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I am trying to get some opinions on this topic without creating a flame war. I am a medical student interested in primary care. I am concerned however about Obama's support for increasing the number of privately functioning NP's. I know Oregon allows NP's to practice seperately from MD's/DO's. Do you guys think this trend will continue? It worries me because I see this trend as having the potential to drive primary care salaries down and at the very least keep them constant.

My thoughts on future scenarios are as follows. Obama's plan: Increase primary care salaries by 8% (maybe a pay increase of 10k a year, maybe?). Decrease specialist (ie Radiologist) salaries by 15% ( a drop of perhaps 100k per year) thus decreasing the average physician salary on average. Increase the number of training programs in NP, PA, FP and IM. The new FP/IM spots will go primarily to foreign grads. (as you could fill 3000+ spots in primary care residency programs with foreign grads if you wanted to). The supply of NP's PA's FP's IM's increases as a whole, thus filling the demand and hence limiting the pay increase to primary care, ie primary care will never be making 250k+ salaries in the long run. (of course i am talking about the starting salaries that you get hired into and not Dr. X who is entrepreneurial enough to make 500k+ off his business model bc this isnt the avg Physician).

I thus think that Obama is "pretending" to favor primary care docs but creating a rift between physicians to decrease the avg salaries of all docs and simultaneously sticking it to GP physicians by increasing competition from NP/PA's that could function privately, thus increasing supply and stagnating pay increases to primary care in the long term.

Ok, that was really long, but what are your thoughts on this? 20 years from now will it still be much better (financially speaking) to be a specialist?

I mean sometimes I feel insulted that starting salaries in primary care in cities are 100k-140k (7 yrs education post bac; goes up to 200k) PA's make 90-120k (2 yrs education; goes up to 160k), CRNA's make 120k-180k (2 yrs education; goes up to 300k+) and our fellow docs start at 200-500k+ ( (8-11 yrs education; goes up to 250k-800k+). Why does society value us so poorly? The politicians say they want primary care and value PCP's but where is the proof? An 8%/7k increase in salaries (half of which goes for taxes)????? Are you kidding me???? No wonder no US grad wants to go into primary care. I suppose it doesnt matter bc you can fill the demand with IMG's.

As future PCP's can we do anything to change this? Should we move to Canada or GB? Or maybe all start concierge practices?

I sacrificed a lot to be where I am and will be 160k+ in debt. This figure will grow in residency. I feel like society doesnt respect us at all. We get ridiculed by nurses, PA's, NP's and even our own physicians and patients. (i'm venting). I've had surgeons stop teaching me in the OR after I tell them I want to do general IM or FM?! Our own collegues! Peds, OB and IM attendings referring to FP residents as "there's the stupid FP resident." There's only so much you can take. And you know what, the sad thing is that it is all about dollars and cents. If we made 300k+ a year, people wouldnt be calling us "stupid GP".

I love primary care (particularly FP) and the interaction with patients/breath of practice, but i've had residency faculty members tell me not to do FM/IM bc they are so unhappy. The starting salary in my city is 90-110k for FM. My PA friends are making more than this 2+ years out. They are done paying their student loans, stable careers in big cities, moving on with their lives. We get nothing for our extra time/sacrifice/responsibility (and exposure to getting sued). Oh wait, Obama gave us an 8%/7k increase in salaries?!?:laugh::confused:

Honestly, someone should stick this post on CNBC or MSNBC. People would probably just write it off as another "greedy doctor."

At least stop sueing us or cap litigation? (oh wait, Pres. Obama doesnt want to do that, not to trial lawyers (their value to society is equal to the bankers/financial institutions who got 700 billion dollars)).

20 yrs from now there will be VERY FEW US trained PCP's. But I suppose it doesnt matter bc IMG's, NP's and PA's will fill in the gaps. (until the IMG's realize its better to be a PCP in GB/Canada and incorporate.)

Maybe the new trend will be to make 2/3 year med schools with 2/3 year residencies to be a PCP (as has already started). Or maybe the 5 years of training that a PCP does over his PA/NP collegues is a waste. After all, it only takes 2 years to master the pathophysiology of the complex interactions taking place in multiorgan disease. ( sarcasm intended).

Being complacent and "sitting back and watching change happen" is why we are in this mess. GP's need to get more active in politics. PA's/NP's are very active and very aggressive, and hence, for better or worse, their practice privledges are increasing.

The question is will our fellow physician specialists help us? If not, what is the point of even being part of the AMA. United we stand, divided we fall. Do we need a seperate body to support GP's outside of the AMA? Is that what it will come to? If 'yes' is the answer, then physicians, GP's and specialists, have already lost on a political front.

For specialists who do not want to support the plight of the GP....maybe your opinions will change when NP's start opening CME clinics on colonoscopies, injections etc. Guess what, it doesnt take an Albert Einstein to do a lot of the procedures that specialists rake it in with. My last statement is that once you allow another political body to train in your field and do what you do for a living, they will continue to proliferate and grab turf until they are your equal. Currently DO's are the equivalent of MD's and are governed by a seperate licensing body that is allowed to create schools and residency programs. We work together and that is great. Perhaps it is time that our governing bodies stopped bickering on who is better/more prestigious, and joined together to create a unified governing council of Physicians that regulate who is allowed to practice medicine. Maybe one day allopathic docs can train at osteopathic residency programs as osteopaths can train at allopathic programs. Imagine that? If you want to learn OMM, you would be able to! And bill for it!!

Or our communities, MD's and DO's, specialists and generalists can squabble amongst ourselves and watch NP's create the AANP with one year residency programs in outpatient GI (scopes), Cards (EKG's/stress tests), Pain (injections), Cosmetics, Anesthesia (oh wait, CRNA's already exist...their first residency program!!) etc. Their argument might be that you dont need a physician to do simple procedures. Physicians are only needed for interpretations and more complex, hospital based procedures or to handle complications.
 
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Jamers

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I am trying to get some opinions on this topic without creating a flame war. I am a medical student interested in primary care. I am concerned however about Obama's support for increasing the number of privately functioning NP's. I know Oregon allows NP's to practice seperately from MD's/DO's. Do you guys think this trend will continue? It worries me because I see this trend as having the potential to drive primary care salaries down and at the very least keep them constant.

My thoughts on future scenarios are as follows. Obama's plan: Increase primary care salaries by 8% (maybe a pay increase of 10k a year, maybe?). Decrease specialist (ie Radiologist) salaries by 15% ( a drop of perhaps 100k per year) thus decreasing the average physician salary on average. Increase the number of training programs in NP, PA, FP and IM. The new FP/IM spots will go primarily to foreign grads. (as you could fill 3000+ spots in primary care residency programs with foreign grads if you wanted to). The supply of NP's PA's FP's IM's increases as a whole, thus filling the demand and hence limiting the pay increase to primary care, ie primary care will never be making 250k+ salaries in the long run. (of course i am talking about the starting salaries that you get hired into and not Dr. X who is entrepreneurial enough to make 500k+ off his business model bc this isnt the avg Physician).

I thus think that Obama is "pretending" to favor primary care docs but creating a rift between physicians to decrease the avg salaries of all docs and simultaneously sticking it to GP physicians by increasing competition from NP/PA's that could function privately, thus increasing supply and stagnating pay increases to primary care in the long term.

Ok, that was really long, but what are your thoughts on this? 20 years from now will it still be much better (financially speaking) to be a specialist?

I mean sometimes I feel insulted that starting salaries in primary care in cities are 100k-140k (7 yrs education post bac; goes up to 200k) PA's make 90-120k (2 yrs education; goes up to 160k), CRNA's make 120k-180k (2 yrs education; goes up to 300k+) and our fellow docs start at 200-500k+ ( (8-11 yrs education; goes up to 250k-800k+). Why does society value us so poorly? The politicians say they want primary care and value PCP's but where is the proof? An 8%/7k increase in salaries (half of which goes for taxes)????? Are you kidding me???? No wonder no US grad wants to go into primary care. I suppose it doesnt matter bc you can fill the demand with IMG's.

As future PCP's can we do anything to change this? Should we move to Canada or GB? Or maybe all start concierge practices?

I sacrificed a lot to be where I am and will be 160k+ in debt. This figure will grow in residency. I feel like society doesnt respect us at all. We get ridiculed by nurses, PA's, NP's and even our own physicians and patients. (i'm venting). I've had surgeons stop teaching me in the OR after I tell them I want to do general IM or FM?! Our own collegues! Peds, OB and IM attendings referring to FP residents as "there's the stupid FP resident." There's only so much you can take. And you know what, the sad thing is that it is all about dollars and cents. If we made 300k+ a year, people wouldnt be calling us "stupid GP".

I love primary care (particularly FP) and the interaction with patients/breath of practice, but i've had residency faculty members tell me not to do FM/IM bc they are so unhappy. The starting salary in my city is 90-110k for FM. My PA friends are making more than this 2+ years out. They are done paying their student loans, stable careers in big cities, moving on with their lives. We get nothing for our extra time/sacrifice/responsibility (and exposure to getting sued). Oh wait, Obama gave us an 8%/7k increase in salaries?!?:laugh::confused:

Honestly, someone should stick this post on CNBC or MSNBC. People would probably just write it off as another "greedy doctor."

At least stop sueing us or cap litigation? (oh wait, Pres. Obama doesnt want to do that, not to trial lawyers (their value to society is equal to the bankers/financial institutions who got 700 billion dollars)).

20 yrs from now there will be VERY FEW US trained PCP's. But I suppose it doesnt matter bc IMG's, NP's and PA's will fill in the gaps. (until the IMG's realize its better to be a PCP in GB/Canada and incorporate.)

Maybe the new trend will be to make 2/3 year med schools with 2/3 year residencies to be a PCP (as has already started). Or maybe the 5 years of training that a PCP does over his PA/NP collegues is a waste. After all, it only takes 2 years to master the pathophysiology of the complex interactions taking place in multiorgan disease. ( sarcasm intended).

Being complacent and "sitting back and watching change happen" is why we are in this mess. GP's need to get more active in politics. PA's/NP's are very active and very aggressive, and hence, for better or worse, their practice privledges are increasing.

The question is will our fellow physician specialists help us? If not, what is the point of even being part of the AMA. United we stand, divided we fall. Do we need a seperate body to support GP's outside of the AMA? Is that what it will come to? If 'yes' is the answer, then physicians, GP's and specialists, have already lost on a political front.

For specialists who do not want to support the plight of the GP....maybe your opinions will change when NP's start opening CME clinics on colonoscopies, injections etc. Guess what, it doesnt take an Albert Einstein to do a lot of the procedures that specialists rake it in with. My last statement is that once you allow another political body to train in your field and do what you do for a living, they will continue to proliferate and grab turf until they are your equal. Currently DO's are the equivalent of MD's and are governed by a seperate licensing body that is allowed to create schools and residency programs. We work together and that is great. Perhaps it is time that our governing bodies stopped bickering on who is better/more prestigious, and joined together to create a unified governing council of Physicians that regulate who is allowed to practice medicine. Maybe one day allopathic docs can train at osteopathic residency programs as osteopaths can train at allopathic programs. Imagine that? If you want to learn OMM, you would be able to! And bill for it!!

Or our communities, MD's and DO's, specialists and generalists can squabble amongst ourselves and watch NP's create the AANP with one year residency programs in outpatient GI (scopes), Cards (EKG's/stress tests), Pain (injections), Cosmetics, Anesthesia (oh wait, CRNA's already exist...their first residency program!!) etc. Their argument might be that you dont need a physician to do simple procedures. Physicians are only needed for interpretations and more complex, hospital based procedures or to handle complications.

Your numbers aren't too far off but, here is the median physician wage by specialty from the department of labor if you are curious: http://www.bls.gov/oco/ocos074.htm

Personally, 150K a year (even if you estimate half going to taxes, so 75K a year or around 6K a month) is A LOT of money to me. I think my dad (after 35 years of working 70 hours a week with the same company) maxed out at $2,500.00 a month; you could, in essence, make 2.5x his wage in a fraction of the time and retain the chance to make more as time went by! But, is it enough?

No, I think the PCPs of our nation do a lot of work and deserve to be paid for it. Hell, 60% of the GPs over in Great Britain (http://www.dailymail.co.uk/news/article-468874/Rise-250-000-GP-half-figure-salaries.html) (I know ewww socialism...wait it isn't really socialism but I need to say that to appeal to the Fox news watchers) are making over 200K a year; yes, there are factors such as a higher cost of living, ect. but it still puts some perspective on things.

As for DNPs wanting to practice on their own without physician supervision and only a fraction of the education/training, I see only disaster. Sure, there are some really intelligent people who go into these fields who I could see making excellent clinical decisions but...what about the rest? Sadly, the people making these decisions are doing so based solely on the fact that 1) we have a shortage and 2)DNPs can fill this shortage for less cost. To reverse this trend its either going to take some strong lobbying by physicians, increases in primary care reimbursement and/or some of these DNPs killing a lot of patients. If you want to see your own patients then suck it up, take the MCATs and get into a medical school.
 
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Aug 6, 2009
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The funny thing is it will probably be disgruntled MD/DO's providing the training for NP colonoscopy clinics and residencies for midlevels. Lol. And who can blame them if the physician network isnt going to stick up for them.

Your arguments make sense. The system is flawed in the end. They pay for procedures but not for thinking/management of complex problems.

I see your point to an extent. I mean, you could probably train a lot of people with less education than MD/DO's to adequately perform procedures in a safe way. And if your arguments stand, NP/PA's that are proficient in performing the procedures should be able to and bill for them. However, the point stands that students would not be entering medical school if there was not a light at the end of the tunnel or cookie for all that hard work. MD: 4yrs grad schl + 3-7 yrs residency. PA/NP: 2 yrs post residency. First off, there is no point to being an MD/DO if your pay is the same as a PA/NP. You could argue that it is about helping people, but PA/NP's help people just as much. Why would anyone go through an MD/DO prgm. But the fact remains that in order to manage multisytem diseases, you need more training than 2 yrs post bac. Much more training. In fact, after residency the training isnt over as physicians continue to learn into their careers. Because our decisions equate to life and death and wellbeing. We carry a HUGE RESPONSIBILITY on our shoulders that NP/PA's carry as well, but not to the extent we do. We also carry HUGE LIABILITY. You want the brightest and hardest working students to enter MD/DO schools because they are the best to shoulder that responsiblity. If you do not have a 'cookie' at the long and arduous journey it takes to be a physician (particularly in the case of PCP's, who essentially have no 'cookie' over being a PA/NP or going to business or law school) you will not attract the brightest/hardest working students and h.care quality will decrease.

There are very few people who are willing to sacrifice the lifestyle of a physician for no financial rewards. We would have no docs.

So, some things need to change. If what your saying is write, allow PA/NP's to do what they can do well. They can do simple office visits/colonoscopies, injections, catheters, etc. But these things should then be reimbursed MUCH LESS than the THINKING parts of the job that involve and M.D./D.O.'s 3-7 years of extra training. But see, the specialists are now crying in rage bc the easy money is gone. GI's wont be raking in 400-800k a year with this philosophy. Neither will the fields of Cards, Pain etc where PROCEDURES PAY, NOT THINKING.

Lets face it, in the REAL WORLD, THE WORLD WE LIVE IN, it is all about TURF. YOU HAVE TO PROTECT YOUR TURF AND PHYSICIANS ARE HORRIBLE AT IT. Dentists have done a great job at this. You dont see midlevels in that field performing the job that dentists do, even though, many like yourself could argue that if they can be trained to do the job, they should be able to do it.

There are educational systems set up do be and function as an MD/DO. If you want to perform the job duties of a medical practitioner, compete for these programs and get in and be a physician. What NP/PA's are doing are side stepping the educational competition that impedes them from making physician salaries by setting up their own systems and residency programs. They want money, and I dont blame them bc so do I and so does everyone else in the real world. We are programmed that way, genetically. Even that kid in Africa you are talking about would sell a blood diamond for cash. MONEY MAKES THE WORLD GO ROUND.

The fact of the matter is this. If you arent paying PCP docs enough, they will be justifiably unhappy. If specialists dont support/respect PCP's they will be justifiably unhappy. You can be as arrogant as you want but realize the arrogance just divides the physician community. This is the arrogance that will lead future PCP's to set up training programs in procedures for NP/PA's (bc they will get paid an extra 100k a year to do so) and ultimately lead to the decline in salaries of specialists and physicians as a whole. This will lead to a decline in US students enrolling in medical school. This will lead to a decrease in the avg GPA/MCAT of students. This will lead to lower quality US trained docs. IMG's wont look to the US as an attractive option. Now we get the first tier IMG's. If salaries in primary care stay as they are or decline and Canada/GB salaries increase as they are, we will get third tier IMG's. The primary care health provided to Americans will decrease as a whole as a result of these changes.

The best solution: either start paying for the THINKING aspects of medicine (which shows a respect for the education and training it takes to be a MD/DO) OR keep the same procedure based reimbursement schemata you have going today and start paying PCP's 100k+ more than their PA/NP counterparts ( 200-250k+ starting , not the 90-140k+ of today).
 
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