Why is family medicine viewed as a low quality field?

[Mad Jack]

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There are very few fields in medicine that pay significantly more than us and work similar hours.

Derm, but that is amazingly competitive so not an option for 99% of medical students.

EM on a purely hourly basis, but you have to factor in nights weekends and holidays.

Am I missing any others?

Psych, PM&R, A&I

 

[VA Hopeful Dr]

Psych, PM&R, A&I

Medscape has those averaging between 260 and 270, while Family Medicine is roughly 220. Not a huge difference.

Those also are at least one year of additional training possibly as many as three more.

 

[Mad Jack]

Medscape has those averaging between 260 and 270, while Family Medicine is roughly 220. Not a huge difference.

Those also are at least one year of additional training possibly as many as three more.

One extra year for 50k a year is a pretty solid investment. Plus if you look at hours with paperwork, FM puts in more hours per week, in addition to having higher malpractice. So I'm not saying it's a bad gig, but that lifestyle-wise, there are slightly better options out there. Hell, I still agonize ovee whether I made the right choice between FM, IM, and psych because I am not sure which I'd love the most.

 

[VA Hopeful Dr]

One extra year for 50k a year is a pretty solid investment. Plus if you look at hours with paperwork, FM puts in more hours per week, in addition to having higher malpractice. So I'm not saying it's a bad gig, but that lifestyle-wise, there are slightly better options out there. Hell, I still agonize ovee whether I made the right choice between FM, IM, and psych because I am not sure which I'd love the most.

We don't put in more hours per week if comparing full time psych to full time FM.

That extra year of residency costs you 150k minimum (resident v. attending FM income). Plus, generally speaking, income increases over time and that 1 year might narrow that pay gap a touch.

And is your malpractice really lower than mine?

 

[Treebeard]

Cutting people in half and screwing around with their organs is 'cool'. Cutting edge laboratory research is also perceived that way.

Helping a patient start on a healthier diet or quit smoking cigarettes is simply not seen that way.

Also, if you took the ortho salary/research funds and flipped them with family medicine, suddenly Harvard would have a family med program and you'd need a 245+ to match anywhere (while ortho would be full of IMGs and whatnot).


Ultimately, most people go into medicine for the prestige, stability, money, and maybe because they enjoy/excel at science. Most are not focused on doing the greatest amount of societal good. Hence, family/psych/peds/etc play second fiddle to surgical sub-sub-sub-specialties.

 

[Man o War]

Cutting people in half and screwing around with their organs is 'cool'. Cutting edge laboratory research is also perceived that way.

Helping a patient start on a healthier diet or quit smoking cigarettes is simply not seen that way.

Also, if you took the ortho salary/research funds and flipped them with family medicine, suddenly Harvard would have a family med program and you'd need a 245+ to match anywhere (while ortho would be full of IMGs and whatnot).


Ultimately, most people go into medicine for the prestige, stability, money, and maybe because they enjoy/excel at science. Most are not focused on doing the greatest amount of societal good. Hence, family/psych/peds/etc play second fiddle to surgical sub-sub-sub-specialties.

This will likely change again. Way back when I was in residency, ortho was not that competitive.
Who knows what the “big dog” specialties will be in another 30 years.

 

[Mad Jack]

We don't put in more hours per week if comparing full time psych to full time FM.

That extra year of residency costs you 150k minimum (resident v. attending FM income). Plus, generally speaking, income increases over time and that 1 year might narrow that pay gap a touch.

And is your malpractice really lower than mine?

Psychiatrists get sued at about half the rate of FM physicians, and suffer a third as many payouts, which tend to be about a third lower than in FM. That's why we've got the lowest premiums around (it's really only a few thousand dollars per year cheaper, but hey).

Slightly less paperwork, decently more money, a more chill residency with potential to moonlight at most places, and statistically lower hours and paperwork. Just gotta be able to deal with the one patient population that only psychiatrists seem to enjoy lol.

 

[MedicineZ0Z]

Psychiatrists get sued at about half the rate of FM physicians, and suffer a third as many payouts, which tend to be about a third lower than in FM. That's why we've got the lowest premiums around (it's really only a few thousand dollars per year cheaper, but hey).

Slightly less paperwork, decently more money, a more chill residency with potential to moonlight at most places, and statistically lower hours and paperwork. Just gotta be able to deal with the one patient population that only psychiatrists seem to enjoy lol.

Paperwork is all about efficiency. Me personally, I was wayyyy faster than literally everyone at notes etc. So it's technically your fault if you spend too much time on paperwork.

 

[Treebeard]

This will likely change again. Way back when I was in residency, ortho was not that competitive.
Who knows what the “big dog” specialties will be in another 30 years.

Ortho was an example of a competitive and highly paid salary. Sub in whatever you wish. Not really the point.

 

[Giovanotto]

Paperwork is all about efficiency. Me personally, I was wayyyy faster than literally everyone at notes etc. So it's technically your fault if you spend too much time on paperwork.

This logic makes my head hurt.

 

[VA Hopeful Dr]

Psychiatrists get sued at about half the rate of FM physicians, and suffer a third as many payouts, which tend to be about a third lower than in FM. That's why we've got the lowest premiums around (it's really only a few thousand dollars per year cheaper, but hey).
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Slightly less paperwork, decently more money, a more chill residency with potential to moonlight at most places, and statistically lower hours and paperwork. Just gotta be able to deal with the one patient population that only psychiatrists seem to enjoy lol.

I thought I'd seen that full time psych malpractice was around 10k which is what FM is.

Those hours are close enough to likely be within the margin of error.

That said, I completely agree that with a decent setup, assuming you like the patient population, so I can be pretty chill.

 

[smq123]

Some thoughts:

FM is good for all the above reasons. But I hear FM is a lot of dealing with insurance companies and filling out all their forms and having patient care decisions dictated by insurance algorithms. But that might be true for other specialties too like hematology and oncology with NCCN guidelines.

All specialties are going that way. Cardiologists fight with insurance companies to get stress tests approved. Endocrinologists have told me about the short cuts they have figured out to get new and expensive insulins approved. My husband, who is a radiation oncologist, came home fuming last week, because he had spent over an hour on the phone with the insurance, to get his radiation treatment plan approved.

Huh, that certaintly makes the accelerated primary care track at the school I'm starting at in August seem like more of an attractive option to consider.

It also makes me even more annoyed that my own primary care doctor has begun rushing me in and out of my appointments within 3 or 4 minutes lately, barely letting me get a word in edgewise. During my last physical, all she did was listen to my heart, look in my ears, and then say, "Okay, you look good" and try to rush out of the room. I had to stop her while she was already heading towards the door to let her know I actually had a concern I wanted to ask about. I had some sympathy before because maybe she was just completely burnt out on doing such a demanding job for such little pay, but she's getting 200K+ to treat me like that? I really need to find a new doctor accepting new pts...

Don't be too hard on her. You don't know why she is treating patients that way. She might be burnt out. She might be covering for another doctor and has to rush. They might be pushing her to see more and more and more patients, in

When you start making 200k do you start pining for more?

Yes. You would be surprised. $200K sounds like an incredible amount of money to you as a med student, but it's not enough to pay for the boat, the summer house, the first ex-wife, the soon-to-be second ex-wife, the Benz, the Bentley, the Tesla. Doctors are INCREDIBLY stupid with money, for the most part. A guy who is a VP for PNC bank told me that doctors are prime targets for bankers - we're dumb with money, we overspend, and we have no idea how to invest.

The big downside of FM is due to insurance companies and all the paperwork not because of the actual practice. Sure you can make 200-300k but your $/hr sucks when you account for all the extra work you have to do outside the usual 7-5 to make your business run smooth.

That's true of any doctor that owns their practice. If you're employed, there's less of that, particularly if you're smart and hire people to do your paperwork. There's no reason for you to do your own prior authorizations when you can hire and train an LPN to do it for you.

 

[smq123]

Part of the issue with primary care, I think, is that it takes a very specific kind of person to do it. It requires a lot of quick shifting of mental gears, as well as juggling a lot of diverse patients all at once. And some people are not good with that. They don't like multi-tasking, quick-shifting from a GYN problem to a GI problem to a derm problem to a cardiac problem is hard, etc. It takes a lot of patience. It also requires being comfortable with "gray zones" - it's one thing for the oncologist to have a discussion with a patient who has biopsy proven cancer. It takes another skillset to have a discussion with someone who might have something bad, but you're not sure yet, because you need to order some tests. Patients do not like uncertainty, but a lot of primary care deals with uncertainty - is this lump bad? Is it benign? Is it cancer? Etc.

 

[Skiiiiiing]

I'm definitely not going into family med but why is the field disliked? The money really isn't bad. 250k is easily doable if you're anything close to efficient. And if you can see more patients, 300k+ is as well without insane hours. The job market is excellent including saturated areas (unlike specialties). And every single field has bread and butter cases that bore you to death if you don't like it, can't pick on FM for its bread and butter.

So... why the hate exactly?

200 for slackers, 250 for producers, caps at low 300s, specialist comp an order of magnitude better for just another year of residency, and what about long run competition from midlevels.

Lots of colds/depression/sprained ankles/referrals

 

[smq123]

200 for slackers, 250 for producers, caps at low 300s, specialist comp an order of magnitude better for just another year of residency, and what about long run competition from midlevels.

Lots of colds/depression/sprained ankles/referrals

You should come rotate with me. I'm THRILLED when I get a run-of-the-mill "I'm just here for referrals" or "I sprained my ankle." It's a chance for my brain to coast for a few minutes.

 

[VA Hopeful Dr]

200 for slackers, 250 for producers, caps at low 300s, specialist comp an order of magnitude better for just another year of residency, and what about long run competition from midlevels.

Lots of colds/depression/sprained ankles/referrals

You do realize what an order of magnitude means right?

Are there lots of specialists earning 2 million that I'm unaware of?

 

[Skiiiiiing]

You do realize what an order of magnitude means right?

Are there lots of specialists earning 2 million that I'm unaware of?

Someone likes details

"at least 100k more per year"

 

[smq123]

Someone likes details

"at least 100k more per year"

Focusing on detail is something that most patients want in their doctor....

 

[Skiiiiiing]

Focusing on detail is something that most patients want in their doctor....

Quibbling over semantics on a forum in this context is probably best read as sour grapes

 

[smq123]

Quibbling over semantics on a forum in this context is probably best read as sour grapes

Why assume sour grapes?

Anyway, for everyone else reading this forum, don't let people talk you out of Family Med. I enjoy what I do. I sometimes try to talk med students out of being doctors, in general, but I never tell people not to do family med. I would get tired of seeing the same types of patients day in, and day out. That's just my personality; that's not how everyone else works. But for people who like the variety, it's a great field.

 

[IntheClouds4ever]

Quite honestly, if you are wanting more money, you should be venturing out in the business avenues of life. If you can’t live off 200k, you suck at life and money.. With a stable income of >200K and plenty of down time, there’s a lot to play with in terms of investing in stocks, local businesses, etc.. with no caps on potential earnings. I feel like many med students are so focused on medicine they forget to look up and see the vast potential they have with money and credentials behind their name.. just my opinion, though.

 

[EmilKraepelin55]

FM is good for all the above reasons. But I hear FM is a lot of dealing with insurance companies and filling out all their forms and having patient care decisions dictated by insurance algorithms. But that might be true for other specialties too like hematology and oncology with NCCN guidelines.

Could always try a direct primary care route in private practice. Less insurance companies, less patients which means more time for comprehensive care, and ultimately less hassle and paper work. Of course, the economic viability of such a model in today’s climate seems a little up in the air. I’m not sure about the average salary of a DPC family med physician, but DPC is certainly an interesting proposition to consider in the coming years as the industry changes. I think it would be better for long term patient care and physician job satisfaction if we could run our primary care this way.

 

[VA Hopeful Dr]

Someone likes details

"at least 100k more per year"

That's a very weird way of saying "I was wrong"

 

[Stagg737]

I don't have a crystal ball, but I have a basic competency in arithmetic. Bruh

Midlevels have existed for a very long time, but the explosion in their training spots is a very recent phenomenon that started in the early 2010s. In 2011 there were only 11,000 NPs graduating per year, then just 5 years later that number has nearly tripled to >25k. Please pause a second and wrap your head around that because it's truly remarkable. Without a doubt the number has grown even more since then. Right now there are 250k NPs in the USA, but a graduating class size of 25k will lead to a steady state NP workforce of 750,000 assuming a rather optimistic (ie low) 30 year average active career. This is also assuming that NP training slots have been frozen at 2016 levels, in reality when you account for future growth in training programs the steady state workforce is probably more like 1 million.

Please continue to tell me that it's "bogus" to worry about a source of low cost competition that will quadruple in size over the course of our careers. Also, the AMA is a pathetic joke that is not only weak, but actively works to undermine the future of the rank and file physicians.

What proof do you have that all these NPs are going into family med or even primary care? You seem to either be ignoring or unaware of the very large quantity of them entering more specialized fields like OB/Gyn, EM, derm, etc. I've even encountered quite a few in less common fields like PM&R, cardiology, and GI. Just because the political argument is that they're going to fill the primary care gap doesn't mean that's what's actually happening.

I have no doubt that hospitalists and Specialists say those kind of things amongst themselves, but in almost a decade of being a family doctor not a single one of them has ever said it to me or to my patients about me.

They know who the patients like more, and Trust more, and it's not them.

If they piss off the primary care types, their income will take a drastic hit and they know it.

True for specialists, imo hospitalists don't care though. When the patient gets sick enough they're going to have to go to the hospital anyway, and when they come in multiple times because the FM keeps switching their meds back after the patient is discharged it can lead to some pretty obscene and derogatory language from the hospitalists when they see the patients for the 6th time in as many months.

We don't put in more hours per week if comparing full time psych to full time FM.

That extra year of residency costs you 150k minimum (resident v. attending FM income). Plus, generally speaking, income increases over time and that 1 year might narrow that pay gap a touch.

And is your malpractice really lower than mine?

I thought I'd seen that full time psych malpractice was around 10k which is what FM is.

Those hours are close enough to likely be within the margin of error.

That said, I completely agree that with a decent setup, assuming you like the patient population, so I can be pretty chill.

Most of the guys I rotated with had malpractice less than 5k/yr. Maybe I'm just in cheaper states, but they made it sound like malpractice was basically a minimal expense for psychiatrists.

From what I've seen so far, psych and FM are pretty comparable in a lot of instances. Both have pretty low floors and the mean/median is lower than most specialties, but the ceilings I've seen are generally higher for psych and the general opportunities aren't the same. If you've got a solid business model in FM, you can hit 300k-400k without too many extra hours. For psych you can easily clear 400k or even 500k if you're smart. Sure there are exceptions and certain niches where the FM docs can kill it, but it's just easier to do in psych right now due to the current status of the field.

Regardless, FM doesn't deserve most of the crap it takes and I wish there were greater incentives for the truly brilliant to enter the field, as the breadth of knowledge required to be great is legitimately that much greater than in most other fields.

 

[dave davita]

Still the fact a CRNA can actually make that much at all and it is more than some practicing physicians infuriates me. They can't even pass a watered down Step 3 but want to be seen the equivalent of an Anesthesiologist.[/QUOTE]

It sucks for MDs that CRNAs would get that much, but maybe the hospital administration thinks this way: if they can do the job why not? Granted they may not be able to pass a watered down STEP3, who cares? How much of STEP3 knowledge will they ever need to practice anesthesia? Probably very little. Knowledge/Thought rarely gets paid for. Look at PhDs who get $55k, after all the research and 5years of doctoral school. Capitalism pays for end product/service. Period. The nail is in the wood. Was it hammered in by a wooden mallet or a guilded hammer? Who cares?

 

[psychMDhopefully]

Still the fact a CRNA can actually make that much at all and it is more than some practicing physicians infuriates me. They can't even pass a watered down Step 3 but want to be seen the equivalent of an Anesthesiologist.

It sucks for MDs that CRNAs would get that much, but maybe the hospital administration thinks this way: if they can do the job why not? Granted they may not be able to pass a watered down STEP3, who cares? How much of STEP3 knowledge will they ever need to practice anesthesia? Probably very little. Knowledge/Thought rarely gets paid for. Look at PhDs who get $55k, after all the research and 5years of doctoral school. Capitalism pays for end product/service. Period. The nail is in the wood. Was it hammered in by a wooden mallet or a guilded hammer? Who cares?[/QUOTE]


I agree, medicine is a guild system, unnecessarily long training to control access to a skill. Nursing doesn't do that to its people, you cant really get mad at nursing for not abusing it trainees.

 

[W19]

Maybe we should be taking a page from the nurses' playbook... There is no freaking reason that one needs to spend 8 years in school to earn a MD/DO degree that worth nothing without residency... One can become a competent IM/FM/Peds doc in these 8 years... The bachelor degree requirement for med school is not needed. Prereqs + 3 years med school and 2-6 yrs residency.

 

[VA Hopeful Dr]

Maybe we should be taking a page from the nurses' playbook... There is no freaking reason that one needs to spend 8 years in school to earn a MD degree that worth nothing without residency... One can become a competent IM/FM/Peds doc in these 8 years... The bachelor degree requirement for med school is not needed. Prereqs + 3 years med school and 2-6 yrs residency.

As always, we have a good system going why chance screwing it up?

 

[Treebeard]

As always, we have a good system going why chance screwing it up?

Do we?

 

[W19]

As always, we have a good system going why chance screwing it up?

The system is inefficient and everyone knows it...

 

[W19]

After getting thru undergrad and med school, no one can tell me with straight face that these 8 years can't be cut down to 6 years EASILY....

 

[VA Hopeful Dr]

After getting thru undergrad and med school, no one can tell me with straight face that these 8 years can't be cut down to 6 years EASILY....

You could cut down undergrad, but I believe it has value.

I'd much rather see tuition be cut down so the extra schooling didn't put y'all $100,000 further into debt.

 

[VA Hopeful Dr]

Do we?

Yes

 

[VA Hopeful Dr]

The system is inefficient and everyone knows it...

It seemed okay when I went through it, although admittedly I did graduate med school 8 years ago.

I would much prefer to improve the medical school experience as opposed to cutting the length of it down.

 

[dave davita]

After getting thru undergrad and med school, no one can tell me with straight face that these 8 years can't be cut down to 6 years EASILY....

Europe goes to med school straight from high school. For example in the British system, after the General Certificate of Education Ordinary Level ('O' levels, US 10th grade equivalent), kids already know whether they are cut out for sciences or arts. They then go for another two years of senior high school to study sciences (math, physics, chemistry, biology) or arts,, courses exceeding/matching the first two years at a very good US college in terms of difficulty. They then sit for the rigorous Advanced Level ('A' level) exams which qualify them for medical schoolboy age 20. No useless bachelor degree. No useless MCAT. Medical research and healthcare delivery rank among some of the best in the world with this system. America has allowed money to get in the way of rationale. The brick and mortar college offering some bachelors degree wants to make money, the MCAT tutoring school wants to make money, residents are abused in a long and tortuous training program infested with redundancy and rigid lobbyists. Why do we subject our doctors to all this?

 

[W19]

You could cut down undergrad, but I believe it has value.

I'd much rather see tuition be cut down so the extra schooling didn't put y'all $100,000 further into debt.

Requiring a master to get into med school might have its value, but would that 'value' justify adding a master to the requirement. If the 'value' does not add much, do you think it is warranted? It boils down to this: How much bang am I getting for my buck (tuition, opportunity cost etc...)?

A lot of schools have 6-12 months research built in their curriculum; therefore, they are getting the message people are going to start asking why are they paying tuition while getting nothing in return... Basics science is 18 months in many schools now...

 

[W19]

Europe goes to med school straight from high school. For example in the British system, after the General Certificate of Education Ordinary Level ('O' levels, US 10th grade equivalent), kids already know whether they are cut out for sciences or arts. They then go for another two years of senior high school to study sciences (math, physics, chemistry, biology) or arts,, courses exceeding/matching the first two years at a very good US college in terms of difficulty. They then sit for the rigorous Advanced Level ('A' level) exams which qualify them for medical schoolboy age 20. No useless bachelor degree. No useless MCAT. Medical research and healthcare delivery rank among some of the best in the world with this system. America has allowed money to get in the way of rationale. The brick and mortar college offering some bachelors degree wants to make money, the MCAT tutoring school wants to make money, residents are abused in a long and tortuous training program infested with redundancy and rigid lobbyists. Why do we subject our doctors to all this?

What pains me the most is once physicians went thru the system and start making attending salary, they have the attitude: 'If I went thru it, the people who are coming behind me should go thru it as well.'

 

[W19]

Of my 8 fourth year rotations, I did 6 of them outside of my home institution but still paid that 30k+ in tuition + fees... Med school really got away with a lot of crap.

 

[VA Hopeful Dr]

What pains me the most is once physicians went thru the system and start making attending salary, they have the attitude: 'If I went thru it, the people who are coming behind me should go thru it as well.'

That's not why we say that, but thanks for that Delightful assumption

 

[VA Hopeful Dr]

Of my 8 fourth year rotations, I did 6 of them outside of my home institution but still paid that 30k+ in tuition + fees... Med school really got away with a lot of crap.

Do you have to pay for aways?

 

[W19]

Do you have to pay for aways?

No...

 

[VA Hopeful Dr]

No...

It's almost like all the different schools agreed to not charge each other students and keeping your tuition at your home institution makes up for that.

I don't know if that's the case, but it doesn't seem unreasonable to think it might be.

 

[W19]

It's almost like all the different schools agreed to not charge each other students and keeping your tuition at your home institution makes up for that.

I don't know if that's the case, but it doesn't seem unreasonable to think it might be.

Probably...

 

[TheIllusionist]

You need to be less qualified to get in. That has to do with money life style averages. Duh...

 

[Lexdiamondz]

You operate as an ER doc for less pay, seeing less interesting cases in a dull office environment.

But I agree with you the distain is largely misplaced. The money is decent and opportunity is wide open

lol. you definitely don't operate as an ER doc.

 

[Giovanotto]

I think the current medical school system set-up is fine in theory, but today that means going 200-400K in debt, and having had a previous career in healthcare, a masters, or some serious research experience. Hasn't residency training length also increased in the last couple of decades?

 

[psychMDhopefully]

I think the current medical school system set-up is fine in theory, but today that means going 200-400K in debt, and having had a previous career in healthcare, a masters, or some serious research experience. Hasn't residency training length also increased in the last couple of decades?

Yeah, a cards fellowship use to be 1 year long after internal medicine

 

[VA Hopeful Dr]

Yeah, a cards fellowship use to be 1 year long after internal medicine

Fellowship =\= residency

 

[W19]

Fellowship =\= residency

OP is a med student, so I am pretty sure he knows that. I think he is probably pointing out the arbitrary nature of these things.... 3-yr EM residency vs. 4-yr

They were even talking about adding an extra year to FM... I know someone will come up with the example of England and Australia etc... without mentioning they don't put in ~ 70 hrs/wk like us... It's just like someone in a leadership position woke up one day and say let's make money out of docs... There are many examples of these things--board recertification Q10yrs... Was there problem they are trying to correct?

 

[Psai]

OP is a med student, so I am pretty sure he knows that. I think he is probably pointing out the arbitrary nature of these things.... 3-yr EM residency vs. 4-yr

They were even talking about adding an extra year to FM... I know someone will come up with the example of England and Australia etc... without mentioning they don't put in ~ 70 hrs/wk like us... It's just like someone in a leadership position woke up one day and say let's make money out of docs... There are many examples of these things--board recertification Q10yrs... Was there problem they are trying to correct?

FM does not put in 70 hours a week