Why would anyone EVER consider primary care?

[larryboy]

Ok I'm not trolling or flaming. Just wanted you get your attention

I'm a very longtime lurker, first time poster.

I'm an internist who has followed on sdn forums since pre-med days, and it's been a great resource for me.

Going through medical school, I had a hard time deciding on a specialty (sound familiar?) I wish that I had more exposure to certain fields. Ultimately I decided on internal medicine and thankfully I'm happy with my choice. But I just as easily could have chosen something that I wouldn't have liked - simply because I didn't have enough exposure to it.

So in efforts to help anyone out there get a 'real' idea of what internal medicine is like, I've started blogging in a very random, sarcastic, and stream-of-consciousness type way about my experience as an internist.

Hopefully it helps to give you insight on what it's like to be an internist.

Anyway, enjoy.

Medicalcraponomics.blogspot.com

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[Stumpyman]

Expected troll. Got spam.

 

[kautionwirez]

Still a troll!

 

[larryboy]

No way peeps - no trollage here! Just trying to give back to the sdn community. I'd be glad to answer any burning questions about school, residency, post-residency, etc.

I wish looking back that I had more access to people who had already been through the process, so I'm doing what I can to aid that effort in some small way.

I'll be around sdn if you have any questions.

larryboy

 

[KnuxNole]

For my personal reasons:

1) Because I enjoy the variety and depth involved
2) I greatly enjoy the clinic setting
3) For IM: If I decide if I want to specialize, I have more doors to open, and if I want to be a general internist, I would be content with that.
4) The "money", I'm fine with that. I'm not ever planning on having a huge house, 5 cars, and a private yacht. I just want to live happily, peacefully, and enjoy life.
5) Some people think it's not prestigious, but I would rather do something for the rest of my life that I'll be happy bout than care about what the majority thinks. There are a lot of things the majority does not agree on in tons of different aspects of life.

Some more, but I'm a bit sleepy to type a lot, just wanted to put that out there....since apparently this is not a troll thread as OP claims

 

[Ignatius M.D.]

When I shadowed in gastroenterology I found it very interesting, and from what I know it is well compensated. Is it worth it considering you have to deal with poop all day though? (serious question). To answer your first question, I know several people interested in FM, but it doesn't appeal to me.

 

[larryboy]

knuxnole - great points.

My hope is that medical school costs will never preclude anyone from choosing primary care, although I can understand why it happens. For many people it's just not a good financial decision.

I have heard that people are coming out with 400K + in student debt nowadays - and with tuition rising every year I can certainly believe it.

In case anyone didn't read the entire post - I am a practicing internist and love my job. There is a lot of value in primary care. While managing chronic disease isn't as sexy as some other specialties, it's certainly more economical and much needed.

 

[flatearth22]

Troll but I'll play along...

1) Obamacare is going to slash payments of specialists while not doing much to primary care - http://www.nypost.com/p/news/opinion/opedcolumnists/slashing_doc_pay_QPgo179t8e1wg1QsAwBhUP

2) Much better job security with primary care - Pathology market is tight right now, Radiology appears to be headed the same way, Anesthesiology is being encroached by CRNA's, etc. etc.

3) Broad knowledge base...get to be a jack of all trades....

4) Get to know your patients extremely well and establish long-term relationships with them over the years which can be very rewarding (check out MT Headed's PS....great stuff: http://www.mdapplicants.com/profile.php?id=23645)

 

[chiddler]

5) Some people think it's not prestigious, but I would rather do something for the rest of my life that I'll be happy bout than care about what the majority thinks. There are a lot of things the majority does not agree on in tons of different aspects of life.

Some more, but I'm a bit sleepy to type a lot, just wanted to put that out there....since apparently this is not a troll thread as OP claims

Prestige...

That's like having to be president instead of grand emperor. Oh noo i'm so sad. I'm not grand emperor but merely president.

 

[serosanguinous]

Not sure why everyone is calling him a troll, but his blog is pretty good. I enjoyed it. Keep up the good work!

 

[seracus]

Re: #1, do politicians really think it's fair to compare American doctors' wages to Europeans when our medical school and undergraduate tuition are much much higher than our counterparts, when we have four extra years of education, when we have to tackle with higher costs for malpractice insurance, and when admissions to the schools are more competitive and thus have higher financial opportunity costs?

Troll but I'll play along...

1) Obamacare is going to slash payments of specialists while not doing much to primary care - http://www.nypost.com/p/news/opinion/opedcolumnists/slashing_doc_pay_QPgo179t8e1wg1QsAwBhUP

2) Much better job security with primary care - Pathology market is tight right now, Radiology appears to be headed the same way, Anesthesiology is being encroached by CRNA's, etc. etc.

3) Broad knowledge base...get to be a jack of all trades....

4) Get to know your patients extremely well and establish long-term relationships with them over the years which can be very rewarding (check out MT Headed's PS....great stuff: http://www.mdapplicants.com/profile.php?id=23645)

 

[NickNaylor]

Other things that physicians like about primary care (or that I've at least heard of):

1) You have longitudinal relationships with your patients

2) You get to manage all of their health conditions and act as a gatekeeper of sorts to specialists

3) Not that this is necessarily untrue of other specialties, but you have tremendous opportunities to hugely impact the health of underserved individuals.

 

[sciencebooks]

For my personal reasons:

1) Because I enjoy the variety and depth involved
2) I greatly enjoy the clinic setting
3) For IM: If I decide if I want to specialize, I have more doors to open, and if I want to be a general internist, I would be content with that.
4) The "money", I'm fine with that. I'm not ever planning on having a huge house, 5 cars, and a private yacht. I just want to live happily, peacefully, and enjoy life.
5) Some people think it's not prestigious, but I would rather do something for the rest of my life that I'll be happy bout than care about what the majority thinks. There are a lot of things the majority does not agree on in tons of different aspects of life.

Some more, but I'm a bit sleepy to type a lot, just wanted to put that out there....since apparently this is not a troll thread as OP claims

I feel like the only people who actually seem to think that are other physicians themselves (unfortunately). Most of my family who aren't in professional positions find it all respectable.

 

[iqe2010]

Family medicine is a great specialty. Managing the health of an entire family can be very awarding. Just think, if someone has a chronic condition or dies early, maybe the doctor could prevent it from happening with their offspring. I think its great when a doctor has built a good relationship with an entire family.

The U.S. is opposite in handling general/family medicine, it's the most important specialty yet it's paid the least and not glorified. In other countries, GPs make considerably more than than other specialties.

Other countries aren't dumb and fat like we in the U.S. are either...

 

[beethousand]

America sure cares alot about its skin. Cough "derm" cough.....

 

[ppfizenm]

Is there a specialty that gets sued more so than others? I can imagine IM being pretty high up there.

 

[exquisitemelody]

It's nice to see a medical blog by a person who actually likes their job. I feel like all the ones I've run into tell me to run the other direction.

 

[IMSingular]

Prevention is better than cure, and that is the task of primary care.

 

[larryboy]

a lot of very valid points made here.

my thought to all of you in medical school or doing pre-med stuff is to try and keep an open mind when choosing a specialty. you'll change your mind a number of times. don't fall into the trap of 'going with the herd', which is quite common in medicine. certain specialties have stigmas attached and we tend to absorb those notions passively when going through the training process. do what you want to do and what you enjoy doing.

i would be lying if i said that i'm not worried about the financial implications of going into internal medicine. the next 5-10 years are going to bring a lot of change, and i'm not sure anyone knows how reimbursement will be affected. when you have 250k in loan debt, you have to worry about these things. the crushing burden of debt doesn't really hit you until you start paying 33% income tax and then 3k monthly going to loan repayment on top of that. all of the sudden your nice new attending salary is whittled down to a glorified resident salary.

internal medicine is not for everyone, and i understand that. i wouldn't recommend you do it if you don't like it. but if you don't like it just because you don't have enough exposure to it, then keep it an option. there are plenty of us who do enjoy it, and i'm trying to share that via my blog.

good discussion - keep it going. i'd be happy to answer any specific questions about my job or anything somewhat related.

larryboy
medicalcraponomics.blogspot.com

 

[MT Headed]

good discussion - keep it going. i'd be happy to answer any specific questions about my job or anything somewhat related.

larryboy
medicalcraponomics.blogspot.com

Disregarding the sex (okay, you'd have to disregard 2/3 of the book then) was House of God a pretty accurate representation of your residency? Your chi-chi article sounded like it was lifted word-for-word.

 

[larryboy]

Is there a specialty that gets sued more so than others? I can imagine IM being pretty high up there.

No, in fact malpractice insurance for internists is on the lower end of the spectrum. We do few procedures and thus don't have nearly the liability of other specialities.

 

[larryboy]

Disregarding the sex (okay, you'd have to disregard 2/3 of the book then) was House of God a pretty accurate representation of your residency? Your chi-chi article sounded like it was lifted word-for-word.

house of god is a classic. it should be required reading for all medical students. it is obviously sensationalistic and hyperbolic, but there are a lot of accuracies. when people ask me what residency was like, i tell them to watch scrubs. it's a show that most people have seen and can relate to. by far the most accurate medical show out there - much more so than the dramatic, overly-romantic trash that i don't particularly care for.

maybe i'll make a post about residency - i could have some fun with that one. sooooo many good stories and experiences. thanks for the idea. stay tuned.

larryboy

 

[drizzt3117]

Is there a specialty that gets sued more so than others? I can imagine IM being pretty high up there.

Ob-gyn and surgery/surgical specs.

 

[BA11]

1: Job security

2: Patient relationships

3: Primary care will be largely untouched by medical reforms

 

[plumazul]

Re: #1, do politicians really think it's fair to compare American doctors' wages to Europeans when our medical school and undergraduate tuition are much much higher than our counterparts, when we have four extra years of education, when we have to tackle with higher costs for malpractice insurance, and when admissions to the schools are more competitive and thus have higher financial opportunity costs?

The link was an OPINION piece in a sleazy tabloid written by what appears to be a political hack. I don't think it is to be taken seriously.

 

[SunsFun]

The link was and OPINION piece in a sleazy tabloid written by what appears to be a political hack. I don't think it is to be taken seriously.

+1,

Until presented with more credible sources, I am skeptical.

 

[plumazul]

Ok I'm not trolling or flaming. Just wanted you get your attention

I'm a very longtime lurker, first time poster.

I'm an internist who has followed on sdn forums since pre-med days, and it's been a great resource for me.

Going through medical school, I had a hard time deciding on a specialty (sound familiar?) I wish that I had more exposure to certain fields. Ultimately I decided on internal medicine and thankfully I'm happy with my choice. But I just as easily could have chosen something that I wouldn't have liked - simply because I didn't have enough exposure to it.

So in efforts to help anyone out there get a 'real' idea of what internal medicine is like, I've started blogging in a very random, sarcastic, and stream-of-consciousness type way about my experience as an internist.

Hopefully it helps to give you insight on what it's like to be an internist.

Anyway, enjoy.

Medicalcraponomics.blogspot.com

OP, looking into the future, do you think it is possible that PC will become the domain of "virtual doctors" used in conjunction with non-MD physical providers? Aren't we already headed in that direction?

 

[larryboy]

If primary care continues on the path that it is currently on, then yes, I see the physician extender (i know they don't like that term, but i used it anyway) model as the only financially viable one. the bottom line is that we live in a setting of increasing overhead and declining reimbursement.

i see solo practices being fewer and further in between. in my area, practices are being snatched up by local hospitals in preparation for the ACO (accountable care organization) changes that are going to start in 2013. if you choose primary care, there is a good chance that you will be working as an employee of a larger organization - one that can still operate at lower margins and still make money off of other services (hospitals, lab, etc).

i'm torn on whether this is a good or a bad thing. there is a perception that quality of care will suffer if we let physician extenders take a larger role, but i'm not convinced that is really the truth. a large percentage of internal medicine outpt visits can be handled by a non-physician, while the more complicated, chronically ill patients can be seen by physicians.

the truth is that in a few years, 45 million people will now be mandated to carry insurance, which in turn means that our offices will be getting busier. unless we start training a bazillion more doctors each year, we're going to have to work right alongside c our physician extender counterparts. again, i'm not bothered by that.

next 5 years in medicine are going to be very interesting...

 

[beargunkarate]

The link was an OPINION piece in a sleazy tabloid written by what appears to be a political hack. I don't think it is to be taken seriously.

+1

Plus, it's only Medicaid payments that will allegedly be cut under the allegedly passed vote/legislation/whatevs. Even if true, a 16.7% cut in Medicaid payments to a doc is not going to put him/her in the poorhouse.

 

[MT Headed]

It seems like insurance exists to remove customer service and profit from the doctor patient relationship through lower reimbursements, paperwork, and necessary support staff.

Do you think there will still be a future for solo or private practice primary care clinics that don't accept any insurance? Even the insured (especially those with hi deductible plans) patronize these no-frills no-insurance establishments today.

 

[sirdudeness]

Honestly, if the pay were better I would probably choose primary care. I've had such good PCP's growing up that I really want to help others like mine helped me.

Unfortunately, the long hours (or so I've read) and relatively little pay coupled with decreasing insurance payments and massive investments of setting up a practice is the harsh truth many PCP's suffer from. I hope in the future something gets passed that makes being a PCP worth it because I think its an incredible important field and I would love to go into it.

 

[larryboy]

Honestly, if the pay were better I would probably choose primary care. I've had such good PCP's growing up that I really want to help others like mine helped me.

Unfortunately, the long hours (or so I've read) and relatively little pay coupled with decreasing insurance payments and massive investments of setting up a practice is the harsh truth many PCP's suffer from. I hope in the future something gets passed that makes being a PCP worth it because I think its an incredible important field and I would love to go into it.

sirdudeness you've hit the nail on the head.

unfortunately with the cost of tuition these days, you absolutely must factor future reimbursement in the equation unless you are ok with taking a large financial hit.

i wish it weren't this way, but it is. i too hope that this will change at some point - but i'm not holding my breath.

something to keep in mind - remember that everything has an ebb and flow to it. while primary care doesn't reimburse as well as other specialties now, it may in the future. if you can financially swing it, chose what you like doing because you never know how your pay is going to change over the next 20 years.

larryboy

 

[TACMON]

There are loan forgiveness programs offered by the gov't for students entering primary care, but I suppose the pay in general is still unattractive when accounting for training time

 

[Bacchus]

The pay is an issue with loan indebtedness. However, I don't have the desire to open and be responsible for a practice which makes me much happier and able to pursue FM in my opinion.

 

[primadonna22274]

Dr Larryboy (curious, as in Veggietales Larry the Cucumber?),

Thanks for your posts. I haven't read your blog yet but it's on my to-do list.

Any advice for someone who is on the fence between IM and FM? If I'm really honest my first love is IM, but several FM friends have told me it's hard to get paid as an internist compared to FM with a wider payor base.

A little about me: 12 yr as a PA, FM & EM/urgent care. Definitely don't want EM. Like teaching. Have no problem being the team leader of a few skilled PAs/NPs esp with my background. Reimbursement is a concern though as between PA & DO school I am looking at $250k loans to repay....

Thanks

Lisa

 

[FTFY]

sirdudeness you've hit the nail on the head.

unfortunately with the cost of tuition these days, you absolutely must factor future reimbursement in the equation unless you are ok with taking a large financial hit.

i wish it weren't this way, but it is. i too hope that this will change at some point - but i'm not holding my breath.

something to keep in mind - remember that everything has an ebb and flow to it. while primary care doesn't reimburse as well as other specialties now, it may in the future. if you can financially swing it, chose what you like doing because you never know how your pay is going to change over the next 20 years.

larryboy

Really enjoying the blog.

What do you think about the increase in the number of hospitalists chosing it as their career over clinic? Do you think it will stick around as a career choice?

I have spent time working in clinic prior to starting medical school, and although I appreciate it, unless I see a major switch where Primary Care becomes the hub of records keeping and care coordination I don't know if I see myself in it. It seems to me that instead of being gathered up into the larger systems, why don't GP's gather together and start sharing resources? Why can we have so many advances in technology, but my soon to be fellow doctors' office don't readily share information with me.

So much time, money, and effort could be saved with combined registration databases, centralized billing offices that are shared between offices to save costs, and the correct selection of positions and staffing for clinics. But, instead what seems to exist is this fragmented system in which nobody talks to each other.

Sorry if that got tangential, it's been a long day at work. But, I do really want to thank you for this blog, and I will be bookmarking it to follow.

 

[Morsetlis]

On pathologists:

"Even though I can't understand how they find joy in their work, I am incredibly grateful that they do what they do. They are doctors' doctors. Without them, a majority of diagnoses would never be made. They are essential to good healthcare. And they are incredibly intelligent folks - they have a robust knowledge base and understand pathophysiology of the human body perhaps as good as - if not better - than any physician."

 

[larryboy]

Dr Larryboy (curious, as in Veggietales Larry the Cucumber?),

Thanks for your posts. I haven't read your blog yet but it's on my to-do list.

Any advice for someone who is on the fence between IM and FM? If I'm really honest my first love is IM, but several FM friends have told me it's hard to get paid as an internist compared to FM with a wider payor base.

A little about me: 12 yr as a PA, FM & EM/urgent care. Definitely don't want EM. Like teaching. Have no problem being the team leader of a few skilled PAs/NPs esp with my background. Reimbursement is a concern though as between PA & DO school I am looking at $250k loans to repay....

Thanks

Lisa

hi lisa,

you must have kids - veggie tales is a favorite in the house right now. love it.

i started out wanting to do FM and changed to IM at the last minute. for me, there were a couple of reasons.

1) i just couldn't get excited about ob. almost fainted seeing a 3rd degree tear - still traumatized by that.
2) you always have the option of specializing out of IM if you want to - you'll be surprised that your interests will change, even in residency,
3) keeps hospitalist option open. you can do hospitalist work as FM, but it may be a bit more difficult depending on area of the coutry you practice in.

i found that i really enjoyed doing hospitalist work. right now i do a bit of both (inpt, outpt), but will be moving to straight hospitalist work in a few months. gonna give that a try.

i'm the type of person that can get bored doing the same thing over and over, and so for me IM gave me more options.

 

[larryboy]

It seems like insurance exists to remove customer service and profit from the doctor patient relationship through lower reimbursements, paperwork, and necessary support staff.

Do you think there will still be a future for solo or private practice primary care clinics that don't accept any insurance? Even the insured (especially those with hi deductible plans) patronize these no-frills no-insurance establishments today.

yes, you've got a good business mind i see. i think an unintended consquence of obamacare will be that more concierge (or cash only) practices will start to pop up. i think they are a great idea. there will always be people willing to pay more for a bit of extra service - especially if they find that their pcp is being deluged with so many new patients and they feel the want 'extra' service.

i've had thoughts about doing this myself. i'm going to wait a few years, though, until i make any concrete decisions as healthcare is in flux right now and i don't know quite what to expect.

i like the idea, though.

 

[larryboy]

Really enjoying the blog.

What do you think about the increase in the number of hospitalists chosing it as their career over clinic? Do you think it will stick around as a career choice?

I have spent time working in clinic prior to starting medical school, and although I appreciate it, unless I see a major switch where Primary Care becomes the hub of records keeping and care coordination I don't know if I see myself in it. It seems to me that instead of being gathered up into the larger systems, why don't GP's gather together and start sharing resources? Why can we have so many advances in technology, but my soon to be fellow doctors' office don't readily share information with me.

So much time, money, and effort could be saved with combined registration databases, centralized billing offices that are shared between offices to save costs, and the correct selection of positions and staffing for clinics. But, instead what seems to exist is this fragmented system in which nobody talks to each other.

Sorry if that got tangential, it's been a long day at work. But, I do really want to thank you for this blog, and I will be bookmarking it to follow.

i'll try to answer these as best I can.

i think IM residents will continue to choose hospitalist work by and large until the outpatient jobs seem more attractive to them. i primarily do hospitalist work now, with a bit of clinic mixed in. i can tell you coming out of residency that hospitalist jobs pay significantly better and have a better work schedule. kinda hard to convince someone to stay in the clinic when you offer a worse schedule and less pay, right? unless you really like clinic, you'll probably stay in the hospital.

outpatient IM is not an easy gig right now. you ahve a lot of unpaid time that you are expected to put in (phone calls, office stuff, etc). unless you have a very well run office, your margin is going to be tight.

also, keep in mind that the entire setup of primary care is going to change in the next 3-5 years. patient-centered medical homes are the new vogue concept, and accountable care organizations are going to start forming as well. google these terms if you aren't familiar with them.

medicine in general is very inefficient when it comes to technology. omg it frustrates me to no end. i hear you on that one. not sure that is going to change any time soon, so you just have to get used to it unfortunately. PCMH and ACO's are meant to address some of these problems, but i'm just not convinced that adding another lay of beaurocracy to an already broken system is going to help. i'm not sure i have any better ideas, however, so i'm not quite sure what to do about it. for the time being i ride along with it and try to not get frustrated.

remember that you can, and lots of IM's do, go back and forth from clinic -> hospitalist and back during their careers. i'm sure i will as i get bored and want to do something new for a while. so keep your options open.

larryboy

 

[larryboy]

There are loan forgiveness programs offered by the gov't for students entering primary care, but I suppose the pay in general is still unattractive when accounting for training time

there are programs out there, and i would highly recommend anyone going in to primary care at least take a look at them. you might find something that works for you. the pay isn't bad from what i've seen/heard. outpatient care reimbursement is pretty standard from what i've seen, unless you are a partner or in a unique situation. so take a look at the programs - even a little bit of loan repayment will go a long way to helping pay off loans quickly.

 

[Eric552]

Medicalcraponomics.blogspot.com

That was very addicting and an enjoyable read. I have it bookmarked and hope that you keep updating!