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?
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