Are we whining about primary care?

Adam, medical students (at least in our survey of over 1000 medical students from 11 schools published in JAMA) do not primarily choose specialities due to the lure of large paychecks. Few students today enroll in medical school knowing they want to be a radiologist or dermatologist. Most pre-meds know that if they want a huge paycheck, they should go to law school or business school.
What happens is that during their clinical years, when they are exposed to primary care, they see unhappy physicians. DB describes this quite accurately. The larger salaries of the specialist and students’ looming debt is only the icing on the cake in their decision not to choose primary care.
I agree that debt forgiveness is a good idea, but it will not be nearly enough to solve the primary care crisis. Smart students will realize that they will be able to make up the difference only a few years down the road. Similarly, blanket increases to primary care will help, but again will not be sufficient. The concept of the Medical Home sounds encouraging, but if the increases are not enough, and the hurdles to get the extra money are too burdensome, the Medical Home may actually make the situation worse.
The main problem is the way primary care is reimbursed. Lawyers and accountants have lots of paperwork, but get paid for doing this. Similarly, they bill for the time spent communicating with their clients. Primary care physicians do lots of paperwork which they can’t get reimbursed for and spend lots of time communicating with patients where they barely get reimbursed (regular appointments) or get no reimbursement at all (after hours emergency calls, phone calls, emails, etc.)
Thus, the problem is money, but salary and student debt are only part of (and not primarily) the issue. To solve the primary care crisis you have to reward (pay) primary care physicians for what they do, decrease administrative burden, or both.

I have been a solo family practice physician for about 9 years. I am happy overall in my career choice. I agree that many family doctors are unhappy. Some of this can be from group disparity, where the younger doctors are paid a fixed and low salary and have little input into the care of their patients. Other people get overwhelmed with the paperwork and insurance preauthorizations.

As a solo doctor, I usually work at least 50 hours a week, but I work for the patients and myself. I don’t have unrealistic quotas, and I don’t have to worry about production bonuses. I have input into the care of my patients and control of my salary. I make over $200,000 a year and enjoy seeing my patients in the office and in the hospital. As a smaller practice, I can spend more time caring directly for my patients instead of dealing with the administrative hassles of my colleagues in group practice. The majority of the primary care doctors in the area appear to be unhappy. In my area, most of the doctors are sponsored by a large nonprofit, state-funded (Medicaid mainly) corporation or the local hospitals. The monthly and quarterly meetings, which require production to keep your job, have caused a lot of primary care doctors to leave the area.

Students have to choose the area of practice that they plan to enjoy lifelong. A specialist may make a lot of money, but there are a lot of unhappy specialists. In town, most specialists are on their second and third marriages, buy a new Porsche/BMW every 2-3 years, and are not necessarily any happier than primary care doctors. People who make more often spend more. You can make a lot of money, but people have to choose the area that will bring them joy for 30-40 years. To me the patients make it worthwhile.

In medical school, they don’t tell you about the paperwork that is involved in primary care. Be ready for free paperwork completion. My accountant charged me $250 to look over some paperwork and write a one paragraph and a two paragraph letter. A few years ago, my lawyer charged me $200 to look at 1 page of bylaws and write me a letter that was 6 sentences. I write letters for patients all the time for free. Primary care is underappreciated as a whole, but seeing the joy on patients’ faces when I keep their power from getting turned off or help them with a work/school paperwork that helps them keep their job or stay in school makes it worthwhile. I also get charged if I call my accountant or lawyer for their time spent covering topics.

The current solutions of paying primary care doctors better sounds great, except most proposals are to take from the specialist and give to the primary care doctor. This would encourage fighting among the doctors. Currently CPT codes exist for telephone calls and paperwork, but none of the insurance companies pay for these services. My main complaint about primary care are the free time spent taking care of preauthorizations for needed studies/medications. I am liable if I make an error, but these currently are free services. Besides the insurance companies, the patients expect free phone call medicine.

Each day I simply want to see my patients without a lot of paperwork. I have not found a solution for the paperwork, but I do know that my electronic records system helps with the forms and templates, to compete the forms. The key is not to let paperwork build up and to know when to choose your battles. I try to remember that the care of the patient is the reason I do the paperwork and come to work each day.

When I have students rotating with me, I try to point out the pros and cons of primary care. Some of them already are set on a certain area, such as surgery or a subspecialty. Other students want to join me in the trenches, where I directly care for my patients. The best way to choose an area in medicine is to try out each area and then to do a subinternship during the last year of medical school. I estimate that half my colleagues chose specialty care for the financial security and notoriety. Hospitals track who makes the most money for the hospitals, and specialists usually are at the top of the list. Primary care physicians, however, are ones who are behind the scenes taking care of the whole patient and often are the admitting physicians.

Hi Matt,

Thanks for your post. In answer to surveys, I don’t believe that any medical student will say that they are in it for the money. Similarly, when asked why a particular graduate would like to be a gastroenterologist, they won’t say that it is because it is like scoping for dollars. They will say that they are fascinated by the colon. Surveys do not tell the story. Unfortunately, the lure of the big money is what drives many students to specialties such as radiology, derm, ophtho, etc. As country solo doc states, they want a new Porsche/BMW every 2 years.
Where would we get the money to pay PCPs? Why, from the specialists, who are grossly overpaid. Training programs must teach evidence based medicine and ethics. The tenets of the ACP’s Ethics statement should be adopted by all (appropriate use of scarce resources, even down to nickels on similar generic meds, etc). Care should not vary illogically from geographic location to location (Eliot Fisher, John Wennberg).
It would, of course, be helpful if the paper work burden was decreased. Some of the paperwork is in place to mitigate the overuse of various procedures and medications many physicians are prone to ordering. It makes it more difficult than just writing for an MRI because someone has a benign headache, for instance.
It’s a dilemma, but as we become less able to afford the wasteful way medicine is practiced today (as Fisher postulates – 30% of current expenditures – I believe it is more than that), things will change for the better.
Thanks,
Adam (Internal Med – Board certified – 20 years experience)