Seeking Honest Advice from Practicing Primary-Care Docs

[BeLikeBueller]

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I'm a 3rd year pharmacy student very interested in attending medical school and practicing as a primary care physician.

I have a fair amount of debt that I have accumulated from pharmacy school and I know that I will accumulate significantly more if I attend medical school. I don't want to boil this decision down to finances, but from a realistic point of view, that plays a huge role in the picture that I'm looking at here.

In your opinion, is this a reasonable path to take in the current climate of uncertainty that seems to be surrounding the healthcare system, particularly with regards to primary care and payment reform?



I appreciate your thoughts - I'm sure a lot of people probably come to this forum with similar questions. I would post this in the pre-medical or the medical student forum, but I fear what I would get is simply a lot of speculation.

 

[VA Hopeful Dr]

I'm a 3rd year pharmacy student very interested in attending medical school and practicing as a primary care physician.

I have a fair amount of debt that I have accumulated from pharmacy school and I know that I will accumulate significantly more if I attend medical school. I don't want to boil this decision down to finances, but from a realistic point of view, that plays a huge role in the picture that I'm looking at here.

In your opinion, is this a reasonable path to take in the current climate of uncertainty that seems to be surrounding the healthcare system, particularly with regards to primary care and payment reform?



I appreciate your thoughts - I'm sure a lot of people probably come to this forum with similar questions. I would post this in the pre-medical or the medical student forum, but I fear what I would get is simply a lot of speculation.

A residency classmate of mine graduated with right at 400k of debt. He's doing pretty well from what I hear.

It also can help with you get loan repayment as part of a contract/rural work.

 

[deleted87716]

I've never met a primary care physician who couldn't pay back their loans.

That being said, the only thing certain about the future is that nothing is certain. We certainly have far less to lose than most other specialties, and a lot more to gain.

 

[BeLikeBueller]

A residency classmate of mine graduated with right at 400k of debt. He's doing pretty well from what I hear.

It also can help with you get loan repayment as part of a contract/rural work.

That makes me feel a lot better about my situation. I'm definitely thinking about rural practice, so I'm investigating all of those potential avenues, but it seems like a lot of states are starting to do away with the incentive programs that used to exist.



@Blue Dog - I guess it's not so much that I am worried that I won't ever be able to pay off my loans, I'm just concerned that they'll be a significant, long-term burden. Hopefully I could get out and be aggressive with loan repayment, but like you said, who knows what the future holds.


I think my heart really lies with primary care. I know everyone says that can change once you're actually in school, but with the perspective I have in pharmacy, primary care is where I feel like I would be the happiest and where I feel like I could make the greatest difference.

My biggest thing is that I don't want to get into medical school and feel like I need to match into a "more lucrative" specialty in order to have reasonable financial stability. That being said, from the two posts above, it sounds like I'm probably over-thinking things and worrying a bit too much, so I appreciate the input.

 

[brats800]

The thing to remember is that if you choose primary care with a lot of loans you may limit the location / type of jobs you could afford. If you are open to what you do and where you do it, primary care will work fine.

 

[BeLikeBueller]

The thing to remember is that if you choose primary care with a lot of loans you may limit the location / type of jobs you could afford. If you are open to what you do and where you do it, primary care will work fine.

Thanks for the advice! Could you elaborate a little bit on the limitations you eluded to above? Are you referring to rural vs. city, employed vs. private, etc? Needless to say, I'm a little unfamiliar with the current job market for physicians.

 

[cabinbuilder]

Thanks for the advice! Could you elaborate a little bit on the limitations you eluded to above? Are you referring to rural vs. city, employed vs. private, etc? Needless to say, I'm a little unfamiliar with the current job market for physicians.

The general rule is the closer you live to a big city (in within a city) the more saturated the market, the lower the pay scales. So you have 3 choices really.

1. Work in the city like Dallas, Denver, Portland, Seattle and expect to make ~150K. A struggle to pay large loans with this.
2. Work for 4-5 years at an underserved site and get your student loans paid off and make 200+K
3. Work locums hard for about 3 years and take no vacations you could have it all paid off in 2-3 years. 250-300K easy.

 

[BeLikeBueller]

The general rule is the closer you live to a big city (in within a city) the more saturated the market, the lower the pay scales. So you have 3 choices really.

1. Work in the city like Dallas, Denver, Portland, Seattle and expect to make ~150K. A struggle to pay large loans with this.
2. Work for 4-5 years at an underserved site and get your student loans paid off and make 200+K
3. Work locums hard for about 3 years and take no vacations you could have it all paid off in 2-3 years. 250-300K easy.

Thanks for the clarification. This is probably good news for me. I think (again a long way off, I know) that I would be more interested in practicing in a rural area, so the underserved route might be a good way for me to go. I'm really looking seriously into the National Health Service Corps scholarship so that I could have tuition taken care of in full, but I know that's not a guarantee. That's why I'm just trying to make sure it's a reasonable financial decision without any outside support, scholarships, etc.

 

[cabinbuilder]

NHSC is good in theory but remember that you will be required to fulfill a 4 year commitment in a location THEY PICK FOR YOU. Could be a really long 4 years. Think hard. Now if you apply for NHSC after medical school then you would have control over the site you go to but then the payback money is not guaranteed. All comes down to what you can/cannot take.

 

[smq123]

NHSC is good in theory but remember that you will be required to fulfill a 4 year commitment in a location THEY PICK FOR YOU. Could be a really long 4 years. Think hard. Now if you apply for NHSC after medical school then you would have control over the site you go to but then the payback money is not guaranteed. All comes down to what you can/cannot take.

This is not quite correct. The NHSC does not pick your location for you. There are location stipulations that you have to fulfill (specifically, the site must have a high enough need score in order to qualify as an NHSC scholar site), but as long as your clinic site fulfills those requirements, then the NHSC will allow you to practice there. The problem is that you might not find a site with a high enough need score in the exact area that you want.

Getting the NHSC scholarship is not a guarantee, either. I did not get it on my first attempt, but I did get it on my 2nd try.

 

[BeLikeBueller]

This is not quite correct. The NHSC does not pick your location for you. There are location stipulations that you have to fulfill (specifically, the site must have a high enough need score in order to qualify as an NHSC scholar site), but as long as your clinic site fulfills those requirements, then the NHSC will allow you to practice there. The problem is that you might not find a site with a high enough need score in the exact area that you want.

Getting the NHSC scholarship is not a guarantee, either. I did not get it on my first attempt, but I did get it on my 2nd try.

Yeah, I'm not sure the NHSC would be worth it to me if you weren't able to "pick" your location. I also thought about possibly the HPSP through the Air Force for a while, but the folks over on the Military Med. forum opened my eyes to a lot of the potential pitfalls of that program (a bureaucratic nightmare, some have said).

Just out of curiosity (and obviously I'm not asking for any specific figures), did the pay seem to be competitive at NHSC approved sites? Not that it would really matter if I minimized and/or eliminated any medical school debt, just wondering.


One other question, since you were actually in the NHSC program, do you have any thoughts on what makes a more competitive candidate? I've looked at the resources on their website and there are general things like good academic standing and commitment to primary care, but was there anything that you changed or emphasized the second time around that you think may have helped you get accepted?

 

[brats800]

Thanks for the advice! Could you elaborate a little bit on the limitations you eluded to above? Are you referring to rural vs. city, employed vs. private, etc? Needless to say, I'm a little unfamiliar with the current job market for physicians.

As was already mentioned by cabinbuilder, it does seem to be more about the rural / city difference. I would've been closer to the $140/150k if I stayed in Chicago. Moving to a medium sized city, I saw the pay increase to closer to $200k. Within the town I work in, there are several medical groups and pay was similar across them when you account for job hours (1 was salary, 1 was private practice with buy-in, 1 was university based with productivity and quality incentives). If you have lots of loans but live within your means (decent cars, decent house, saving for kids' college, etc) and don't need to drive the newest best shiniest car every year or live in a penthouse condo in a big downtown, you'll be fine and be able to find jobs that allow you to pay off the loans.

 

[cabinbuilder]

This is not quite correct. The NHSC does not pick your location for you. There are location stipulations that you have to fulfill (specifically, the site must have a high enough need score in order to qualify as an NHSC scholar site), but as long as your clinic site fulfills those requirements, then the NHSC will allow you to practice there. The problem is that you might not find a site with a high enough need score in the exact area that you want.

Getting the NHSC scholarship is not a guarantee, either. I did not get it on my first attempt, but I did get it on my 2nd try.

When I was looking at NHSC it was 10 years ago and at that time if you got the scholarship while in school there was no option as to where you were placed after residency - it was a crap shoot as the government decided where they needed you most. Now that was different from applying after graduation after you took a job at a qualified site of your choice. But then again, it's not guaranteed that you will get the loan repayment. I applied for it once in 2009 and was declined due to lack of funds in the program. Not sure how much that has changed now?

 

[smq123]

Yeah, I'm not sure the NHSC would be worth it to me if you weren't able to "pick" your location. I also thought about possibly the HPSP through the Air Force for a while, but the folks over on the Military Med. forum opened my eyes to a lot of the potential pitfalls of that program (a bureaucratic nightmare, some have said).

Just out of curiosity (and obviously I'm not asking for any specific figures), did the pay seem to be competitive at NHSC approved sites? Not that it would really matter if I minimized and/or eliminated any medical school debt, just wondering.

One other question, since you were actually in the NHSC program, do you have any thoughts on what makes a more competitive candidate? I've looked at the resources on their website and there are general things like good academic standing and commitment to primary care, but was there anything that you changed or emphasized the second time around that you think may have helped you get accepted?

The pay is decent at the NHCS sites. It's not anywhere near the $200K mark you could make in rural areas or even in a really hard-working private practice, but it's more than I would have made if I had decided to stay in the hospital system where I did residency. You can PM me if you want hard numbers.

I honestly have no idea what makes a more competitive candidate, to be honest. Especially now as they have an essay-based application process. Back when I applied, it was a multiple choice personality test (I **it you not).

When I was looking at NHSC it was 10 years ago and at that time if you got the scholarship while in school there was no option as to where you were placed after residency - it was a crap shoot as the government decided where they needed you most. Now that was different from applying after graduation after you took a job at a qualified site of your choice. But then again, it's not guaranteed that you will get the loan repayment. I applied for it once in 2009 and was declined due to lack of funds in the program. Not sure how much that has changed now?

The NHSC has changed drastically, even since I applied in 2006 and 2007. Several dramatic changes were made, even from one year to the next.

The first year I applied, there was a mandatory interview to get the scholarship.

The following year that I applied, they had gotten rid of the interview, and went solely by the application (which was a multiple choice questionnaire).

The year after I was awarded the scholarship, they had gotten rid of the multiple choice question application, and switched to an essay application.

A year or two ago, they started requiring letters of recommendation.

I have spoken to physicians who went through the NHSC 10-15 years ago, and they also chose their placement site after residency. I don't know if it was a temporary experiment that they tried the year you looked at it, but when I applied, that was never the case.

If you do not have a job contract with an approved site by the March before you graduate, then yes, they will choose a site for you. However, that has always been the case, and most people do not have to go through that. You have almost 9 months to find a job; most people can find something on their own in that time frame.

I had been told by people with the NHSC that the government is diverting funds from the scholarship program, and putting more emphasis on the loan repayment program. The loan repayment amounts also went up by $10K. If you applied for it now, you might have better luck.

 

[BeLikeBueller]

The pay is decent at the NHCS sites. It's not anywhere near the $200K mark you could make in rural areas or even in a really hard-working private practice, but it's more than I would have made if I had decided to stay in the hospital system where I did residency. You can PM me if you want hard numbers.

I honestly have no idea what makes a more competitive candidate, to be honest. Especially now as they have an essay-based application process. Back when I applied, it was a multiple choice personality test (I **it you not).



The NHSC has changed drastically, even since I applied in 2006 and 2007. Several dramatic changes were made, even from one year to the next.

The first year I applied, there was a mandatory interview to get the scholarship.

The following year that I applied, they had gotten rid of the interview, and went solely by the application (which was a multiple choice questionnaire).

The year after I was awarded the scholarship, they had gotten rid of the multiple choice question application, and switched to an essay application.

A year or two ago, they started requiring letters of recommendation.

I have spoken to physicians who went through the NHSC 10-15 years ago, and they also chose their placement site after residency. I don't know if it was a temporary experiment that they tried the year you looked at it, but when I applied, that was never the case.

If you do not have a job contract with an approved site by the March before you graduate, then yes, they will choose a site for you. However, that has always been the case, and most people do not have to go through that. You have almost 9 months to find a job; most people can find something on their own in that time frame.

I had been told by people with the NHSC that the government is diverting funds from the scholarship program, and putting more emphasis on the loan repayment program. The loan repayment amounts also went up by $10K. If you applied for it now, you might have better luck.

Thanks so much for the in-depth information. I think the NHSC is my best bet if I make the decision to pursue medicine. I'm not as concerned with salaries post-graduation as long as it's enough support a family in addition to meeting my financial obligations (e.g. student loans).

Medicine is something that I know I would love, but it is definitely a significant commitment. I am in a unique position compared to most "pre-med" students, in that in a little over a year, I can walk out into a job that can provide a very comfortable lifestyle for a family (which is of the utmost importance to me). So for me, there is a lot of weighing pros and cons - I don't want to regret giving up on a "sure-bet," even though I may have greater job satisfaction, if it results in any sort of unstable financial situation.

[EDIT: I should say that I use the term "sure-bet" very loosely. If you wander over to the pharmacy forums, you'll see a lot of talk of saturation in the pharmacy profession.]

Then again, there is always the possibility that job satisfaction might elude me if I were to become a physician. One of the best quotes I ever heard was something to the effect of, "Some physicians probably wake up and leap out of bed, ready to get to work. Others probably wake up hoping that their practice was hit by a SCUD missile in the middle of the night."

In any case, I like to think that I would have greater job satisfaction as a physician and I know that I would have the opportunity to have a greater impact in my work. On the other hand, I wouldn't be miserable being a pharmacist - it's an enjoyable profession in my opinion. So, because I can certainly live with the "lesser" alternative, I have to maximize the pros of going into medicine and minimize the cons or barriers, if that makes sense. To me, the two biggest barriers are the additional debt that I would be incurring and the time/opportunity cost of medical school and residency. There is no way to control the latter, but with regards to the former, I am very grateful for all of the advice and input above.

 

[cabinbuilder]

The pay is decent at the NHCS sites. It's not anywhere near the $200K mark you could make in rural areas or even in a really hard-working private practice, but it's more than I would have made if I had decided to stay in the hospital system where I did residency. You can PM me if you want hard numbers.

I honestly have no idea what makes a more competitive candidate, to be honest. Especially now as they have an essay-based application process. Back when I applied, it was a multiple choice personality test (I **it you not).



The NHSC has changed drastically, even since I applied in 2006 and 2007. Several dramatic changes were made, even from one year to the next.

The first year I applied, there was a mandatory interview to get the scholarship.

The following year that I applied, they had gotten rid of the interview, and went solely by the application (which was a multiple choice questionnaire).

The year after I was awarded the scholarship, they had gotten rid of the multiple choice question application, and switched to an essay application.

A year or two ago, they started requiring letters of recommendation.

I have spoken to physicians who went through the NHSC 10-15 years ago, and they also chose their placement site after residency. I don't know if it was a temporary experiment that they tried the year you looked at it, but when I applied, that was never the case.

If you do not have a job contract with an approved site by the March before you graduate, then yes, they will choose a site for you. However, that has always been the case, and most people do not have to go through that. You have almost 9 months to find a job; most people can find something on their own in that time frame.

I had been told by people with the NHSC that the government is diverting funds from the scholarship program, and putting more emphasis on the loan repayment program. The loan repayment amounts also went up by $10K. If you applied for it now, you might have better luck.

Not worth it to me to apply now. I don't have a permanent job and having really for 4 years. Not looking for one anytime soon, either. Just love the freedom of locums.

 

[realism]

I'm a 3rd year pharmacy student very interested in attending medical school and practicing as a primary care physician.

I have a fair amount of debt that I have accumulated from pharmacy school and I know that I will accumulate significantly more if I attend medical school. I don't want to boil this decision down to finances, but from a realistic point of view, that plays a huge role in the picture that I'm looking at here.

In your opinion, is this a reasonable path to take in the current climate of uncertainty that seems to be surrounding the healthcare system, particularly with regards to primary care and payment reform?



I appreciate your thoughts - I'm sure a lot of people probably come to this forum with similar questions. I would post this in the pre-medical or the medical student forum, but I fear what I would get is simply a lot of speculation.

Hi,
I have been in Family Medicine practice as a physician for the last 10y.
You will get many points of view in the responses.
I am very dissatisfied with the current changes and the direction of the changes.
I am working for large medical corporation.
Here are some thoughts:
Finances become very real as soon as they start affect you. There is a discrepancy in payments for what physicians do. It is not a secret that 1 hour of Ophthalmologist's work doing procedures is equivalent to 12.5 hrs of Family Physician's work .
(see http://thehealthcareblog.com/blog/tag/paul-fischer/ )
Family life counts a lot:
If you plan to practice in a rural area you need to consider limits on your spouse's employment and advancement, reduction of your kids educational opportunities, often high crime nearby.
I compared what was available at High School to my daughter in a 6K town and to my cousin's daughter in Chicago.
Work itself: When I refer my patients to specialists then they are usually seen by Nurse Practitioners (neurology, endocrinology, etc) telling me in what they think and how the patient should be treated.
My managers tell me how to practice medicine. This is done often indirectly. This is a separate quite complex topic.
Nurse Practitioners: my opinion is that they provide primary care at the level expected by the licensing boards and are equivalent to Family Physicians. They are often receiving better satisfaction scores than male Family Physicians.
I think that they do the same quality job and that is why the Family Physician pay should be lowered to the level of Nurse Practitioners. Even thou some state that their pay should be increased.
( http://well.blogs.nytimes.com/2013/06/27/the-gulf-between-doctors-and-nurse-practitioners/?_r=0 )
When I am older and myself need some outpatient medical care I would definitely prefer a Nurse Practitioner over a Family Physician and of course pay significantly less for the same services provided.
Insurance payers know it too. It will be a natural progression to have a less expensive primary care consisting of Nurse Practitioners.
I believe that the specialists should continue receiving high pay because they usually do the job that no one else can do. They provide specific value to the patient.
Personally I suggest to avoid Family Practice as a specialty. I would not choose Family Medicine as a physician again.
Real thing: The healthcare environment will be very much different by the time you finish medical school and the choices will be hopefully easier.
I welcome your questions.

I just got a statement from someone:
"I doubt it. Nobody in the field for even ten minutes, much less ten years, would say "Family "Medicine practice."
so, please see:
The American Board of Family Medicine, Inc https://www.theabfm.org/
The Journal of Family Practice http://www.jfponline.com/
Yes, there is such a thing called "Family Medicine practice"

 

[BeLikeBueller]

Hi,
I have been in Family Medicine practice as a physician for the last 10y.
You will get many points of view in the responses.
I am very dissatisfied with the current changes and the direction of the changes.
I am working for large medical corporation.
Here are some thoughts:
Finances become very real as soon as they start affect you. There is a discrepancy in payments for what physicians do. It is not a secret that 1 hour of Ophthalmologist's work doing procedures is equivalent to 12.5 hrs of Family Physician's work .
(see http://thehealthcareblog.com/blog/tag/paul-fischer/ )
Family life counts a lot:
If you plan to practice in a rural area you need to consider limits on your spouse's employment and advancement, reduction of your kids educational opportunities, often high crime nearby.
I compared what was available at High School to my daughter in a 6K town and to my cousin's daughter in Chicago.
Work itself: When I refer my patients to specialists then they are usually seen by Nurse Practitioners (neurology, endocrinology, etc) telling me in what they think and how the patient should be treated.
My managers tell me how to practice medicine. This is done often indirectly. This is a separate quite complex topic.
Nurse Practitioners: my opinion is that they provide primary care at the level expected by the licensing boards and are equivalent to Family Physicians. They are often receiving better satisfaction scores than male Family Physicians.
I think that they do the same quality job and that is why the Family Physician pay should be lowered to the level of Nurse Practitioners. Even thou some state that their pay should be increased.
( http://well.blogs.nytimes.com/2013/06/27/the-gulf-between-doctors-and-nurse-practitioners/?_r=0 )
When I am older and myself need some outpatient medical care I would definitely prefer a Nurse Practitioner over a Family Physician and of course pay significantly less for the same services provided.
Insurance payers know it too. It will be a natural progression to have a less expensive primary care consisting of Nurse Practitioners.
I believe that the specialists should continue receiving high pay because they usually do the job that no one else can do. They provide specific value to the patient.
Personally I suggest to avoid Family Practice as a specialty. I would not choose Family Medicine as a physician again.
Real thing: The healthcare environment will be very much different by the time you finish medical school and the choices will be hopefully easier.
I welcome your questions.

I just got a statement from someone:
"I doubt it. Nobody in the field for even ten minutes, much less ten years, would say "Family "Medicine practice."
so, please see:
The American Board of Family Medicine, Inc https://www.theabfm.org/
The Journal of Family Practice http://www.jfponline.com/
Yes, there is such a thing called "Family Medicine practice"

Very interesting points. I especially appreciated the link to "The Health Care Blog" - there are a lot of great perspectives on primary care there. In reference to one of the articles I was reading there, I count myself among the "idealistic" for my interest in primary care (see http://thehealthcareblog.com/blog/2012/08/08/the-most-powerful-health-care-group-you’ve-never-heard/). I've had the thought of pursuing something like anesthesiology, simply because it would be a much better return on investment, but I really do have a passion for primary care.

I am very interested in the implementation of patient centered medical homes. I know there is a lot of push back from primary care physicians about "team-based" care, and I understand why. PAs and NPs have taken a much greater foothold in primary care than anyone probably anticipated. But I think that if it is done right, team-based care in a patient centered medical home is the best way to help physicians spend the time they need to with the patients that need it most (and I think it is a good way to improve overall reimbursements, if the right people are getting paid for the right things). I'm obviously a little biased towards pharmacy involvement in PCMHs, but hopefully you can all understand why. I've heard that the average visit for a DM-type 2 pt. might last anywhere from 25-30 minutes, while the physician will only be reimbursed for 12 minutes of that visit. I've also heard that about half of that time is spent adjusting therapies and counseling the patient on their disease state. [Please feel free to correct me if that is not your experience]. But my thought is - why not shell out some of the more routine/mundane work so that you can see more patients and/or spend more time with the patients that require it most.

On top of that, in my area, there are some very successful "cash-only" practices that do not accept any type of medical insurance. A news article about one of these practices quoted one of the physicians as saying that he had a comparable annual income compared to accepting insurance with considerably less headache.

I don't really know what is necessarily viable and beneficial in the health care system at this particular point in my education/career, but I do know that the answer to just about every problem we have in healthcare (too expensive, not enough access, poor health indicators vs. other countries, etc., etc.) lies with primary care practice. Myself - I want to be a problem solver. I don't know what that will exactly look like, but I do know that primary care is my best chance at making a difference.