Dr. Rob speaks out:
I work as many, if not more hours as a specialist. I trained for four years in residency, where many of them trained nearly the same length of time. My knowledge base is far broader, and my direct effect on the lives of people is greater. It is part of a normal day that primary care physicians save the lives of their patients. We diagnose them with heart problems before they become serious, we diagnose appendicitis (or gallbladder problems, for that matter), and quickly decide regarding the seriousness of people’s illnesses, referring to the cardiologist, gastroenterologist, or surgeon who does the final procedure to “save the patient.”
Update:
Roy Poses with his take.
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{ 15 comments }
If all of this is true, then why did the “gatekeeper” strategy of the 80’s (and 90’s) fail so miserably? Particularly in those closed panel systems like Kaiser where the disparity between specialists and Primary care doctors was much narrower?
I agree with Dr. Rob entirely (although yes i am a primary care doc). Unfortunately I think it is getting near-impossible to sell primary care to the general public. We can’t even sell it to other DOCTORS i.e. specialists:
ENTs feel that we can’t recognize & treat an ear infection
Cardios (and the general public)think that every chest pain from the ER should be seen by them and ruled out / stressed/ holtered/ echo’ed
GIs love to scope but hate the Hep.C. or transaminitis consults
Etc.
Another factor is the growing concept of patient-centered care. This has become a euphemism for “give the patient what they want even if it makes no sense medically”. This is further fueled by things like DTC advertising, physician profiling as if we’re child molesters (which in NY doctors pay for through licensing fees), and online ratings of doctors (yes, most are positive, but the idea that a patient has the medical knowledge to rate the appropriateness of their doctor’s care is RIDICULOUS).
Most people will only realize the necessity of primary care when they or their family member is run through the procedure mill annually with no real benefit to health or happiness (or their wallets).
Just because something is identified as true and unfair doesn’t mean anything will change. Specialists make more money because there are less of them and congress has decided they should be paid more. What primary care doctors have to do is to decide individually is if they want to live with this inequity or do something else. I was a primary care doctor for 5 years and am going back to fellowship. I think that is a bad strategy for the general public, but it is a good strategy for my financial and mental wellbeing.
No one is listening to the complaints of the primary care community. Accept it and decide for yourself whether you still want to do this or not.
b
p.s.–If I seem bitter it is because I am. I trained at a mid tier academic program and was offered several fellowship slots, but thought gen med would be more interesting and rewarding. Then after five years of working harder and making less than everyone else with an MD after their name I had to convince the wife to take a $100,000/yr pay cut and move our young children across the country wherever the fellowship lottery sent us. I feel like I was mistreated by an unfair system.
I am not in primary care, and see the problem a little differently. I think the problem is that the distorted parody of a marketplace that we have doesn’t recognize the value of primary care for two primary reason.
First is a fee-for-service payment system based on procedures rather than time.
Second is a pseudo market in which the value of services are set by central planners rather than by the consumer who is demanding the service. In the latter system, proceduralists would do well, but primary care would do much better than it does now. The most valuable thing in the healthcare system is the skill and knowledge of an astute clinician. The most highly reimbursed thing is technology. That is a flaw. I could give many instances of expensive unnecessary procedures that have occured in my own family members that would have been avoided with a decent history.
A third factor has been that the ethic of primary care doctors themselves with so much talk about everyone being “entitled” to or “deserving” or having a “right” to healthcare has led them to be insufficiently self-protective in a society always ready to take advantage of anyone who will permit it. They have therefore cooperated with the devaluing of their own services.
If they want to revive primary care, they will have to stop going to Washington hat-in-hand and simply refuse to accept Medicare, RVS, and other 3rd party valuations of their labor, and assertively take charge of their own economic destiny and sell their services directly to patients focusing on quality, value and service. There are few enough of them now that they can do that without starving and as the healthcare system continues to deteriorate, smart patients will see the need for and value in paying for a family doctor.
I am looking for a good one now who will serve as our families PCP with good service (not cattle chute) and charge us whatever it takes to do that. I pay my accountant and lawyer that way, why not my doctor?
Anon 9:35
I agree with your insight and perspective. I also add that PCPs whine but never act. Subspecialty organizations get a great deal of support from it’s members to protect their territory and fees. However, PCPs, who are too busy in the office practicing what they know isn’t in the best interest of their patients or themselves, ie “treadmill medicine”, are an extremely passive group. Most carry on the almost martyr like persona that no matter what, they will treat all patients regardless of cost. It’s a great idealogy, practicing ideal medicine as posted by the AMA code of ethics. But they ignor the reality of what the system has froced them to become, as they pass patient’s through the grinder jsut to stay afloat.
I jsut got off the phone with an excellent clinician, who also is very efficient and productive and has an excelletn work ethic. He sees 45 patients PER DAY, 6 days a week as a PCP. Sure he makes good income, better than most PCPs. But I can tell you I would NEVER want to be his patient.
Goes against everything that medicine realy stands for, the patient-physician relationship. Hopefully I can reverse this in my professional career with my concierge medicine practice.
http://www.myconciergedoc.com
Anon903,
I agree with your assessment. However you should feel fortunate that you are an internal medicine doc where you can apply for worthwhile fellowhips (cardiology, heme/one, GI, etc.). I am an FP and in FP the fellowships are, in my opinion, typically wothless.
happyman- I agree with you 100%. In particular the specialists thinking they have the market on simple diagnoses, and the “Give the patient what they want” mentality. I work in a managed medicaid/medicare plan, and belive me, these patients are as demanding as anyone else. They see a specialist for a diagnostic eval, something that can be managed by their PCP, but said specialist and patient must have another 6 visits. For no abnormalities- just for “monitoring”. I feel for the PCP’s- you get paid next to nothing, and have the burden of being the one who has to try and convince a patient they really don’t need surgery, or specialty consults, all in just a few minutes while still trying to actually provide the care they DO need.
I’m calling bullshit on this one.
I have done primary care and I have done specialty care (I am a general surgeon).
The longest PC residency is the same length as the shortest SC one.
The surgical residencies are not only longer but more intense than the primary care ones, as a rule (more call, more stress).
The stress of the OR, the stress of post op care when there is a problem, the responsibility of being the “last resort-” are all greater than being the primary care doc who has the luxury of trying this or that and then referring to a medical or surgical specialist if either the patient or physician are not happy with progress being made.
I’m not saying that every internist or FP works less than every specialist, or earns less. It’s just that I did not hear any complaints when you were starting your 6 figure jobs 3 years post-MD and I and my colleagues had another 2 or 3 or 4 years of low pay, high hour, high stress training to do.
It’s all about money, isn’t it? Would you be complaining if we all made the same income?
jb,
The point is this: When people realize that their work is not rewarded, they will stop doing that work. The payment system is built to reward those who do longer residencies, so everyone is comfortable with a cardiothoracic surgeon making much more than an internist. But when a radiologist does one more year than me, makes 3 times what I do and walks out of the hospital at night when I’m walking in, that grates.
Physicians in training have realized this and the mix of internits going into primary care has gone from 50/50 primary care/specialist to 25/75. Additionally, I know at least 10 people who have been out for one to two years and are matching into a specialty. That is not reflected in the ACGME numbers.
Those numbers are not bullshit.
To the FP who is feeling the pinch: Unfortunately, I think your only option is to go “commando” fire all of your staff and hire a one room office somewhere seeing only 8 patients a day. There are multiple stories on the web of people who did that and almost approximate their previous income while maintaining their sanity. If it makes any difference I know what you are going through.
b
This whining by non-procedurists sounds too familiar. I remember in the 1980’s, the RVS system and E& M system were created by the feds to supposidly reward cerebral medical care and cut procedural care. Well,guess what: the Ivory Tower whiners fell for this and the feds CUT everybody(PCPs and procedurists). Until all of us(PCPs and specialists) get together and realise that we’re on the same team, the feds and insurance companies will continue to control our destiny.
Two residency programs same institution. One is primary care and has 3 spots a year. It has no call, regular hours and 3 years in length. 20 applied, 10 interviewed they filled 2 out of 3 spots. The other is specialty surgery 8 calls a month, wildly erractic hours, 5 years until graduation. 900 apply they interview 9 and accept 3. Ten with 95% or higher on the USMLE didn’t even get an interview. Exactly why again should graduates of each make the same when they get out?
I think primary care doctors should decide whether they are paid fairly or not, and argue that. I don’t think saying you should be paid more or less than specialists is going to carry a lot of weight.
And remember, for the most part it’s not your patients who decide what you are paid. It’s insurance companies or congress or somebody else.
Alot of specialists see more patients as well. I know an orthopod that sees 100 patients during his office days. Why should he get paid the same as someone seeing 20 patients. You can only cut the pie so may ways as well. There are more overall physicians in primary care than in specialties. If you bump up the salaries of primary care and decrease specialists you spend more money because of the higher number of PCPs and no one is interested in spending more than we are right now.
Most everyone is saying the same thing. I think that surgeons do deserve more than I do, as well as cardiologists and other procedural fields. The problem is not the existence of the gap, it is the degree of the gap and the fact that it is widening. I have sympathy on anyone who decides to bolt for the specialty arena, but I really think there are ways to level the playing field now.
One of the main points of the post is being missed in this discussion: the fact that the lack of PCP’s costs the entire system (including the specialists, in the long-run). The approach to the problem is not to just address the inequity, it should be focused instead on the systemic flaws that lead to this inequity.
Rob
PS – thanks for the link.
As a family practicioner I feel that specialists should be paid more for their added training. However, the discrepancy is huge. For example, I know a dermatologist who just finished her 3 year residency (plus a trasitional year) who was getting offers of $300,000 first year out. An primary care physician who has trained just as long gets less than half. So the relationship between time spent training and salary falls apart.
Another point is that primary care physicians are held to the same standards as specialists when making a diagnosis. If a primary care physician was being sued for missing an appendicitis, a surgeon would testify against them. If they missed a melanoma, a dermatologist would testify against them. If the training is so much less, then what people expect out of an encounter should be less…but it’s not.
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