I wrote a few days ago that a civil war is brewing between primary care and specialists.
Robert Centor fans the flames, saying “excuse me while I take time to cry for this orthopedic surgeon. I am really not interested in how much you get for one procedure, rather look at total income.”
Should we escalate the tensions between the two sides?
With a marked disparity in salary, specialists are the albatross preventing primary care physicians from winning the public relations battle with patients and politicians. They are showing little interest in making any concessions, and are yielding little of their influence over major decisions in the AMA and the RUC.
It is difficult to have any sympathy for generalists’ plight when the average salaries of dermatologists and radiologists are repeatedly quoted in the media.
Distancing ourselves from our specialist colleagues may be the key strategic move to save primary care.
Related posts:
- When specialists provide primary care, and why patients aren’t complaining
- Why primary care doctors shouldn’t be pain specialists
- Should specialists be re-trained as primary care physicians?
- Should specialists spread the wealth to primary care?
- The primary care problem
- Males = specialists, females = primary care physicians
- Can specialists do primary care?
{ 14 comments }
And yet, the world over specialists are paid more than generalists. Specialists also have much higher malpractice rates.
So I suppose you could pay the generalists more — pay the specialists less, make them give a greater percentage of their income over to lawyers and insurance companies. That’s not going to cause a shortage.
GPs will be replaced by NPs. It’s already happening in England, it will happen here too. The lawyers make too much money off malpractice for it to come out any other way.
That’s assuming that nurses want primary care jobs in the first place, which is not always the case:
http://www.kevinmd.com/blog/2008/11/will-nurses-be-new-primary-care.html
Kevin
Stop fighting among yourselves. The enemy isn’t the other doctor, it is RUC which was always intended to set doctors fighting among themselves. Don’t take the bait.
The enemy isn’t the other slave in your cage fighting you over the one bowl of food, it is the man who put you in the cage. Join forces and break out.
We are doing what tyrants were never able to do–break the House of Medicine and allow government of control of doctors and through them of patients.
There already is distance.
The “lets all work together” nonsense coming from specialists now is hypocritical. They did not care while we have been crapped on for the past 2 decades by a skewed RUV system.
You should have cared however. Once they get rid of us, they are coming for you next.
If you want to “join forces”, you can try to see things our eyes. You can also treat us better. How many of you specialists have your answering machine/service say “If this is an emergency, go to the ER or call your primary care physician?” How many of you orthopedists say “I don’t prescribe pain meds, call your pcp?” (In my neck of the woods, they do) How many of you orthopedists tell the er “I’ll be consult, have primary care admit?” (like we’re residents.)
In my community, the local orthopedic group recently negotiated an annual stipend in excess of a million dollars on an annual basis to provide ER coverage to the hospital. This is in addition to any separately billable fees, such as hip fracture surgery. That does not exactly establish good will amongst physicians. No one is giving me a stipend to provide medical service to the er, as required by bylaws.
Come on, you hypocrites. Work together? Give me a break. Too late for that.
Anon 9:17: ditto, ditto, ditto!
We PCPs are the Michael Claytons of medicine. We deal with the issues nobody else wants to acknowledge…but these are invariably the most important to the patient. We are the responsible adults in the room. We are the janitors cleaning up other doctors’ messes. Because we do so much, and in so many ways, our jobs are quite difficult to understand without firsthand knowledge. But without us, everything falls apart. Done right, primary care is by far the most intellectually demanding field in medicine…and medical students are rightly intimidated by the breadth of knowledge the field requires.
Those who devalue primary care do not practice it. They have no idea what it takes. Anybody can be a bad PCP…just as easily as I can be a bad surgeon. Being a good PCP requires talent, intelligence, stamina, insanely good interpersonal skills, and a willingness to accept a learning curve that never levels off. Only the very best medical students have what it takes, and unfortunately the skewed payment system makes it financially damaging to choose primary care when you have other options. Regardless of whether payment inequity is the root cause of this evil cycle, we all know payment reform will end it.
It’s time for primary care to form a new organization. I’ve had it with the AMA, my state medical society, and the ACP (which includes way too many procedural specialists). For primary care to resume its rightful place at the very top of the food chain, we need to be willing to engage in a long and divisive political fight. We cannot do this if we ask our lobbyists to also represent the pocketbooks of procedurists and imagers.
Most of the bloggers taht have commented(including Kevin) do not seem to remember what happened the last time primary care/internal medicine tried to attack specialists by wanting to be rewardd more for their “more cognitive ” care. The government created RVUs and budget neutrality and basically all physicians lost income. Instead of attacking specialists constantly, Kevin, you should encourage all physicians to align and fight the real enemy. What the government is doing to physicians is a common battle tactic called “divide and conquer”.
Yes, 10:27, it is a battle tactic called “divide and conquer” but one in which specialists have been willing participants.
what stops the primary care docs from negotiating money from the hospital to cover er call as the orthopedists did?
This question is idiocy. What primary care doctors should do is stop taking insurance and government payments, and set their own rates. The purpose of insurance is to cover those costs that you cannot be reasonably expected to cover on your own. Thus you enter into an agreement with others to share the risk. Primary care is cheap enough that there is no need for insurance to pay for it. Honestly, what’s keeping you there, taking pennies on the dollar? If you work isn’t valued, drop out. See if they value you then.
I can’t agree more with anon 6:25. I have had it with the deafening whine of victimhood from passive primary care docs. Don’t like the way your are being treated? Take control of your practice and run your business yourself instead of letting others do it. Sure, it involves some risk, but nothing ventured, nothing gained.
Guys You act like “specialists” are a monolithic stalinst entity. It’s not. For every neurosurgeon/orthopedist rollng in the dough there is an ID doc or rheumatologist who is not. You do realize that oncology practices have taken a huge hit since the drug markup was disallowed (I don’t disagree with that, but CMS never made up for it in anyway. Oncology patients are as complicated as they come). Also don’t forget that even procedural docs in rural practices don’t necessarily do that well with such a medicare/medicaid heavy population. The simple fact is the way things are structured medicare/medicaid is not a long term financially viable operation for ANY OF US. Each year CMS will come after a different group of docs to minimize payments (see oncology above). Personally I think anon 18:25 is on the right idea. Stop taking medicare/medicaid. I know there is the two year rule, but if AARP starts harassing congress because their constituents can’t find docs, things will change. Very simply congress doesn’t give a crap about what docs think and most of us can’t unionize/strike. That is the fact.
Anon 7:37 is right about coalition building. The split isn't specialist vs. PCP, it is procedural vs. non-procedural.
Also, for people who complain that PCP complaining about income disparities led to the RVU system and budget neutrality, maybe the problem isn't the neutrality it is that the RUC is specialist/proceduralist heavy …. we spend enough money on healthcare in the US to cover everyone, but only if we accept the fact that the cost of that is surgeons making >500k taking a hit so PCPs make enough money to draw new grads into the field
Anonymous 9:59’s comment “And yet, the world over specialists are paid more than generalists…” reminded me of Martin Roland’s piece on primary care in last Thursday’s NEJM, in which he says “U.K. primary care physicians now have average earnings of $220,000 (in U.S. dollars), which is more than many specialists earn…”
Somehow a physician earning over 400,000 dollars a year doesn’t seem quite right and yet I know MANY. Here is the Northeast I doubt there are many proceduralists who aren’t making that kind of money. Come on. We supposedly went into medicine for reasons other than bloated incomes that rape the public. No, Dr. Proceduralist, you really aren’t worth that kind of money, despite what you and your colleagues keeping telling yourselves.
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