Once viewed as a vocation with great esteem and respect, a desire to be a doctor may not be desired as a career path by many. While this profession requires admirable commitment and dedication, as reflected in their training regimen in the U.S. that consumes about a third of their lifespan, the complications associated with practicing medicine in many situations presently may be why others are not seeking this profession. Such complications may include:

Primary Care Doctors perhaps more than other physician specialties seem to be choosing to practice medicine under the direction of health care systems for financial security, primarily, as the cost involved with running a medical practice is quite expensive. These regional and nationally created healthcare systems are typically composed of numerous hospitals and clinics in a certain geographical area.

The often monopolizing nature of the business models of these health care systems of increasing growth is not necessarily a desired method to practice medicine as a primary care physician in particular. Often, these often large health care systems employ their authoritarian stance by limiting as well as dictating how their health care providers practice medicine. This is further aggravated by possibly unreasonable expectations of their health care system employer- such as mandating that doctors they employ to see as many patients as they can in a full day.

There actually have been cases of physicians being fired by a health care system for lack of patient volume that they have in their practice.

Conversely, there are instances where health care providers receive financial rewards for seeing more patients a day than what is determined as average visits by the health care organization, it is believed. Such requirements likely and potentially affect the clinical judgment that is determined by physicians employed in this manner, as well as the quality of care the doctors provide their patients. Medicine should not be viewed as a profession of speed and volume.

Another reason may be due to the increasing premiums for their mandatory malpractice insurance, which may make doctors financially unable to work independently due to such factors involved with practicing medicine presently. In regards to malpractice insurance for physicians, many doctors find this type of insurance in need of reform for a variety of reasons. These premiums become more costly for doctors as it relates to their chosen specialty as a health care provider. For example, the malpractice insurance premiums of an OB/GYN doctor are usually higher than one of a specialty viewed less risky for lawsuits, such as Dermatology, perhaps. With malpractice cases that are initiated, those who initiate a lawsuit against a doctor win about 25 percent of the time, with monetary awards averaging nearly a half a million dollars for these who sue doctors and win. Around 95 percent of these cases are settled out of court, it has been reported.

In addition, the issue of medical malpractice is also frequently a catalyst for a doctor to practice what has been called defensive medicine. This basically means that the health care provider is prohibited from relying upon their subjective factors in their assessment of their patients, which in itself raises the question of what the point was of all of their training in the first place. They are compelled to order perhaps unnecessary diagnostic testing to rule out medical conditions or disease states that likely such patients do not have. This practice of defensive medicine may be encouraged by the health care systems that employ such doctors as well. This waste of medical resources is further validated by the legality reflected in the tone of the notes a doctor usually annotates or dictates with their patients after they see them for treatment. So one could argue that over-treatment is as common as under-treatment of patients in today’s health care system.

Such excess and limitations imposed on today’s primary health care provider are usually not fully illustrated during their training for this profession, which is one that has been viewed as one that is quite noble and of great responsibility. This may be why this medical profession may no longer be viewed as distinct from other vocations as it once was, or one that has been desired more than apparently it is now.

Some claim that doctors are somewhat understandably more cynical and demoralized than they have been in the past, which may be replacing the pride and responsibility that they historically have had with what they believed were their callings as doctors, as well as the perceptions of patients in the U.S. Health Care System.

Further complicating and vexing to these restrictions is the usual financial state of the individual physician after their training, as many have debt that may exceed over 100 thousand dollars. This is much more debt than what doctors experienced after their training only a few decades ago, it has been said.

Remarkably, there are obviously some others who believe that doctors in the U.S. are over-paid and greedy. In spite of how they are judged, physicians are likely not absent of financial concerns as with many other people, yet the situation with doctors may be of more of an issue than many other professions, comparatively speaking, in addition of taking on more responsibility that is of greater importance compared with other vocations, one could argue.

Such realistic variables should be factored in when one chooses to judge the profession of a physician. On the other hand, no physician should view their jobs as no different from any other venture capitalist when rationalizing their income and motives related to this exceptional vocation as a doctor, as others are more dependent on their judgment for the restoration of their health.

It has been determined by others, and suggested often and lately, that many of today’s physicians practicing medicine in the United State do not recommend or speak favorably of their professions compared with their typical views of their profession in the not so distant past. While this self-perception physicians may have of a negative nature may be somewhat understandable, it is also unfortunate for the health of the public in the future, and the perception normally associated with the medical profession which could deter ideal medical care for others.

There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state perceived by themselves as well as others of their profession as medical doctors.

Again, and for perhaps Primary Care Physicians in particular, the medical profession clearly needed by others to some degree appears to be absent as a desired path of today’s careerist. The authentic reasons for what many believe to be a negative perception of possibly the entire health care system may never be known, yet many would agree that most U.S. citizens are understandably concerned with the state of this system of great importance to society. Yet need to be active more in assuring this necessity is more aseptic.

“In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero

Dan Abshear (ex-military medic and physician assistant for nearly 20 years)

Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.

not the obscene differences in income that presently exist.

Whether you agree or not, how much support is received for internists and family practitioners getting paid better is going to depend on giving up your support of robbing Peter to pay Paul. If you buy into the idea that this is a zero-sum game, and has to remain so, then you will be on your own. No support will come from specialists, that’s for sure.

I am an ophthalmologist. As it happens, a sub-specialist ophthalmologist in a particularly thinly-subscribed sub-specialty, largely because of the large amounts of cognitive effort required relative to, say, high-volume cataract practice. That aside, my specialty has seen some of the most dramatic and earliest cuts in procedural fees and is due to receive even more in the coming two years. Cuts of 80% of the surgical fees paid a few years ago for cataract surgery have significantly changed my profession and made it much more difficult for younger practitioners to start independent practices. When you list ophthalmology with derm, you betray your failure to keep up to date with what has changed in my field–changed IMO for the worse–and impeach your argument. The fact is, most surgical specialists see more patients in a day than do internists, and work longer days and have to cover just as much ER call–often more–as well as their own practices. Our coding requirements are just as stringent as those of generalists. And let’s not even go into what it costs to equip and staff our offices, an order of magnitude greater or more.

Divide and conquer thinking has failed you once. It will fail you again.

You know anon I don’t agree. Anesthesia, optho, and derm have done one more year of residency. Rads two. Remember, that usually includes a transitional year, which IMO is usally not nearly is rigorous as a real interniship year (unless it was a prelim). Should they really get paid 3-5 times or more than a general internist? Especially given their lifestyle and hours are usually significantly easier? The simple fact is that in the american medical system financial reward is based on doing things (procedures). Does that really mean the non-procedure specialties are less valuable in medicine? A good general internist/FP is critical to a well run medical system. Compare the US to europe/Aus/NZ on this matter and it is obvious. I personally have met the rare generalist who expects to be paid as much as a subspecialist. What they expect is be paid a fair wage relative to the subspecialists and not treated like dirt by us. Personally, I think that is reasonable. When is the last time you heard a know-it-all subspecialist makes derogatory comments about their primary. It was last friday for me. Sadly, this was by a subspecialist who doesn’t know squat about medicine outside of his specialized field. Either we docs start sticking together for each other and our patients or third parties will continue to eat us alive. Think about it.
PS: I am a medical subspecialist.

Internists might start by refusing to act as “gatekeepers,” to the insurance companies. That is an assigned “role” that has degraded the specialty into becoming bureaucratic agents of third-party payers. The ACP should publicly reject this and recommend to its members that they refuse to be the writers of required “consults”, unless the reason is medically significant to the physician’s care for a patient. Likewise, refuse to be the scribe and secretary for all the ancillary public and private benefits plans, all the applications for devices, disability benefits and all the other stuff that really has nothing to do with patient care. I recommend refusing to sign off on drivers’ license renewals, clearances for school activities and applications for any special occupations. If you want to do those things, charge what it really costs for your time. Giving that service away for nothing just reinforces the unjust belief that your time is worth nothing.

Lastly, get over the idea that you are entitled to be paid as much as a physician that did twice as much postgraduate training as you did. I am getting the impression that many internists who should be unhappy with what they are being paid for their service have inherently bought into the idea of a zero-sum, fixed-size budget scheme, that every dollar extra has to come from someone who does procedures. (As if they don’t also see patients in their offices as well and don’t also have to deal with static pay against rising costs, please.) You will win no support when you whine that “proceduralists” should be paid less so you can be paid more. All that does is convince those who hear you that you are so beaten down by your present circumstances that you can be led around by your noses.

Call general practice whatever you want, require however many years of residency and create whatever new board certifications you want–the public will continue to think of it as a lesser kind of medicine, and expect exhuasting levels of commitment on the cheap. They always have and always will because they have an emotional need to do so.

They want a doctor that they have a sense of ownership of and familiarity with for the illnesses that they consider the ordinary burdens of life. They want him to be a bit on a pedestal above them, but not too much, and everything in our culture is valued by money, he must therefore not charge more than a certain amount.

When they feel really frightened or threatened, his very familiarity and social approachability, make him an insufficiently revered and insufficiently mysterious figure for them to have faith in at that point. They need a more remote, inaccessible, and socially higher (better paid) magician/shaman in which to put their faith.

Calling internal medicine specialists “PCP”s and primary care providers refers only to a perceived relationship by a third-party carrier, the person who acts as “gatekeeper”.

I suggest internists as a specialty refuse the “gatekeeper” assignment. That puts them in an unwanted roles of policeman for the insurance company and porter for the patient. (Not that there is anything wrong with those occupations, but why invite the confusion?)