This blog has consistently sounded the death throes of primary care – and the ivory tower academics don’t seem to get it. John Black sounds of on the many issues leading to the death of the profession:
Primary care is dying, and those in the ivory towers need to start beating the drum. One cannot tell the true vitality of internal medicine by what one saw and heard in San Diego. For one thing, probably more than half of the members of the ACP are subspecialists, not general internists. We can continue to have a dynamic annual meeting of the ACP, even if no general internists ever came to it again. True, the ACP did author “The Impending Collapse of Primary Care” and came up with the Advanced Medical Home concept. However, only 11% to 15% of third-year internal medicine residents are going into general internal medicine, and the vast majority of internal medicine residents are becoming hospitalists, not outpatient physicians.
His solution?
Separate the evaluation and management (E/M) coding for general outpatient internal medicine and family medicine from other E/M coding, and double the reimbursements. This is basic supply and demand. No one will do the job, no matter how needed, if the pay is too low to cover overhead. And make a decent salary commensurate with one’s training and skills.
The bottom-line: make primary care more attractive to medical students. And whether you like it or not, the hard truth is that money speaks volumes.
Health Care Renewal with more doom and gloom.
Related posts:
- Should general internal medicine merge with family practice?
- Are family physicians better suited to practice primary care?
- Primary care, supply and demand
- Primary care shortage and physician recruiters
- Even physician assistants are dissing primary care
- Will retainer medicine save primary care?
- Academia responsible for the primary care shortage?
KevinMD.com on Facebook
{ 16 comments }
I guess what I don’t understand is comparing specialties to primary care is not comparing apples to apples.
1. They do not have the same length of training. Specialists have to train longer. Not only is this a sacrifice socially and family wise, but it is a economic sacrifice too as family practice members are out making their average 160k salaries while a cardiologist makes 40 K for those 3-4 years.
2. Specialty work can actually be PHYSICALLY harder. It is hard to stand and concentrate for various surgeries/interventions for hours at a time. Also it mentally draining to always have to be on your A game because if you screw up it will be known.
3. Many of the better paid specialists have a more rigorous call schedule.
4. Specialists have to give the final word on a patient that has been referred. They cannot pass their patient onto another patient without being looked down on in contempt in most cases.
5. Primary care does not have its pick among the most hard working, intelligent medical students and it hasn’t for some time. Therefore, if there are an actual advancement system that paid on merit, specialists would probably be paid higher anyway. Consider how someone at the top of their class in law school DOES get paid higher than someone in the bottom 50 percent of law school.
6. There are opportunities open to family physicians that are not open to specialists. My state offers full tuition reimbursement if you will go to a rural area for three years. This program is not open to anyone who plans on specializing.
All things considered, primary care should not be paid the same as specialities. I do believe that primary care should be paid more than they are being paid, but at the same time this should not come at the expense of specialty medicine (but this is what many sites like this propose).
Anon 12:06, most of what you say seems reasonable to me. But one thing made me laugh out loud.
“4. Specialists have to give the final word on a patient that has been referred. They cannot pass their patient onto another patient without being looked down on in contempt in most cases.”
I’m sorry but this is just absurd. Specialists routinely hand off patients they can’t figure out to specialists in other specialties, but even worse they frequently deny the patient has a problem related to their specialty and refer it right back to the primary as if the referral were an affront to them.
If this has never been done BY you, I’m sure you’ve seen it done and to act like it doesn’t happen and that every patient given a referral gets a final and definitive diagnosis from the first specialist they see fits perfectly with the arrogant stereotype that most specialists are undeservedly (in most cases) tagged with.
Well, I suppose I was a bit zealous in this point.
Re the six points made by anonymous…
Point 1 is clearly justified, but I have to challenge the rest.
Don’t forge that “primary care” is generally meant to include family practice, general internal medicine, and general pediatrics. So:
2. This assertion would be very hard to prove. Many generalists, including FP, GIM hospitalists, and general pediatricians, do considerable in-hospital care of very sick patients. It would be hard to argue that this is not physically demanding.
3. Call schedules clearly vary. I know some sub-specialists with very rigorous call schedules who do not complain about running into the hospital at 3 AM to do an emergency cardiac cath. And I know how hard it may be to get the so-called on call doctor in certain sub-specialties that do not see a lot of emergencies to answer their pages.
4. As a previous part-time hospitalist, I can tell you about all the times the sub-specialists refused admissions they deemed not sufficiently related to their field, but the final common pathway was always general internal medicine. I can also tell you about sub-specialists who were quick to “sign off” on cases they thought were no longer interesting. Again, the care always defaulted to GIM.
5. Whether this is true now is unclear (but a bit insulting to current trainees.) It surely was not clear when I trained. But the divergence in reimbursement started long ago.
6. How many such opportunities are there, and how much money is really involved?
1. Agreed
2. No, I don’t think this is hard to prove. In general, doing an intervention/surgery is going to be more physically draining than doing rounds and filling out paperwork with charts or having clinic. I have had to take this into account when choosing my career because I have a bad back. My rheum. and I have had a copule of talks about which specialities are too physically demanding for me to enter.
3. There is no way the call schedule for family practice compares with many of the specialities like cards, ortho, neuro, etc. –> We of course are speaking on average. I know and respect the fact that primary care work their a##es off too.
4. I have conceded this point already
5. This is definately true.
Step 1 averages of those that matched (based on March 15, 2007 Match)
1. Plastic Surgery, Step 1= 243 Step 2= 246
2. Dermatology, Step 1= 240 Step 2= 240
3. ENT, Step 1= 239 Step 2=240
4. Diagnostic Radiology, Step 1 = 235 Step 2= 238
5. Radiation Oncology, Step 1 = 235 Step 2=237
6. Orthopedic Surgery, Step 1 = 234 Step 2= 236
7. Transitional Year, Step 1 = 233 Step 2=231
8. Internal Medicine, Step 1=222 Step 2=228
8. General Surgery, Step 1=222 Step 2=228
8. Pathology, Step 1=222 Step 2=226
11. Medicine-Pediatrics Combined, Step 1=221 Step 2=233
11. Emergency Medicine, Step 1=221 Step 2=228
13. Anesthesiology, Step 1=220 Step 2=224
14. Neurology, Step 1=218 Step 2=226
15. Pediatrics, Step 1=217 Step 2=226
16. Ob/Gyn, Step 1=213 Step 2= 224
17. Family Medicine, Step 1=209 Step 2=219
18. PM&R, Step 1=208 Step 2=214
19. Psychiatry, Step 1=208, Step 2=213
6. These opportunities are literally everywhere. This is your full medical education paid in full. They will even do this retroactively for students! In other words, say the word and the state will cut you a check for 200k! This doesn’t even count all the small towns that will do this same exact program. You just have to be willing to sacrifice some time. One of my friends recently was just offered 250K guarantee 3 years with loan repayment in a small town.
Primary care is not dying, it is being brutally murdered. The perpetrator is de facto socialzed medicine in the form of Medicare and Medicaid, enslaving the poor and the elderly/disabled, respectively.
Primary care is now essentally stone cold dead in Massachusetts, and 90 to 95% of few remaining PCPs have closed their practices to new patients. Why? the new “universal health care” has utterly annillated PCP practice.
Ed Sodaro MD
The primary goal of E/M coding was to save money, and it does this in a rather brutal fashion, then once instituted, payments get reduced, and it gets harder to justify higher levels of coding.
Basically they were flawed to begin with, since there is nothing about them that had much to do with what a patient would consider to be quality medicine. It was alleged that it wasn’t just about time, but it’s all about time, and in essence not paying for time spent with a patient to help them understand what was going on, explain things, answer their questions. There was some sense that you could quantify the brain power or the difficulty of the medical decision-making in a given situation, but we all ended up like accountants filling cells of a spreadsheet. Then every patient gets all the cells filled in, so they had to reduce reimbursements, because as I said, it’s all about saving money, not about health care delivery.
Primary care is dead because the reim bursement is shitty, the paperwork is tedious, it is considered 2nd class (see the first post from Anon here if you doubt that!) and the workload is enormous. The amount of knowledge and responsibility that is required to be an excellent general internist far exceeds most micro focused specialists. Young doctors get it!
Some of the dumbest people I know ended up specializing. One woman got a Cardiology spot because she slept with the director.
So spare me how much “smarter” the speiclaists are. The smarts come from doing something 1000 times.
Just because you know a person who slept with someone to get a cardiology spot doesn’t mean that specialists aren’t smarter/harder workers in school.
They have higher board scores and higher grades as shown by the amount of people who are AOA going into these specialities.
I know what I’m talking about. So spare me the crap of giving your anecdotes of how someone slept with someone to get a spot. In primary care they just want you to have a pulse to get a spot, you don’t even have to sleep with anyone.
So anon are you a med student? resident? I am saying this from experience (I used to be an internist before subspecializing and going back into practice). Medicine ain’t a board exam or a med school exam. A competent well-trained internist/FP is worth their weight in gold (and other subspecialist’s will tell you that). Their knowledge base is much broader than any specialist and denigrating them will get your ass-chewed off when you get in the real world. Additionally, when I worked as a internist/hospitalist, I worked a hell of alot harder than I am now (I still work hard). I am saying this from real life experience not text book/internet research. If we (society) don’t fix primary care to the point where people aren’t running away screaming then we are all fu*&ked. Mid levels have their place, but I can’t tell you how many c/s I get from midlevels that I could answer as an internist. It may be easy money, but is it in the patient’s/society’s best interest?
I’m a resident who just went through match. I know what I’m talking about.
Trust me I know what a good internist is worth since that is what I am doing my residnecy in currently and I am not a good one yet.
My only point is that currently family practice does not have its pick amongst the top students in school. HOw this translates into the real world I do not know yet. But, school grades and test scores are used as an indicator for gaining better/higher paying jobs in every other area such as law school and MBA programs. So why not medical school too.
My only point was that family care docs should not expect to be paid on the same level as specialists due to these many factors. BUT, I sure as hell think that they ought to AT LEAST be breaking 200K average.
That is my only point. Oh, and I am in the real world and that is why I save my rants for anonymous message boards…
“Oh, and I am in the real world and that is why I save my rants for anonymous message boards…
”
Actually you are a second month intern, not exactly the real world. But good luck to you, you will be soon enough.
When I was finishing 20 (or so) years ago, the residency spots for the higher paying specialties were more competetive and I think got higher GPA’s on average–but there were people from every sector of the class going into every field. There were a number of people who scrambled for a medicine spot after not matching in surgery, and I think primary care/psychiatry got a lower GPA overall.
Having said that, the top 10% of the class sent a disproportionate number of students to general internal medicine and psychiatry. So basically the generalizations are simultaneously valid and also bullshit insofar as people make too much of them. For one thing, if you know you want to go into orthopedics, you are going to gun for grades in med school, whereas most (in my class) really didn’t worry about grades much.
One specialist looking for a good internist here.
You can argue about specialist being paid more that generalist because they are worth more all you want. The fact is, you can’t really know that because the market place is distorted by centralized price fixing. The fixers obviously fix payments for most specialists at an adequate level because I can get one tonight if I need it. They obviously fix the price too low for generalist because they are hard to find.
The solution is not to try to correct the erroneously fixed prices by doubling the rate for primary care. The solution is to stop fixing prices centrally. Let medicare decide what it will pay but let all providers balance bill at whatever level the market will bear. The market will then decide whether primary care services are worth the public paying a rate that good medical students will be glad to work for.
My own opinion is that in an actual free market, general internists would do just fine. If they did, some specialists would find themselves hurting because much of what many specialists occupy themselves doing would be be done by generalists were reimbursement not a barrier to their availability and to them doing their best work when they are.
I’m a surgeon, and a specialist (trauma). All I have to say is that WE (doctors) have to stick together. I have enormous respect for a talented general internist… and a talented “specialist” They are underpaid, and so am I. We are not the enemy. It saddens me to see us throwing darts at one another. Please don’t quibble about board scores or anything else. Your level of commitment to your patients and the profession is what really matters. (and yes I was AOA, in the top of my class, good board scores etc), but what I take the most pride in (and what really matters) is being a GOOD DOCTOR and it has so little to do with all of that other crap.
Comments on this entry are closed.