Why the aversion to primary care specialties?

[NurWollen]

---

Members don't see this ad.

Obviously it exists but I'm interested in discussing why it exists. To paraphrase something I saw @Goro say on these forums, people act like primary care is the 7th Circle of Hell. Why? The simple answer is that primary care pays less, but that's not always true. Prestige is a big factor for some people but that leads straight back to 'why?' I've come to the conclusion that you can divide medical students into people who would consider primary care, and others who act like it doesn't even exist. Is that a reasonable assessment?

 

[Mad Jack]

I was into it, until I realized how fierce the competition is going to get in the near future. It just isn't worth the risk.

 

[Dr. Death]

I was into it, until I realized how fierce the competition is going to get in the near future. It just isn't worth the risk.

As opposed to what fields? Seems like competition is going up across the board

 

[NurWollen]

I was into it, until I realized how fierce the competition is going to get in the near future. It just isn't worth the risk.

Do you mean competition from midlevels?

 

[Drrrrrr. Celty]

I was into it, until I realized how fierce the competition is going to get in the near future. It just isn't worth the risk.

Competition? Last I checked our population is growing and there are plenty of people who are inadvertently going to be covered over the coming years.

 

[kenjixshadow]

OP, for me personally, I just can't fake caring about such benign disease for 15 visits a day and NPs are a threat to PCPs like CRNAs are to Gas. Despite that, I haven't completely r/o FM b/c they are in a great demand everywhere = get a job more easily than a specialist. Nevertheless, it seems like Family Medicine gets disrespected the most by medical students and residents, but in reality when they start practicing medicine independently, they'll love PCPs to give them referrals.

 

[NurWollen]

OP, for me personally, I just can't fake caring about such benign disease for 15 visits a day and NPs are a threat to PCPs like CRNAs are to Gas. Despite that, I haven't completely r/o FM b/c they are in a great demand everywhere = get a job more easily than a specialist. Nevertheless, it seems like Family Medicine gets disrespected the most by medical students and residents, but in reality when they start practicing medicine independently, they'll love PCPs to give them referrals.

Good points, but I might as be the one to point out that HTN, HLD, DM etc. are hardly benign. But I do understand what you mean. It's certainly not for everyone.

 

[D4C]

Good points, but I might as be the one to point out that HTN, HLD, DM etc. are hardly benign. But I do understand what you mean. It's certainly not for everyone.

Benign no, but it's not going to kill your patient today, or tomorrow...probably not for quite some time. All those fun drugs your managing for your patients 101 issues? Will you ever know if you actually prevented a poor outcome with your interventions? The rewards are too nebulous for me. Plus there isn't enough financial incentive to deal with all the social work that comes with outpatient medicine.

 

[group_theory]

government mandated best-practices/meaningful use/quality performance measures. Remember, the doctor will be "graded" on this.

Is your patient up to date on the pneumonia (PCV23 an PCV13) vaccinations?
Is your patient up to date on the tetanus (TDaP) vaccination?
Is your patient up to date on the influenza vaccination?
Have your patient received the Shingles vaccine (if applicable)?
Did you receive any specialist report electronically?
Did you review current medication information and updated it?
Did you review current allergies and updated it?
Did you review the BMI and counsel the patient on weight loss (and document such counseling)?
Is the BP under control and less than 140/90?
Is your patient up to date on breast cancer screening (if applicable)?
Is your patient up to date on colorectal cancer screening (if applicable)?
Did you talk to your patient about prostate cancer screening (if applicable)?
Did you talk to your patient about LDCT for lung cancer screening (if applicable)?
Is your patient up to date on pap/pelvic screening (if applicable)?
Is your patient's LDL control? If not, is your patient on a statin?
If diabetic, A1C less than 7?
If diabetic, recent neuropathy screen?
If diabetic, recent urine protein screen?
If diabetic, recent dilated eye exam/retinopathy screen with documentation in the EMR?
Osteoporosis screening and treatment?
Does patient have access to their electronic medical records via patient portal?
Can the patient email provider via patient portal or other secure messaging platform?
Is the patient demographics correct?
Patient smoking status? Did you discuss and document smoking cessation?
Did you review vital signs and documented that you reviewed vital signs?
Did the patient get a updated copy of his visit summary at the end of this visit?
Depression Screen?
Send reminders for preventive/follow-ups?
Have you done a security audit within the past 3 months and attest to the security of your EMR?


Now that the above have been reviewed and addressed, let's address your chief complaint?

Oh, do the above (and address the chief complaint) in 10-15 minutes total. Otherwise you'll start running behind.

*as a specialist, I can do one office procedure and get reimbursed the equivalent of five 99215 visits

 

[Mad Jack]

http://healthaffairs.org/blog/2015/...nt-and-pharmacist-pipelines-continued-growth/

As opposed to what fields? Seems like competition is going up across the board

There are roughly 3,000 and some change FP spots out there. In comparison, the number of NPs has gone up by over 100,000 in over just the last 15 years, and the number of PAs has doubled in just over a decade. There are 26,000 midlevels training at any given time now, the majority of which are mainly qualified to enter primary care. Eventually they're going to saturate the market. If you go into a high-liability or procedure-heavy specialty, you're much safer, as midlevels are far less likely to take these positions for medicolegal and scope of practice reasons. I'm looking at being an IM specialist in a field with procedures that cannot be performed by a midlevel (or even other physicians) and be reimbursed, because screw losing my job to some hack that never made it through medical school 20 years down the line.

 

[hallowmann]

Benign no, but it's not going to kill your patient today, or tomorrow...probably not for quite some time. All those fun drugs your managing for your patients 101 issues? Will you ever know if you actually prevented a poor outcome with your interventions? The rewards are too nebulous for me. Plus there isn't enough financial incentive to deal with all the social work that comes with outpatient medicine.

So what you really mean is acute vs. chronic. For me the idea of patching someone up everytime they say have an exacerbation just so they stay a couple days out of the hospital is practically an exercise in futility. The damage is done and they'll be back in a few days anyways because of the lack of support.

It honestly seems to vary a lot by an individual's personality. I actually enjoy the social stuff. I enjoy the patient education stuff, and ignorance when it occurs doesn't really bother me. The fact that those are the reasons people hate FM the most kind of demonstrates that it really varies person to person, and what they view as fulfilling varies just as much.

The thing is FM isn't for everyone. I hear a bunch of people being, oh I can just do FM if things don't work out in x specialty, but that's no recipe for happiness. Anyway, I may even change my mind, but as of now its PC, and most likely FM. There are downsides to every field, midlevels at almost every field, and honestly people should just do what makes s them happy.

 

[D4C]

So what you really mean is acute vs. chronic. For me the idea of patching someone up everytime they say have an exacerbation just so they stay a couple days out of the hospital is practically an exercise in futility. The damage is done and they'll be back in a few days anyways because of the lack of support.

It honestly seems to vary a lot by an individual's personality. I actually enjoy the social stuff. I enjoy the patient education stuff, and ignorance when it occurs doesn't really bother me. The fact that those are the reasons people hate FM the most kind of demonstrates that it really varies person to person, and what they view as fulfilling varies just as much.

The thing is FM isn't for everyone. I hear a bunch of people being, oh I can just do FM if things don't work out in x specialty, but that's no recipe for happiness. Anyway, I may even change my mind, but as of now its PC, and most likely FM. There are downsides to every field, midlevels at almost every field, and honestly people should just do what makes s them happy.

Agreed

 

[Goro]

An MD/PhD student once told me that he felt Family Practice was like being a traffic cop. You send the sick to others who do the "real work".

This kid ended up getting kicked out of the PhD track!

It may a combination of ignorance or the "wow" factor that specialties have, especially from media-generated images. I would submit that while Primary Care sees a lot of the same things, one has to be on one's toes for everything, even it it means palming them off to the "ologists"

Obviously it exists but I'm interested in discussing why it exists. To paraphrase something I saw @Goro say on these forums, people act like primary care is the 7th Circle of Hell. Why? The simple answer is that primary care pays less, but that's not always true. Prestige is a big factor for some people but that leads straight back to 'why?' I've come to the conclusion that you can divide medical students into people who would consider primary care, and others who act like it doesn't even exist. Is that a reasonable assessment?

 

[jtm0021]

government mandated best-practices/meaningful use/quality performance measures. Remember, the doctor will be "graded" on this.

Is your patient up to date on the pneumonia (PCV23 an PCV13) vaccinations?
Is your patient up to date on the tetanus (TDaP) vaccination?
Is your patient up to date on the influenza vaccination?
Have your patient received the Shingles vaccine (if applicable)?
Did you receive any specialist report electronically?
Did you review current medication information and updated it?
Did you review current allergies and updated it?
Did you review the BMI and counsel the patient on weight loss (and document such counseling)?
Is the BP under control and less than 140/90?
Is your patient up to date on breast cancer screening (if applicable)?
Is your patient up to date on colorectal cancer screening (if applicable)?
Did you talk to your patient about prostate cancer screening (if applicable)?
Did you talk to your patient about LDCT for lung cancer screening (if applicable)?
Is your patient up to date on pap/pelvic screening (if applicable)?
Is your patient's LDL control? If not, is your patient on a statin?
If diabetic, A1C less than 7?
If diabetic, recent neuropathy screen?
If diabetic, recent urine protein screen?
If diabetic, recent dilated eye exam/retinopathy screen with documentation in the EMR?
Osteoporosis screening and treatment?
Does patient have access to their electronic medical records via patient portal?
Can the patient email provider via patient portal or other secure messaging platform?
Is the patient demographics correct?
Patient smoking status? Did you discuss and document smoking cessation?
Did you review vital signs and documented that you reviewed vital signs?
Did the patient get a updated copy of his visit summary at the end of this visit?
Depression Screen?
Send reminders for preventive/follow-ups?
Have you done a security audit within the past 3 months and attest to the security of your EMR?


Now that the above have been reviewed and addressed, let's address your chief complaint?

Oh, do the above (and address the chief complaint) in 10-15 minutes total. Otherwise you'll start running behind.

*as a specialist, I can do one office procedure and get reimbursed the equivalent of five 99215 visits

For the reasons stated above, I've had two primary care physicians tell me not to go into primary care.

 

[Carbon090]

government mandated best-practices/meaningful use/quality performance measures. Remember, the doctor will be "graded" on this.

Is your patient up to date on the pneumonia (PCV23 an PCV13) vaccinations?
Is your patient up to date on the tetanus (TDaP) vaccination?
Is your patient up to date on the influenza vaccination?
Have your patient received the Shingles vaccine (if applicable)?
Did you receive any specialist report electronically?
Did you review current medication information and updated it?
Did you review current allergies and updated it?
Did you review the BMI and counsel the patient on weight loss (and document such counseling)?
Is the BP under control and less than 140/90?
Is your patient up to date on breast cancer screening (if applicable)?
Is your patient up to date on colorectal cancer screening (if applicable)?
Did you talk to your patient about prostate cancer screening (if applicable)?
Did you talk to your patient about LDCT for lung cancer screening (if applicable)?
Is your patient up to date on pap/pelvic screening (if applicable)?
Is your patient's LDL control? If not, is your patient on a statin?
If diabetic, A1C less than 7?
If diabetic, recent neuropathy screen?
If diabetic, recent urine protein screen?
If diabetic, recent dilated eye exam/retinopathy screen with documentation in the EMR?
Osteoporosis screening and treatment?
Does patient have access to their electronic medical records via patient portal?
Can the patient email provider via patient portal or other secure messaging platform?
Is the patient demographics correct?
Patient smoking status? Did you discuss and document smoking cessation?
Did you review vital signs and documented that you reviewed vital signs?
Did the patient get a updated copy of his visit summary at the end of this visit?
Depression Screen?
Send reminders for preventive/follow-ups?
Have you done a security audit within the past 3 months and attest to the security of your EMR?


Now that the above have been reviewed and addressed, let's address your chief complaint?

Oh, do the above (and address the chief complaint) in 10-15 minutes total. Otherwise you'll start running behind.

*as a specialist, I can do one office procedure and get reimbursed the equivalent of five 99215 visits

Savage. This is a shame because I do have interest in family medicine.

 

[TheaterOfTheme]

Savage. This is a shame because I do have interest in family medicine.

Agreed...the broad knowledge base and the inability to predict what will happen next is pretty interesting. The family med doc I shadowed loved family medicine. I always saw interesting and perplexing things while shadowing.

 

[SLC]

Agreed...the broad knowledge base and the inability to predict what will happen next is pretty interesting. The family med doc I shadowed loved family medicine. I always saw interesting and perplexing things while shadowing.

Family medicine is great, I certainly love it.

 

[chizledfrmstone]

Some of the smartest and most hardworking students I know are interested in family medicine.

I don't know if they're just saying that though.

 

[Captain DO]

I think its because some people care so much about prestige and feel the need to impress other people. Its cooler to talk about an emergency situation as an ER doc than a diabetes consult as a PCP. But after that 5 minute conversation is over, hopefully they enjoy it for other reasons. Cause prestige won't get ya squat in the long run.

To me, being a PCP would be great. Its a low-stress, relatively easy job that will pay you 200k+. I mean damn.
Don't feel like dealing with something? Kick it to a specialist and let them deal with it.
Find a job in any city in the country.
Get to know your patients and its almost like visiting with friends at work.

One genuine reason I think people have is that they like to do more procedures, etc. Thats a good reason to specialize. But for someone like me who couldn't care less about procedures, blah...

I think another reason is the higher salary in the specialties. But I was living happily on 26k before med school. So if you can't live happily on 200k with a low stress job like a PCP...something is wrong with you.

 

[SLC]

I think its because some people care so much about prestige and feel the need to impress other people. Its cooler to talk about an emergency situation as an ER doc than a diabetes consult as a PCP. But after that 5 minute conversation is over, hopefully they enjoy it for other reasons. Cause prestige won't get ya squat in the long run.

To me, being a PCP would be great. Its a low-stress, relatively easy job that will pay you 200k+. I mean damn.
Don't feel like dealing with something? Kick it to a specialist and let them deal with it.
Find a job in any city in the country.
Get to know your patients and its almost like visiting with friends at work.

One genuine reason I think people have is that they like to do more procedures, etc. Thats a good reason to specialize. But for someone like me who couldn't care less about procedures, blah...

I think another reason is the higher salary in the specialties. But I was living happily on 26k before med school. So if you can't live happily on 200k with a low stress job like a PCP...something is wrong with you.

Primary care isn't exactly what I'd call low stress. But it's not a 90hour work week like you can expect as a cardiologist either.

 

[racerwad]

I think its because some people care so much about prestige and feel the need to impress other people. Its cooler to talk about an emergency situation as an ER doc than a diabetes consult as a PCP. But after that 5 minute conversation is over, hopefully they enjoy it for other reasons. Cause prestige won't get ya squat in the long run.

To me, being a PCP would be great. Its a low-stress, relatively easy job that will pay you 200k+. I mean damn.
Don't feel like dealing with something? Kick it to a specialist and let them deal with it.
Find a job in any city in the country.
Get to know your patients and its almost like visiting with friends at work.

One genuine reason I think people have is that they like to do more procedures, etc. Thats a good reason to specialize. But for someone like me who couldn't care less about procedures, blah...

I think another reason is the higher salary in the specialties. But I was living happily on 26k before med school. So if you can't live happily on 200k with a low stress job like a PCP...something is wrong with you.

LOL @ the idea that primary care is low stress...

You might not be coding folks on each shift, but to think that primary care is low stress is maybe the most naive thing on SDN. Arguably, the amount of stress is one of the reasons that students choose not to go into primary care. For some, the amount of stress relative to the compensation just doesn't pencil out.

In addition a good PCP doesn't just consult a specialist because they "don't feel like dealing with something." WTF kind of lazy approach is this, anyway? You should be consulting because your patient has a legitimate issue that you lack the resources to treat adequately, not because it's 4:45pm on a Friday.

 

[SLC]

In addition a good PCP doesn't just consult a specialist because they "don't feel like dealing with something." WTF kind of lazy approach is this, anyway? You should be consulting because your patient has a legitimate issue that you lack the resources to treat adequately, not because it's 4:45pm on a Friday.

So far in intern year, the only thing I've referred to specialist for (from my clinic) is specialty testing. Things like sleep study, colonoscopy, stress-testing etc.

I've got one patient I may be getting ready to refer to Endocrine, but we'll see, I'm not there yet.

That's not to say there won't be reasons for me to refer in the future, there certainly will, but it's nowhere near as frequent as one might imagine.

 

[costales]

Not my cup of tea, but I know there are plenty of smart people in FM. The guy who took top honors last year at TCOM is an FM resident. It takes a certain type of personality to deal with FM patients, many of whom don't seem to give a damn until they get their foot cut off or until you show them there is a tumor - whereas most people do seem to pay close attention to a specialist (or for that matter, any doctor in a hospital) - because the danger is more imminent.

 

[Mad Jack]

I think its because some people care so much about prestige and feel the need to impress other people. Its cooler to talk about an emergency situation as an ER doc than a diabetes consult as a PCP. But after that 5 minute conversation is over, hopefully they enjoy it for other reasons. Cause prestige won't get ya squat in the long run.

To me, being a PCP would be great. Its a low-stress, relatively easy job that will pay you 200k+. I mean damn.
Don't feel like dealing with something? Kick it to a specialist and let them deal with it.
Find a job in any city in the country.
Get to know your patients and its almost like visiting with friends at work.

One genuine reason I think people have is that they like to do more procedures, etc. Thats a good reason to specialize. But for someone like me who couldn't care less about procedures, blah...

I think another reason is the higher salary in the specialties. But I was living happily on 26k before med school. So if you can't live happily on 200k with a low stress job like a PCP...something is wrong with you.

If you don't feel like dealing with it kick it to a specialist? Yep, that mentality is exactly what makes a bad PCP.

 

[W19]

A PCP is a social worker with a prescription pad... That's the truth!

 

[W19]

The future of FM is bleak... You have NP with a semester of online watered down pathophysiology and pharmacology who will saturate the market...

 

[Mad Jack]

The future of FM is bleak... You have NP with a semester of online watered down pathophysiology and pharmacology who will saturate the market...

You're always so grim W19 you really need to lighten up

 

[Captain DO]

If you don't feel like dealing with it kick it to a specialist? Yep, that mentality is exactly what makes a bad PCP.

Yes. You can refer out whatever you want. How great is that? 😛

 

[Captain DO]

LOL @ the idea that primary care is low stress...

Maybe your definition of stress is different than mine. Either way, I don't care. Primary care is very low stress to me. Deal with it 😛

In addition a good PCP doesn't just consult a specialist because they "don't feel like dealing with something." WTF kind of lazy approach is this, anyway? You should be consulting because your patient has a legitimate issue that you lack the resources to treat adequately, not because it's 4:45pm on a Friday.

lol oh lawd. Thats not what i meant. I think yall know what I meant, but of course you'll put that spin on it. I don't care to explain. Take it as you like. And if that post offended you so much, print it out and take a **** on it. maybe youll feel better. 🙂

 

[GlowInTheDark]

I try to think, "if I go into X, where will things be in 20 yrs?"

I don't like the future of being a PCP. Heck, I hardly like the present.

 

[SLC]

I try to think, "if I go into X, where will things be in 20 yrs?"

I don't like the future of being a PCP. Heck, I hardly like the present.

You should speak with the specialists. They aren't that high on the future either.

 

[Mad Jack]

A PCP is a social worker with a prescription pad... That's the truth!

Really depends on where you're practicing and what mix of patients you have, as well as your reimbursement model.

 

[Winged Scapula]

Please keep the conversation civil and professional.

 

[Mad Jack]

Please keep the conversation civil and professional.

It seems civil enough to me. Is there something I'm missing or do you just see things going south and are giving a pre-emptive warning? I'm not asking out of disrespect, I just honestly want to avoid a thread lock if possible.

 

[NontradCA]

The simple answer is that primary care pays less

 

[Winged Scapula]

It seems civil enough to me. Is there something I'm missing or do you just see things going south and are giving a pre-emptive warning? I'm not asking out of disrespect, I just honestly want to avoid a thread lock if possible.

You're missing a comment above that we received several complaints about.

 

[Danbo1957]

Primary Care physicians will always be needed (I am IM). As I have said, let the mid-levels take 50% of what I currently do, and I'll do more of that other 50% that they'll never be able to do.

 

[MedNation907]

When I think of "aversion" to primary care it's legislation that comes to mind before income or prestige. My take is that the field suffered once their focus forcefully shifted from taking care of patients to tending to the increasing legislative demands. This idea stems from a book I read a few years ago written by a PCP who felt the shift in his medical practice in the mid 90s; and the doctor I scribed for mentioned the same thing. All of this in turn makes income an issue because it's just more stress on these doctors who feel they should be earning more for it. Family Medicine still remains an interest for me and no one has straight up told me not to enter it, that would be pretty discouraging coming from a practicing physician, but I have my concerns and I'm not sure yet if they are justified.

 

[235009]

Unfortunately in primary care we've taken to treating the chart and satisfying metrics instead of treating the patient. @group_theory's post is on point. The most important thing in every patient visit now is documentation and billing... making sure you're clicking all the right buttons and tinkering with the meds to make the patient's lab values look good. The patient's actual chief complaint is no longer important. Add to that the mountains of paperwork: prior authorization, disability, housing, VNA, etc etc etc and you do feel like an overqualified secretary and social worker.

Don't feel like dealing with something? Kick it to a specialist and let them deal with it.

You're welcome to do that but insurance companies will quickly flag you as a high utilizer. They might decrease your reimbursement or drop you altogether. And it's no skin off the back of the specialist. If it's a really easy bread and butter case they will manage it in 5 minutes and still get paid the full amount for their office visit. As a specialist you also have the luxury of turfing back topics not directly related to your specialty back to the PCP.

So far in intern year, the only thing I've referred to specialist for (from my clinic) is specialty testing. Things like sleep study, colonoscopy, stress-testing etc.

I've got one patient I may be getting ready to refer to Endocrine, but we'll see, I'm not there yet.

That's not to say there won't be reasons for me to refer in the future, there certainly will, but it's nowhere near as frequent as one might imagine.

This is an extremely dangerous attitude. Your ego is going to end up hurting patients. Also as an intern I'm assuming you're seeing each patient for 45 min to an hour. When you barely have 15 min per patient as a senior come back and let me know how this attitude is working out for you.


Finally I'm really glad that after residency I'll no longer have to deal with prescribing narcotics for chronic pain. What a disaster that has been for our patients and our country.

 

[SLC]

This is an extremely dangerous attitude. Your ego is going to end up hurting patients. Also as an intern I'm assuming you're seeing each patient for 45 min to an hour. When you barely have 15 min per patient as a senior come back and let me know how this attitude is working out for you.

Oh you again...

I'm sorry but hearing MT lecture me or anyone else for that matter about 'attitude' just makes me chuckle.

One thing I will say is that you definitely have some finely honed critical reading skills... 🙄

 

[IsWhat]

This is an extremely dangerous attitude. Your ego is going to end up hurting patients. Also as an intern I'm assuming you're seeing each patient for 45 min to an hour. When you barely have 15 min per patient

Where I'm from the PCP only refers for extreme cases - not from ego, but out of necessity. I wouldn't fault any FM intern or resident for trying to manage a patient for as long as possible under attending supervision, because in many parts of the country the PCP is all you have for 100 miles.

 

[SLC]

Where I'm from the PCP only refers for extreme cases - not from ego, but out of necessity. I wouldn't fault any FM intern or resident for trying to manage a patient for as long as possible under attending supervision, because in many parts of the country the PCP is all you have for 100 miles.

Bingo!

We refer when necessary, I haven't encountered a situation where it's been necessary just yet.

 

[racerwad]

Maybe your definition of stress is different than mine. Either way, I don't care. Primary care is very low stress to me. Deal with it 😛



lol oh lawd. Thats not what i meant. I think yall know what I meant, but of course you'll put that spin on it. I don't care to explain. Take it as you like. And if that post offended you so much, print it out and take a **** on it. maybe youll feel better. 🙂

So what do you mean? I did add any spin - I just read what you wrote about consulting on cases because you simply "don't feel like it." If there is a more nuanced version in your head, I would be up to hearing it.

I'm not an FP, so I'm not personally offended. I just wonder how little effort you plan on spending on behalf of our patients?

 

[metopic]

I knew I would never do primary care the first day of my cardiology rotation. I had just finished a family medicine rotation that treated medical students like interns, and it was overwhelming. All the things that group theory mentions, they want refills for meds for 5 chronic conditions, they have DM and HTN which you need to check their numbers, plus 4 chief complaints (i'm having back pain, i get this weird chest pain, I have headaches, oh and I'm constipated). And we'd have 20 minutes to talk to them and write the note, then we'd present to the attending. I felt like I was running a sprint all day long.

Then I go to cards. New consult, atypical chest pain. 10 minutes to make some small talk, get to know them, do a leisurely review of systems, review their history, and a PE. Present to attending: plan stress and echo. Wam bam thank you next. It was like night and day. 10 minutes of work in a 15 minute slot vs 90 minutes of work in 20 minutes. And hilariously the attendings in both were across the board billing mostly level 4's. Not to mention what I was insulated from as a student -- the FM attending would be bombarded all day long with telephone messages refill requests lab results referral requests letters from specialists disability paperwork DME paperwork etc it was nuts. All the cards attendings would do is read echos, vascular u/s, holters, and stress tests in their down time, so more RVU's. Plus everyone would get annual EKG's and new consults would all get EKG's so more RVU's there too.

Anyway I'm applying IM and I enjoy the challenge of primary care. But there's no way I'd sign up for a lifetime of that when I can be a subspecialist and make more doing less.

 

[NurWollen]

I knew I would never do primary care the first day of my cardiology rotation. I had just finished a family medicine rotation that treated medical students like interns, and it was overwhelming. All the things that group theory mentions, they want refills for meds for 5 chronic conditions, they have DM and HTN which you need to check their numbers, plus 4 chief complaints (i'm having back pain, i get this weird chest pain, I have headaches, oh and I'm constipated). And we'd have 20 minutes to talk to them and write the note, then we'd present to the attending. I felt like I was running a sprint all day long.

Then I go to cards. New consult, atypical chest pain. 10 minutes to make some small talk, get to know them, do a leisurely review of systems, review their history, and a PE. Present to attending: plan stress and echo. Wam bam thank you next. It was like night and day. 10 minutes of work in a 15 minute slot vs 90 minutes of work in 20 minutes. And hilariously the attendings in both were across the board billing mostly level 4's. Not to mention what I was insulated from as a student -- the FM attending would be bombarded all day long with telephone messages refill requests lab results referral requests letters from specialists disability paperwork DME paperwork etc it was nuts. All the cards attendings would do is read echos, vascular u/s, holters, and stress tests in their down time, so more RVU's. Plus everyone would get annual EKG's and new consults would all get EKG's so more RVU's there too.

Anyway I'm applying IM and I enjoy the challenge of primary care. But there's no way I'd sign up for a lifetime of that when I can be a subspecialist and make more doing less.

I think it pretty much depends on what is stressful to you as an individual. I've worked with PCPs who were stressed in all the ways you just mentioned, but worked 45-50 hours a week with no nights, no call and few weekends. One in particular was able to get his charting done during the day, so when he went home, he was done. On the other hand, I've seen specialists who work 12 or 14 hours a day AND almost every weekend (the latter made a fortune, I'm sure.) So like everything else it goes back to what you like and what you want.

 

[NurWollen]

The thing is, there are specialties that make scarcely more than a PCP- such as endo, nephro, or ID- that nonetheless are seen as more "worthy" pursuits. I'm talking about the kind of discouragement students at some med schools get from going in to FM, for example.

 

[67552931811]

The thing is, there are specialties that make scarcely more than a PCP- such as endo, nephro, or ID- that nonetheless are seen as more "worthy" pursuits. I'm talking about the kind of discouragement students at some med schools get from going in to FM, for example.

Be an individual and do what you want to do. Ignore the prognostications and you do you. I haven't met another person in my class who wants to do what I want to do. That isn't to pat myself on my back but to say that I've had enough introspection to know who I am and what I want out of life/ medicine. Apply that and be happy. Be it FM or an IM doc with 4 fellowships under his/her belt. Money/ Prestige/ "Respect" won't replace a soul-sucking 60-80 hour week if you loathe your occupation. Different strokes, just my .02

 

[NurWollen]

Be an individual and do what you want to do. Ignore the prognostications and you do you. I haven't met another person in my class who wants to do what I want to do. That isn't to pat myself on my back but to say that I've had enough introspection to know who I am and what I want out of life/ medicine. Apply that and be happy. Be it FM or an IM doc with 4 fellowships under his/her belt. Money/ Prestige/ "Respect" won't replace a soul-sucking 60-80 hour week if you loathe your occupation. Different strokes, just my .02

Solid advice, of course. Just for the record, I do fully plan on doing what I want to do. I meant this thread as more of am intellectual exercise in where prestige comes from.

You're 100% right though. Medical education is one long, strenuous exercise in figuring out what you want to do. We all had plenty of people telling us not to go to med school. We all could have been lawyers or PAs or nurses or landscapers or baristas or engineers etc. Find your thing and run with it.

 

[67552931811]

Solid advice, of course. Just for the record, I do fully plan on doing what I want to do. I meant this thread as more of am intellectual exercise in where prestige comes from.

You're 100% right though. Medical education is one long, strenuous exercise in figuring out what you want to do. We all had plenty of people telling us not to go to med school. We all could have been lawyers or PAs or nurses or landscapers or baristas or engineers etc. Find your thing and run with it.

Haha, my bad. I realized after my post that I didn't answer the actual question. Honestly, I think prestige comes mostly from the history of medicine and the fact that the more intense/ sought-after (usually correlated with more $)/ emergency-heavy fields have always equated with more respect/ prestige. Is that still true today? I have no idea, I'll let someone my senior, and a practicing physician, answer that one.

 

[NontradCA]

The thing is, there are specialties that make scarcely more than a PCP- such as endo, nephro, or ID- that nonetheless are seen as more "worthy" pursuits. I'm talking about the kind of discouragement students at some med schools get from going in to FM, for example.

Those are the least competitive fellowships from IM, so I'm not sure what you're getting at. I think discouragement in medical school mainly happens in DO programs, where they are actively trying to push FM down students' throats. I think it's a natural human response, and it probably adds to the chip on the shoulder of FM. Like you bought a lemon from some sneaky salesman.