Why does everyone hate primary care?

[old blue]

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I would love to hear of specific reasons - I usually only hear vague ones.

One thing I do hear about is large amounts of paperwork. But isn't this now true of ALL specialties?

 

[mpp]

For me it's the fact that you train for a long time to use the extra skills you've learned (beyond the PA or NP level) about 1 percent of the time, if that. The vast majority of visits to the primary care provider are URI/UTI/Pharyngitis/Minor muscluloskeletal pain/Managing HTN/Managing diabetes/Managing depression. There are some complicated issues that come up, but it is uncommon and the vast majority of what you do is porotocol...something that someone that can read the protocols, do a half-way decent physical exam/history, and checks the patient's allergy list before prescribing can do. I can't spend this much time training to end up doing what a PA, or even a halfway decent nurse, can do just as well as I can.

 

[juddson]

This is just my impression of why people who don't like primary care don't like it. The top ten reasons:

1. Money
2. Money
3. Money
4. "I don't like working with people"
5. Money
6. Money
7. Money
8. What mpp said
9. Money
and
10. Money

reasons 11 through 25 are "Money".

Judd

 

[kinetic]

...said the person who has never done primary care. Thanks for your insight, Juddson.

Income is undeniably a part of it for many, if not most, people. But the main issue is that you have to see lots of people, most of whom have non-specific, chronic, or silly (like a one-day cough or a runny nose) problems.

As far as money, though, that will likely soon change because the pendulum of supply and demand swing back and forth between specialists and GPs all the time. With everyone subspecializing these days, GPs are going to soon be in high demand and likely their salaries will rise. Purely anecdotally, I have heard of some people who are GPs in underserved areas who make money hand over fist; but if you want to remain in a large urban area, that probably will never happen.

 

[kappasigMD41]

I think it is money and the time you have to spend to make the money. My preceptor is a 58 yo internal med doctor who works in a small group of 4 dr's. He works 5 days a week from 6 am to 6 pm, and takes his own call on the weekends. He averages a 70 hr work week. This doesn't seem to mad now, but I don't want to be working that much when I'm 58!!!!! When I asked him why he worked so much he said he had to if he wanted to make any profit. He is a very good man, and takes a lot of patients with medicare and tenncare, so money is not his only motivation. But at the same time he kills himself. He told me he has to work twice as hard to make half the money he did twenty years ago. I am convinced that IM is not for me.

 

[cytoborg]

My vote is with kinetic and mpp - it's the type of problems that primary care docs see. Hypertension, diabetes, arthritis, headache, vague pain complaints, URI, etc...after a while, perhaps a bit boring for some. Don't get me wrong, it's very important work, but maybe not so stimulating from an intellectual standpoint. As someone mentioned, the treatments are all embedded in guidelines and you pretty much just follow the flowchart - "first try x, if it doens't work, try y, if this comorbidity present, use z." Then when cool stuff finally happens, you turf it to a specialist. Patients demand to see specialists even for basic things like managing depression which can be annoying. And of course, there are the drug seekers, the personality disorders, etc. whom you are forced to interact with over the long term. Income is yet another reason. I've heard a lot of people say, "I don't want to end up managing hypertension and getting paid squat." Average incomes for primary care are much lower than procedure-based specialties (however as someone pointed out, there are always exceptions, and there are myriad practice environments and niches.)

It should be noted that EVERY area of medicine is fairly algorithmic, and EVERY specialty has its boring aspects. You know what the vast majority of a GI specialist's work is comprised of? Irritable bowel syndrome. Yep. And I'd be willing to bet that neurosurgeons see mostly chronic pain patients. At least they have procedures mixed in for entertainment, which primary care just doesn't have, outside an isolated punch biopsy, cyst drainage, cortisone injection, etc. So a lot of people use the procedures vs. no procedures criteria for choosing primary care or not. A lot of people say that the great thing about primary care is that you get to know your patients over the long-term which can be very rewarding. However, you can also get that in other specialties - such as transplant surgery, rheumatology, oncology, to name a very few.

 

[old blue]

Thanks for the replies.

2 reasons given and my thoughts:

1) Money: ALL specialties deal with Medicaid/ reimbursment issues so isn't this this a nonissue (procedures not withstanding)?

2) Protocol driven practice: Specialty tx actually follows algorithms moreso than prim care (cardiologist working up a fib, GE w/u diarrhea, etc). Plus, those guys see the same diseases day after day, year after year, which drives them to follow the algorithms.

Am I wrong?

 

[b&ierstiefel]

I think many or perhaps all medical specialties, primary care or tertiary care or whatever, are very algorithmic in nature; likely due to ensuring standardized care or maybe given the litigious nature of our society. If you don't wanna deal with algorithms based on already discovered knowledge, perhaps go the research route and create new knowledge. Of course, you don't get paid squat for doing so.

Personally, I was frustrated with the algorithmic approach to medicine. But I understand why it has to be done. But, this approach to patient care is mind-numbing and limits creativity and outside-the-box thinking.

 

[doc05]

primary care sucks because of (1) poor income compared to hours worked; (2) it's more mind-numbing than any other specialty; (3) you're the patient's primary doctor, which means they call you first, often with nonspecific or silly complaints.

keep in mind that long-gone are the days when patients actually respected their doctors.

 

[Smurfette]

Personally, after rotating through all the different specialties, the reason why I am not going into primary care has NOTHING to do with money. Most of my classmates who are not going into primary care do not care either. Keep in mind that while primary care fields may not pay as well as others, those fields still make a damn good living, especially compared to the population at large.
I can't think of a single person in my class who loved their primary care rotations (FP, IM or peds) who is not going into that field b/c it doesn't pay well enough. By the way, psych and PMR (among others) also pay about what primary care does.

Personally, I do not like the primary care/clinic-oriented specialties b/c most of the day is URI, back pain, diabetes check, HTN check and so forth. Too dull for my tastes. I realize that there are exceptions to this, but overall, I like a different type of variety. I like talking to people, I like helping them, but I like to be more hands-on than simply tweaking someone's insulin for the upteenth time or adding another anti-HTN med to the patient's regimen. Some people enjoy this long-term care aspect of primary care; I like more acute, fix-it-now type of cases and am happy to let others deal with the patients with chronic back pain and fibromyalgia who need better pain control or diabetics with HA1c's of 9 needing better glucose control. I am very grateful for the primary docs out there who take care of this stuff so I don't have to!

It's just different preferences...thankfully medicine is broad enough to let us all focus on the areas we find most gratifying.

 

[docB]

1) Money: ALL specialties deal with Medicaid/ reimbursment issues so isn't this this a nonissue (procedures not withstanding)?

Am I wrong?

Yes. Even though all specialties deal with the government primary care docs work really hard for comparitively little money. The same person could make more per hour doing something else. The other big reason not to go into primary care is the ever increasing pressure to see more than one pt every 10 minutes. Again that has to do with money but it all boils down to working too hard for what you get.

 

[roja]

I think your question is a little bit leading. I can tell you why I chose not to go into primary care. However, I have a number of friends that love it. The only think that keeps them in residency is the thought of being done and getting into the clinic.

I find clinic phenominally boring. It'sl like pull;ing teeth for me. Its slow, involves alot of routine stuff adn doesn't move fast enough. But that's why I'm in EM.

Good primary care docs are really wonderful. You really won't know until you do it.

Different things appeal to different people.

 

[kristing]

Thanks for the replies.

2 reasons given and my thoughts:

1) Money: ALL specialties deal with Medicaid/ reimbursment issues so isn't this this a nonissue (procedures not withstanding)?

Am I wrong?

The reimbursement is different for the complexity of the issue, the type of issue (procedure vs non-procedure), as well as if the complaint has not been able to be managed by a PCP so has been sent over to a specialist. Then the reimbursement goes up for a specialist vs a PCP treating the same thing.

 

[PCN]

I would like to put my 2cents into this discussion. I always used to think that people who go into primary care are the ones who don't do well on their boards, get into poor IM residency and can't get fellowships or are FMG. I have realized that actually this is not true. One has to have a certain personality. I am in a situation where I have done very well in med school with research and 1st author pubs and am interviewing at some of the more prestigious places for IM. I am pushing the idea that I am interested in subspecializing during my interviews b/c that is what I feel many of the programs I am applying to want to hear. I am truly interested in a certain subspecialty, however, deep inside I really like primary care and am still thinking about it.

I have a few things to say about primary care. I would encourage people not to do Family Medicine b/c you are not going to be considered a specialist but rather a generalist, while IM is still considered a specialty. It is harder to get a job as FM doc. If you like peds and meds, do meds-peds (just one extra year). In regards to the money issue, I think it is all about how you run your practice. In my Fam Meds rotation I rotated with a guy who had a Royce, and 4 other very expensive cars. He owned his own building, rented out some space to other docs. He did many little procedures. He had a room which he called his "heart transplant" room where he did his sigmoids, his I&D, knee taps, injection... He had his 2D echo machine and had a tech come in once a week. He billed for all of this. In contrast to this I did my continuity clinic with an IM doc who was very laid back and did not want to bother with stuff. He didn't even have an X-ray machine and sent all his patients to the radiology center across the street. He did not have a nurse, did all blood draws by himself... He told me that his overhead was very low and he did not work hard, did not make a huge profit, but lived comfortably. I believe he made somewhere in the $150,000.

I think the nice thing about primary care is that you can steal a lot from the specialists if you are willing to learn and invest time and money. Procedures make money and if you look at the way billing works, a simple I&D is considered surgery just like your lap chole. Ok, the reimbursement is obviously not the same between the two, but this 10 min procedure is going to get you good cash in your pocket. Plus, if you buy up your own equipment, like holter monitors, x-ray machine, electrocautery, endoscopes... you can bring home some bacon. Don't forget you can do your GYN stuff and make some procedural reimbursement also.

In regards to the ? lack of challenge in Prim Care, I would disagree. It all depends on how you want to run your practice. If you want to go to the hospital more and see your HF patients, fistulizing Crohn's patients, ESLD cirrhotics... you can do that. If you don't want the challenge you hand them off to a hospitalist to do all your inpatient admissions and you work 9-5 4 days a week and still make a living if you know how to run your practice. My feeling is that in Prim Care you can get involved as much as you want in patient care. If you just don't want to read and keep up with stuff, then you send your patients to a specialist. I have seen Gen IM docs do a lot by themselves and only rarely consider sending their patients to a specialist if they needed a procedure like hip replacement, colonoscopy, or a cath. Think about it, if you are a gen IM doc you can take care all of your rheum patients. It’s not that hard if you read. You can do your own knee taps, injections. If you are willing to read a bit about derm you can also do 90% of what a dermatologist does in his office as a PCP. You don't have to refer. However, a lot of docs are not willing to invest the extra money into their own education, and equipment and then cry about not making enough. I think it is all up to you. Also remember that if you do Gen IM for example, you don't have to waste an extra 3-4 years doing a fellowship. If you are the type of person who can pick up a book and learn how to do a procedure or two and how to bill the correct way you will be well off. Someone once told me that the most important person in a doctor's office is not the doctor, but the biller.

Anyway, sorry for the long explanation.

Check out this website, it gives good tips on how to run your own practice, http://www.memag.com/memag/

PCN

 

[Finally M3]

By the way, psych and PMR (among others) also pay about what primary care does.

However, we don't have to work as many hours for the same amount of compensation. That, and we always can become an EMG or injection mill and make lots of money...and become a robot

 

[PCN]

I disagree. I am not absolutely sure that prim care is for me, but I know there are good opportunities threre if you are smart. First, as far as the hours, you will never do 6 to 6, 6 days/week like a cardiologist. Although, I guess PM&R has the best hours, so you win. Second, people should not be stuck on the idea that to make money it has to be direct patient care related. You will have more time, and if you are smart, you will invest in equipment, realistate... and make as much if not more then any specialist. You don't have to become a robot and feel that you will only make money off of injections. That is kind of stupid.

PCN

However, we don't have to work as many hours for the same amount of compensation. That, and we always can become an EMG or injection mill and make lots of money...and become a robot

 

[pockey]

PCN is right on. A lot of people get hooked on average salary statistics and think that's what they're going to make. But if one takes the time to understand how to bill, become business savvy, and learn office procedures, then a primary care doc can make quite a bit of money.

I also agree what PCN said about the intellectual challenges of primary care. If an IM or FM doesn't read, doesn't commit themselves to continually learning, and is content to just refer away, then they're not challenging themselves (also money may be lost if the patient is in an HMO). But the good IM/FMs, do most of their own medical management, biopsies etc. They view the specialties such as GI or Cards as "technicians", meaning, they'll refer to them for a cath or colonoscopy, but otherwise, are able to handle the med management themselves.

My view is that primary care is the most difficult field, because you have to know something about everything. Perhaps that is why people avoid it. Who knows. It's personal preference I guess.

 

[undecided05]

PCN has a good general view, but some misguided points I think... Briefly, the PCP with the cars, property, bling-bling did not make that money through his medical practice. Where docs and this is most docs make their big cash is through other business investments; without knowing the PCP, I'd bet on owning the properties. Great time for land owners.


Also, another reason why many don't go to primary care is that many of us have egos. People like being the best at what they do. No PCP is going to be as qualified as a GI doc or cardiologist when it comes time to actually dealing with a complicated issue.


As for reimbursements, I believe it's been well covered by others earlier in these posts. But one thing I've seen consistently, is that many docs actually undercode. Friend of mine just started using an EMR system and realized that he could code up for many of the visits he was doing. When another physician accused him of screwing over other docs by overbilling, my friend pointed out that in actuality it was the other doc screwing over others by not billing enough.

 

[Disciple]

By the way, psych and PMR (among others) also pay about what primary care does.



I disagree, somewhat.

Inpt. PM&R will average slightly more than primary care.

Interventional PM&R including a good number of EMGs/NCVs can start at anywhere from $200K-400k.

 

[PCN]

wouldn't even try to argue that with you. Like I said, it takes a certain personality to be in primary care. If you got your ego issues then that is the way you are going to choose your specialty. There is nothing wrong with that. I have my own ego issues that are pushing me towards a particular subspecialty. Yet there is still that little voice inside that is telling me I'll be happy doing gen IM. I guess it is not as clear for me as it is for other people what I should do.

PCN

PCN has a good general view, but some misguided points I think... Briefly, the PCP with the cars, property, bling-bling did not make that money through his medical practice. Where docs and this is most docs make their big cash is through other business investments; without knowing the PCP, I'd bet on owning the properties. Great time for land owners.


Also, another reason why many don't go to primary care is that many of us have egos. People like being the best at what they do. No PCP is going to be as qualified as a GI doc or cardiologist when it comes time to actually dealing with a complicated issue.


As for reimbursements, I believe it's been well covered by others earlier in these posts. But one thing I've seen consistently, is that many docs actually undercode. Friend of mine just started using an EMR system and realized that he could code up for many of the visits he was doing. When another physician accused him of screwing over other docs by overbilling, my friend pointed out that in actuality it was the other doc screwing over others by not billing enough.

 

[undecided05]

by the way, I don't "hate" primary care... just not for me. Maybe I'm bored with it. 95% of the stuff that comes in is chronic problems that seems like there is little a physician can do to actually "cure" the patient. Not to over-minimalize it, but primary care to me is mostly managing chronic problems (most of which could improve if not for wide-spread non-compliance).

My favorite example is the 300 lbs COPD patient who c/o SOB but smokes 2 packs a day, doesn't like O2 b/c it burns the nose, doesn't like steroids b/c they keep the patient up at night, doesn't want to do any exercise or lose weight, but wants you to do something for them when they're not willing to do anything for themselves.

 

[erichaj]

Many medical students who went into primary care for the love of it. still love it, but wish they had not chosen to go into it.

This is becasue it wears you down. You work long hours and get paid the least.

Most of those Primary care doctors have to work extra hours to make a profit in their private practice.

As far the income goes to the general popullation,

Well, NP makes 90000 per year for far less work and education.

Pa makes 60 k for a bach. degree

Md has 4 years of undergrad/4 medschool/3 residency and tons of student loans. When you add it up. we get paid less than the above.

 

[roja]

Also, another reason why many don't go to primary care is that many of us have egos. People like being the best at what they do. No PCP is going to be as qualified as a GI doc or cardiologist when it comes time to actually dealing with a complicated issue.

i disagree. there are some really superb FPs out there that really shine. they are truly the best at what they do. and there are tons of crappy ones

 

[Fermata]

Although I usually don't like to be serious on these forums, I felt inclined to give my 2 cents on the matter since I've practiced IM in the recent past--and perhaps--have more experience than most of you. I agree with most of what has been said--except income. Although primary care tends to be a lower paying specialty on average compared to others, it is by no means "low paying". My first year after residency, I made 160k while working 33-45hrs/week and only 1 mandatory call/month. 2nd year I made 180k, 3rd year 195k. Others in my group(who are older, partners, and have been practicing for longer) were making 240-300k. While this is certainly not the level of a neurosurgeon's income, it compares more than favorably to many other specialties. Yes, you may argue this is unusual for primary care, and blah blah blah there are exceptions to every specialty, but the numbers I quoted above are in fact the incomes of Internists at one of the largest HMOs in the country. Why did I leave Internal Medicine if everything was so 'terrific'? It wasn't, and for many of the same reasons listed by posters in this thread I felt it was a good idea to get out of primary care. Income, however, was not one of the reasons.

Out of curiousity, about how much time did you have per patient?

 

[Doctor B.]

I didn't choose primary care b/c I didn't enjoy dealing with the multiple social and personal issues of many patients. In just the relatively brief time of medical school, I got tired of telling patients to quit smoking again and again and again. I'm not condemning it or belittling it but it just wasn't what I enjoyed.

 

[Finally M3]

You will have more time, and if you are smart, you will invest in equipment, realistate... and make as much if not more then any specialist. You don't have to become a robot and feel that you will only make money off of injections. That is kind of stupid.

PCN

I'm speaking directly about profitability in the medical field. You get the most reimbursement per time spent with patient by doing interventional procedures, be they diagnostic or therapeutic. However, doing 10 scopes a day or 20 epidural injections a day is deathly boring (thus the robot comment).

And of course how much money you make is gonna be dependent on how you run your practice and how you invest your money...but I thought we were talking about medicine, not investing.

 

[banner]

What I think everyone has to remember is that the population who tends to show up in doctor's offices the most are attention seekers with silly complaints which probably everybody else has, but they don't obsess about it. Sure, not everyone is like this, but if you were such a person, where would you go to satisfy your need for an authority figure to take care of you? MDs office of course, because nobody else would tolerate this nonsense.

A specialist has the advantage of limiting their interactions with these individuals. Whereas, a primary care MD becomes a surrogate mother/father.

Here's an anecdote to show you what I mean. I have a friend who is an FP. He gets a call at 3 AM from a patient whose electricity was turned off because the patient didn't pay the bill in two years. The patient says to the FP that she is thinking of killing herself because the power is off. So the FP has to call the power company and beg them to turn the power on for the night.

No cardiologist or GI or surgeon would have to deal with that.

 

[kappasigMD41]

What I think everyone has to remember is that the population who tends to show up in doctor's offices the most are attention seekers with silly complaints which probably everybody else has, but they don't obsess about it. Sure, not everyone is like this, but if you were such a person, where would you go to satisfy your need for an authority figure to take care of you? MDs office of course, because nobody else would tolerate this nonsense.

A specialist has the advantage of limiting their interactions with these individuals. Whereas, a primary care MD becomes a surrogate mother/father.

Here's an anecdote to show you what I mean. I have a friend who is an FP. He gets a call at 3 AM from a patient whose electricity was turned off because the patient didn't pay the bill in two years. The patient says to the FP that she is thinking of killing herself because the power is off. So the FP has to call the power company and beg them to turn the power on for the night.

No cardiologist or GI or surgeon would have to deal with that.

While that is silly and really sucks, I don't know if it is a very good argument for not going into primary care. At least your friend cared enough to help the person, which is after all what we are supposed to do.

 

[margaritaboy]

The title of the thread is a bit leading. I happen to like primary care, and liked my primary care rotations in medical school. Ultimately, I chose Emergency Medicine, but I probably would have been happy in more than one field (hence EM, where I get to do some of everything).

I met a number of happy, well compensated FPs who were very knowledgeable and good at what they did. Also, if you own your own practice, you get to set your own hours. For the most part, work was low stress and the docs had balanced lives.

It's not all bad. 👍

 

[CambieMD]

primary care sucks because of (1) poor income compared to hours worked; (2) it's more mind-numbing than any other specialty; (3) you're the patient's primary doctor, which means they call you first, often with nonspecific or silly complaints.

keep in mind that long-gone are the days when patients actually respected their doctors.

The above quote says it all. I have worked in primary care for 3.5 years and can't wait to leave. The one omission by the poster was the red tape which should be #4. Do not buy the taking care of the whole pt thing that they are telling you in med school.

CambieMD

 

[CambieMD]

I am amazed that med stuents will read all of these posts and still choose primary care. Before they complete residency they will know that they have made a mistake. You have been warned.

CambieMD

 

[banner]

While that is silly and really sucks, I don't know if it is a very good argument for not going into primary care. At least your friend cared enough to help the person, which is after all what we are supposed to do.

Well, sure there is an optomistic way of looking at that story, as you point out. But one should really be okay with dealing with issues like that if interested in priamary care. The optomism should feel natural and not have to be forced or intellectualized.

Personally, I would feel like I'm wasting my time and losing sleep for nothing, as my friend did. I would have difficulty mustering up sympathy for people like that. I think over-achievers tend to have difficulty relating to this type of person, which may explain why a significant amount of Docs don't like primary care.

But, there are some out there who like it.

 

[Smurfette]

I am amazed that med stuents will read all of these posts and still choose primary care. Before they complete residency they will know that they have made a mistake. You have been warned.

CambieMD

Wow...I have no interest in primary care, but this almost makes me want to go into FP and like it just to spite this post.

Many people in many specialties end up miserable. Some primary care docs may be miserable, but I know several surgery, psych and anesthesia residents who are equally or more miserable or who have switched into other residencies because they discovered they did not like it as much as they initially thought. We need people to do primary care because without PCP's, every specialist would have to do primary care as well.

This thread is biased because most responders are stating why they don't like primary care fields...I think most med students are bright enough to realize this bias.

 

[CambieMD]

Wow...I have no interest in primary care, but this almost makes me want to go into FP and like it just to spite this post.

Many people in many specialties end up miserable. Some primary care docs may be miserable, but I know several surgery, psych and anesthesia residents who are equally or more miserable or who have switched into other residencies because they discovered they did not like it as much as they initially thought. We need people to do primary care because without PCP's, every specialist would have to do primary care as well.

This thread is biased because most responders are stating why they don't like primary care fields...I think most med students are bright enough to realize this bias.

I promise that this is my last post on this topic. I am not biased . I came to primary care with an open mind but the realities of primary care have caused me to turn from primary care. I am not saying that primary care isn't for anyone. However, think long and hard before deciding on primary care.
I look ar HIPPA regulations and the recent push towards EMR. We PCPs
incur expenses that we have to eat. Greater responsibilities will be placed on PCPs. As expenses rise and reimbursement declines PCPs will be further squeezed.

There is no bias against primary care. The nature of primary care makes it an unattractive career choicefor many. Are we biased against skunks or do we avoid them because they stink and can infect us with their odor.

I simply want medical students to enter primary care with their eyes open.

I will go away now.

CambieMD

p.s.
the patient who called her pcp because the electricity was disconnected should have called her case worker.Sociomas make a waste of a medical education.

 

[gherelin]

No one addressed the comments that primary care is routine, intellectually unchallenging and not rigorous enough, easily algorithmizable, so I thought it needed to be done at least once. If anything is algorithmizable it is specialties-with just a few diagnoses and usually very clear recommended algorithms for treatment-take a look at the American Cardiology Association guidelines on anything from ACS to Afib. Just looking at a one of my patients today (not at all atypical in her complexity): a 47 year old woman, my first time seeing her as she is a patient of another resident in our clinic, comes in with abdominal pain. She is not a new patient so she is scheduled for the usual 15 minutes. She has a history of Crohn's Disease s/p remote colostomy, not currently on anything although Pentasa may be started by GI, a recent admission for severe iron deficiency anemia, s/p prbc transfusion, recent transvaginal ultrasound showing multiple thick-walled complex cysts in an enlarged left ovary (has not seen gyn), recent labs showing iron deficiency anemia, sky-high epopoietin level, and normal LFTS except new unconjugated hyperbilirubinemia. Your mission--in 15 minutes, do history, exam, decide on differential dx, decide on labs to order, which consultants to contact, how urgent this all is, as well as fill out proper coding forms (much more complex in primary care due to the huge number of potential codes) and dictate a note. (Let me know when you've got the algorithm that includes all of this. I could use it!)

 

[deltamed]

Although I usually don't like to be serious on these forums, I felt inclined to give my 2 cents on the matter since I've practiced IM in the recent past--and perhaps--have more experience than most of you. I agree with most of what has been said--except income. Although primary care tends to be a lower paying specialty on average compared to others, it is by no means "low paying". My first year after residency, I made 160k while working 33-45hrs/week and only 1 mandatory call/month. 2nd year I made 180k, 3rd year 195k. Others in my group(who are older, partners, and have been practicing for longer) were making 240-300k. While this is certainly not the level of a neurosurgeon's income, it compares more than favorably to many other specialties. Yes, you may argue this is unusual for primary care, and blah blah blah there are exceptions to every specialty, but the numbers I quoted above are in fact the incomes of Internists at one of the largest HMOs in the country. Why did I leave Internal Medicine if everything was so 'terrific'? It wasn't, and for many of the same reasons listed by posters in this thread I felt it was a good idea to get out of primary care. Income, however, was not one of the reasons.

It's nice you made a good income but you can't deny the national surveys. Look at MGMA and physicians associates. The average internist 3 years out of residency is making 130-140k. Starting is hovering just about at 100k.
Could you tell us which major HMO you worked at that paid so much more?
Thanks.

 

[juddson]

...said the person who has never done primary care. Thanks for your insight, Juddson.

Income is undeniably a part of it for many, if not most, people. But the main issue is that you have to see lots of people, most of whom have non-specific, chronic, or silly (like a one-day cough or a runny nose) problems.

As far as money, though, that will likely soon change because the pendulum of supply and demand swing back and forth between specialists and GPs all the time. With everyone subspecializing these days, GPs are going to soon be in high demand and likely their salaries will rise. Purely anecdotally, I have heard of some people who are GPs in underserved areas who make money hand over fist; but if you want to remain in a large urban area, that probably will never happen.

This is true. I have not yet practiced medicine. Still, little in your post seems to dispute my list. In fact, as far as I can tell you agree with it about 90% or so.

Judd

 

[deltamed]

As far as money, though, that will likely soon change because the pendulum of supply and demand swing back and forth between specialists and GPs all the time. With everyone subspecializing these days, GPs are going to soon be in high demand and likely their salaries will rise. .

I doubt this. GPs have always made less than specialists and I see that gap only widening in the future. With the hordes of PAs and NPs starting to enter the workforce, the going rate will only drop to near midlevel salaries as they dilute the marketplace. A few smart GPs will likely make a lot of money by creating efficient practices with many PA employees. But as insurance realizes this they will continue to decrease reimbursements. This will happen to a lesser extent in the specialties but less people are willing to see an NP or PA for what they percieve to be a more "serious" problem. No one will see a PA if they have cancer or to have a surgery.
Hell, Target is opening minute clinics for the common primary care needs. As trends like this continue the scope for GPs will decrease along with their salaries.

 

[toughlife]

Here's an anecdote to show you what I mean. I have a friend who is an FP. He gets a call at 3 AM from a patient whose electricity was turned off because the patient didn't pay the bill in two years. The patient says to the FP that she is thinking of killing herself because the power is off. So the FP has to call the power company and beg them to turn the power on for the night.
QUOTE]



I would make sure her power stays off until she does. Problem solved!

 

[b&ierstiefel]

I didn't choose primary care b/c I didn't enjoy dealing with the multiple social and personal issues of many patients. In just the relatively brief time of medical school, I got tired of telling patients to quit smoking again and again and again. I'm not condemning it or belittling it but it just wasn't what I enjoyed.

I totally agree and I realized this more and more as I did my subI months earlier this year. I didn't go to medical school to do social work and arrange a bunch of consults (which is all we did at Jokewood hospital). Seriously, I would rather be someone who is consulted than the one asking for consults and micromanaging all that stuff. And then there are all the malingering drug-seekers...NO THANKS!

 

[kristing]

No one addressed the comments that primary care is routine, intellectually unchallenging and not rigorous enough, easily algorithmizable, so I thought it needed to be done at least once. If anything is algorithmizable it is specialties-with just a few diagnoses and usually very clear recommended algorithms for treatment-take a look at the American Cardiology Association guidelines on anything from ACS to Afib. Just looking at a one of my patients today (not at all atypical in her complexity): a 47 year old woman, my first time seeing her as she is a patient of another resident in our clinic, comes in with abdominal pain. She is not a new patient so she is scheduled for the usual 15 minutes. She has a history of Crohn's Disease s/p remote colostomy, not currently on anything although Pentasa may be started by GI, a recent admission for severe iron deficiency anemia, s/p prbc transfusion, recent transvaginal ultrasound showing multiple thick-walled complex cysts in an enlarged left ovary (has not seen gyn), recent labs showing iron deficiency anemia, sky-high epopoietin level, and normal LFTS except new unconjugated hyperbilirubinemia. Your mission--in 15 minutes, do history, exam, decide on differential dx, decide on labs to order, which consultants to contact, how urgent this all is, as well as fill out proper coding forms (much more complex in primary care due to the huge number of potential codes) and dictate a note. (Let me know when you've got the algorithm that includes all of this. I could use it!)

Thanks for this. My god. Why does everything in these forums turn into "your choice is stupid, my choice is smart" sort of discussion.

I am glad that you all want to do specialty medicine as it fits your personality, but it doesn't fit all of ours.

Just because some of you find primary care "mind numbing," those of us who are going into it find it challenging (look at the above post as an example).

Pediatricians have the highest satisfaction ratings, too. Look outside your little self imposed boxes, people.

 

[double elle]

I didn't take the time to read ALL the posts above - but I thought I'd add why I chose to avoid primary care. First - I absolutely LOVED IM, so I'm not "anti-Primary Care". It's just that I found out early that I hated the office - the same scenary every day. I like bee-bopping all over the hospital.

The main reason I didn't like primary care was all the psych issues. Now, I am a VERY nice gal who can sympathize with most...and empathize with even more than most. I didn't have it easy...lost my parents very young..on my own at 17...bad choices...was assaulted and went thru a 2-year criminal trial and the assaulter got 20 years....more bad choices...straightened my life out...and will be graduating in June. That being said, you'd think I'd be the perfect person to sit and listen to how bad some of these people's lives are. However, it's just the opposite. I found myself not having the patience to sit there and listen to their excuses of why they can't get out of a certain situation. I feel like the patients look at us and just assume that we've just been on the straight path to medical school and we 'don't understand' what it's like to be socioeconomically challenged.

I felt that I was going to come out of my skin listening to their excuses time after time. I loved the well-child exams with FP and peds, but that was about it.

I just kept feeling that if I beat the odds and made it out of bad situations, then some of these people could to.....I could have made excuses and ended up a druggie or something..but I didn't make those choices. I honestly feel badly about the way I look at things - but I just don't have time for the people who won't help themselves.

I don't know what percentage of the patients I saw were like this...but even if it was a small percentage...it was enough to completely turn me off.

I am currently doing an inpatient FP rotation and I like it all right. I couldn't bear doing another office month, so I scheduled this one in the hospital. I find myself looking in the ER for lacs to sew...or eavesdropping to hear if a procedure is being planned that I can at least watch. I admire the docs who chose this field. They have to put up with a lot...and I think that anyone who can handle all the BS that goes along with primary care is a special sort of person. I just know my fuse is too short for some reason. lol...I don't think I'd have many patients if I was a primary care doc.

Take care and good luck everyone.

 

[roja]

Thanks for this. My god. Why does everything in these forums turn into "your choice is stupid, my choice is smart" sort of discussion.

I am glad that you all want to do specialty medicine as it fits your personality, but it doesn't fit all of ours.

Just because some of you find primary care "mind numbing," those of us who are going into it find it challenging (look at the above post as an example).

Pediatricians have the highest satisfaction ratings, too. Look outside your little self imposed boxes, people.

Perhaps you should step outside your own self imposed box and take that chip off your shoulder. First the questions was directed at those in specialty medicine and asked why we don't like it, hence CONTEXT.

Perhaps your own insecurity drives the interpretation of 'primary care is a stupid choice'.

As has been pointed out by many people here, some more eloquently or politely than others, is thier OWN reasons to not go into primary care. (For example... I find it 'mind numbing'. but that doesn't mean I don't find primary care an incredibly valuable field of medicine or discount it. I have primary care friends who find what I do mind numbing. doesn't mean they dont'
respect what I do.. they are just grateful they don't have to do it because its not right for them.

No one said that specialty medicine was for EVERYONE. They were responding to a question about why they had chosen NOT to go into it.

Every field of medicine is valuable. We would all be seriously f*cked if everyone wanted to do the same thing, including primary care.

Everyone is a PC and your patient needs a colon resection. Sorry, there are no surgeons because no one wants to do it. Your patient has a massive MI. sorry no ED's, no cardiologists.

Your a surgeon and your patient needs preventive care. sorry, no primary care docs.

🙄

 

[rcella]

As a praticing PCP -
1. I scored top 5% on my boards - I consider myself competitive and a good physcian - I chose PCP.
2. As far as PA's doing my job - I cringe everytime I get handed a patient from a PA - we have them in there ER and frequently I get a patient from them - they miss huge things - forgeting to add lovenox or like to a patient with chest pain. Pumping fluid into my alcoholic with liver disease with a low sodium. Missing abdominal pain in a patient with an AAA.
3. I agree that some of the work is protocol but it is like that in all fields. Can you honestly tell me that a colonoscopy takes any great brain work??
4. The pay is horrible for the hours. PCP are the dumping ground for every other field. Commonly do I get a call from another specialist about a patient of mine they should be admitting - but they risk the patient's life to transfer them to my office so they will not be responsible.
5. I did part time work as a wound care and found that they can pay 220K for a lot less work then I do - for scraping an ulcer with a spoon!!
6. We do not get payed for our studies - I constantly find myself with a patient that has a finding that would not have been found by someone without the training (or basically have the sense of patient ownership - mid level providers do not have this).
- anyway I will admit I am frustated by the hours, work, and at times I feel like a waiter taking patient orders - and I get tired of the constant manipulation attempts by some of my patients that think I am rich greedy doctor and should give them every minute of my day. Also there is incredible risk in PCP with the volume - yes - and the high volume you need can easily miss something.
7. Would I do it again - mixed feelings - my wife - a nurse - makes more than I do when you add up the hours. If it was up to her I would have been a radiologist.​

 

[Law2Doc]

...
1) Money: ALL specialties deal with Medicaid/ reimbursment issues so isn't this this a nonissue (procedures not withstanding)?
...

No way. It's all about the value of your time. For instance, a cardiologist that spends a half hour interpreting an echo and speaking to a patient about it makes a lot more money than a family doc who spends that same half hour talking to a patient about his high blood pressure and prescribing a medicine regimen. The same half hour is simply worth less in primary care, and declining each year. And as you mentioned, procedures are cash cows, and so if your field has procedures that can be done by non-physicians in your absence and interpreted by you later (echos, imaging, stress testing), you make money for that on top of the hours you spend.

So primary care docs address these issues by trying to spend less time per patient, and seeing more patients per day. This keeps up with the decline of reimbursements, but reportedly removes all the enjoyment primary care docs once had of sitting down and actually talking with their patients. Nobody who goes into a field for patient contact wants to work on an assembly line, and this is what decreasing reimbursements have made primary care into.

 

[CambieMD]

Since my last post on this topic I left FP and completed an anesthesia residency. Every specialty has its' challenges, but I really like what I am doing now.

Cambie

 

[Law2Doc]

As a praticing PCP - ...​

Dude, if you bump a 5 year old thread, can you please acknowledge that's what you are doing, so some of us don't waste time responding to folks who may no longer be on SDN. Thanks.😡​

 

[dragonfly99]

What I think everyone has to remember is that the population who tends to show up in doctor's offices the most are attention seekers with silly complaints which probably everybody else has, but they don't obsess about it. Sure, not everyone is like this, but if you were such a person, where would you go to satisfy your need for an authority figure to take care of you? MDs office of course, because nobody else would tolerate this nonsense.

A specialist has the advantage of limiting their interactions with these individuals. Whereas, a primary care MD becomes a surrogate mother/father.

Here's an anecdote to show you what I mean. I have a friend who is an FP. He gets a call at 3 AM from a patient whose electricity was turned off because the patient didn't pay the bill in two years. The patient says to the FP that she is thinking of killing herself because the power is off. So the FP has to call the power company and beg them to turn the power on for the night.

No cardiologist or GI or surgeon would have to deal with that.

I agree with this. Though this was an extreme example, it shows one of the problems in primary care. One of my reasons for not doing primary care is that I don't want to deal with drug seeking patients for the rest of my life. In cardiology, I can tell the patient if they don't have cardiac pain, there's no medical indication for me to keep giving them narcotics, and that's it. No argument, no "But doctor, you don't CARE how I SUFFER!!! I'm going to complain to the medical board that you wouldn't treat my PAIN!".

I don't think most people decide not to do primary care out of greed/wanting more money. I'm sure that factors in for some, but internal med still does all right...IF you are willing to be an employee, or if you are a very good businessperson and practicing in the right area of the country. Small 1-4 doc private practices are not doing well in general in most places...they have to work more and more hours seeing more and more patients to keep their income near where it was a few years ago. Many fear for the future of primary care as a career for physicians, since the gov't may take things over and decide it's cheaper to just use NP's/PA's for this and decide to do so.

I disagree that primary care is routine/algorithmic, any more so than most other specialties. Internal med, in particular (because we tend to see many older patients with multiple medical problems) is not "easy" per se, although of course outpatient medicine is easier than inpatient medicine, in the sense it is hard to hurt/kill a patient who isn't very sick. You CAN however, harm a patient by not giving the correct treatment, not doing cancer screenings, not realizing who is really sick (vs. wimpy, anxious or malingering, etc.).

There IS more paperwork in primary care vs. most other specialties, particular in HMO type situations, because the primary doc is the final common pathway to fill out family/medical leave paperwork for the patients, their family members, give out handicapped parking stickers, get the patient a power scooter from Medicare, fill out wound care orders on a patient because the surgeon who did the surgery told them to "have their primary care doctor do it", etc. etc. and on and on.

There is also the aforementioned ego issue, and people's general discomfort with not knowing things (you CANNOT know everything about everything, so there will always be things you don't know as a primary care doc, whereas as a specialist you can at least have the delusion that you know everything in your field).

There is also the fact that primary docs have to see too many patients/day. On my endocrine clinic rotation in residency, the endocrine docs were seeing fewer patients than the general IM clinic would see, but only taking care of 1 or 2 problems (say, hypothyroidism and maybe, at most, one other like diabetes). In a similar visit at my IM resident clinic, I'd see an equal or greater number of patients in a half day, and take care of the same patient's anxiety, back pain, obesity, Type IIDM, HTN and then have to remember to refer them for a colonoscopy.

 

[civic4982]

Rcella:

Nice work bringing this thread back. I actually do think it's of value to discuss. You bring some good points... subbing for the discussion.

 

[Brian Griffin]

This thread has been very interesting to read.

I have always been interested in doing primary care - I like the idea of the "traditional" doctor - I like knowing a bit about everything, and I like knowing how to take care of common problems. I like the idea of knowing how to take care of the whole body, not just one part. I love the outpatient setting. I enjoy the social issues/psychological issues you have to address in primary care (I know, you all probably think I'm crazy! I actually loved my psych rotation and probably should have picked that). I think primary care is intensely complex and not AT ALL algorithmic - I like the challenge of having to deal with multiple issues and triage them, especially with geriatrics patients.

Having said all that, I was dead set on doing Family Med during 3rd year. Add in the fact that my school has a very well-respected Family Medicine department in an urban location, which seems to be pretty rare.

However, when I started telling everyone I was doing Family Med, I got so many mixed reactions, most of them being negative. People were acting like I was wasting my life away, or making the worst decision of my life. I have to admit, it was hard to not let my ego get in the way.

During fourth year, I made sort of a last-minute switch from FM to IM right before I sent my applications out. I figured this way, I'd have the option of doing primary care or specializing (I didn't really like peds or OB so much anyway). When I started telling people I was doing IM, I got NONE of the negative feedback I got when I used to tell people I was doing FM (even if I still said I was interested in primary care/general medicine - odd!)

I still kept my residency application very primary care-oriented (personal statement, research, and activities all very geared toward primary care). I think programs either loved it or they hated it. I consider myself a competitive applicant for IM (top 3rd of my class, great board scores, etc)... but I got turned down for many interviews ... and I wonder if things might have been different if I had claimed all kinds of love for GI or cards like everyone else in the world does... maybe programs would have thought I would have fit in there better (although I know I probably would not have!). I think the more progressive programs who acknowledge the vast need for PCPs were more impressed with my interest in primary care, though.

I just matched into an IM program I'm happy with and I think is going to be a great fit for me (yay!). I'm not 100% what the future holds. I'm still thinking about primary care, and I do think it would be a good fit for my personality, but I really am trying to keep in mind what everyone has said in this discussion (and in many real-life discussions I've had on this topic)....and it would be a tough choice. I'm also considering endocrine, which I think would appeal to all the things I like - outpatient, whole body, complex issues... and I'm sure the compensation and lifestyle would be a lot better....