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

[TheCybermen]

It is not that easy to pull that off as a surgeon.

could you say then, perhaps, that this is true for more most hospitalists in general, given their requisite inpatient service rotations and on-call schedules?

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[spicedmanna]

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?

I think people are saying that it would be nice if PCP's got better compensation for their work. Others are saying they don't like the work.

 

[sirus_virus]

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?

You are very correct, that is why in socialized medical systems Primary care physicians are the big boys on campus(U.K comes to mind). Trust me when I say: you have not heard the last from primary care.

 

[lilnoelle]

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.

You misread me. Or I wasn't very clear. 30K a year loan repayment on top of whatever salary you bring in.

 

[jsnuka]

You misread me. Or I wasn't very clear. 30K a year loan repayment on top of whatever salary you bring in.

I understood that you meant $30K for the LRP, but there are many out there that do 35-45K. Again, depends upon where you want to be in the country, but it is POSSIBLE and they do exist.

 

[OncoCaP]

You misread me. Or I wasn't very clear. 30K a year loan repayment on top of whatever salary you bring in.

Whew, ok. Much better ... well, not great, but still better than just earning $30K/yr.

 

[sirus_virus]

could you say then, perhaps, that this is true for more most hospitalists in general, given their requisite inpatient service rotations and on-call schedules?

Yes. To add to that point my neigbour is a PCP and he has 3 hospitals/groups that he works with(at different points in the year). He gets payed about ~$70/hr plus his medmal insurance is covered by the hospital. He makes about 140K/yr for 40 hour weeks. Last year he went into stealth mode and worked ~60 hours a week and made almost 220K. You can do that in Primary care because they are not enough of them, not the case for some of the other specialties(surgery etc) where you are the last line of defense and they are counting on you to maintain a regular schedule.

 

[TheCybermen]

Last year he went into stealth mode

ahaha! this had me laughing -- very clever!

all that aside, great story and insight.

 

[lilnoelle]

I understood that you meant $30K for the LRP, but there are many out there that do 35-45K. Again, depends upon where you want to be in the country, but it is POSSIBLE and they do exist.

Where?

 

[jsnuka]

NIH, Alaska, American Indian Reservations, and other rural communities (and some urban ones).

I am sure once you get into a residency program, the opportunities will be more apparent to you.

I do not have access to my bookmarks at work. Do a search for them and they will pop up for you.

 

[Law2Doc]

Yes. To add to that point my neigbour is a PCP and he has 3 hospitals/groups that he works with(at different points in the year). He gets payed about ~$70/hr plus his medmal insurance is covered by the hospital. He makes about 140K/yr for 40 hour weeks. Last year he went into stealth mode and worked ~60 hours a week and made almost 220K. You can do that in Primary care because they are not enough of them, not the case for some of the other specialties(surgery etc) where you are the last line of defense and they are counting on you to maintain a regular schedule.

In a lot of the country primary care folks are going into that stealth mode (60+hrs/wk) just to get to the 140k.

 

[lilnoelle]

NIH, Alaska and other rural communities (and some urban ones).

I do not have access to my bookmarks at work. Do a search for them and they will pop up for you.

Maybe I just don't know where to look for this information, but how do you find it? I went through the NHSC website to various states and sent emails to the individual in charge. NIH only does $30k, and the states I checked that are in the midwest (where I grew up and where I go to med school) didn't exceed that amount. Iowa in particular says they only give something like 8 of these LRP out a year and it is limited to two years. I didn't want to send out 50 emails and figured the midwest would probably be one of the most generous because of the amount of shortage. I don't mind moving out of the midwest, though Alaska is probably a long shot.

 

[sirus_virus]

In a lot of the country primary care folks are going into that stealth mode (60+hrs/wk) just to get to the 140k.

That is true too, all you need is a whole buch of medicare patients and your show is over. BTW, pediatricians are now officially sitting below 100k/yr, so clearly some PCPs are scrapping the bottom of the barrel.

 

[sirus_virus]

The biggest threat to primary care is the mid-devils that are hell bent on getting autonomy to practice.

 

[zimmie256]

I think most of those programs offer you a salary on top of $20-30k annually towards loans, but perhaps I'm mistaken... It's been a few months since I looked into those programs.

 

[TheCybermen]

That is true too, all you need is a whole buch of medicare patients and your show is over.

...highlighting, of course, what some would argue is the real issue here.

 

[lilnoelle]

...highlighting, of course, what some would argue is the real issue here.

and one that will not likely improve since government is wanting to cut medicare expenses.

 

[8744]

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.

We admit something like 20 percent of our patients at our two emergency departments. It was rare, when I was in family practice, to "admit" a patient (by telling them to go to the ED, that is) and happened so infrequently that I remember the three times in one year that it happened to my patients. It may have elements of primary care but it's not primary care.

Not counting traumas and medical emergencies, even the run-of-the-mill patients are a lot sicker, a lot more demented, or a lot more drug-dependent than you would see in straight primary care.

I think people are discovering that Family Practice is not really a lifestyle specialty. Those mother ****ers work.

 

[8744]

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.

Primary care is over-rated. People who avail themselves of primary care generally don't need it and those who do wouldn't take advantage of it even if they had it, case in point our incredibly sick, incredibly comorbid patient population of GM employees up here who had access to incredible health insurance but are just as sick as their uninsured peers of a similar age and race.

It's a hoax. A myth. Or at least those researching it have had a defnite interest in showing how wonderful primary care is for everybody and have never looked at compliance, the most important factor.

My research project is going to show this (or not).

 

[OncoCaP]

...
I think people are discovering that Family Practice is not really a lifestyle specialty. Those mother ****ers work.

The article I read in the WSJ claims that those 4 patient / hour quotas (30 patients per day) are due in large part to the low reimbursement rates and high / inefficient overhead of ~60% (paper files all over the place, time-consuming paperwork procedures, etc.). If the reimbursements were higher and practices were run more efficiently, PCPs wouldn't need to work quite as hard, apparently.

 

[sirus_virus]

The article I read in the WSJ claims that those 4 patient / hour quotas (30 patients per day) are due in large part to the low reimbursement rates and high / inefficient overhead of ~60% (paper files all over the place, time-consuming paperwork procedures, etc.). If the reimbursements were higher and practices were run more efficiently, PCPs wouldn't need to work quite as hard, apparently.

You are now speaking my language.

 

[Towelie]

I think people are discovering that Family Practice is not really a lifestyle specialty. Those mother ****ers work.

FPs do have consistently very high job and life satisfaction. I wonder what that's all about. Self selection maybe?

 

[MChitty]

My parents are both IMs in private practice. The amount of staff needed to run a 2 physician office is about six people. This is because they have to do referrals, handle all the tests that are being run on their patients, have people at the front desk, plus they have hired a NP for days that one of them isn't in the office.

A specialist in the same position would have probably less than half of that staff because of the reduced amount of paperwork. Plus they get higher reimbursement rates.

When they entered the field 30 years ago, IM was the toughest residency to match with because usually the brightest students went into because you needed so much knowledge. Now that is not the case because of the lower pay and increased amount of paperwork. They're looking to switch to ERM, but it's expensive as well as not super user-friendly.

All I know is that my parents told me NOT to go to into PC because of all the reasons above, which is too bad because I think that would be what I was interested in.

 

[OncoCaP]

FPs do have consistently very high job and life satisfaction. I wonder what that's all about. Self selection maybe?

http://www.merritthawkins.com/pdf/MHA2006SurveyofPrimaryCarePhysicians.pdf
53% of PCP's are "dissappointed" with their net income.
30%-40% are "somewhat" or "very dissatisfied" with Primary Care overall
~30% would not choose to become a physician if they had to do it all over again.
~22-46% would choose a surgical or diagnostic specialty if they had to do it over again.
---> It looks like a large fraction of PCP's are not happy campers.

http://content.nejm.org/cgi/content/full/355/9/864
"Some have said that this decline reflects a lack of commitment among the current generation of trainees. I disagree. Medical students and residents are no less idealistic or dedicated today than they have been in the past. But the decrease in job satisfaction, the increase in educational debt (which now routinely exceeds $100,000), and the growing disparity in salary relative to other specialties could together create a strong sense that becoming a primary care physician may be a fool's errand. If the current problems of primary care practice are not addressed, the number of students and residents entering the field will undoubtedly continue to decline.

With all the changes in our health care system, one thing remains constant: the needs of patients. Patients want a continuing relationship with a doctor whom they trust, and they increasingly need that doctor to act as an advocate to help them get the best care within a fragmented health care system.4 A strong primary care infrastructure is associated with better health outcomes, lower costs, and a more equitable health care system, since primary care is key to providing services to vulnerable populations.5 There is an urgent need to reverse current trends. Although the line of students signing up for a career in primary care medicine is getting shorter, the line of patients in need of primary care doctors is getting longer every day.

Percent Change between 1998 and 2006 in the Percentage of U.S. Medical School Graduates Filling Residency Positions in Various Specialties.

Data are from the National Resident Matching Program.

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1468-0009.2005.00409.x
[5] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502. [CrossRef][ISI][Medline]

"Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

 

[sirus_virus]

http://www.merritthawkins.com/pdf/MHA2006SurveyofPrimaryCarePhysicians.pdf
53% of PCP's are "dissappointed" with their net income.
30%-40% are "somewhat" or "very dissatisfied" with Primary Care overall
~30% would not choose to become a physician if they had to do it all over again.
~22-46% would choose a surgical or diagnostic specialty if they had to do it over again.
---> It looks like a large fraction of PCP's are not happy campers.

http://content.nejm.org/cgi/content/full/355/9/864
"Some have said that this decline reflects a lack of commitment among the current generation of trainees. I disagree. Medical students and residents are no less idealistic or dedicated today than they have been in the past. But the decrease in job satisfaction, the increase in educational debt (which now routinely exceeds $100,000), and the growing disparity in salary relative to other specialties could together create a strong sense that becoming a primary care physician may be a fool's errand. If the current problems of primary care practice are not addressed, the number of students and residents entering the field will undoubtedly continue to decline.

With all the changes in our health care system, one thing remains constant: the needs of patients. Patients want a continuing relationship with a doctor whom they trust, and they increasingly need that doctor to act as an advocate to help them get the best care within a fragmented health care system.4 A strong primary care infrastructure is associated with better health outcomes, lower costs, and a more equitable health care system, since primary care is key to providing services to vulnerable populations.5 There is an urgent need to reverse current trends. Although the line of students signing up for a career in primary care medicine is getting shorter, the line of patients in need of primary care doctors is getting longer every day.

Percent Change between 1998 and 2006 in the Percentage of U.S. Medical School Graduates Filling Residency Positions in Various Specialties.

Data are from the National Resident Matching Program.

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1468-0009.2005.00409.x
[5] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502. [CrossRef][ISI][Medline]

"Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

So primary care is the solution to our healthcare crisis. Pay them more and problem is solved.

 

[OncoCaP]

So primary care is the solution to our healthcare crisis. Pay them more and problem is solved.

Increasing the amount of money going into healthcare is not exactly a popular solution. My guess is that mid-levels will become more of a factor. Maybe some PCPs will find certain niches that still pay well (cash-only practices, etc.). Mid-levels don't cost as much and they don't need to go through ~7 years of graduate education and post-graduate training to get a real paycheck.

 

[sirus_virus]

My guess is that mid-levels will become more of a factor. Mid-levels don't cost as much and they don't need to go through ~7 years of education to get a real paycheck.

Yeah but that is only under the premise that midlevels are well payed. the moment you stop bringing out the big bucks they will all disapear. BTW, midlevels choose that route because they like the lifestyle, so you could hire two 30hr/week midlevels for 70K each as opposed to one FP(better trained) for 60hrs/week at 150k, either way it's a wash. Also they are going to start getting sued anytime from now so there goes their zero overhead.

 

[OncoCaP]

Yeah but that is only under the premise that midlevels are well payed. the moment you stop bringing out the big bucks they will all disapear. BTW, midlevels choose that route because they like the lifestyle, so you could hire two 30hr/week midlevels for 70K each as opposed to one FP(better trained) for 60hrs/week at 150k, either way it's a wash. Also they are going to start getting sued anytime from now so there goes their zero overhead.

PC is not my first choice. If for whatever reason, this is what I wound up doing, here are the kinds of business tactics I would look into. I know that it's hard to provide great care if the business end is falling down and crashing. I would considering working my PAs more hours (60 hrs/wk?) and paying them more ($85K ?) and hire ~5-6 minimum over time. Maybe I would look into a couple of different offices with different philosophies. Maybe one would be more high-volume and another would be slower pace, cash-only or with lots of out-of-pocket-paid procedures.

I would work the mid-levels hard but treat them right. I would make the work environment with the workflow and responsibilities as good as possible, including user-friendly automation that reduces paperwork and potential for error as much as possible. Having some of them at grocery-store clinics sounds interesting (cash-only). I would immediately get rid of any that are making too many mistakes or doing sloppy work. I would seek to build the practice slowly if I had to rather than trying to grow too fast and make mistakes. I would try to make sure I had enough overlap so that if they have a family issue that comes up, one of them could leave or that you can cover sick-leave. Vacations and holidays are probably important benefits as well. I would only let them call in prescriptions to certain reputable pharmacies that you know check the prescriptions unless you check them over (I realize there is limited control here). You basically handle all the high-risk / complicated cases yourself and they handle all the colds, routine checkups. Don't give any refills on meds without a refill fee or office visit, which will bring in more dollars. Refer anything non-obvious or not routine to a specialist unless you can do it with low risk and high compensation. With a well-run business, you would stand the best chance of providing excellent care IMO.

 

[MJB]

In a lot of the country primary care folks are going into that stealth mode (60+hrs/wk) just to get to the 140k.

Can you tell us where? You seem to know, and I'd be interested.

 

[Law2Doc]

so you could hire two 30hr/week midlevels for 70K each as opposed to one FP(better trained) for 60hrs/week at 150k, either way it's a wash.

It doesn't really work that way because you have to carry insurance for both (which doesn't get halved just because the employee works part time), have to make various filings and pay various benefits to each, (as well as have state uninsurace/workers comp obligations based on # of employees and the like) and the learning curve on any training takes twice as long if they only work half the hours. Allowing professionals to work part time schedules always costs significantly more money to the employer than just having one employee, even if the hours are the same. Which is why in eg law, when people get a part time schedule it is often more like reducing hours from 60 hrs/wk to 45 hrs/wk but with a huge reduction in salary -- I suspect the economics in medicine is similar. For this reason, employers are often less amenable to allowing part time options, and as workloads increase (as they are doing in primary care) you are going to see fewer and fewer of these options.

 

[Law2Doc]

Can you tell us where? You seem to know, and I'd be interested.

In the last year or so there was a study referenced by the NY Times, Young Physician magazine etc indicating a significant decline in physician salaries over approximately the past decade. For primary care, the decline was about 10%, and for physicians overall it was 7%. There have also been numerous articles on the increase in hours of primary care docs in the face of reimbursements. For evidence of salaries below $140 in primary care, note the averages (meaning a lot of people earn less than this) for eg family practice or peds in the JAMA table of a few years ago, along with the average hours worked. http://www.medfriends.org/specialty_hours_worked.htm.

 

[MJB]

Thanks for the information.

It sounded like you might have some geographical data showing where the problem is worse than others. Is the biggest problem with PC salaries in metropolitan areas where people have more access to specialists, etc?

 

[Law2Doc]

Thanks for the information.

It sounded like you might have some geographical data showing where the problem is worse than others. Is the biggest problem with PC salaries in metropolitan areas where people have more access to specialists, etc?

The salaries are almost certainly different in different regions, but I've mostly seen anecdotal evidence of this. I suspect that the salaries in metropolital areas differ more because of higher overhead and the more prevalent types of healthcare payors (medicaid), rather than access to specialists.

 

[Darksmurf]

Bottom Line: Primary care is boring. Who want's runny noses? Besides, anything cool gets passed on to someone else.

 

[YupGypsy]

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.

so taking loans out of the equation, we should be satisfied with whatever we make? If the purpose of that huge paycheck is to pay back loans, why go through all the trouble in the first place? You can be happy with your puny pay since you get to do something you "truly love," but for the majority, they want decent compensation for the amount of work & crap that they've gone through. Please wake up, most people go after $$$making field (like medicine), and rarely are these fields interesting or fun.

I don't know how doctors are "making 10 times" what their patients make, but who cares, they didn't go through 10 years of training.

 

[YupGypsy]

http://www.merritthawkins.com/pdf/MHA2006SurveyofPrimaryCarePhysicians.pdf
53% of PCP's are "dissappointed" with their net income.
30%-40% are "somewhat" or "very dissatisfied" with Primary Care overall
~30% would not choose to become a physician if they had to do it all over again.
~22-46% would choose a surgical or diagnostic specialty if they had to do it over again.
---> It looks like a large fraction of PCP's are not happy campers.

http://content.nejm.org/cgi/content/full/355/9/864
"Some have said that this decline reflects a lack of commitment among the current generation of trainees. I disagree. Medical students and residents are no less idealistic or dedicated today than they have been in the past. But the decrease in job satisfaction, the increase in educational debt (which now routinely exceeds $100,000), and the growing disparity in salary relative to other specialties could together create a strong sense that becoming a primary care physician may be a fool's errand. If the current problems of primary care practice are not addressed, the number of students and residents entering the field will undoubtedly continue to decline.

With all the changes in our health care system, one thing remains constant: the needs of patients. Patients want a continuing relationship with a doctor whom they trust, and they increasingly need that doctor to act as an advocate to help them get the best care within a fragmented health care system.4 A strong primary care infrastructure is associated with better health outcomes, lower costs, and a more equitable health care system, since primary care is key to providing services to vulnerable populations.5 There is an urgent need to reverse current trends. Although the line of students signing up for a career in primary care medicine is getting shorter, the line of patients in need of primary care doctors is getting longer every day.

Percent Change between 1998 and 2006 in the Percentage of U.S. Medical School Graduates Filling Residency Positions in Various Specialties.

Data are from the National Resident Matching Program.

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1468-0009.2005.00409.x
[5] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502. [CrossRef][ISI][Medline]

"Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

That is my favorite graph. Let's hope radiology maintain its growth!

 

[JLT91W]

The main reasons I am avoiding Primary Care are:

"Can I get a work excuse?"

and

"My head hurts. When I blow my nose green stuff comes out. I have a sore throat." Hmmm.....let's see....what COULD that be? It's just too mundane for me.

 

[MJB]

Bottom Line: Primary care is boring. Who want's runny noses? Besides, anything cool gets passed on to someone else.

I honestly don't know what I want to do, but I'm not going to rule it out because it might be something I would enjoy.

The personality tests all tell me that Derms is where I need to be. I can't even imagine myself being a zit doctor.

 

[Law2Doc]

The personality tests all tell me that Derms is where I need to be. I can't even imagine myself being a zit doctor.

Just as well because odds are you won't have that opportunity. Only a small percentage of successful med students realistically get to consider that specialty.

 

[MJB]

Yep...I haven't even really researched how many spots are available in each of the various specialties because for all I know, things will change immensely in the next 4 years...and I haven't been through any rotations to really see what I like and don't like. I'm definitely keeping an open mind.