I’m hearing so many mixed things about primary care .. help

[Appellatelove]

I’m strongly leaning towards primary care for the flexibility and long term relationships. Talking to mentors it seems that the pay has increased recently. However, I find that either people think it’s the worst job in the world or the best job in the world. People either say the work 80 hour weeks with inbox messaging nonstop or that they are done promptly at 5pm and go to all their kids games, etc. What accounts for this difference? Is it the administration? MA support? Individual factors? How can one make sure they have a good primary care set up?

Thanks!

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[VA Hopeful Dr]

You have to find a place that values primary care, that realizes it has an important role in health care. Places like that are more likely to give you the tools you need to both do well and be happy.

You also have to build the practice you want. If you don't want patients to send you 800 portal messages a day, then don't deal with much over messages. I'll answer basic questions about existing issues/labs but I won't deal with new issues. If a message exchange takes more than a couple of messages from me, its time for an appointment. Streamline things, figure out when someone needs a follow up and give them enough medication to get to that appointment. That'll save you on endless refill requests. Don't spend too much time in the exam room, if you start that way then your patients will expect that. That doesn't mean to have 3 minute visits, but don't chit chat for 45 minutes.

 

[DrMetal]

It's a conundrum now in the 20th Century. The problem in primary care is that patients now don't listen to their doctors. The brazen disregard of a physician's advice is daunting. Was certainly not the case 50-, or even 30- years ago. I blame the internet and global warming.

People basically do WTF they want to do. And even worse, they go provider-shopping until they find one who agrees with their silly ways.

Wanna drink green tea for your blood pressure instead of taking your medications? Sure, go ahead (says the naturopath). Want to decline the COVID vaccine? Sure, go ahead.

I guess I shouldn't fret. It all makes for a very lucrative hospitalist gig when people show up to the ER with a BP of 225/110 and COVID+.

 

[Kaustikos]

It's a conundrum now in the 20th Century. The problem in primary care is that patients now don't listen to their doctors. The brazen disregard of a physician's advice is daunting. Was certainly not the case 50-, or even 30- years ago. I blame the internet and global warming.

People basically do WTF they want to do. And even worse, they go provider-shopping until they find one who agrees with their silly ways.

Wanna drink green tea for your blood pressure instead of taking your medications? Sure, go ahead (says the naturopath). Want to decline the COVID vaccine? Sure, go ahead.

I guess I shouldn't fret. It all makes for a very lucrative hospitalist gig when people show up to the ER with a BP of 225/110 and COVID+.

Wanna get a PICC line and get lifelong suppressive therapy with Doxycycline for Chronic Lyme Disease?

 

[bronx43]

It's a conundrum now in the 20th Century. The problem in primary care is that patients now don't listen to their doctors. The brazen disregard of a physician's advice is daunting. Was certainly not the case 50-, or even 30- years ago. I blame the internet and global warming.

Wait, hold up. Global warming? Do elaborate.

 

[NewYorkDoctors]

do not be a primary care physician for a large health system . The administrators and an ICU nurse will make more than you.

On the other hand primary care can be extremely lucrative and rewarding if you open your own practice and you are the boss and all revenues goes through you

 

[VA Hopeful Dr]

do not be a primary care physician for a large health system . The administrators and an ICU nurse will make more than you.

On the other hand primary care can be extremely lucrative and rewarding if you open your own practice and you are the boss and all revenues goes through you

That's not even close to true. I'm an FP in a large health system and I make great money for my field.

 

[DrMetal]

do not be a primary care physician for a large health system . The administrators and an ICU nurse will make more than you.

On the other hand primary care can be extremely lucrative and rewarding if you open your own practice and you are the boss and all revenues goes through you

I don't think money is an issue here. you can make money if you want to. I'd be more concerned about job satisfaction.

The other problem I have with primary outpatient care (I do some, I'm 90% hospitalist, 10% outpatient, forced by the DoD) is the low acuity nature of it all. I didn't go to medical school to take care of benign Msk complaints and fill out FMLA paperwork. And those who are really sick and need to be seen don't come in enough, you'll see them in the ER though.

 

[voxveritatisetlucis]

I don't think money is an issue here. you can make money if you want to. I'd be more concerned about job satisfaction.

The other problem I have with primary outpatient care (I do some, I'm 90% hospitalist, 10% outpatient, forced by the DoD) is the low acuity nature of it all. I didn't go to medical school to take care of benign Msk complaints and fill out FMLA paperwork. And those who are really sick and need to be seen don't come in enough, you'll see them in the ER though.

In your opinion, what is a good alternative/compromise. Meaning for somebody who wants something high acuity but wants something that is also roughly the same difficulty to match

Is being a hospitalist more exciting/stimulating than outpatient work?

 

[NewYorkDoctors]

That's not even close to true. I'm an FP in a large health system and I make great money for my field.

Are you making $1M plus like some of the 99213 PCP mills I’ve seen in the NY metro area ?

NYC tends to be somewhat oversaturated to some extent . There are local factors in play . I will add the caveat of everything I wrote but add in “in nyc .”

Things could be different elsewhere . 99213 mills probably can’t exist the same way as they do in a large city

 

[DrMetal]

Is being a hospitalist more exciting/stimulating than outpatient work?

In my opinion, yes. But hospitology comes with its fair share of problems too. It can be the opposite end of the spectrum; the patients are so far gone, it quickly seems pointless. Still though, at least you know they're really sick.

 

[VA Hopeful Dr]

Are you making $1M plus like some of the 99213 PCP mills I’ve seen in the NY metro area ?

NYC tends to be somewhat oversaturated to some extent . There are local factors in play . I will add the caveat of everything I wrote but add in “in nyc .”

Things could be different elsewhere . 99213 mills probably can’t exist the same way as they do in a large city

No but I'm a good doctor.

 

[VA Hopeful Dr]

I don't think money is an issue here. you can make money if you want to. I'd be more concerned about job satisfaction.

The other problem I have with primary outpatient care (I do some, I'm 90% hospitalist, 10% outpatient, forced by the DoD) is the low acuity nature of it all. I didn't go to medical school to take care of benign Msk complaints and fill out FMLA paperwork. And those who are really sick and need to be seen don't come in enough, you'll see them in the ER though.

There's a big IM group here that has NPs for all of their acute stuff. The doctors do all the chronic disease management and keep a full schedule of just that.

And staff should be doing 99% of your forms.

 

[Appellatelove]

There's a big IM group here that has NPs for all of their acute stuff. The doctors do all the chronic disease management and keep a full schedule of just that.

And staff should be doing 99% of your forms.

What is your schedule like? Do you spend lots of hours at home catching up on paperwork?

 

[VA Hopeful Dr]

What is your schedule like? Do you spend lots of hours at home catching up on paperwork?

First patient at 8am, last at 4pm. Half day Wednesday. I take a 90 minute lunch break (11:45 patient and 1:30 patient). I rarely leave after 4:30. I generally do a little work in the morning before my kids get up (usually about 15 minutes or so) but that's purely to let me leave work earlier. If I did zero work at home I might have to occasionally stay until 5pm and I'd rather not do that.

I take around 6 weeks off per year give or take a few days.

 

[Appellatelove]

First patient at 8am, last at 4pm. Half day Wednesday. I take a 90 minute lunch break (11:45 patient and 1:30 patient). I rarely leave after 4:30. I generally do a little work in the morning before my kids get up (usually about 15 minutes or so) but that's purely to let me leave work earlier. If I did zero work at home I might have to occasionally stay until 5pm and I'd rather not do that.

I take around 6 weeks off per year give or take a few days.

What factors allow for this? Should I focus my job search on a supportive administration? Insist on MA support?? I’d really like that type of set up but I’ve spoken to some people who have found this type of work -life unsustainable in primary care. Also are you academic? Is academic better?

 

[VA Hopeful Dr]

What factors allow for this? Should I focus my job search on a supportive administration? Insist on MA support?? I’d really like that type of set up but I’ve spoken to some people who have found this type of work -life unsustainable in primary care. Also are you academic? Is academic better?

Hospital employed in the south east. My first post in this thread details some ideas that can help.

 

[tylerb1800]

Primary care is really whatever you want to make it. You have to shape your clinic and your patient panel to how you want it. You also have to set expectations with patients and stick with those. I am a hospital employ but the clinic is run like private practice with full autonomy over scheduling, visit length, choosing staff, dismissals, etc. My wRVU bonus as well as quality bonuses are good. I am happy with what I take home. I am home between 4:45 and 5pm and I do not do any work at the house. If paperwork needs completing, then the patient schedules a visit to complete it. All messages (phone or EMR messages) go through my staff. I see less than 10% of the messages as my staff is able to handle vast majority of it.

 

[bronx43]

Are you making $1M plus like some of the 99213 PCP mills I’ve seen in the NY metro area ?

NYC tends to be somewhat oversaturated to some extent . There are local factors in play . I will add the caveat of everything I wrote but add in “in nyc .”

Things could be different elsewhere . 99213 mills probably can’t exist the same way as they do in a large city

A million? That’s like 100 patients per day. That’s only possible if a practice has been established for decades. No young doc is going to be able to establish in a metro area and have that volume.

 

[Kaustikos]

A million? That’s like 100 patients per day. That’s only possible if a practice has been established for decades. No young doc is going to be able to establish in a metro area and have that volume.

Alternatively, you can do what some of the shady hospitalists in NYC do and work at multiple hospitals and try not to get noticed.
Like one of my Attendings doing night call at two separate hospitals.
NYC has some shady practices and they'll brag about the money but it's....disgusting.

 

[VA Hopeful Dr]

A million? That’s like 100 patients per day. That’s only possible if a practice has been established for decades. No young doc is going to be able to establish in a metro area and have that volume.

Or have lots of ancillary stuff going on. One of the private groups here in town has a contract their patients sign agreeing to a yearly physical which if you're over 40 involves a yearly stress test. 800 stress tests per year can make you decent money.

 

[bronx43]

Or have lots of ancillary stuff going on. One of the private groups here in town has a contract their patients sign agreeing to a yearly physical which if you're over 40 involves a yearly stress test. 800 stress tests per year can make you decent money.

How do they get insurers to pay for it? Stress test for 40 yo without symptoms would be denied.

 

[VA Hopeful Dr]

How do they get insurers to pay for it? Stress test for 40 yo without symptoms would be denied.

Patient pays if insurance doesn't cover it, but there's always ways to get it covered.

 

[NotAProgDirector]

If said contract is in writing and you can get a copy of it, you can retire on the whistleblower payout.

Honestly, if you bring it to CMS's attention even without a written contract and the ETT rate is >90%, they will probably be fined.

 

[VA Hopeful Dr]

If said contract is in writing and you can get a copy of it, you can retire on the whistleblower payout.

Honestly, if you bring it to CMS's attention even without a written contract and the ETT rate is >90%, they will probably be fined.

It's vaguely worded enough that I doubt that would work. Basically it's "you have to have a yearly wellness exam which includes the tests your doctor thinks are needed".

Given that a Medicare quality measure is the AWV and lots of preventative testing, not sure you could really use over that.

 

[InternistDO]

I’m strongly leaning towards primary care for the flexibility and long term relationships. Talking to mentors it seems that the pay has increased recently. However, I find that either people think it’s the worst job in the world or the best job in the world. People either say the work 80 hour weeks with inbox messaging nonstop or that they are done promptly at 5pm and go to all their kids games, etc. What accounts for this difference? Is it the administration? MA support? Individual factors? How can one make sure they have a good primary care set up?

Thanks!

Primary care is a pretty diverse field. There are PCP jobs that expect you to see 30 patients a day and some that expect 15-20. There are PCP jobs where you're supposed to refer any "real problem" to a specialist and others where you're supposed to manage almost everything yourself. There are practices where the doctors room their own patients and practices where each physician has two MAs and an RN to do all the rooming, care coordination, paperwork, phone triage, etc.

From what I've seen, the best predictors for a good primary care job are reasonable patient volumes (somewhat dependent on how complex your panel is--if you see mostly young patients and are doing physicals, gyn/birth control and sick visits you can see a lot of patients, impoverished older patients in an inner city neighborhood you have to see less), good support staff who do rooming, prior auths/paperwork and are trained to help you with procedures, and enough higher up support so you have some back up for abusive patients and inappropriate use of patient portal messages and don't get bent over the altar of patient satisfaction whenever someone complains.

I think another issue is that lots of people who do primary care, and medicine in general, have a genuine desire to help people. This can lead to things like checking your inbox at 7pm at night and trying to diagnose a patient over the phone before clinic starts so they don't have to come in for a visit. I'm not saying you shouldn't sometimes go above and beyond for your patients, but if you do it all the time you'll find yourself working 80 hours a week even with a perfect practice set up, and that's a one way ticket to Burn Out Island.

 

[DrMetal]

I think another issue is that lots of people who do primary care, and medicine in general, have a genuine desire to help people.

I think we all have a desire to help people (no matter what your specialty choice and structure). The problem is: people rarely want to help themselves.

 

[Kaustikos]

I think another issue is that lots of people who do primary care, and medicine in general, have a genuine desire to help people. This can lead to things like checking your inbox at 7pm at night and trying to diagnose a patient over the phone before clinic starts so they don't have to come in for a visit. I'm not saying you shouldn't sometimes go above and beyond for your patients, but if you do it all the time you'll find yourself working 80 hours a week even with a perfect practice set up, and that's a one way ticket to Burn Out Island.

Eww. Just eww. I only do this when I'm on call but even then I don't mess around and tell the patient to go to the ED usually. I agree you'll burn out but you're also putting yourself at risk of making mistakes.
*shudders*

 

[collegestud2013]

I’m strongly leaning towards primary care for the flexibility and long term relationships. Talking to mentors it seems that the pay has increased recently. However, I find that either people think it’s the worst job in the world or the best job in the world. People either say the work 80 hour weeks with inbox messaging nonstop or that they are done promptly at 5pm and go to all their kids games, etc. What accounts for this difference? Is it the administration? MA support? Individual factors? How can one make sure they have a good primary care set up?

Thanks!

It seems like those who are most satisfied with doing long-term primary care are those who have established their own practices or are part of a physician owned practice. In these settings you have much more control over your workload and staffing and resources. It's often even a better setup for those doing cash-based concierge primary care as they can avoid dealing with a lot the insurance/billing headaches, and charge a market price for their services rather than what insurance sets (and in many cases make the same or more while seeing less patients).

The high burnout tends to be more for those in employed positions, especially for large health systems where pay is low for the volume you are expected to see (and it's not easy to scale back on your volume unless you quit your job and go somewhere else), and you have to deal with a lot of insurance hurdles, or maybe the place is poorly staffed and all the work falls on you.

 

[voxveritatisetlucis]

It seems like those who are most satisfied with doing long-term primary care are those who have established their own practices or are part of a physician owned practice. In these settings you have much more control over your workload and staffing and resources. It's often even a better setup for those doing cash-based concierge primary care as they can avoid dealing with a lot the insurance/billing headaches, and charge a market price for their services rather than what insurance sets (and in many cases make the same or more while seeing less patients).

The high burnout tends to be more for those in employed positions, especially for large health systems where pay is low for the volume you are expected to see (and it's not easy to scale back on your volume unless you quit your job and go somewhere else), and you have to deal with a lot of insurance hurdles, or maybe the place is poorly staffed and all the work falls on you.

How much cash upfront does one need to get equity in these physician owned places?

 

[grt398]

It seems like those who are most satisfied with doing long-term primary care are those who have established their own practices or are part of a physician owned practice. In these settings you have much more control over your workload and staffing and resources. It's often even a better setup for those doing cash-based concierge primary care as they can avoid dealing with a lot the insurance/billing headaches, and charge a market price for their services rather than what insurance sets (and in many cases make the same or more while seeing less patients).

The high burnout tends to be more for those in employed positions, especially for large health systems where pay is low for the volume you are expected to see (and it's not easy to scale back on your volume unless you quit your job and go somewhere else), and you have to deal with a lot of insurance hurdles, or maybe the place is poorly staffed and all the work falls on you.

I hope a lot of what you've said here becomes more of an option over time, particularly in setting up small cash-based primary care. One of the biggest aspects that drove me away from doing clinic in any specialty was the volume of patients you are expected to see. I enjoy my current field, but if my life circumstances changed/I just got tired of full time CC work as I get older, I could certainly see myself being happy having a small clinic/patient panel where I saw 8-10 patients/day, spent as much time as I thought was needed with each patient, and only documented the things in my notes that I thought was relevant. And no dealing with insurance companies in any form, for any reason. I'd be fine earning less doing so. I've always thought more docs would consider this route if it was an option and many of us weren't so burdened with insane levels of debt and starting our careers in the early-to-mid 30s.

 

[VA Hopeful Dr]

I hope a lot of what you've said here becomes more of an option over time, particularly in setting up small cash-based primary care. One of the biggest aspects that drove me away from doing clinic in any specialty was the volume of patients you are expected to see. I enjoy my current field, but if my life circumstances changed/I just got tired of full time CC work as I get older, I could certainly see myself being happy having a small clinic/patient panel where I saw 8-10 patients/day, spent as much time as I thought was needed with each patient, and only documented the things in my notes that I thought was relevant. And no dealing with insurance companies in any form, for any reason. I'd be fine earning less doing so. I've always thought more docs would consider this route if it was an option and many of us weren't so burdened with insane levels of debt and starting our careers in the early-to-mid 30s.

I've done the 8-10 patients per day. It is mind numbingly boring.

 

[tylerb1800]

I've done the 8-10 patients per day. It is mind numbingly boring.

I agree. 8 to 10 in a half day is fine but I could not do a full day with this few of patients

 

[grt398]

I've done the 8-10 patients per day. It is mind numbingly boring.

For the type of clinic I'm thinking about, it's equally the lifestyle/change stuff I'd want to focus on, so more time is required. I don't know what the interest really would be but based on patient responses from my resident clinic, I think it could work. I can see probably 15ish pts/day now doing normal primary care stuff. Sitting down with someone to go over their average dietary intake after having them keep a food diary for a week, and talking about why some choices are better than others, understanding what their day-to-day life is like and the stressors that make it difficult for them to live a healthier lifestyle, maybe prior experiences that led to where they are now, aka all the motivational stuff, and then seeing how we can translate that into a different path going forward...that all takes time. But I'm also one of the only CC fellows I know who genuinely enjoys palliative care just as much as CC and if I wasn't so completely fed up with being a trainee right now, would do a palliative fellowship. I also would gladly staff a post-ICU clinic if such things became more popular.

 

[collegestud2013]

I hope a lot of what you've said here becomes more of an option over time, particularly in setting up small cash-based primary care. One of the biggest aspects that drove me away from doing clinic in any specialty was the volume of patients you are expected to see. I enjoy my current field, but if my life circumstances changed/I just got tired of full time CC work as I get older, I could certainly see myself being happy having a small clinic/patient panel where I saw 8-10 patients/day, spent as much time as I thought was needed with each patient, and only documented the things in my notes that I thought was relevant. And no dealing with insurance companies in any form, for any reason. I'd be fine earning less doing so. I've always thought more docs would consider this route if it was an option and many of us weren't so burdened with insane levels of debt and starting our careers in the early-to-mid 30s.

I've only seen 8-10 patients per day be financially viable in private practice in a cash-based set up. The percentage of the patient population willing to pay cash for primary care services is still pretty small and tends to be mostly upper middle professionals and anyone else wealthier than that (who want a concierge type experience), and a majority of them reside in big cities (where there's already a lot of competition from other providers, both PP and large health systems). Most newer practices will probably have to rely on some mix of insurance patients and cash patients at first.

Even with primary care reimbursements improving somewhat in recent years, for someone only taking mostly commercial insurance and some Medicare, the patient volumes need to be financially sustainable are closer 20 per day. Also with large student debt burden these days it's hard for most new grads to get the upfront cash needed to start their own practice right out of residency.

 

[NonNocere]

I’m strongly leaning towards primary care for the flexibility and long term relationships. Talking to mentors it seems that the pay has increased recently. However, I find that either people think it’s the worst job in the world or the best job in the world. People either say the work 80 hour weeks with inbox messaging nonstop or that they are done promptly at 5pm and go to all their kids games, etc. What accounts for this difference? Is it the administration? MA support? Individual factors? How can one make sure they have a good primary care set up?

Thanks!

Your profile says you are a medical student. Why don't you do some shadowing and/or rotations in primary care. It varies greatly from doctor to doctor.

 

[Appellatelove]

Your profile says you are a medical student. Why don't you do some shadowing and/or rotations in primary care. It varies greatly from doctor to doctor.

I’m a resident! Need to change that.

 

[NITRAS]

First patient at 8am, last at 4pm. Half day Wednesday. I take a 90 minute lunch break (11:45 patient and 1:30 patient). I rarely leave after 4:30. I generally do a little work in the morning before my kids get up (usually about 15 minutes or so) but that's purely to let me leave work earlier. If I did zero work at home I might have to occasionally stay until 5pm and I'd rather not do that.

I take around 6 weeks off per year give or take a few days.

I feel like you should have a dot phrase or a sticky. (I know this is an older post, but this question comes up a lot).

Some times I regret not doing something with clinic with repeat customers that I want to see. I really enjoy hospital medicine, but the aggravation of dealing with stupid doctors/NP’s/PA’s/RN’s and patients can drive me up the wall. The 90 hour weeks don’t always help.

 

[NonNocere]

I’m a resident! Need to change that.

Oh, ok, cool. I think it has a lot to do with the individuals involved and the practice settings, as you mentioned in your first post.

 

[Kaustikos]

I feel like you should have a dot phrase or a sticky. (I know this is an older post, but this question comes up a lot).

Some times I regret not doing something with clinic with repeat customers that I want to see. I really enjoy hospital medicine, but the aggravation of dealing with stupid doctors/NP’s/PA’s/RN’s and patients can drive me up the wall. The 90 hour weeks don’t always help.

I mainly prefer hospital because clinic involves lazy patients showing late. Or people trying to show up same day. Or unnecessary consults I can't reject.
Granted, my nurses have gotten smarter and reached out to me before scheduling referrals.


Wait... Shoot. This isn't about consults.

Whatever. I wrote this