Warning from my Internist: Please specialize

[sanityonleave]

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boo hoo quit crying,
no matter how little you think a primary care doctor makes, you will still be wayyy over the national income average...and wayyyyyyy over the world income average....if debt was such a big deal for you then why didn't you just go to your in-state school?
My in-state school is about 10k a year tuition...i didnt get in because i didnt have high enough scores, so im going to another school that i did get into which is 37k a year. I accept the responsibility of having more debt because i know that someone worked harder for the school seat that costs 10k.
nobody in life is entitled to making bank....it all comes from god...i know that sounds difficult to hear but its true...it all comes from god...he gives, he takes...you could be a radiologist and get sued for everything...you could be a family doctor and make millions just by being in a good location and knowing how to do buisness....
meh.....maybe im just over the whole >150k salary lusting...i get that you wanna make alot, but when you want to make money so much it won't happen....focus on perfecting your craft and people will give you the money that you deserve.

I'm going to start you on an albuterol inhaler -- I want you to take two puffs any time you're about to post on a message board. If you don't get relief from two puffs or you find yourself having to use the inhaler more than QID, I'd like you to come back and see me and we'll see about starting you on some inhaled corticosteroids. Either way, I'll see you again in six weeks.

 

[Jolie South]

boo hoo quit crying,
no matter how little you think a primary care doctor makes, you will still be wayyy over the national income average...and wayyyyyyy over the world income average....if debt was such a big deal for you then why didn't you just go to your in-state school?
My in-state school is about 10k a year tuition...i didnt get in because i didnt have high enough scores, so im going to another school that i did get into which is 37k a year. I accept the responsibility of having more debt because i know that someone worked harder for the school seat that costs 10k.
nobody in life is entitled to making bank....it all comes from god...i know that sounds difficult to hear but its true...it all comes from god...he gives, he takes...you could be a radiologist and get sued for everything...you could be a family doctor and make millions just by being in a good location and knowing how to do buisness....
meh.....maybe im just over the whole >150k salary lusting...i get that you wanna make alot, but when you want to make money so much it won't happen....focus on perfecting your craft and people will give you the money that you deserve.

I think your perspective might change when you have a little more experience and are sitting where I sit now.

 

[Longer Road]

Who are you to tell people what there priorities should be?

He is absolutely right.

Who are you ******s going in to medicine now?

I encourage you to leave before you garner too much debt.

 

[DrVanNostran]

I tend to agree. Sadly the current system is straggling primary care. Too much bull**** for too little money, which is all the more frustrating when you know that there is plenty of money floating around the system when anesthesia and radiology can pull the salaries they do. I'm all about people making as much money as they possibly can so I'm not hating. Bottom line, the peeps that went into rads and gas, even if it only was for the money and lifestyle made the smart decision.

So, unless you have a hard on to "save the world" one primary care patient at a time, or you know you want to do an IM subspecialty (2-4 more years of training after three years of IM), don't go into IM. Go into something else if you like it.

<--- IM resident, done in 3 days (going to fellowship)

Man, just when I was set on IM/Heme-Onc. I need to re-re-re-reconsider Rads again

This thread is hilarious.

For you guys out there:

Ortho-->Gets Jessica Alba
Family-->Gets to google Jessica Alba

 

[smq123]

Wow. Just wow. SOOOOO many misconceptions, so little time.

Myth #1: Primary care is a terrible lifestyle.

I am the first to promote family time. Yet if it distracts from your purpose, you are misguided.

Cry me a river about the sacrifice of school, debt, long hours. That is life. If you are entering medicine expecting nothing but roses and lavish pay for minimal work you are in for a rude awakening.

If its because I'm hitting you where it hurts most, that you want a great income and great lifestyle..

One of the things about primary care that I LIKE (disclaimer: I'm a PGY-2 Family Medicine resident) is its flexibility. If I want to work part time? I can. If I want to work in an urgent care clinic with no call and do shiftwork? I can. If I want to join a practice with minimal call? I can. If I want to work at a wound care clinic with NO call? I can.

Primary care has a perfectly good lifestyle. While I appreciate your misconceived notion that all of us in primary care are vying with Jesus for World's Biggest Martyr....sorry to burst your bubble , but most of us like primary care BECAUSE it can offer a decent lifestyle, if you choose.

Myth #2: Specialists don't offer the poor/underserved any benefit.

Honestly. Who in medical school goes in to dermatology, these days, because they want to "help the poor, unattended people?"

Actually, I am currently rotating in a free clinic for people with no insurance. Specialists come and give their time because, honestly? The underserved sometimes need a specialist just as much as they need a PCP. I can diagnose your herniated disc; I'm not going to do surgery (if it's needed) on it. I can diagnose your kidney tumor, I'm not going to operate and get it out.

I've met many ophthalmologists who donate time and energy to educate the poor and underserved on good eye care, and do free glaucoma screenings. How is that not as valuable as a PCP who treats your diabetes?

Myth #3: Specialists don't work hard.

If its because I'm hitting you where it hurts most, that you want a great income and great lifestyle..

I have met interventional cardiologists who work 3 times as hard, and 3 times as many hours, as my primary care attendings. They have to, because they take so much more call. I've met dermatologists who work plenty of weekends to build their practices up, plastic surgeons who run around like crazy covering 3 different hospitals, radiologists who are forced to work evenings and weekends every now and then. The urologist that I rotated with often put in 15 hour days, particularly as they were trying to start up their EMR. They definitely work hard for the money that they take in, no doubt about it.

Myth #4: Primary care is poorly reimbursed.

What do you say to the guy with >$200K in debt who shuns a Primary Care specialty because of $140K starting salary (thats generous from what I hear)?

$140K is actually fairly standard, if you want to live in a pretty decent sized city, and do adult primary care. (Peds is different; they are sometimes reimbursed less than family med.) If you're willing to live somewhere more rural, it's not unusual to get job offers for something slightly higher ($160K) for 4 days a week. Two of our graduates got really really NICE job offers in California and New Hampshire.

 

[CWWinning]

Theres a dentist's practice right under my apartment that seems rather prosperous.

Hours: M-Th, 9-3, Friday 9-12. We're in the wrong field.

What many fail to realize is that dentistry is a profession that puts A LOT of wear and tear on your body. The majority of dentists will suffer from musculoskeletal problems in their practicing careers (bad necks, backs, elbows, shoulders, carpal tunnel syndrome, etc). Some retire early because their body can't do the work anymore. They work fewer hours than physicians not only because they can (right now) but because the body needs time to recuperate. Dentists will also have shorter practicing careers than physicians for these reasons. And the profession could turn upside down as soon as reimbursements get slashed.

 

[GoSpursGo]

This is the problem. No you do not. By taking on a medical career you have the right to care for patients. Your personal gains are an exception, not the rule.

I am the first to promote family time. Yet if it distracts from your purpose, you are misguided.

You might get lucky and you might do well on Step 1. If you don't, primary care is a great field and needs people like you to fill in for the spots that your ego long ago evacuated.

Wow this is so patently wrong I'm not sure where to begin.

I think you need to separate "the right reasons" to go to medical school from "my personal reasons." To suggest that anyone who is going to medical school for any reason other than your own is far more egotistical than anything anyone else has said in this thread.

Honestly. Who in medical school goes in to dermatology, these days, because they want to "help the poor, unattended people?"

Is the reason that most people go into derm to "help the poor, unattended people?" Probably not. But I'm sure going to be glad when I get melanoma that I have a dermatologist to go to. I sure am glad that I have an anesthesiologist to keep surgery from hurting. And smq said, so are those poor, unattended people.

I'm glad that you're so gung-ho about caring for the underserved. The world needs some. But I'm not sure why you need to tear other people down to make you feel better about yourself.

 

[Jolie South]

What many fail to realize is that dentistry is a profession that puts A LOT of wear and tear on your body. The majority of dentists will suffer from musculoskeletal problems in their practicing careers (bad necks, backs, elbows, shoulders, carpal tunnel syndrome, etc). Some retire early because their body can't do the work anymore. They work fewer hours than physicians not only because they can (right now) but because the body needs time to recuperate. Dentists will also have shorter practicing careers than physicians for these reasons. And the profession could turn upside down as soon as reimbursements get slashed.

I call BS. If that were true, surgeons wouldn't be able to work the long hard hours that they do.

 

[CWWinning]

I call BS. If that were true, surgeons wouldn't be able to work the long hard hours that they do.

Both of my parents are dentists, and I have relatives who are dentists. I grew up around the practice. I'm well-qualified to speak on these matters. Do YOUR homework.

Edit to add: Dentists work on a scale of tenths of a mm...few surgeons have to operate under that precision. You have a cup of coffee as a dentist and the shakes can affect your work that morning to where a procedure fails.

And tell me, what surgeon does surgery all day long hunched over patients M-F, 45-50 weeks a year. Yeah.

 

[Jolie South]

Both of my parents are dentists and have relatives who are dentists. I grew up around the practice. I'm well-qualified to speak on these matters. Do YOUR homework.

Edit to add: Dentists work on a scale of tenths of a mm...few surgeons have to operate under that precision. You have a cup of coffee as a dentist and the shakes can affect your work that morning to where a procedure fails.

And tell me, what surgeon does surgery all day long hunched over patients M-F, 45-50 weeks a year. Yeah.

I apologize. It does sound taxing.

 

[Slack3r]

With even a $250,000 debt load, $200,000 in government backed and $50,000 in private loans, the maximum monthly payment would be $2,500.

Ruh-roh. Someone doesn't know how loans work.

Once you get above 150-200k, the whole cliche "money can't buy happiness" thing is true. (Yes, studies have looked at this))

Actually, the "magic number" for happiness is $77k. 😉

I agree with you entirely. We need specialists and we need well educated people to pursue these fields.



Frankly, I have to disagree with you.

You pursue the field you are interested in for the monetary and lifestyle gain. If primary care paid $750,000/year and you worked 20 hours/week you surely would do that. It is sad that you can not see through your lust.


And to address the other thought that the median income does not include that, as an MD, you have an advanced degree. It does not matter. There are PhDs earning $40,000 and Bill Gates college drop outs earning millions. It is a median for a reason. It reflects that you are earning much, much more than your AVERAGE patient. Much more than the average American family. Get over it. You will be able to pay off your loans, send your kids to college, and still have nice vacations. Stop being so selfish.

Is it lonely up there on your pedestal?

You might get lucky and you might do well on Step 1. If you don't, primary care is a great field and needs people like you to fill in for the spots that your ego long ago evacuated.

Nick has a 4.0 and a >40 MCAT. I'm sure he'll do fine.

 

[DrVanNostran]

Both of my parents are dentists, and I have relatives who are dentists. I grew up around the practice. I'm well-qualified to speak on these matters. Do YOUR homework.

Edit to add: Dentists work on a scale of tenths of a mm...few surgeons have to operate under that precision. You have a cup of coffee as a dentist and the shakes can affect your work that morning to where a procedure fails.

And tell me, what surgeon does surgery all day long hunched over patients M-F, 45-50 weeks a year. Yeah.

Neurosurgeons, Plastics, etc. Except their surgeries can last up to 12-16 hours.

 

[inspirationmd]

General surgery is considered primary care.

Emergency Medicine should not be a subspecialty but, instead, be what it was where both surgery and medicine covered the department.

I have no issue with medical or surgical subspecialties, per se. They are, indeed needed. However, going in to medical school thinking you want to do radiology, dermatology, rheumatology, etc. is problematic.

We need more PCPs. We can afford it on the current reimbursement level, we just don't want to.

Did you really say that general surgery is a primary care specialty? I would love to see you provide ANY source that classifies a general surgeon as a primary care physician. That's just a ludicrous statement. On top of that...you are a surgical subspecialist! What do you even know about primary care beyond a 3rd year clerkship and maybe a Sub I as a 4th year. Where does your extensive knowledge about the challenges of PCPs come from?

Emergency Medicine has been a recognized and important specialty for over 40 years now. I can assure you that IM and Surgeons do not have the training to adequately handle the issues of the ED for an extended period of time. Their training makes them think differently and as a result you hear about the previous burnout of attendings who were practicing a specialty they were not trained to do. I know EM/IM residents who even struggle early on to master the difference in thinking so that they are effective both in the ED and on the floors/in the clinic. EM residencies will continue to exist and EM will grow stronger as more and more med students jump on it. It should not be a subspecialty of IM or Gen Surg.

People in this country are able to choose their paths as they see fit. Your insistence on telling people what specialty they should practice is a little much. This is especially true given your career as a surgical subspecialist. How do you plan to advocate for a field you have barely any experience with?

 

[Longer Road]

1) Medicine is a privilege

2) Your life outside medicine is less important than your commitment to medicine

3) If 1 or 2 are a problem, rethink medical school

 

[2012mdc]

all 4th year medical students interested in primary care need a stat CT head

Or a psychiatrist

 

[MilkmanAl]

1) Medicine is a privilege

2) Your life outside medicine is less important than your commitment to medicine

3) If 1 or 2 are a problem, rethink medical school

I rethought it. I'm still here. What should I do now, sir?

 

[genswim24]

Both of my parents are dentists, and I have relatives who are dentists. I grew up around the practice. I'm well-qualified to speak on these matters. Do YOUR homework.

Edit to add: Dentists work on a scale of tenths of a mm...few surgeons have to operate under that precision. You have a cup of coffee as a dentist and the shakes can affect your work that morning to where a procedure fails.

And tell me, what surgeon does surgery all day long hunched over patients M-F, 45-50 weeks a year. Yeah.

Besides what was already mentioned you have vascular surgeons, cardiovascular surgeons, some parts of ortho (hand docs especially) all work way more hours, under just as precise conditions (probably more so), where the consequences of things gone awry tend to be much worse.

You may have plenty of dentists in your family but you clearly have no idea what surgeons lives are like.

 

[Longer Road]

I rethought it. I'm still here. What should I do now, sir?

You should probably leave now and make your position available for someone who actually cares.

 

[2012mdc]

1) Medicine is a privilege

2) Your life outside medicine is less important than your commitment to medicine

3) If 1 or 2 are a problem, rethink medical school

Disagree on count 2.

Once I have a wife and kids they will be more important than my work

 

[sineapse]

1) Medicine is a privilege

2) Your life outside medicine is less important than your commitment to medicine

3) If 1 or 2 are a problem, rethink medical school

 

[soeagerun2or]

PICTURE

I honestly hope you are kidding.

 

[VoiceofReason]

You should probably leave now and make your position available for someone who actually cares.

it doesnt matter if you care it matters if you do your job competently

 

[ozzi22]

I'd say he did

 

[Naijaba]

Soeager,

What do you say to the guy with >$200K in debt who shuns a Primary Care specialty because of $140K starting salary (thats generous from what I hear)? A new traditional IM, FM, or Peds grad at 29 presumably would like to think about starting a family at some point. Exactly how would they afford to make $3000 a month loan payments, live, save for retirement , etc with $95K in disposable income after taxes?

EDIT: And don't give me the IBR, and loan repayment for underserved arguement. No one knows if IBR will last the 10 years and the loan repayment locations are often undesireable positions (which is why they must offer loan repayment). I am actually for the service to the underserved but it should be a choice not something you feel like you have to do to survive. That makes for unhappy physicians and potential burnout.

Wait...what? You're arguing that $95K is *not* enough to start a family? Seriously?

Oh wait, nm, I got it..that's after taxes alone, before the other stuff.

 

[FutureDoctor317]

According to this

http://www.mgma.com/press/default.aspx?id=1366542

The average salary for IM is 205K/year and from what I hear MGMA is the most reliable salary data. Although this may not be a lot of money to some people, I don't think its low enough to warrant complaining. From what I hear most internists are upset about dealing with different insurance companies and being forced to rush through patients to make a profit.

 

[MilkmanAl]

You should probably leave now and make your position available for someone who actually cares.

I don't have to sell my soul to medicine to "actually care" and be good at my job, thanks. I'm glad people as dedicated as you exist, but don't you dare try forcing that idealistic crap on others. If you choose to lead a hollow life consisting solely of work, that choice is yours and yours alone.

 

[username456789]

1) Medicine is a privilege

2) Your life outside medicine is less important than your commitment to medicine

3) If 1 or 2 are a problem, rethink medical school

I just threw up in my mouth a little. Learn to make trolling more subtle.

 

[Longer Road]

I don't have to sell my soul to medicine to "actually care" and be good at my job, thanks. I'm glad people as dedicated as you exist, but don't you dare try forcing that idealistic crap on others. If you choose to lead a hollow life consisting solely of work, that choice is yours and yours alone.

I don't mean to break your bubble, but you sould your sould.

If you find out along the way you're not as dedicated then get off this ship and let someone who is take over.

This whole conversation was started about the limted number of positions in medicine per year, and the paucity of individuals who go in to primary care.

You should go in to primary care by default. UNLESS something else piques your interest

 

[username456789]

I don't mean to break your bubble, but you sould your sould.

If you find out along the way you're not as dedicated then get off this ship and let someone who is take over.

This whole conversation was started about the limted number of positions in medicine per year, and the paucity of individuals who go in to primary care.

You should go in to primary care by default. UNLESS something else piques your interest

Seriously, we get that you made this account just to troll. What's your usual username?

 

[soeagerun2or]

According to this

http://www.mgma.com/press/default.aspx?id=1366542

The average salary for IM is 205K/year and from what I hear MGMA is the most reliable salary data. Although this may not be a lot of money to some people, I don't think its low enough to warrant complaining. From what I hear most internists are upset about dealing with different insurance companies and being forced to rush through patients to make a profit.

Agreed.

No one wants to deal with actual patients. They prefer to see them as images or biopsies.

 

[ArcGurren]

Who are you to piss on more than half the country?

The median family income is $50,233.00.

Imagine those that earn much, much less than that. Which do they have a greater need for, a dermatologist or a PCP?

OHHHHHH NO YOU DIDN'T.

One of my huge pet peeves is people who hate on specialists for... well, specializing - just because it's "not primary care". What the hell kind of logic is that?

Let me describe an average day in the FM practice I'm doing my clerkship at to you...

1. Guy comes in with urinary retention, nocturia, strong family history of prostate cancer. Prostate exam is negative, stool guaiac is negative, but his medical history is spotty. What do we do? refer to a urologist.

2. Woman comes in with abdominal cramps. We think it might be IBS but as it turns out she's been passing heavy menstrual periods. We examine her and figure out the pain is worse during her menstrual period and she shows no signs of acute abdomen. refer to ob/gyn. In the meantime we refer her to a breast surgeon for a biopsy to r/o a mass.

3. Dude comes in with dyspnea. We send him off for a CXR and we see ground glass opacities with hilar lymphadenopathy. 3 days later after being referred to the pulmonologist he comes back with sarcoidosis.

4. Man comes in with pedal edema, orthopnea, and long history of trouble breathing intermittently. We hear fluid in his lungs and immediately refer him to cardiology. Turns out he has congestive heart failure (no surprise there, his presentation was classic).

So don't give me this crap about how people in all of these higher paying specialties (specialty surgery, urology, cardiology, and medicine fellowships) are somehow less important than primary care. Half of what I see in the office involves referrals. Is the job of the PCP important? of course it is. Just don't play with this absolute BS nonsense that specialty care is somehow less important. I don't want to go into primary care mainly because I enjoy working with my hands.

 

[ArcGurren]

Agreed.

No one wants to deal with actual patients. They prefer to see them as images or biopsies.

Wow you don't even take a hint when you're on probation

 

[smq123]

OHHHHHH NO YOU DIDN'T.

One of my huge pet peeves is people who hate on specialists for... well, specializing - just because it's "not primary care". What the hell kind of logic is that?

Let me describe an average day in the FM practice I'm doing my clerkship at to you...

1. Guy comes in with urinary retention, nocturia, strong family history of prostate cancer. Prostate exam is negative, stool guaiac is negative, but his medical history is spotty. What do we do? refer to a urologist.

2. Woman comes in with abdominal cramps. We think it might be IBS but as it turns out she's been passing heavy menstrual periods. We examine her and figure out the pain is worse during her menstrual period and she shows no signs of acute abdomen. refer to ob/gyn. In the meantime we refer her to a breast surgeon for a biopsy to r/o a mass.

3. Dude comes in with dyspnea. We send him off for a CXR and we see ground glass opacities with hilar lymphadenopathy. 3 days later after being referred to the pulmonologist he comes back with sarcoidosis.

4. Man comes in with pedal edema, orthopnea, and long history of trouble breathing intermittently. We hear fluid in his lungs and immediately refer him to cardiology. Turns out he has congestive heart failure (no surprise there, his presentation was classic).

So don't give me this crap about how people in all of these higher paying specialties (specialty surgery, urology, cardiology, and medicine fellowships) are somehow less important than primary care. Half of what I see in the office involves referrals. Is the job of the PCP important? of course it is. Just don't play with this absolute BS nonsense that specialty care is somehow less important. I don't want to go into primary care mainly because I enjoy working with my hands.

Wow, that's a pretty crappy office they have you rotating in.

(Sorry, I couldn't help myself. I try not to rely on specialists to make a diagnosis; only refer for definitive treatment. But that's my bias. 🙂)

 

[ArcGurren]

Wow, that's a pretty crappy office they have you rotating in.

(Sorry, I couldn't help myself. I try not to rely on specialists to make a diagnosis; only refer for definitive treatment. But that's my bias. 🙂)

Crappy? If you have a high suspicion for BPH but can't confirm it via prostate exam, unless you have a rectal ultrasound i'm not sure how else you would confirm it.

We don't refer EVERYTHING, just the stuff that we can't manage. We knew the guy had CHF, but he was still referred to the cardiologist for confirmation, followup, and treatment.

 

[smq123]

Crappy? If you have a high suspicion for BPH but can't confirm it via prostate exam, unless you have a rectal ultrasound i'm not sure how else you would confirm it.

We don't refer EVERYTHING, just the stuff that we can't manage. We knew the guy had CHF, but he was still referred to the cardiologist for confirmation, followup, and treatment.

My point is, there are things you can do before automatically reaching for the referral pad.

Did they check a PSA before sending him to urology? And I'm not completely clear how you can have high suspicion for BPH (bad enough that he has significant symptoms) and not feel it via DRE. It takes a while, but I've finally started getting better at estimating a 40g prostate vs. a 60g vs. an 80g.

CHF is not, generally, that hard to manage. Was it a really unusual case of CHF, or did he have a lot of other comorbidities that made it hard to manage?

The GYN patient - did they check an ultrasound before automatically referring to GYN? Evaluate the endometrial stripe? Check for fibroids? Do a bimanual?

I've gotten more cautious at just automatic referrals. Not just because I need to learn how to be a better PCP, but also because a lot of the insurance plans around here have doubled their copays for specialists. I've had patients tell me that they just can't afford the $40 or $60 that they have to pay to see their specialist. Which puts more of the burden of management on me.

 

[Journey2become]

I don't know what the use it is to reply to a banned member or one on probation...but here goes:

1) Medicine is a privilege

2) Your life outside medicine is less important than your commitment to medicine

3) If 1 or 2 are a problem, rethink medical school

So a doctor/futuredr that loves and cares for his family enough to actually want to spend time with them should reconsider medicine – who are we left with? Doctor's that don't care about anybody?

This is the problem. No you do not. By taking on a medical career you have the right to care for patients. Your personal gains are an exception, not the rule.

I am the first to promote family time. Yet if it distracts from your purpose, you are misguided.

Next you'll advocate that doctor's should be celibate so that family and relationships do not get in the way of their purpose. You know why? Because the only way of not having the possibility of being distracted by family is to not have one.

this thread is going to the crapper, and fast...

You CALLED IT!!!

For what it's worth. I'm sincerely considering PC, however, I am keeping an open mind for the best fit.

 

[lrkoehle]

OHHHHHH NO YOU DIDN'T.

One of my huge pet peeves is people who hate on specialists for... well, specializing - just because it's "not primary care". What the hell kind of logic is that?

Let me describe an average day in the FM practice I'm doing my clerkship at to you...

1. Guy comes in with urinary retention, nocturia, strong family history of prostate cancer. Prostate exam is negative, stool guaiac is negative, but his medical history is spotty. What do we do? refer to a urologist.

2. Woman comes in with abdominal cramps. We think it might be IBS but as it turns out she's been passing heavy menstrual periods. We examine her and figure out the pain is worse during her menstrual period and she shows no signs of acute abdomen. refer to ob/gyn. In the meantime we refer her to a breast surgeon for a biopsy to r/o a mass.

3. Dude comes in with dyspnea. We send him off for a CXR and we see ground glass opacities with hilar lymphadenopathy. 3 days later after being referred to the pulmonologist he comes back with sarcoidosis.

4. Man comes in with pedal edema, orthopnea, and long history of trouble breathing intermittently. We hear fluid in his lungs and immediately refer him to cardiology. Turns out he has congestive heart failure (no surprise there, his presentation was classic).

So don't give me this crap about how people in all of these higher paying specialties (specialty surgery, urology, cardiology, and medicine fellowships) are somehow less important than primary care. Half of what I see in the office involves referrals. Is the job of the PCP important? of course it is. Just don't play with this absolute BS nonsense that specialty care is somehow less important. I don't want to go into primary care mainly because I enjoy working with my hands.

Couldn't an NP or PA handle all the easy stuff and be the one handing out all these referrals? Doesn't it seem like 4 years of undergrad, 4 years or med school, and 3 years of residency is a waste just to be handing out referrals all day? Perhaps those who go into FM are not the noble ones after all. Perhaps they're the ones wasting a spot in med school just to go do something an NP or PA could do, and specialists are the noble ones who are actually helping patients?

Before everyone get's all upset, I'm just trying to irritate soeager into getting his/herself completely banned.

 

[tigress]

boo hoo quit crying,
no matter how little you think a primary care doctor makes, you will still be wayyy over the national income average...and wayyyyyyy over the world income average....if debt was such a big deal for you then why didn't you just go to your in-state school?
My in-state school is about 10k a year tuition...i didnt get in because i didnt have high enough scores, so im going to another school that i did get into which is 37k a year. I accept the responsibility of having more debt because i know that someone worked harder for the school seat that costs 10k.
nobody in life is entitled to making bank....it all comes from god...i know that sounds difficult to hear but its true...it all comes from god...he gives, he takes...you could be a radiologist and get sued for everything...you could be a family doctor and make millions just by being in a good location and knowing how to do buisness....
meh.....maybe im just over the whole >150k salary lusting...i get that you wanna make alot, but when you want to make money so much it won't happen....focus on perfecting your craft and people will give you the money that you deserve.

Okay, so if your in-state school costs $10k/year, good for you. I go to a state school that costs $33k/year (and $40k for 3rd year). I also have 3 kids, and take out maximum loans. I'm not concerned with "making bank". I need to have enough money to live comfortably with my kids, so yes, debt is a huge issue to me. I am somebody who could very well go into primary care--I don't know, since I'm not nearly at a place in my training where I could know, but it's a real possibility. But primary care peds simply doesn't pay well. My kids' pediatrician hardly even draws a salary anymore (she has a husband who makes a ton so she can do that, but she also works more than full-time and is always happy to take calls on the weekend and once even met us in a grocery store parking lot on a Sunday to see my then baby's rash--she's that kind of doctor), so she can pay her staff well and the other younger docs in the practice can make enough to live comfortable off of.

That said, and in reference to the OP, this same pediatrician has never once suggested to me that I shouldn't go into primary care, nor have the other docs in her practice. In fact, they encourage me to. But I don't think I need to justify to anybody why I would consider specializing just so I could have an easier way to pay off my loans and live comfortably.

In agreement with the family medicine resident, the flexibility is one reason a friend of mine is glad he went into IM. He currently does shifts in an urgent care because he is seriously pursuing another interest, and he has a lot of time for his family. He will readily admit that the urgent care routine can get a bit dull, but overall he's very content with where he is professionally.

 

[lrkoehle]

My point is, there are things you can do before automatically reaching for the referral pad.

Did they check a PSA before sending him to urology? And I'm not completely clear how you can have high suspicion for BPH (bad enough that he has significant symptoms) and not feel it via DRE. It takes a while, but I've finally started getting better at estimating a 40g prostate vs. a 60g vs. an 80g.

CHF is not, generally, that hard to manage. Was it a really unusual case of CHF, or did he have a lot of other comorbidities that made it hard to manage?

The GYN patient - did they check an ultrasound before automatically referring to GYN? Evaluate the endometrial stripe? Check for fibroids? Do a bimanual?

I've gotten more cautious at just automatic referrals. Not just because I need to learn how to be a better PCP, but also because a lot of the insurance plans around here have doubled their copays for specialists. I've had patients tell me that they just can't afford the $40 or $60 that they have to pay to see their specialist. Which puts more of the burden of management on me.

Do you feel concerned that if you don't refer some one to a specialist and something you though was routine and easy to manage wasn't and something went wrong, that you could get sued? This is a serious question. Couldn't they claim you weren't qualified and that lead to the bad outcome?

 

[ArcGurren]

My point is, there are things you can do before automatically reaching for the referral pad.

Did they check a PSA before sending him to urology? And I'm not completely clear how you can have high suspicion for BPH (bad enough that he has significant symptoms) and not feel it via DRE. It takes a while, but I've finally started getting better at estimating a 40g prostate vs. a 60g vs. an 80g.

CHF is not, generally, that hard to manage. Was it a really unusual case of CHF, or did he have a lot of other comorbidities that made it hard to manage?

The GYN patient - did they check an ultrasound before automatically referring to GYN? Evaluate the endometrial stripe? Check for fibroids? Do a bimanual?

I've gotten more cautious at just automatic referrals. Not just because I need to learn how to be a better PCP, but also because a lot of the insurance plans around here have doubled their copays for specialists. I've had patients tell me that they just can't afford the $40 or $60 that they have to pay to see their specialist. Which puts more of the burden of management on me.

I think the way you run your practice is admirable. Yes we checked a PSA, yes we did a pelvic exam for fibroids (no US machine in the office), the guy with CHF had everything possible wrong in the world with him and his presentation was, while typical, not consistent with the severity of his symptoms so yes he had to be referred. We made the decision to refer him to urology because of his severe retention and strong family history. His PSA came back elevated (no surprise) but you know what a crappy test that is, so the urologist confirmed. Surprise surprise he's having a TURP done to free up his prostate... that should hopefully give us some info on whether it's neoplastic.

And mind you we always check before referral as to who takes their insurance and whatnot.

But in any case my point still stands... whether you make referrals for some of your patients or most of your patients the fact is that specialists are an absolutely integral part of medicine and an essential part of the workup in most of these patients.

Plus like it or not... defensive medicine is practiced for the most part... so it's a safer decision to refer for the practice than otherwise.

 

[soeagerun2or]

Couldn't an NP or PA handle all the easy stuff and be the one handing out all these referrals? Doesn't it seem like 4 years of undergrad, 4 years or med school, and 3 years of residency is a waste just to be handing out referrals all day? Perhaps those who go into FM are not the noble ones after all. Perhaps they're the ones wasting a spot in med school just to go do something an NP or PA could do, and specialists are the noble ones who are actually helping patients?

Before everyone get's all upset, I'm just trying to irritate soeager into getting his/herself completely banned.

Interesting you say that, as it is often the response of the medical community.

Personally, I care little about this but those of you in anesthesia, radiology, and primary care might want to look in to it. In some states, they can practice independently.

 

[smq123]

Do you feel concerned that if you don't refer some one to a specialist and something you though was routine and easy to manage wasn't and something went wrong, that you could get sued? This is a serious question. Couldn't they claim you weren't qualified and that lead to the bad outcome?

No, it's a good question, and I don't take offense to it.

Medico-legally, you'll probably never go wrong by referring to a specialist right away on almost everyone. It's less mentally stimulating, but that's secondary in this particular discussion.

I don't think they can successfully claim that you're "not qualified," as long as you're a licensed physician. To win a malpractice suit, they have to prove that you deviated from the standard of care. A PCP doing, say, bloodwork to check a PSA or managing fairly typical CHF is not a deviation from the standard of care. A PCP removing a gallbladder in his office, though, definitely is.

Part of the hard part of being a physician is learning how far to go without putting patients in jeopardy. And that's true of all physicians.

For instance, there was a delivery in the hospital a few weeks ago. The OB was having a hard time getting the baby out. Rather than call for forceps, he called another OB, who is older and more experienced, to come and help him. Now, is an OB "qualified" to deliver a baby? Of course. Is an OB, any OB, "qualified" to deliver a baby with forceps? Of course. But this particular OB said that he hadn't delivered a baby with forceps for many many years, that he didn't feel comfortable, so he called for help. He knew how far he could go without putting a patient in jeopardy.

 

[smq123]

But in any case my point still stands... whether you make referrals for some of your patients or most of your patients the fact is that specialists are an absolutely integral part of medicine and an essential part of the workup in most of these patients.

Oh, definitely. No argument here. 🙂

And mind you we always check before referral as to who takes their insurance and whatnot.

I'm glad that you guys do that. However, whether or not the specialist accepts the insurance is not always the issue.

I rotated in an outpatient cardiology office, a few weeks after many of the local insurance carriers increased the copay. The cardiology group STILL accepted the same insurance plans. But a lot of their patients were calling saying that they had been planning to come while the copay was still $20 or $25...but now that the copay was $50, they couldn't come in, because they couldn't afford to pay the copay before each visit. They were going to come in only once a year, instead of twice, etc. I mean, when you're elderly and on a fixed income, $50 is a lot.

It's a crappy system.

 

[lrkoehle]

No, it's a good question, and I don't take offense to it.

Medico-legally, you'll probably never go wrong by referring to a specialist right away on almost everyone. It's less mentally stimulating, but that's secondary in this particular discussion.

I don't think they can successfully claim that you're "not qualified," as long as you're a licensed physician. To win a malpractice suit, they have to prove that you deviated from the standard of care. A PCP doing, say, bloodwork to check a PSA or managing fairly typical CHF is not a deviation from the standard of care. A PCP removing a gallbladder in his office, though, definitely is.

Part of the hard part of being a physician is learning how far to go without putting patients in jeopardy. And that's true of all physicians.

For instance, there was a delivery in the hospital a few weeks ago. The OB was having a hard time getting the baby out. Rather than call for forceps, he called another OB, who is older and more experienced, to come and help him. Now, is an OB "qualified" to deliver a baby? Of course. Is an OB, any OB, "qualified" to deliver a baby with forceps? Of course. But this particular OB said that he hadn't delivered a baby with forceps for many many years, that he didn't feel comfortable, so he called for help. He knew how far he could go without putting a patient in jeopardy.

Thanks for your response.

 

[jdh71]

Man, just when I was set on IM/Heme-Onc. I need to re-re-re-reconsider Rads again

This thread is hilarious.

For you guys out there:

Ortho-->Gets Jessica Alba
Family-->Gets to google Jessica Alba

Heme/onc is a really good way to make a living. My point was out-patient, primary care IM isn't worth it, in my opinion, unless you're on a mission to save the world.

 

[Jolie South]

Crappy? If you have a high suspicion for BPH but can't confirm it via prostate exam, unless you have a rectal ultrasound i'm not sure how else you would confirm it.

I know this is far from the point of the thread, but. . .

I haven't seen TRUS used for BPH dx. In the office, we've used PSA, U/A, flow rate, and PVR along with history and DRE.

The size of the prostate does not always correlate with the severity of LUTS either. All you need is hyperplasia surrounding the prostatic urethra to get symptoms. Conversely, some people have huge prostates with minimal symptoms.

 

[coldweatherblue]

yeah how many guys on flomax for "BPH" have path-confirmed biopsy?

guy comes in, can't pee, +nocturia, +hesitancy, etc. PSA < 4.0, large prostate on DRE... otherwise asymptomatic.. he's gonna get started on an alpha-1 blocker without any kind of uro consult unless he has great insurance and requests it. no point in doing a bx unless indicated for CA.

 

[carolinablue]

Okay, so if your in-state school costs $10k/year, good for you. I go to a state school that costs $33k/year (and $40k for 3rd year). I also have 3 kids, and take out maximum loans. I'm not concerned with "making bank". I need to have enough money to live comfortably with my kids, so yes, debt is a huge issue to me. I am somebody who could very well go into primary care--I don't know, since I'm not nearly at a place in my training where I could know, but it's a real possibility. But primary care peds simply doesn't pay well. My kids' pediatrician hardly even draws a salary anymore (she has a husband who makes a ton so she can do that, but she also works more than full-time and is always happy to take calls on the weekend and once even met us in a grocery store parking lot on a Sunday to see my then baby's rash--she's that kind of doctor), so she can pay her staff well and the other younger docs in the practice can make enough to live comfortable off of.

That said, and in reference to the OP, this same pediatrician has never once suggested to me that I shouldn't go into primary care, nor have the other docs in her practice. In fact, they encourage me to. But I don't think I need to justify to anybody why I would consider specializing just so I could have an easier way to pay off my loans and live comfortably.

In agreement with the family medicine resident, the flexibility is one reason a friend of mine is glad he went into IM. He currently does shifts in an urgent care because he is seriously pursuing another interest, and he has a lot of time for his family. He will readily admit that the urgent care routine can get a bit dull, but overall he's very content with where he is professionally.

i yeah i can see where your coming from.....i guess its just because i'm 23, single, and am fairly cheap...to me, a salary above 50k a year is great....all i want in life is to lease an a5 coupe, a small apartment in a nice city, and some cash to finance art projects i couldnt afford to make during college lol....the problem with loans is interest...my religion forbids messing around with interest (its a corrupt system where people make money from....doing nothing..) but for med school there is no option but to get at least half my tuition from loan money..it sucks big time...i have no big problem with a family doctor making 150k...i think its messed up that residents get 45k for several years...i wanna make money while im young so bad, but i know i cant have my cake and eat it to...i dunno...i still have this belief that if you put your heart into helping others (by being a damn good doctor whos compassionate), good things will happen...its just how the world works....

things will be alright guys....negative people will always be negative...they complained in highschool about the SATs....they complained in college about the MCAT and their organic professor....they complain in med school about the long hours of studying....being negative is a choice.....i guarantee that you wont go a day without having something to eat...your good bro...your gonna be a freakin doctor....like seriously, how sweet is that?

 

[2012mdc]

Man, just when I was set on IM/Heme-Onc. I need to re-re-re-reconsider Rads again

This thread is hilarious.

For you guys out there:

Ortho-->Gets Jessica Alba
Family-->Gets to google Jessica Alba

Umm neither gets jessica alba

 

[cowme]

Umm neither gets jessica alba

If you get a good training in plastics, you could mimic some of her features