Internal medicine-primary care

[sunshinefl]

I originally came to medical school with internal medicine—>primary care as my number one interest, and so far (wrapping up 2nd year) I have cemented that more than ever. (Rheumatology and Infectious disease round up the top 3).

It is where my heart lies, but I also have concerns about compensation, mid-levels, potential future of the field, etc. (This is not a troll post and I don’t want it to turn political or DO vs PA/NP). I’m just hoping to hear thoughts from others who have a similar interest, like to use this as a sounding board for each other.

Sometimes you can work through your own thoughts better by engaging with others, and sometimes you even gain a new perspective directly from them.

tldr; sincere interest in IM PCP but concerned about future demand and compensation.

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[Dr. Death]

IM PCP is one field where future demand and compensation are fairly low concerns. There will always need to be physicians taking care of hospitalized patients. Mid-levels are increasingly being used to manage the run of the mill patients (uncomplicated CHF exacerbations, for example), but the higher complexity patients need to be managed by physicians

 

[IntheClouds4ever]

:eye roll:

Infectious disease is one of the lowest paid specialties. So you’re list of desired specialties are generally all “low paying”, but low paying is a relative term. If you are wanting to do rural PCP, you’ll be making far more than you think. employed physicians in rural areas are paid well and have the options of working as little or as much as they want (compensation goes down for less work, obviously) plus you have options for picking up hospitalist and ER shifts, as well as doing medical director positions for nursing homes, etc, to increase your revenue streams. If you are wanting to stay in a large metro area, then you should be aware that you are swimming upstream as a pcp as far as options and variability in your practice.

Also, in your third year, you will see the vast disparity in education/knowledge when it comes to DO/MD and PA/NP. People like to speculate that the sky is falling, but you’ll soon realize there isn’t a comparison and that you are irreplaceable, even as a pcp. This questions came up on an early interview I had this week. “How do you feel about NPs/PAs?” — even those in the C-suite know they need both and need team players from both sides.

 

[sunshinefl]

:eye roll:

Infectious disease is one of the lowest paid specialties. So you’re list of desired specialties are generally all “low paying”, but low paying is a relative term. If you are wanting to do rural PCP, you’ll be making far more than you think. employed physicians in rural areas are paid well and have the options of working as little or as much as they want (compensation goes down for less work, obviously) plus you have options for picking up hospitalist and ER shifts, as well as doing medical director positions for nursing homes, etc, to increase your revenue streams. If you are wanting to stay in a large metro area, then you should be aware that you are swimming upstream as a pcp as far as options and variability in your practice.

Why the eye roll? Yes I am aware they are among the lowest paying, hence the concern. But my interests are what they are.

I don’t want to be rural, but I also don’t want to be in NYC/Miami/SoCal. I’m looking to stay in Florida—think Gainesville, Jacksonville and surrounding area, Tampa and surrounding area, Orlando and surrounding area, Sarasota, Fort Myers. That type of location.

 

[IntheClouds4ever]

Why the eye roll? Yes I am aware they are among the lowest paying, hence the concern. But my interests are what they are.

I don’t want to be rural, but I also don’t want to be in NYC/Miami/SoCal. I’m looking to stay in Florida—think Gainesville, Jacksonville and surrounding area, Tampa and surrounding area, Orlando and surrounding area, Sarasota, Fort Myers. That type of location.

Because it’s beating a dead horse. If you aren’t rural, you need to say if you are going to be employed, do a traditional practice, or new DPC model. Compensation/security/benefits vary drastically between each one and there isn’t a one size fits all answer. If you arent going to specialize, you might be better off doing family as you will be able to treat kids which can help to quickly increase the size of your practice early on when building one. For chronic management, there isn’t much difference at all between a general IM and FM doc.

“The only poor, struggling doctors are the ones who can’t manage finances.” — you’ll be making plenty of money to live a good lifestyle no matter the speciality

 

[libertyyne]

One thing is for certain. The future is uncertain.

Who knows what compensation will look like for any subset of physicians or specialties going forward, it could all change overnight.

So make your decision based on the information you have now.

Is the work enjoyable?
Does the compensation seem fair?
Do you have enough flexibility you desire?
Is the job Market good enough?
Is the work life balance good ?

 

[BorntobeDO?]

I originally came to medical school with internal medicine—>primary care as my number one interest, and so far (wrapping up 2nd year) I have cemented that more than ever. (Rheumatology and Infectious disease round up the top 3).

It is where my heart lies, but I also have concerns about compensation, mid-levels, potential future of the field, etc. (This is not a troll post and I don’t want it to turn political or DO vs PA/NP). I’m just hoping to hear thoughts from others who have a similar interest, like to use this as a sounding board for each other.

Sometimes you can work through your own thoughts better by engaging with others, and sometimes you even gain a new perspective directly from them.

tldr; sincere interest in IM PCP but concerned about future demand and compensation.

Rhuem is very protective, I don't see midlevels as a real threat there. ID has a terrible job market, and I often run into ID docs who just end up working as hospitalists anyway.

I do believe that the job market will be better for general IM than FM in the probably somewhat distant future. Hospitals have a big incentive to move patients in and out. Midlevels are great for getting people in, but they suck at getting them better and out. My buddy (who is FM) decided to work as a hospitalist and when his hospital hired him and another fresh FM grad to take over their service their Length of Stay went from 4.5 days with the prior NPs to barely over 3 days with physicians. Thats a huge improvement, and it was with fresh FM (not even IM) grads. So I believe hospitals know that physicians are indeed, worth it for inpatient services. And since IM has such a heavy focus on hospital medicine, I think this clearly favors them (although you will be fine with just FM for the next 15 years IMO).

Right now the market is hotter in general for FM, but I hate how almost every non-FM physician I talk too seems to think midlevels are the future of outpatient primary care. They all agree that NP's and PA's aren't as good as FM, but they just don't think it matters. Its this kind of apathy that is the biggest challenge. When I already hear doctors talking about 'in the future you will have to see an NP before you ever see a physician.' I find it very disheartening.

But just based on current demands, FM is the place to be. I just don't think it will be in about 10-15 years. But thats so far away, you can pretty much ignore it and do what you want. Personally I just do not want an Anesthesia situation, where I all do is supervise midlevels and lose all patient contact.

 

[QueenJames]

Rhuem is very protective, I don't see midlevels as a real threat there. ID has a terrible job market, and I often run into ID docs who just end up working as hospitalists anyway.

I do believe that the job market will be better for general IM than FM in the probably somewhat distant future. Hospitals have a big incentive to move patients in and out. Midlevels are great for getting people in, but they suck at getting them better and out. My buddy (who is FM) decided to work as a hospitalist and when his hospital hired him and another fresh FM grad to take over their service their Length of Stay went from 4.5 days with the prior NPs to barely over 3 days with physicians. Thats a huge improvement, and it was with fresh FM (not even IM) grads. So I believe hospitals know that physicians are indeed worth it for inpatient services. And since IM has such a heavy focus on hospital medicine, I think this clearly favors them (although you will be fine with just FM for the next 15 years IMO).

Right now the market is hotter in general for FM, but I hate how almost every non-FM physician I talk too seems to think midlevels are the future of outpatient primary care. They all agree that NP's and PA's aren't as good as FM, but they just don't think it matters. Its this kind of apathy that is the biggest challenge. When I already hear doctors talking about 'in the future you will have to see an NP before you ever see a physician.' I find it very disheartening. But just based on current demands, FM is the place to be. I just don't think it will be in about 10-15 years. But thats so far away, you can pretty much ignore it and do what you want. Personally I just do not want an Anesthesia situation, where I all do is supervise midlevels and lose all patient contact.

None of that will matter when we start the 50th DO program and sucker more clueless pre-meds into the process.

MUAHAH!

 

[BorntobeDO?]

None of that will matter when we start the 50th DO program and sucker more clueless pre-meds into the process.

MUAHAH!

We are already over 50, I think we will probably be the 70th by the time we get up and running 🙂. Got to fulfill that primary care shortage.

 

[Neopolymath]

Rhuem is very protective, I don't see midlevels as a real threat there. ID has a terrible job market, and I often run into ID docs who just end up working as hospitalists anyway.

I do believe that the job market will be better for general IM than FM in the probably somewhat distant future. Hospitals have a big incentive to move patients in and out. Midlevels are great for getting people in, but they suck at getting them better and out. My buddy (who is FM) decided to work as a hospitalist and when his hospital hired him and another fresh FM grad to take over their service their Length of Stay went from 4.5 days with the prior NPs to barely over 3 days with physicians. Thats a huge improvement, and it was with fresh FM (not even IM) grads. So I believe hospitals know that physicians are indeed, worth it for inpatient services. And since IM has such a heavy focus on hospital medicine, I think this clearly favors them (although you will be fine with just FM for the next 15 years IMO).

Right now the market is hotter in general for FM, but I hate how almost every non-FM physician I talk too seems to think midlevels are the future of outpatient primary care. They all agree that NP's and PA's aren't as good as FM, but they just don't think it matters. Its this kind of apathy that is the biggest challenge. When I already hear doctors talking about 'in the future you will have to see an NP before you ever see a physician.' I find it very disheartening.

But just based on current demands, FM is the place to be. I just don't think it will be in about 10-15 years. But thats so far away, you can pretty much ignore it and do what you want. Personally I just do not want an Anesthesia situation, where I all do is supervise midlevels and lose all patient contact.

I think Rheum is probably the safest job of those being discussed from both an encroachment and financial angle. As everyone knows on SDN, midlevels are not flocking to work in Surburban areas with people like rheum docs (they want surgery/derm in the city like everyone else despite their national orgs saying they are filling the rural deficit LOL). Compensation certainly isn't going to go down in any of these specialties listed. That seems certain. Politically, rheumatology provides a very safe space for gifted physicians. People either don't want to deal with those patients because they can be both socially and medically challenging and the treatments are still emerging/are an art given how individualized the decisions are. ***I'm not saying we don't need FM docs etc*** but politically the first people who will get shafted if anyone does is going to be PCPs. Everyone still views Rheum as experts who you send your people to when you have no idea wtf is going on with a weird presentation. They are busy with outpatient and inpatient consultations and don't have the chance to get taken out of the loop so to speak. It is a safe spot when both bad NPs and great PCPs refer their patients to you.


As for OP, and people are probably going to disagree, but a lot of this decision making depends on your debt and financial goals. You will never be hungry as a physician, but you have to adjust your plans if you got 400k debt and become a pediatrician in the city.

 

[BorntobeDO?]

I think Rheum is probably the safest job of those being discussed from both an encroachment and financial angle. As everyone knows on SDN, midlevels are not flocking to work in Surburban areas with people like rheum docs (they want surgery/derm in the city like everyone else despite their national orgs saying they are filling the rural deficit LOL). Compensation certainly isn't going to go down in any of these specialties listed. That seems certain. Politically, rheumatology provides a very safe space for gifted physicians. People either don't want to deal with those patients because they can be both socially and medically challenging and the treatments are still emerging/are an art given how individualized the decisions are. ***I'm not saying we don't need FM docs etc*** but politically the first people who will get shafted if anyone does is going to be PCPs. Everyone still views Rheum as experts who you send your people to when you have no idea wtf is going on with a weird presentation. They are busy with outpatient and inpatient consultations and don't have the chance to get taken out of the loop so to speak.

Rhuem is a very challenging field for a midlevel to go into, as is something like Endocrine (but midlevels are more willing to try some here). If you have no clue what your doing in Rhuem it will come out much faster IMO than outpatient primary care where you can just refer everything. Plus with all the new complex treatments coming out, Rhuem is an interesting and growing field. They really do immunology, which you would think would be A&I, but its not. The science background alone makes Rhuem intimidating for NP/PA.

I agree that the patient population isn't what a NP really wants to see also.

 

[Neopolymath]

Rhuem is a very challenging field for a midlevel to go into, as is something like Endocrine (but midlevels are more willing to try some here). If you have no clue what your doing in Rhuem it will come out much faster IMO than outpatient primary care where you can just refer everything. Plus with all the new complex treatments coming out, Rhuem is an interesting and growing field. They really do immunology, which you would think would be A&I, but its not. The science background alone makes Rhuem intimidating for NP/PA.

I agree that the patient population isn't what a NP really wants to see also.

The patient and the system would be even more in debt if midlevels did rheum given all the expensive tests you can do now that probably don't even change the management of the patient. I feel like at some point insurance companies/hospital systems would notice this too.

 

[BorntobeDO?]

The patient and the system would be even more in debt if midlevels did rheum given all the expensive tests you can do now that probably don't even change the management of the patient. I feel like at some point insurance companies/hospital systems would notice this too.

Agree, I think most mid-levels aren't very aware that Rhuem exists either, cause it has minimal inpatient presence.

 

[AMEHigh]

As a primary care doctor you will always be able to find a job so that shouldn’t be a worry.

The sky is not falling in regards to midlevels. The jobs for doctors will be there.

No one can predict compensation, but my gut tells me that PCPs aren’t going to go from making 200k to 100k overnight.

Lastly another pro for being IM (or FM) trained is you really have the option of working many many many places since you get broad training. If it comes down to it and you want a different job but want to stay in the medical field you can work at a college/student health, urgent care, private employer (like I know companies like amazon have doctors), non-profit organizations, etc. If you’re a super specialized doctor those options likely aren’t as available to you if need be.

 

[Dr.Bruh]

Just look at the MedScape physician compensation report. Physician salary has risen every single year for the past decade including primary care. It’s not going down despite what people say and their anecdotes.

 

[deleted407021]

Just look at the MedScape physician compensation report. Physician salary has risen every single year for the past decade including primary care. It’s not going down despite what people say and their anecdotes.

If anecdotes have been anything to go by, it seems that reported salary averages are often lower than what people are realistically making.

 

[SLC]

IM primary care is safe, no midlevel can ever replace a properly trained physician in that realm. The knowledge gap is staggering, there’s no way around it.

And folks who say that the knowledge gap doesn’t matter in a primary care setting don’t know what it takes to do primary care well.

In today’s medical climate, where primary care is moving toward value based/capitated payment strategies, a good primary care doc is indespensible. We can keep patients out of the hospital much better than any midlevel provider, and less admissions/better managed patient panel means more $$$ in the system we’re moving toward.

Finally, make a commitment to yourself today that you just won’t supervise midlevels, we as doctors hold the key to their ability to even practice; and if we don’t give it to them then we have nothing to worry about in terms of encroachment.

 

[sunshinefl]

Thank you for everyone’s discussion so far.

Personally I just do not want an Anesthesia situation, where I all do is supervise midlevels and lose all patient contact.

Exactly!! This is my biggest fear. I want direct patient relationships. If somehow the whole field became about supervising midlevels, I would honestly regret just not having become a midlevel.

Finally, make a commitment to yourself today that you just won’t supervise midlevels, we as doctors hold the key to their ability to even practice; and if we don’t give it to them then we have nothing to worry about in terms of encroachment.

Yes, and I have been following your thread about it.

 

[siliso]

Who knows what the future holds, for anyone. I can tell you for now that the job market is just fine. There aren’t enough physicians who want to do primary care - thus the NPs just to keep the waits from being months long to see a doc. The people are only getting older thanks to us, there’s no shortage of work or job offers or headhunters. Compensation is plenty satisfactory to me in combination with high job satisfaction - I guess it depends what you want and where you want to be, and it’s the part that I think is most crystal-ball unrealistic to predict not just for IM primary care but any field in medicine. I do mostly outpatient (and love being a PCP, it turns out) and also some inpatient, and teach, so I figure I’m still adaptable to what change may come while being satisfied now.

 

[QueenJames]

IM primary care is safe, no midlevel can ever replace a properly trained physician in that realm. The knowledge gap is staggering, there’s no way around it.

And folks who say that the knowledge gap doesn’t matter in a primary care setting don’t know what it takes to do primary care well.

In today’s medical climate, where primary care is moving toward value based/capitated payment strategies, a good primary care doc is indespensible. We can keep patients out of the hospital much better than any midlevel provider, and less admissions/better managed patient panel means more $$$ in the system we’re moving toward.

Finally, make a commitment to yourself today that you just won’t supervise midlevels, we as doctors hold the key to their ability to even practice; and if we don’t give it to them then we have nothing to worry about in terms of encroachment.

I plan on NEVER getting involved or signing any contract that involves supervising ANY PA or midlevel.

 

[Sardonix]

I plan on NEVER getting involved or signing any contract that involves supervising ANY PA or midlevel.

The good old boys and girls over on the FM forum know what's up.

 

[Ho0v-man]

Mid levels aren’t clamoring to take over primary care. They’re trying to take over higher paying specialties. Right now, they really seem to fight for the jobs where they do things like consults for GI so the GI doc can just scope all day. Or assist in the OR and handle admissions so you he doc can keep grinding in the OR. Honestly, they’re much better suited for handling <5 things for a specialist than they ever would be for outpatient primary care. The only reason they can even function in this role independently is because if they don’t do it right the results aren’t usually acutely apparent. Handling a complex IM subspecialty is a non starter. And the pay isn’t there for them to really try anyway.