Why does everyone hate primary care?

[mercaptovizadeh]

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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....

Endocrine is not compensated much better than straight IM, although I agree with you that the subject matter is very interesting. There just aren't (m)any procedures. Mostly they focus on thyroid and diabetes, whereas the sex hormone stuff goes to ob/gyn or whoever deals with male sex hormone issues. IF you want to work on zebras, you need to associate with an academic center. There you will have certain people who focus mostly on pituitary or adrenal stuff, which is a little less bread-and-butter than diabetes/thyroid.

 

[BlondeDocteur]

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....

This sort of thinking makes me SO angry. My school sends practically no one into primary care, but they're much happier if they match into an IM-primary care spot than FP. The bias is incredible.

On match day this week there was a girl in my class who went into FP. She matched at her first choice (a kickass, do-it-all, unopposed FM program) and she was so excited. "I got ____!" she shouted. Everyone smiled politely but you could see them thinking "poor thing, I suppose she couldn't do anything else" (which is BS-- she was very solid). Actually desiring to become a rural family practitioner was beyond the pale, it seems.

If your interest is primary care, then follow your heart. Don't let the culture of your school, the analyses of your fellow students (and new residency colleagues) or anyone else tell you what sort of doctor you should be.

 

[flumazenil]

This sort of thinking makes me SO angry. My school sends practically no one into primary care, but they're much happier if they match into an IM-primary care spot than FP. The bias is incredible.

On match day this week there was a girl in my class who went into FP. She matched at her first choice (a kickass, do-it-all, unopposed FM program) and she was so excited. "I got ____!" she shouted. Everyone smiled politely but you could see them thinking "poor thing, I suppose she couldn't do anything else" (which is BS-- she was very solid). Actually desiring to become a rural family practitioner was beyond the pale, it seems.

If your interest is primary care, then follow your heart. Don't let the culture of your school, the analyses of your fellow students (and new residency colleagues) or anyone else tell you what sort of doctor you should be.

if i had the power to nominate post of the year- id give it to blondedocteur. So well stated. That is what it is all about folks. doing what makes you happy. Besides, I have noticed once you start actually practicing and are moving on with your life no one seems to care anymore- its all within pre med/college/ med school/ resident group.

 

[VMSmith]

I think that stigma against primary care as being for uncompetitive students does have an effect on deciding to avoid it.

Yes, all the other stuff has a big influence too (money, time pressures, treating chronic illnesses, dealing with psych and social issues, etc etc), but at my school we were always given the impression that if we were good students we should be considering the ROAD specialties, and that anything else would be a waste of our talents. This would manifest in things our Dean would tell us, like, "If you score above a 240 on Step 1, you have a chance at the really competitive specialties like dermatology or orthopedics." In other words, that by studying hard and doing well, our "reward" would be a residency in a high paying, prestigious (at least in the eyes of our fellow med students) specialty.

5 people from my school are going into FM this year. Pretty much everyone going into IM wants to subspecialize, and close to half of the peds people do too. I have a 3rd year friend who wants to do primary care, and when he describes the type of practice he wants it seems like FM would be the perfect fit for him. But he wants to do med/peds for reasons he isn't able to explain very well. I have the feeling he's worried about the way people will perceive him if he does FM. When I bring up FM, he goes on talking about med/peds as if he didn't hear me. Whatever. It's his life right?

 

[medicienne]

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

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

Excuse me, Family Medicine is a specialty. Don't get me started on that one 😎

 

[dragonfly99]

I agree there is a stigma at many academic medical centers r.e. family practice, such that some faculty will encourage students to do medicine, peds or med/peds rather than family practice. I agree they shouldn't really do this. Some people are just prejudiced, whereas others have genuine concerns about whether a resident can really "learn to do it all" (i.e. adults, kids, delivering babies, etc.) in a 3 year residency, which I don't think is a completely invalid concern. However, for someone who really wants to practice in a rural environment, and/or just strongly believes in the fp philosophy (and realizes that in order to do OB an extra year of fellowship might be needed) I think fp can be a good choice.

My medical school was also biased against family medicine and I did encounter negative comments and statements about fp as a specialty.

As far as the comment above about it being difficult to find a job as an fp, I know that is definitely not the case in the Midwest or South. IM docs tend to be preferred a little for hospitalist jobs (although an fp with recent extensive inpatient experience would easily get hired as well). For outpatient urgent care clinics and ER jobs, fp and med/peds docs actually tend to be preferred, because they can treat kids as well as adults. As far as outpatient primary care jobs, and/or jobs that are traditional outpatient + inpatient, family docs are in demand. I get postcards all the time (almost daily) from recruiters trying to hire people for general IM and/or family practice.

I don't think getting a job will be a concern/problem for anyone graduating from a decent fp or IM residency in the next few years...I have some fears about 10-20 years down the line as far as downward salary pressures, etc. if the gov't and insurance companies decide to use PA's and NP's extensively to provide primay care, but I still think docs will have a job. They just might have less negotiating power in terms of working conditions (i.e. how many patients/hr they'll have to see) and salary, and perhaps more and more trouble keeping a private practice afloat, even if being in private practice vs. being employed would be their preference.

 

[Saluki]

I don't hate primary care😀

I'm planning on becoming a general pediatrician... I probably could get into another specialty if I wanted to- dermatology would certainly be a much nicer lifestyle option, and even if I just chose a subspecialty of peds and wrote fifty research papers on incredibly rare disease Z, I would be much more likely to impress my school and my classmates...

In the end, though, none of that matters... I want a job where at 80 years old, I still want to keep practicing if I've still got enough of my vision left to see my young patients...

I think people are reluctant to go into primary care because a lot of the cases are routine; the money isn't as good; and it tends not to be as hands on as the surgical specialties, interventional cards, GI, etc.

I think to truly love primary care you have to be the sort of person who can find the variety from getting to counsel with a lot of different families rather than the excitement of what actual medical condition they come in with.. And general pediatricians are as happy as they come, even if they do make a little bit less than the average neurosurgeon😛

And if you're willing to practice in scenic (read "middle of nowhere") Wyoming, Montana, Idaho- you can get a pretty good salary, loan repayment and a starting bonus! How much better can life get??😀