Medical students avoiding primary care, is it more than money?

A common assertion is that excessive school debt factors in a medical student’s choice of specialty.

It’s something that I still believe, but Colin Son points to some studies showing debt load to be an insignificant point for medical students when it comes to choosing primary care or not.

I concede that the point is controversial, as you can find students on both sides of the fence.

What’s less disputable is the lack of any happy primary care role models, which may be a more important factor. As Colin observes, “in my experience, I met only one happy primary care physician.” Internist Matthew Mintz agrees, noting that when medical students “are exposed to primary care, they see unhappy physicians,” and that, “the larger salaries of the specialist and students’ looming debt is only the icing on the cake in their decision not to choose primary care.”

So, does money matter? I continue to believe that the answer is yes, but only as part of a larger construct of reasons that dissuades many American medical students away from generalist practice.

Comments

Anonymous
I think when we focus too much on money it is to our detriment. First of all, it doesn’t garner us any sympathy with the public, and let’s face it, even the lowest-paid physician makes twice what the average American makes. Second of all, it distracts us into fighting with specialists over reimbursement issues. Third, it takes attention away from other very important factors that steer students away from primary care. One of these factors is poor job satisfaction, due not only to salary discrepancies but also to increased amounts of paperwork, decreased time with patients, and late hours at the office to perform tasks that don’t relate to patient care. Another problem is lack of respect from specialist colleagues, which is evident to any med student in an academic environment. I have also found myself put off recently by a widespread belief that the role of a PMD can be easily taken over by a mid-level provider; it’s depressing that our value isn’t seen by the public or by many of our own colleagues. We need to focus on all of these areas, not just reimbursement.
Anonymous
I don’t see what the problem is…most primary care physicians in my community have nice lifestyles..almost no call…we have a hospitalist group at both main hospitals in town and they make the specialists do most of te work anyway.
Coleen
These students need to come work with me. Despite complaining about our reimbursement here, I am very satisfied professionally and always try to pass that on to the students I precept. Most of them find their rotation with me to be among their favorites. Hopefully I am doing my part in helping some chose primary care……
Anonymous
I agree with you that, while money may be a factor, for many people it is a relatively unimportant one in their decision. As an attorney who decided to become a nurse, many people ask me why I didn’t go to medical school instead. The reasons are the same as why many med students choose a specialty over primary care. As a nurse I can practice the kind of care PCPs want to provide – getting to know patients and their families, educating them not only to see them through the current crisis but for better quality of life overall, etc. But I can do so without the huge student loan, the expenses, the insurance hassles, etc. Do I sometimes miss the authority and higher pay I received as an attorney? Yes, of course; but the freedom to pick whatever job I choose anywhere in the world, collect a paycheck that is still much higher than the average Americans’, and hearing a patient’s heartfelt “thank you for caring about me”, more than offsets any loss of ego gratification. My personal PCP felt the same way. By giving up his practice and going to work for the Health Dept. he was able to spend real time with patients and make independednt medical decisions, which more than made up for some loss of income and perceived prestige. Most go into medicine because they truly care – there are many easier career paths to choose if your primary motivator is money. Until the healthcare system in this country is completely overhauled, offsetting medical school costs will not be able to adequately adress our growing need for PCPs to deal with the chronic conditions of our ageing population.
Anonymous
Hello, I am currently a fourth year medical student. I believe that most medical students strive for excellence and expertise, and the current subspecialty system funnels motivated medical students down to niche professions. It’s the difference between being an “expert” and a “generalist”. I personally plan to do primary care internal medicine however sometimes I question my decision on the basis that I might not “be all that I can be”.
JB
I agree with the fellow in the article. In college, I met with many GPs who were so unhappy with their work that I changed my premed path completely.
I’ve since come back to the field, but not until excessive research and conversations with other doctors. To sympathize with GPs,it’s tough to love what you do when everyone else decides how you should do it.
Peter
As a second-year medical student, I see primary care medicine as a dying field. The following are some perceptions contributing to that conclusion:
1) The perception that the future of the field is threatened by nurses expanding their practice and politicians willing to let nurses take over primary care to cut the costs of paying physicians.
2) The perception of “low” pay. Some nurses with half the education are paid more than some primary care physicians. (article here.) Mandated health insurance seems like it will lead to increased cost pressure to decrease physician payments.
3) The perception that the future of the field will be dictated by the government. What happened to physicians driving healthcare policy?
4) The perception that primary care is handled mostly by FMGs. (Personally, I can not remember ever visiting a primary care physician who was not a foreign-medical graduate.)
Anonymous
I’m a medical student about to graduate and this is how I see it: If it was a question of making $100k/yr vs. making $300k/yr, I would still do primary care. But the way things stand, I can’t rationalize making the same amount of money as I was making as a medic, while working harder and longer hours and probably being sued. I don’t want to have to struggle to run a business just because the government wants to run everything.
Anonymous
from a patient:
I am so sad, and even frightened, to hear in articles and remarks that the satisfaction of healing and contributing to the quality of life of the patient is side-lined in discussions around medical personnel choosing a field of practice.
I send bountiful gratitude to the primary care doctors and generalists who took care of me during a recent medical situation. I applaud their meticulousness, their excellent problem-solving (due to holistic experience), their willingness to interview me and listen to my account, and, most of all, their humanity.
I had to be sent to the "expert" surgeons, who then did not record in my medical documents my specific instructions for conservative diagnostic surgery. the outcome of surgery was: no disease, a mutilated abdomen and pelvis, a maimed and disabled human being.
Speak the truth: physicians no longer seek patient care through service & humane practice; physicians seek research & teaching opportunities, prestige among colleagues (not patients), a swanky lifestyle and, for some, a celebrity image.
You can choose medicine for helping the ill, or for healing. OR choose it for your own benefit.
Many blessings for those who choose primary care and general services.
Anonymous
It’s not the salary for the job, but the job. Primary Care was terminal when:
1. Third party payment became the norm, and transformed the doctor-patient relationship from a sacred covenant to strictly a duty-entitlement relationship. That was bound to eventually destroy one of the age old rewards of real medicine and it has. The humanist part of the humanist-clinician-scientist triad died.
2. Both the society and the profession became obsessed with technology. The clinician part died.
3 . HMO’s gave generalists the role of gatekeeper and, while they retreated, the perception of the role of PCP’s as soley gatekeepers and protocol followers stuck–primary physicians as scientist became a dim memory.
All of this was predicted by “reactionaries” and “old-fogeys” upon the introduction of Medicare in the mid-sixties and the creation of managed care in the early 70′s.
The latter was a deliberate ploy to destroy the ability of medicine to resist government control–as was the flooding of the market with FMG’s from outside the Hippocratic tradition of the west. As these initial efforts were not sufficiently effective in deprofessionalizing medicine, they planted the time bomb of RVS, intended to bait us into turning on each other.
Primary care is not along in this, but it is the canary in the coal mine for the entire profession. Many specialties are equally devoid of personal reward and full of unenthusiastic demoralized plodders–but they get the money to keep them doing it. PCP’s find that for comparable effort, their are many things that they can do outside of medicine even with commensurate pay.
Rogue Medic
In Made to Stick, the authors discuss how we tend to make our own choices for complex reasons – reasons that are not necessarily focused on money. When we are asked how to best appeal to others, we expect that their motivation will be much more focused on money.
Money is just one factor. It is not insignificant, but perhaps we should treat future doctors as intelligent individuals capable of making complex decisions.
If I am being treated by a doctor, I sure hope that this is the case.
Evan Falchuk
For the last few decades we have systematically devalued the importance of doctors. The legacy of managed care is the wreckage of medical practice and especially in primary care.
Cutting reimbursement to doctors saves some money, but it also leads to fewer doctors, less time spent with patients, lower quality. We need to get off this merry-go-round and value doctors and their time as we should.

Medical students avoiding primary care, is it more than money?

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