Why are primary care physicians paid significantly less than specialists?

[45408]

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You're forgetting internal medicine, which is pretty much dead in the middle. And I'm not arguing that proceduralists work fewer hours, I know they don't and it is represented in the data.

I did overlook IM, but 100 hours per year? That's 2 hours a week.

 

[Substance]

Primary care will always be paid pittance compared to most specialists.

Our medical system has grown very fond of measuring worth by volume, and valuing procedural work over cerebral/social. Primary care is low volume social work.

Family doctors are essentially gatekeepers, and most of their work is seen by the bureaucrats to be necessary, but pedestrian, hence the rise of noctors.

The RVU committee is mostly proceduralists, so of course the procedures will get higher remuneration.

Practicing true family medicine is a cost-prohibitive affair. Those that go into family medicine generally choose not to practice it, instead opting for encroachment on other fields such as emerg, pain, derm, cosmo, etc.

The idealistic save-the-world mentality of academic primary care zealots runs counter to the trend of specialization and to the interests of medical students. Medical students do not see this as inspiring but instead as delusional. Academic family medicine departments are often seen as laughing stocks by both students and staff.

I say we just let the nurses have primary care. MDs don't want it. IMGs want it because its their only way in. Nurses are cheaper. Most of it is cookbook. There's the savings.

 

[Smokemont]

Primary care will always be paid pittance compared to most specialists.

Our medical system has grown very fond of measuring worth by volume, and valuing procedural work over cerebral/social. Primary care is low volume social work.

Family doctors are essentially gatekeepers, and most of their work is seen by the bureaucrats to be necessary, but pedestrian, hence the rise of noctors.

The RVU committee is mostly proceduralists, so of course the procedures will get higher remuneration.

Practicing true family medicine is a cost-prohibitive affair. Those that go into family medicine generally choose not to practice it, instead opting for encroachment on other fields such as emerg, pain, derm, cosmo, etc.

The idealistic save-the-world mentality of academic primary care zealots runs counter to the trend of specialization and to the interests of medical students. Medical students do not see this as inspiring but instead as delusional. Academic family medicine departments are often seen as laughing stocks by both students and staff.

I say we just let the nurses have primary care. MDs don't want it. IMGs want it because its their only way in. Nurses are cheaper. Most of it is cookbook. There's the savings.

Wrong. Generally, they are forced.

The reason primary care is paid less is because, as you have stated, the makeup of the RUC. It's as simple as that. Even specialists admit the way reimbursements are set is ****** up. But guess what, human greed will always win out in the end.

 

[KinasePro]

Wrong. Generally, they are forced.

The reason primary care is paid less is because, as you have stated, the makeup of the RUC. It's as simple as that. Even specialists admit the way reimbursements are set is ****** up. But guess what, human greed will always win out in the end.

Don't you think the average person values, say, a knee replacement more than a 10 minute conversation about losing weight? What about a simple knee injection vs a lecture on remaining compliant w/ blood pressure medications? Part of the reason PCPs aren't paid well is because the public doesn't value primary care very much, IMO. Specialists are able to game the RUC because they can actually get away with it. I don't think it's simply because there are more of them on the committee.

 

[Smokemont]

Don't you think the average person values, say, a knee replacement more than a 10 minute conversation about losing weight? What about a simple knee injection vs a lecture on remaining compliant w/ blood pressure medications? Part of the reason PCPs aren't paid well is because the public doesn't value primary care very much, IMO. Specialists are able to game the RUC because they can actually get away with it. I don't think it's simply because there are more of them on the committee.

If the average person needs a knee replacement then yes I imagine they would value it more. I'm not saying that specialists should earn less, as I believe the majority of them earn their money.

Don't you think the average person values a doctor that takes the time to sincerely talk and explain to them their condition, listens to their concerns with empathy and makes it there goal to prevent said condition from, say, developing into CHF? What do you think would be the biggest complaint against doctors if you surveyed the average person. My guess would be some form of "my doctor makes me wait and then doesn't spend enough time with me." Isn't medicine supposed to be a public service profession? If this is true then shouldn't we fix this? Well the only way to fix it is to change how primary care doctors are reimbursed.

It is the average person's myopic view of their health and our reactive focused system that devalues primary care. Once again, I have nothing against specialists, as they are critical.

 

[Pons Asinorum]

I think some do, hence the rise of concierge arrangements, Rob Lamberts, etc. But the average person? No, they don't, because they don't do much signaling that feeling with their wallets. Nothing about our current PCP system indicates that it MUST be the way that it is. If people valued primary care as much as they valued their cable tv package, they would spend the same kind of money on it. They don't/won't though.

 

[SpecterGT260]

Um no. The junior attendings in surgery work more hours than the residents. ACGME duty hour caps put ceilings on what residents and fellows can work but as soon as you are an attending those caps are gone. The younger attendings do the lions share of call for their group, and so topping 100 hours a week is not that unusual while "paying your dues" as a junior attending in a group. You will see attendings up all night doing emergency cases and then still have to do a normal work day the next day, while residents aren't allowed to go beyond 28 hours in a row under the current rules.

My comment was mostly tongue in cheek. I don't know all the exceptions. I just know that the surgeons I have worked with (who are more senior) have families they go home to every night.

 

[KinasePro]

Don't you think the average person values a doctor that takes the time to sincerely talk and explain to them their condition, listens to their concerns with empathy and makes it there goal to prevent said condition from, say, developing into CHF? What do you think would be the biggest complaint against doctors if you surveyed the average person. My guess would be some form of "my doctor makes me wait and then doesn't spend enough time with me." Isn't medicine supposed to be a public service profession? If this is true then shouldn't we fix this? Well the only way to fix it is to change how primary care doctors are reimbursed.

My general gestallt regarding primary care is that for every patient that really wants to truly utilize their PCP & receive good health counseling, there are 2-3 patients that just view their PCP as a means to an end. They want a referral, paperwork signed, antibiotics, pain meds, sildenafil refills, etc...

Ideally, the PCP would be the physician you describe, and I have seen many like this who are awesome at what they do. But many patients aren't looking for this service IMO. They think they already know what they really need from the healthcare system, and would ultimately prefer to have their heart failure managed by their favorite cardiologist, thankyouverymuch 🙄.

These days, we're more like auto-mechanics of the human body than trusted & revered experts on esoteric topics. The cognitive work offered by PCPs is devalued because patients (erroneously) believe they can find it elsewhere (Dr. Google). That's just my $0.02 though, as an MS3 who's rotated through primary care recently.

It is the average person's myopic view of their health and our reactive focused system that devalues primary care. Once again, I have nothing against specialists, as they are critical.

Agreed, and I think this relatively common attitude contributes to the salary gap. I just think that the lament we hear from AAFP and other primary care organizations that the RUC is at fault for the salary discrepancy is too much of a simplification.

 

[Law2Doc]

My comment was mostly tongue in cheek. I don't know all the exceptions. I just know that the surgeons I have worked with (who are more senior) have families they go home to every night.

Where Ive worked, while they go home to their families for dinner, some inevitably end up coming back to the hospital each night to do cases. It's not the "exception" -- taking the lion's share of the call is the rite of passage for junior partners at MOST practices. The guys you know who are more senior paid their dues, but frankly the pyramid has a lot more levels than it did when they were junior, such that people stay junior for quite few more years then when they started. So yeah, a ton of people do see their hours jump up, not down, when they emerge from the duty hour restrictions of residency. I know quite a few guys who talk with nostalgia about all the free time they had during residency.

 

[SpecterGT260]

Where Ive worked, while they go home to their families for dinner, some inevitably end up coming back to the hospital each night to do cases. It's not the "exception" -- taking the lion's share of the call is the rite of passage for junior partners at MOST practices. The guys you know who are more senior paid their dues, but frankly the pyramid has a lot more levels than it did when they were junior, such that people stay junior for quite few more years then when they started. So yeah, a ton of people do see their hours jump up, not down, when they emerge from the duty hour restrictions of residency.

I wasn't intending to argue with you on it. Just stating where the comment came from. Thanks for the info 👍

 

[Law2Doc]

I wasn't intending to argue with you on it. Just stating where the comment came from. Thanks for the info 👍

Just keep in mind that 80 hours a week can go by in a blink if some of your days are 24-28 hours long each week. Before they did away with 30 hour call shifts, the 2 calls a week ate up most of your duty hour limit, so you actually ended up in the hospital fewer days each week then now. So it's not the total number of hours but how they are concentrated that may matter most.

 

[John Lannister]

Just keep in mind that 80 hours a week can go by in a blink if some of your days are 24-28 hours long each week. Before they did away with 30 hour call shifts, the 2 calls a week ate up most of your duty hour limit, so you actually ended up in the hospital fewer days each week then now. So it's not the total number of hours but how they are concentrated that may matter most.

True, it would be much better to live at the hospital.