields).

Financial reasons could never be my only reason for avoiding primary care. I'm used to living on ~50K with a hubby and two kids and feel quite comfortable at that level. No, financial reasons are not my reasons for avoiding primary care. I listed my main reason earlier.

 

[sirus_virus]

Just thought I'd throw this into the conversation. From my research on lifestyle specialties, I found that PCP could actually decide if they want a lifestyle schedule or not depending on how much they want to get payed. I can't tell you how many FMs I have bumped into recently working bank hours with huge vacations. If you are really set on working part-time as a doctor Primary care might be the route. It is not that easy to pull that off as a surgeon.

 

[jsnuka]

Even more to the point, let's look at it this way.

Some of you seem to be intimating that it makes good sense for Primary care to fail, b/c if that continues to happen there will be a need for more unnecessary surgeries (b/c the condition that caused it was not diagnosed earlier) and unfortunate deaths.

The backbone of secondary/tertiary care is the conituned failure of primary care. IF/WHEN primary care functions as it should and citizens have access, don't you think salaries for specialists will take a downturn too (not enough surgeries to go around)?

Is that right or am I taking what you guys/gals are saying the wrong way?

 

[lilnoelle]

Just tthought I'd throw this into the conversation. From my research on lifestyle specialties, I found that PCP could actually decide if they want a lifestyle schedule or not depending on how much they want to get payed. I can't tell you how many FMs I have bumped into recently working bank hours with huge vacations. If you are really set on working part-time as a doctor Primary care might be the route. It is not that easy to pull that off as a surgeon.

However, this is more likely if you are in a big city, and not in an underserved area. A rural practitioner is going to have a hard time being open only 9-5 four days a week and avoiding emergencies on weekends.

 

[Critical Mass]

There are numerous opportunities for people in PC and someone has to fill them.

This is why I wanted to go to PA school.

 

[jsnuka]

I am talking about LRPs after medical school.

 

[OncoCaP]

... I sent some emails around, looked at various websites, and found numbers like $30K a year for underserved primary care. ...
Financial reasons could never be my only reason for avoiding primary care. I'm used to living on ~50K with a hubby and two kids and feel quite comfortable at that level. No, financial reasons are not my reasons for avoiding primary care. I listed my main reason earlier.

Err ... $30K/yr for primary care?? That's 150% of the 2006 poverty level for a family of four. I'm not sure a lot of people would be willing to do that for very long ... I could only see foreign medical graduates taking this, and only long enough to meet their ?5 year? obligation.

That's certainly well below the average of ~$120K. I'm not too worried about pay, but $30K is below my threshold.