My last post delved into the state of the primary care physician workforce. Bottom line: We need more of our medical students choosing primary care -- general internal medicine and family medicine, specifically -- to bolster our health care workforce in preparation for the growing population in need of its services.
The challenges facing primary care are complex. Let me rephrase: They are very complex. To boil down every issue into one or two short pieces is simply not possible. And the respect I have for the profession compels me to point that out.
The purpose of this second, follow-up post is this: Why, exactly, would a medical student choose to pursue a career in primary care? And why would they choose not to? I will approach this from my own perspective, having traveled this path.
I come by my chosen profession as a family doctor naturally. I am a second-generation family physician and grew up watching my father exercise his calling. He was more than happy to go about providing care for entire families for 40 years, often saying it was simply a bonus that he got paid (because he loved it so much he would do it for free). I also vividly recall the respect inherent in the profession -- respect for the patients and the respect the patients had for their beloved doctor. There was an air of mutual trust and in most cases, a relationship that spanned many years. My husband's grandfather, known as "Grandpa T" to the Haines clan, was also a family physician and provided care for an entire town for decades. He was a man of gentle intelligence and caring, deeply respected in his community.
Why did I choose family medicine in 1998? Because my role models were so exceptional. Because I considered the salary to be more than enough. Because I expected to achieve a better work-life balance than the other specialties I was considering (plastic surgery and interventional radiology). And because I truly enjoy people and helping them live happier and healthier lives, which is the basis of primary care. I wanted to spend my time around people and enjoy the connection with them.
The reality of life as a primary care provider was much different than what I imagined it would be, and much different from the experiences of my father and Grandpa T. As examples: the time spent with patients? Not as long as I anticipated and desired. The time spent in administrative tasks or non-direct patient care? Astronomically higher than I ever dreamt. The relationships? Too often cut short because of third-party dictates on coverage. That more than adequate salary? When you factor in loans with the desire to own your own home one day, have children and retire at some point, well, it is still a very solid salary.
The real issue, in my opinion, is the work-life balance necessary in maintaining that salary. You need to see more patients each year to make the same amount, or maybe a little more or a little less. You need to run faster when you already felt you were running as fast as you could.
It is my view that the heavy weight of a career in primary care isn't really about the time or the loans to get there, the salary you earn, or even how this compares to the salaries of your peers who choose higher paying gigs like radiology or dermatology. It is mostly -- again, my opinion -- about your quality of life and the time you get to spend doing what you really wanted to do in the first place: sharing quality time with your patients and helping them as you have been extensively trained to do.
In primary care, the relationship between physician and patient is paramount. It's arguably more critical than in any other clinical pairing. It is often much more effective to spend 30 minutes talking to someone about how to lower their blood pressure through specific dietary tweaks and a customized exercise plan, recognizing all of the individual risk factors they have. But it is certainly not more efficient than writing a prescription for hydrochlorothiazide.
The current model of medicine generally favors the more efficient approach. Our system also values procedures much more than face-to-face time and counseling.
Some commentators say that the "cure" is to get rid of primary care physicians altogether and give the job of primary care to nurse practitioners and physician assistants. Or we could increase the number of foreign medical graduates providing this type of care. Others suggest that the government will solve many of the current primary care challenges.
I do see value in bolstering the workforce in these novel ways. And I also have hope that governmental influence will, indeed, help provide relief and restoration. But I really hope that we not only continue to see the value in primary care physicians providing the bulk of primary care, but that the value becomes more commensurate with the services being provided. I hope that primary care gets back to doing more of what it is intended to do: providing comprehensive -- and let us not forget preventive -- care for our patients.
Surely things are different now and evolution is not always a bad thing. Can we take the best of the past, combine it with what is working now and move into the future better than ever? Or is primary care, as my dad and Grandpa T knew it, gone forever?
Follow Dr. Cindy Haines on Twitter: www.twitter.com/drcindyhaines
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Back when I was in medical school, I chose Internal Medicine for the same reasons that you did. Regular insurance wasn't the issue as most plans didn't cover outpatient visits. Fees were reasonable and patients often made arrangements if they couldn't pay up front.
Then came HMO's, and it's evil spawn, MCOs. They did cover outpatient visits. Oringinally, in order to attract physicians to their networks, fees for visits were reasonable. But quickly declining reimbursements year after year became the norm, and with it came burgeoning demands for paperwork. Physicians found that they were financially tied to an HMO/MCO and they could no longer live without them....and in the process, had lost all control over their business model.
If we are ever to make primary care attractive, physicians need to be able to again spend time with patients, patients cannot be regarded as widgets on a conveyor belt, and perhaps EHRs can evolve to reduce the administrative burden. As for payment, a straight salary with the potential for a bonus, based on the quality of care delivered rather than the number of patients seen, should be considered.
Let's find a way to reduce the administrative burden so that our primary care docs can spend the quality time that is needed to provide excellent preventive medical care!
(And thank you to those of you who chos eto sacrifice imcome for providing us with primary care.)
American Association of Naturopathic Physicians
http://www.naturopathic.org/content.asp?contentid=59
As a specialist in an increasingly important and low-paying field (endocrinology), I cannot emphasize enough the importance of excellent primary care. Patient's pay double in money and time to see me for easy problems that could be managed by an intelligent primary who had more than 5-10 minutes to take care of her patients.
-The system is broken for so, so many reasons. For the below posters, I don't think the AMA is limiting MDs for economic reasons....one simply has to have the grades and tests scores to get into medical school. Lowering the standards would be a typical American solution. Hiring foreign docs is great, but a band-aid solution.
I could never be a primary doc, NOT because of money, or even work hours. The hassles, haggles with insurance companies, and complete theft of the sacred doctor patient relationship would break my heart. More power to you, Cindy. For all non-docs, most of your MDs are good people, who came into the profession with passion and compassion. Our for-profit system is destroying both the docs and the patients.
I suspect that the physician shortage is partially a product of the AMA wanting to limit the supply of physicians in order to control the economics of the system. Perhaps the country should make a large investment in building more medical schools, so that all qualified students could go into medicine. This might even result in some cost controls.
In addition, the system might be modified to allow for some upward mobility. So a nurse could go back to school and become a PA or MD etc. I imagine that it would also help to increase the number of PAs, nurse practitioners etc. We could pay for all of this by eliminating the parasitic insurance industry. Maybe some of these people could learn to deliver health care, and not profit by denying care.
Look at what we have, law suits, bureaucratic waste on an immense scale, and a system that delivers for all intents and purposes sub standard care for nearly twice what our world wide competitors pay.
Some doctors get into medicine to help others, some get into it because it is the best paying field in the US. I prefer the former.
Our entire system is crazy (for lack of a better term). Emergency rooms as the delivery system for the indigent? $200,000 in education costs before ever going to work? Liability insurance that may cost more then a doctor makes?
A public health system could remedy all of these problems and more. How many would be doctors simply can't afford the cost of education? Wouldn't it be better for everyone if they were subsidized (as long as they maintained their grades) and spent a few years working in a government supported clinic at reduced wages to cover that cost? Government clinics would also be much more cost effective than hospital emergency rooms, and they would be accountable. Who really knows what the cost is for treating those that can't afford insurance under our present system. For that matter why do employers provide health insurance? Is there any incentive for them to provide the best insurance, or just the cheapest?
Our whole system is nuts. Personal Opinion
Knowing what I know now, if I had it all to do over again, I would have chosen medicine.
On the other hand, if I were young, with a degree, and a newly minted MD or DO under my belt, I'd be gone.
I personally would emigrate to a country with a better system then ours. I've researched (online) New Zealand's medical practices, and to me they have a lot of good ideas. Public Medicine, government employees all, 40 hr work week, 2 weeks paid vacation (to start, 4 weeks or more with seniority), $180,000 a year (starting salary), and no liability insurance. Mistakes happen, the State has a special fund and their own doctors to follow them up. It weeds out the incompetents, and makes things better for everyone.
I also like what I've researched of Denmark, public financed education for as far as you can go, as long as you can maintain your grades. That's how to move a country forward, and that's why we will continue to fall behind. Money has no intelligence, yet seemingly makes all of our most important decisions. Including who goes to college.
Our system makes absolutely no sense to me what soever. But it does make lots and lots of dollars, mostly for large corporations, and the politicians in their pockets.