Physicians love their work but are frustrated

I recently finished reading In Their Own Words: 12,000 Physicians Reveal their Thoughts on Medical Practice in America. It is a summary of a 2008 survey from the Physicians Foundation. I vaguely remember filling out this survey. I was interested to see what my colleagues had to say.

Many physicians describe themselves as at the breaking point.

“I am so mired in this mess that I can’t see clearly enough to give any good advice.”

“I make close to the average American salary of $37,000 though I haven’t had a vacation in six years and I’m on call 24/7.”

“We are drowning in a sea of regulations and paperwork.”

“I plan to quit as soon as I possibly can.”

Some simply wrote “help.”

It was not surprising to learn that nearly sixty percent of respondents would not recommend a career in medicine to their children or other young people.  Nearly half of the physicians were planning to reduce their patient volume, retire or seek work in a non-medical field within the next three years. Some of the dissatisfaction stems from the increased volume of paperwork physicians are doing. Sixty three percent of respondents report it caused them to spend less time with their patients.

The authors provide background into some of the unique aspects of medical care in the US. Unlike most professions, physicians typically do not set their own fees; a third party whether Medicare, Medicaid or private insurer determines the payments. Actually getting paid is another ball of wax; physicians must fill out myriad forms or pay staff to do their billing for them. It is among the reasons that many physicians have turned to cash only practices, opting out of all insurances.

Physicians in the area of primary care are especially struggling to keep up with their business expenses as expressed by this comment, “I cannot provide care for $37-50 per patient when my overhead — malpractice, labor, light bill, rent and supplies — is $60-75 per patient.”

After eleven or more years of schooling and facing school debts of $100,000-200,000 these physicians are finding the work is unsustainable. Another comment sums it up, “hairdressers charge more than what we receive for office visits.”

Although physicians generally agree the current system is in trouble, they were divided as to how to fix it. Among the approaches physicians suggested were a single payer system, malpractice reform, reduced cost for medical school, enhanced use of the medical savings accounts and other market driven approaches. The most radical and intriguing suggestion I found was “bring a class action lawsuit against the managed care industry.”

Clearly physicians are frustrated with the current state of affairs. Many however expressed their love of the work and the calling that first brought them into medicine. One respondent summed it up, “I just want to be able to treat my patients to the best of my ability.”

If you have ever wondered what physicians are really thinking, this book is enlightening.

Aldebra Schroll is a family physician who blogs An Apple a Day at NorCal Blogs.

Submit a guest post and be heard.

Comments are moderated before they are published. Please read the comment policy.

  • Martin Young

    Great post!

    The situation is identical here in South Africa. So doctors have a global problem in need of a global solution.

    The economic example of businesses with low margins is that to succeed they need large volumes. The same applies to medical practice. So I see there being two types of medical practice -” low cost-high volume, risking low quality”, and “higher cost- lower volume with quality assurance.”

    Each doctor needs to choose which he or she wants to be. Likewise each patient should know which choice he or she is making by going to either kind of doctor.

    • crocoduck

      i don’t know about south africa, but in america “low cost-high volume, risking low quality” is not possible because american patients are not willing to accept any risk. “low cost-high volume, high quality or i’ll sue” is the reality.

      • Dr.Pramod Chandran

        These articles are real eye openers to a Doctor like me having a solo practice in a small town in India.We do not have the Medical Insurance forms to fill out.(However ,the industry is trying hard to bring Insurance coverage for all!)I am a Homoeopathy Physician and keep the number of patients less so that I can take more time and do my work to my satisfaction.Maybe ,it is because I studied Medicine in a Government College in India and thus my “Overheads” or “Capital Expense” is low!The article changes my perception regarding the Health Scenario in US.

  • Ben M2

    Is this for real? I’m a second year medical student, and I am hoping to go into primary care, but I keep hearing things like this, and it’s extremely discouraging. Is it really so terrible that half of practicing physicians want to quit? What am I getting myself into?

    • Vox Rusticus

      You might as well know now. Telling you something different than the truth would be a disservice to you.

      • Ben M2

        That’s certainly true. But I’ve read many articles like this, and whether in The New York Times or in a blog, I can’t help but wonder if they tend to exaggerate the issue. A physician making only $37,000 a year must be on the extremely low end of the pay scale. But if you want someone to be interested in your article, you need to talk about something interesting.

        I even wonder if these extreme examples, while they’re very helpful in highlighting all the problems with medicine today, are helping to scare students away from primary care, where we’re desperately needed.

        I’ve done my homework and shadowed physicians, and I realize there will be a lot of crappy paperwork and haggling with insurance companies, but I’m hoping that if I steel myself for what I’m getting into, I’ll handle it better than most. Still, there’s clearly cause for concern, and I do often wonder what it will be like when I’m practicing.

    • Alina

      If I would be you I would do my own research and make my own opinion about how things really are. If you are a good doctor you can make money.

      • dr-im-getting-out-while-i-can

        Hey Ben,

        This is a good example of what others out in the world think of primary care. Alina is a good example. She is a frequent poster on KevinMd. She has her strong opinions, as is her right, and sometimes she gets it, very clearly, but i too often see her with completely off ideas on how it truly is. she is clearly not a doctor, has never run a private practice, never worked for a small or large medical group as a physician, yet she thinks from her perspective she knows whats going on. In regard to her statement, “If you are a good doctor you can make money”, this is COMPLETELY WRONG. Insurance companies decide HOW MUCH money you will make. unfortuntately and paradoxically, how good you has little to do with how much money you will make as a primary care doc. look at my example: i REFUSE to do the 5 min visit with a patient. i spend time with my patients. first i sit them down in my office, take the history, AND THEN bring them to the exam room next door to complete the encounter. they feel listened too. i sit in the same type of chair across from them, not behind my big desk, and listen without interrupting for at least two minutes. but by spending time with them, this brings down my revenue i can bring in and now i just cant do it anymore. so all the great, and important things you are learning about in medical school: how to take a good medical history, how to listen, how to make your patients feel comfortable ect will NOT actually help you “make money” as Alina says in her advice to you. those good things will actually SLOW things down in the office and you will not make money. in regard to being a good diagnostician, this too is the same answer: you get paid exactly the same whether or not you successfully diagnose or help the patient or not. im not saying any of the above i describe is right, its not, but thats the way it is. and nothing is going to change.

        so be careful who you listen too. especially online.


        • Alina

          Dr Igowic,

          I don’t believe I ever suggested that I am a physician. At the same time, perhaps you should allow for the possibility that some patients do have strong relationships with their physicians and we know that if you are a good one you can live very comfortably. I know mine does. And if you follow my comments, as it seems that you do, then you would also know that my regular PCP spends an average of 20 minutes with his patients regardless of their payment method. Hmm…I wonder how he does it….Just because we are not a “medical professionals” doesn’t mean that we’re naïve. In general, businesses who think this way about their customers end up failing.

          It’s interesting that you posted yet one more piece of advice for Ben, even though you’ve made your point some three comments ago, yet no further clarification to the other items: how many severe capitated patients do you have, medicaid share, etc. I don’t have to be a physician to see when someone uses “some” numbers but not all in order to paint a certain picture.
          “so be careful who you listen too. especially online.” Alas, we agree on something. Ben, if there is one piece of advice you should take, this would be the one. Gather your data from the people you trust and from your own observations. I’ve seen quite a lot of sensationalism, a ton of inaccuracies, and half-way truth posted by people who clearly have an ulterior motive.

    • Max

      I suggest quickly developing an intense interest in:

      1. Dermatology

      2. Physical Medicine and Rehab

      3. Radiation Oncology

      Aside from number 1, most people won’t know what you do, even other physicians, but you’ll be raking in tons of money for little work.

    • Patrick W. Hisel MD

      The ingredients for happines are present in primary care. For me this includes loving relationships, self improvement via lifetime learning, and helping others. This article and the posts that follow are a true representation of what you will face from an economic standpoint. Also, I encourage you to spend some time reading the comments to other articles on KevinMD. Patient will continue to lean on sites like this more in the future. Several posters will stand out as very entitled and anti-doctor. Others, clearly pro-doctor. You will encounter both types in your practice. Setting clear expectations will help you and your patients decide early on if you are right for each other. It can be great, many patients have touched my heart and I have touched theirs. In spite of all the negative, it is still a very rewarding profession, a true privilege. When I was in your shoes, I wish someone would have told me to keep the ingredients for happiness in mind. It is easy to find yourself working too much trying to meet everyone’s needs, and you can’t. So be sure and set limits on your workload, even if you end up out in the country like me. What does your childhood doctor think? Good luck brother, and keep an objective mind.

    • dr-im-getting-out-while-i-can

      hey ben,

      yeah, its all for real. im a board cert fam med doc and i loved primary care from the first day i walked into med school. i was the “im going into primary care” poster boy through out med school. and sure, i heard alittle bit about concerns in primary care, but i thought I’LL BE DIFFERENT. my patients will love me. i can make this WORK.

      now i regret completely going into primary care because i CANT make it work despite trying my butt off. the pay is lousy, the work tedius with all the insurance companies, and the respect low from your specialist collegues outside of primary care. believe me when i say society doesnt value your services as a primary care physician because if it did the pay wouldnt be so low. docs in my area make about 40% of what an anesthesia doc makes. not fair. and dont believe anyone when they say thats gonna change. its not. i see nothing in politics, the AMA, or society that suggests pay will increase for primary care.

      so im getting out. been training for about 9 months to learn how to do botox, juvaderm, all the fillers. will be opening up my aesthetic medicine practice within 3 months. cash only. :) wish me luck. i need it.

      yeah, im out. which is sad because i LOVE primary care. YES, LOVE IT. and i have loyal, wonderful patients. and im in private practice. but i gotta think about buying a house, saving for my retirement etc.
      and my 140K in loan wont be paid off until another 24 years. for real.

      and dont think its just me saying these things. my other collegues in primary care feel the same things. they are just frozen in unhappiness and wont take the courage to make some changes.

      ben, dont do it. dont become like me. dont be the rigid guy in his 20′s who wont listen to advice and goes full speed ahead to follow your dream only to realize the dream ends up to be a nightmare.

      that was me once.

      now im more flexible. more open minded. more mature now. and im out. i still have time to make some changes and im doing it. im glad. sure, im sad im leaving fam med, but you dont always get what you want in life.

      good luck ben, ok? i truly wish you the very best.

  • IVF-MD

    I realize that my specialty (infertility) is different in general and my life and practice are different specifically than an average physician’s situation. However, as I’ve expressed many times, I truly believe that more freedom and autonomy and less coercion and external control are some of the keys to job satisfaction and happiness.

    On a scale of 1-10, I would rate my job as an 8 or 9 and the areas that I personally like are the autonomy, the complexity and variety, the great degree of deep human interaction and the tight relationship between how much effort I put in and how much satisfaction I get back. The last part is critical and I greatly empathize with the frustrated physicians who get no difference in feedback despite whether they put in 100% effort or whether they just show up, clock in and clock out.
    When I chat in the doctors’ dining room with some of the older doctors, they report that there was a time that THEY also loved their jobs as much as I do now. The difference is that their autonomy has slowly been taken away underneath their noses. I do fear that someday it will happen to me. It’s probably inevitable unless we have a dramatic return to more freedom and less government in all aspects, and not just medicine.
    My heart goes out to those physicians who took this above survey and expressed sadness in their jobs. My question to them would be, “How much of the dissatisfaction is due to loss of fundamental freedom?” My guess is that much of it is due to this. And this extends to all Americans and not just to physicians specifically. It’s just that expectation for happiness are higher for physicians given how much of our lives we’ve invested into the training and that’s why it’s such an issue being discussed here. Maybe it’s not too late to turn things around. We can only hope.

  • justin

    Are you paying for school? If so you may want to join the military or get a job and eat you med school debt. Residency is a long, long road.

  • Barb Chamberlain

    A local magazine, INHealthNW, just had a cover story on a similar topic, “What’s Ailing Doctors?” briefly examines life on call, reimbursement rates, medical malpractice suits, little time with patients, and patient noncompliance as stressors.

    As we expand education for the health professions on the campus at Washington State University Spokane where I work, we’re emphasizing an interprofessional, team-based approach. I don’t know how much that might help with some of the stresses facing the medical students now on our campus, but I hope they can build support networks that serve them well in the future so they don’t feel so alone.

    And as a patient, I’m reminded that I should do what my care provider recommends since I’m also part of the healthcare team.


  • Dr. Mary Johnson

    Yes, Ben. There is no Santa Claus. No hope or change on the horizon either.

    Run, Forrest. RUN!

  • Alexey

    Physicians in US making 37k per year as average American??? Where in US?
    As far as I know resident’s salary is around 50k. What 37k as physician are you (they are) talking about?

  • Alina

    I agree, school fees are completely off the chart here in the States and they are set to ration education and mostly limit it to the ones that actually have the funds, not necessarily the brains like in most countries. Sure there are some exceptions, and some people take loans, but we do it at our own risk sort of speak and we become indebted for a very long time. It’s absurd! Other countries invest in their brightest because they recognize that it benefits the society in the long run.

    Now about the survey, the person that wrote he or she making $37,000 it’s a little bit of a stretch, unless they work ½ a day a week.

    Also, it’s interesting when some doctors compare themselves with plumbers and now hairdressers. I wonder why is never with the firefighters or policemen. Could it be because these people also save lives and actually get paid significantly less than physicians?

    You mentioned $37-$50 per patient and an overhead of $60-75 per patient. Seriously were are these numbers coming from? My PCP makes a lot more per visit (I see the fee on the EOB) and he also spends about 20 minutes with the patient. Could some of the issues outlined in your article be due to operational inefficiency?

    Don’t get me wrong I am not a fan of the insurance companies and I think they are a complete waste of our healthcare dollars. But, didn’t you guys signed up with them in the first place?

    • Primary Care Internist

      my typical reimbursement for a 99213 is about $40-$50 (including copay), and I work in perhaps the most expensive part of the country.

      And cops/firefighters have, by far, the best deal in terms of bang-for-the-buck. Best benefits, early retirement (around 50 yrs old???), and in long island, cops make as much, or more than, a primary care doctor.

      • Patient Taylor

        What is the most expensive area of the country you’re referring to? I am in a pretty expensive area (DC/Northern VA) and I see my doctors are typically reimbursed between $120-$160 (depending on visit).

        • stargirl65

          I am in Maryland and get $65(99213)-$98(99214) from United and only $55-$85 from the Blues. A COMPLETE PHYSICAL from the Blues only pays $75.

          A survey of Maryland Family Physicians a few years ago showed avg take home pay was $104,500.

          • Vox Rusticus

            Medicare is at $66.25 for a 99213 in Maryland region 99, and $99.22 for the 99214, same region.

            The BC/BS plans in Maryland are worthy of RICO prosecution, as is UHC.

          • Alina

            So, for the United fees that you outlined, the following are the hourly fees:
            99213 is for a 15 minute visit, which would mean that for 1 hr the fee is $260.
            99214 is for 25 minutes – 1 hr = $235.20

            For Blue:
            99213 @ 1 hr = $220
            99214 @ 1 hr = $204

            My current insurance pays slightly higher than United in your area. The insurance I had previously paid significantly higher than United – in line with what Patient Taylor stated.
            Now, the question is how much of your business comes from these two CPTs? Also, what is your payer mix: how much of the United, Blue, other third party, etc you have. Then surely you must have some new patients, which in turn comes with a higher fee. Add to this other CPTs for more complicated visits, which also comes with higher fees than the ones you listed.

        • Allen Bishoff


          They don’t get paid in units for Office Visits. Nice try but not factual. Lets look at it this way: If you see 4 patients per hour and can collect $300 total in 45 days. You have to support at least 4 FTE. At an average salary + benes of $50,000 (conservative and doesn’t incluide other operational expenses) you are now only paid $100 for that hour or $25.00 per patient seen. Deduct additional operational expenses, taxes etc. and you can easily see that the PCP doesn’t profit from general medicine.

          I am a believer that the lifestyle expectation needs to change for physicians in order for change to happen but I would argue that it is better to do it on their terms vs. at the whim of the government or the insurance company.

          PS – I heard yesterday that another MD friend has sold his practice to a large hospital system. IMO he is trading one problem for another.

          • Alina

            Come on, Allen. You’re considering the revenue for 1 physician and expenses for how many?
            “at least 4 FTEs” and each paid “50k”. Can we post some real numbers here?

            I’ve seen that you’re promoting cash practices and I think these businesses (cause that’s all they are) are just wrong. How can we call this care? They are nothing more than the equivalent of high deductible plans and we’ve all seen how they turned out for the end users. You should know better having worked on the insurer side.

          • Allen

            Hello Alina,

            I’d like to address the “you should know better” comment first, if I may, before I share with you my “real numbers”. I retort that you should know better than to assume that insurance is the answer to our woes when in fact it is proving the opposite. I want them to understand that there are alternatives and that by selling your practice to a large health system allows you to only trade one problem for another. I am not promoting cash practices but rather freedom from system bondage. If you did enough research on the cash model or a modified insurance model you would conclude that it is a viable option. Get back to me on that if you’d like because I think it is a worthy debate.

            On to the real numbers:
            1) Modern Medicine recently concludes it takes 5.0 FTE per MD to operate in the current system (I use 4.0)
            2) MGMA reports that you need 2 billing FTEs per MD to operate in the current system
            3) Lockton reports that the average employer expense for benefits and fringes are 25%
            4) is my source from base salary using zip code 6210 or Overland Park Kansas

            A) Staff Nurse – $64 + bene = $80K
            B) Medical Receptionist – $35K + bene = $43,750
            C) Billing Clerk – $31K + bene = $38,750
            D) Billing Clerk – $42K + bene = $52,500 (I added some Admin duties for this position)

            Total expense = $215,000K

            You have to see a lot of patients to overcome this expense plus operational expenses i.e. supplies, building, utilities, medical records, insurance, taxes and on…and on….


          • stargirl65

            I have only one employee in my office. She gets about $31K per year. She gets no benefits except retirement which is a pension type plan and last year we put in $0

            My books are done by my husband (an acct) for free. I pay for a payroll service to pay my employee and do taxes etc. My overhead is about 65%. This depends on the insurance plan as well, so shifts in plan percentages can make a difference. BTW, I also hate the Blues and United which seem to be exempt from any type of collusion or price controls. Definitely should be charged under RICO acts. You cannot negotiate with either company. They give out blanket rates and have so much power you take it or leave it.

          • Allen Bishoff


            You are the exception and not the rule. However, your business model is one that should be more efficiently in use across the country in small practices in that outsourcing and using family resources can be a tremendous way to offset expenses. I do not know what your Payor mix is but it sounds as if the volume in your practice allows you to accept the laws of diminshing return and still survive.

            Having negotiated many contracts with United and the Blues I will say that they are negotiable depending on your positiing in the community. The only good starting point in a negotiation with large Insurance companies is that you will walk away from the relationship unless a fair reimbursment is reached. One common mistake made frequently is the dollar pressure from the rules and regulations of the contract language. If it ends up costing you $13.00 to file every claim then the gross rate must increase or you need to walk away.

            The business of medicine is a chess match and its killing decent physicians who are essentially government employees.


          • Alina

            Hi, Allen

            My physician who is in a practice with one other colleague shares a receptionist and a nurse, plus 0.5 FTE. He spends an avg of 20 minutes with all patients, he drives a very nice car and takes 3 weeks vacation each year.

            MGMA’s recommendation seems quite excessive and unattainable considering the cost involved. How many patients would one doctor need to see under their recommendation?

            About the numbers you listed – Physicians Practice published a salary survey data by regions and in your area (south central) the numbers are as follows:
            1) RN (11-20 years experience) = $54,500 (maybe $70k with benefits)
            2) Medical biller (3-5 years) @ $28k; $33.5k for 11-20 years exp (let’s say $40k with benefits)
            3) receptionist $25k with 3-5 years exp (about $33k with benefits)

            The site is pretty generous – I doubt that many pay both 401k and pension. Plus the time off (vacation, sick time) comes up as 1 1/2 month and insurance benefits is just some standard number regardless of your region.

            Concierge businesses are just like insurance companies – bad to the bone. One of them was actually funded by a former insurance executive. They are quick money-making scheme and wrong for most of us (patients and doctors alike). I’ve heard people refer to them as country-club practices and it’s true. They charge a membership fee, then still bill the insurance companies or Medicare for the visit, plus the patient’s copay. So much for not wanting to deal with the insurance hassle.

            It’s also been said that the doctor’s quality of life improves, but they offer 24/7 service so how can that be? In terms of the convenience of getting same day appointment it’s not even gtd by most practices. BTW, I get that with my PCP – not a concierge business. Some of these doctors are making $900k per year and for what?

            Insurers get to do what they want because a good majority of lives are in self-insured plans with very little regulation. Bad for both patients and doctors. They may negotiate only if you’re in an area where they need more access.

          • Allen Bishoff

            Hi Alina,

            Perhaps, although I do not know for sure, the MGMA assumes that the practices are absorbing direct expenses and isn’t outsourcing. And even if they are outsourcing the expense ratio is an equivalent of 5.0 FTE. I use 4.0 because in my market that is a proven statistic.

            I can’t hire an RN for that price in the metro area of Kansas City and if I did I would get what I pay for..if you know what I mean.

            Let me just quickly say, and then I’m out early to get a jump on my weekend!, that Concierge medicine has a place in my model but is not what I see as a valid replacement for Family Medicine. I am more interested in the physician who wants to sever ties with insurance. It doesn’t mean that their patients cannot use their insurance it would just be at the out-of-network price and the FP would then discount the out-of-pocket. That in combination with other revenue sources and terrific relationships with subs would make for a profitable (albeit less) business model and minus the stressors being consumed in the current system.

            Granted, it isn’t for everyone.


  • DrA

    Ben, I was exactly where you were 5 years ago when I choose primary care. Now I’m exactly in line with all the physicians cometing the survey. I selected a concierge practice, but while that helps the economics of running a solo practice, everything else remains true. If you do primary care, then concierge has the best hope for QOL. But if I would do it again, I would have gone into another specialty

  • Winslow Murdoch

    As a family doc with 20 years experience, I can easily have worked 55 hours a week and made 37K.
    Here in S. East Pennsylvania we have one insurer that pays less than 50% of the national average for physician services, and in my area they represent 75 % of insured patients. Historically they would not pay primary care Docs for counseling for smoking cessation, or weight management of obesity, and for some time they refused to reimburse for counseling or treating mental health issues as they subcontract with a stand alone mental health system.
    All Cat scans, Mri tests, all cardiac tests other than an office EKG and 1 in 5 Rxs need preauthorization. Each of these tasks can take 30+ minutes of staff and some doctor time to perform.
    They also routinely deny payments for a multitude of lab tests and the patient calls our office furious, demanding we “fix it.”

    Many local specialists will recommend studies like MRIs etc or order an Rx that needs prior authorization and ask the patient to have the primary care office do the insurance dance for them. (trust me, they get a piece of my mind!).

    Rx refills, email communications, follow up phone calls, research of diverse problems and treatments, on call care on phone in hospital and office (when covering other doctors often done gratis)
    Realizing that 2/3 of what we bring patients in for in regards to chronic disease management could/should be done over the phone, and the frequent false expectations of patients that require me to call sometimes multiple specialist offices begging them to fit a patient in urgently for often not so urgent problems all eat my time.
    Additionally, I get about a half dozen letters a day that are computer pukes from Rx management companies or insurers almost always with incorrect information asking me to review a patients chart and see if because they are on three blood pressure medications that I am not unknowingly duplicating therapy, not ordering a lipid panel yearly for a diabetic patient, not ordering an eye exam or HgbA1C test when in fact they were all done appropriately.
    My day is filled with things that just take a minute. If I have one more thing added it becomes almost unbearable as my day is filled!
    So, if a primary care doctor tries to be a patient advocate and do even remotely the right thing by his/her patient then game over.
    In an insurance/medicare/Medicaid driven system you have to “use” the patient to play the game, which requires that you spend a few more minutes- Need I say more?

    This is why doctors in primary care are feeling disenfranchised and doing things like concierge, academic positions leaving clinical practice or signing employment contracts that give some financial support.

    By the way, part time in primary care, due to the extremely high overhead of practice/liability and for mainenance of professional licensure and board and hospital memberships etc requirements would make it very easy for a primary care doc to have to work 40+ hours a week (part time in this profession) to make 37K
    often ask patients

    • Patrick W. Hisel MD

      All true. Well said Winslow.

    • Allen Bishoff

      here here Dr. Murdoch

  • Bob Blumm

    Needless to say, that this article was an eye opener for me and I have been a practicing PA for the past forty years. Demographics are definitley a part of the entire picture and I have never heard of a physician making 37,000 per year but why would this doctor stretch the truth? I beleive that the number reflects the remainder after paying for all the overhead, dues and malpractice.
    This situation is not going to continue, as doctors will go from anger and frustration to depression and exasperation, ultimate reality and just find another career. I live and practice in New York where physicians have the same frustrations of overhead and fighting for their rightful fee for service but all are still quite well off. When one surveys the parking lot , the ratio of BMW’s and Mercedes or Cadillacs has been replced by Ford, Chevy and Honda and Toyota. Status would be the ability of a physician and spouse eating at a 3-4 star resturant one to two times monthly. Non-physiican providers are making decent salaries although their lives are usually filled with attitudes and comments made to them concerning inferirity however it is indisbutable that they perform in a superior manner and are worth their salaries and respect. The danger lies in institutions creating smear campaigns against them because they do not suffer the same expenditures to maintain a decent lifestyle.
    Years ago , the idea of socialized medicine angered the medical community whereas today, if a physician could be assured of 100-150,000 per year with a set schedule and no overhead, I’ll bet it would be accepted. The reality is that the federal government could no longer pay for such a process and it has elded the grasp of modern medicine, I don’t blame the contemporary physician for entertaining throwing in the stethescope or recreating a new enviornment. Perhaps , this is the solution, recreatig a new practice paradigm. My physician partner/associate/supervisor with whom I have worked with for 38 years refused to allow his son to attend Harvard Medical School and that offspring literally makes millions of dollars today running a scientific fund. Originally I questioned his rationale but today I see him as a cutting edge thinker.
    This book needs to be read my the pre-med student before attaining 200,000 worth of debt and being in a situation of pressure to meet their monthly bills.
    Bob Blumm, MA, PA-C, DFAAPA

  • Matt

    In what area of the United States does a primary care physician make $37,000 a year? On an Indian reservation maybe?

  • Dr. Mary Johnson

    People, the doctor who says he makes $37,000/year is most likely self-employed and is probably refering to what the he actually has to “take home” after paying all the bills. It’s very easy to believe.

    And if you compare the investment in time and money and blood and sweat and tears with the take-home – or the way many doctors are being treated these days by the expensive MBA’s who were going to solve all of our problems and let us “just practice medicine” – it does not add up.

    I cannot, and do not recommend medicine – particularly primary care medicine – to any young creative/intelligent/independent person who wants a real life and a future – especially not after what happened to me in government service – and after.

    Wake up. Medicine eats its young. And no one cares.

  • Mt Doc

    To Ben M2,

    Choose your practice carefully. I was in a small group practice for many years and what Winslow above said was true. You spend the first 35-40 hours of the workweek meeting your overhead. Once that is done, you work for your salary. You can work 40 hours a week and make nothing, or 70 hours a week and make a decent living financially, at the expense of your personal life. (This isn’t just medicine. Ask any small business owner and he or she will tell you everyone gets paid before the boss does. The boss gets what’s left over, if anything.) The advantage to your own practice is you have more say in how the practice is structured. One attraction of concierge practice is that the overhead is lower and the hassles are less so you can spend more time with fewer patients. If you work for a large group, you can get salaried and maybe have a better lifestyle but what you do is dictated for you.
    If you choose primary care you should do it for reasons other than financial. Interactions with some patients are very rewarding. Realize that a lot of interactions are just the opposite.

  • Max Power

    I for one think that cash only practices and health savings accounts are the answer. My recommendation for anyone thinking about primary care is to seriously consider a cash only or retainer style practice.

    Some people criticize it because it excludes poor patients. But those same people complain about how they don’t have enough time with their patients. It seems like we have to choose between providing good care to a few patients and getting paid for it, and providing substandard care to a lot of patients for free.

  • Anon


    You are all about the medicine now, as you should be at your stage of training. But once you get out a few years, you will want to own your home in a nice neighborhood and save for your childrens college and your own retirement. And you’ll watch the radiologists, who earn twice as much as you leave at 5 PM and take 5 or 6 weeks vacation. Then your kids will need braces at a fee that no one, no one would ever pay for your services and you’ll still be paying the student loans for 20 years and the orthos will be talking in the doctors lunch room about the surgi-center they own and the new building they own and how they are going to start up an ACO to keep the government from screwing them while it’s you who keeps getting screwed and probably won’t ever be able to afford retirement anyway. By that time, it’s too late. Become a dermatologist for heavens sake! Primary care could be and should be the most interesting and rewarding field in medicine but it isn’t and it’s not going to change for you, sorry.

    • Max

      Good points. I’ve often wondered how those surgeons manage to not only buy a building or three, how do they then pay the mortgage, the property taxes, the maintenance, paving, plowing, insurance etc, pay 10-20 staff and still take home $400k? Really? I know they write alot off but you still have to have the $$ there in the first place. How do they do it? Not by talking anyone out of a procedure, I’m guessing.

      • Vox Rusticus

        They are buying an income stream that exceeds what they receive from their professional fees. All they really need to show is the cash flow from their surgical practice to demonstrate the capacity to generate a stream of surgical center receivables. The math is pretty simple.
        As for buying real estate, there isn’t much difference between a triple-net lease and a mortgage, except you get the title after the mortgage is paid.

  • paul

    of course, most of the nearly 50% of docs that are planning to get out in the next 3 years will still be doing the same thing 3 years from now- planning to get out within 3 years.

    i on the other hand am among those docs and have alredy started my step-wise exit, having reduced my clinical time considerably. if american medicine gets fixed i would be open to coming back, even for less pay (would require the reduction in hassles to outweigh the reduction in pay). but i would be shocked if medicine got fixed in my life time, let alone before i retire. good luck finding a doctor.

    • anonymous

      Do you care to elaborate on your plans for those of us nervous about taking this big step?

  • dr-im-getting-out-while-i-can

    dear alina,

    your questions about what the insurance pays and what the primary care doc gets to take home:

    before you do the math, keep these points in mind:
    1) sometimes the insurance REFUSES to pay no matter what you do or no matter how many times you bill them. and sometimes when you turn around and then bill the patient cuz the insurance wont pay, the patient refuses to pay. so you CANT rely on getting paid 100% from the insurance companies. try 95%. or less.

    2) most practices have medicaid patients (medi-cal in california)- they pay around $35 for a 99213. so that SIGNIFICANTLY brings down the revenue per hour that is generated. medicaid is one of the worst- if not THE worst payer in the country.

    3) most practices have the occasional patient who just… cant …pay for their visit (especially in this great recession) and ask for a “free visit” just this once, or reduced rate, or to not pay their copay. this might happen a number of times per week. so for example, if United Insurace allows $65 per 99213 and the patients’ copay is $20, United will pay the doc $45 ($65-$20=$45). so if the patient CANT/WONT pay the $20, this significantly brings down the potential revenue. believe me, this happens. more than it should. and it hurts the take home pay the doc gets. you think that $20 doesnt make a difference. it does.

    4) with HMO’s, most primary care docs are paid what is called a “capitated rate”. this is where the doc gets paid only a certain amount of money per month for that patient no matter HOW MANY times the patient comes in. docs in my area are getting around $12-$13 (i get $13 per month)per patient per month. so when i saw my patient three times this month to follow up closely on his bad diabetic foot ulcer i got paid $43 TOTAL (he has to pay $10 for each visit therefore 10×3 + 13=$43). that averages out to $14.33 per visit. and he is NOT A SIMPLE patient. he has many meds to moniter, a foot that might get worse, non compliance issues to work through, hypertension, obesity (oh, goodness the list goes on)- so it wasnt a 15 min appointment. it was much more. but he needed the time from me cuz he might lose his foot if we both dont work hard to save it. so in a capitated market (most primary care docs have at least some capitated patients in their patient panel), this will bring down your “hourly” amount of money you can earn. bitter painful. many docs in my area have between 30-50 PERCENT HMO patients.

    5) please dont think a doc can see 4 patients/hr. to do GOOD primary care, you can do about 3 pts per hour. and these are follow-up patients, not new patients. new patients take even more time. if a doc is seeing 4 pts/hr in an 8 hr day, that is 32 patients and IT CANT BE DONE. only if a doc is NOT giving good care, just running into the exam room and running out can this work to see this many patients. thats bad care and that is why people complain that their doc doesnt spend enough time with them and they dont feel “heard” by their doc. in my EXPERIENCED opinion, i can do 23 patients in an 8 hr DAY and do it well where i can listen to my patient and make it work. there can be 2 new patients in that 23. thats it.

    the typical % that is paid to office overhead is 2/3. so if a doc earns one dollar, at least 2/3 goes to overhead. overhead is killing me. For example, i pay 7% of MY GROSS revenue that is COLLECTED to my billing company to to GET the money. $65 becomes $60.45. it adds up and hurts.

    so when you look at those factors, a primary care doc might bring home after paying expenses 100 K to 110 K. please dont think i am exagerating cuz thats what my 2009 taxes say i earned after paying office expenses.

    alina, is that worth it in your opinion? my educational tract was 4 yrs of undergrad, 2 yrs of pre-med, 4 yrs of med school, 3 yrs of residency, one yr of a fellowship. 14 yrs total. if you were me, would you, alina, think its worth it?

    well, for me, its not worth it. that is abysmal pay for working my butt off for YEARS to become a good primary care doc, then working my butt off in my office to keep it going.

    im out. the pay sucks. and im working like a dog. i know nurses that get paid more than i do.

    does that help you, alina to understand why primary care docs are leaving?

    Hey BenM2- what do you think?

    • Patient Taylor

      One word: NIGHTMARE!! One thing though, why accept HMOs? My doctors do not accept HMO plans. My gynecologist accepts them for established patients, but not new and my PCP practice does not accept them at all.

    • Alina

      I appreciate you sharing your experience with us. Now I’m going to share some of my observations over the years. Insurance companies have been sending patients the EOB for years now and we can see how much a physician billed, what the negotiated fee is and in turn how much the insurance paid. At least in the past 10 years I have not seen any negotiated fees below $70 dollars and I am talking about regular PCP visits, no major illness. The highest fee I’ve seen for a PCP was $124 which quite frankly I thought it was excessive. These fees are for large metro areas, so it does depend where the physician is. If you’re in a more remote area, the fees are lower because the cost of living is lower.

      You mentioned a 95% reimbursement rate. Do I think this should be 100%? Yes, but to be fair I also don’t have all the circumstances surrounding the denials. BTW, I’m no fan of insurance companies, which I think they are a big waste of our money and sanity. But, unless doctors and patients pull together (all of us), nothing will ever change. Also, concierge practices will not work because most people cannot afford them.

      About the medicaid fee and how most practices have these type of patients. To be fair, we should mention that most physicians have a maximum (underlined) share of 15% for medicaid. Sure there are some exceptions where some doctors are in areas with heavier medicaid population, but this is not the norm. There are also doctors who do not accept medicaid and/or medicare patients and I think this is wrong.

      The majority of the physicians revenue comes from the insurance companies and there are also some cash paying patients, whose rates (in general) are quite acceptable (again speaking from my experience over the years).

      “most practices have the occasional patient who just… cant …pay for their visit (especially in this great recession) and ask for a “free visit” just this once, or reduced rate, or to not pay their copay. this might happen a number of times per week.” Honestly I have not seen or heard of an instance where the doctor’s office would even allow this. All doctors post a big sign right at the reception that all copays are due that day and all are actually collected before you even get to see the doctors. Also, most doctors do not even offer a “prompt-pay” discount for the cash-paying patients, which one would think that would be offered considering that the doctor is collecting the fees on the spot. So must be doing things very differently than most of your peers.

      I am aware of the capitated fee and its structure. I don’t mean to be a stickler, but I like to consider all angles. Let’s say that in your area, which is different than what I’ve experienced, most MDs have 30-50% of HMO patients with a capitated fee structure. We know that some of them are patients with chronic diseases that need a lot more attention than other. In order to have a clear picture we also would need to know how many of these HMO-capitated patients fall into that severe category.

      In general, we should also mention that although HMOs have a higher share in your area, when we look at the aggregate, nationwide data this is not the case. So again, it depends which area you live in.

      You seem to be one of the few physicians who are compassionate and spends time with his patients. Most doctors don’t. I’ve seen practices that run like assembly lines with visits no more than 5 minute. In the area I currently live in that’s pretty much the norm.

      Do I think that people should be paid based on their value and education? Absolutely. I’m thoroughly disgusted when I see insurance companies CEOs making hundreds of millions every year for nothing. I think that insurance companies have done a very good job of divide and conquer. Although not your case, many doctors started to have very short visits (5-10 minutes), which in turn did not come with good outcomes as it would be quite impossible. While some physicians are very knowledgeable and compassionate, others are quite the opposite. Patients became just a number or a certain payer. In turn, they became frustrated for not receiving the proper care, but paying more and more every year. And that is pretty much how we got to the current situation.

      We have to find a way to learn from our past mistakes and try to fix them for this system to ever change. We can’t keep putting a band-aid to a wound that needs major surgery.

      • Max

        So Ben can take your advice, a patient telling doctors she knows how their day runs and how much they make, or he can take another physicians advice. Guess which one he’ll take, Alina?

        • Alina

          As I mentioned above he should do his own research and use his own judgement. Reading his comments I think that he’s a pretty smart person and will make the right decision. Is that what you’re afraid of?

          • Max

            Oh I made no judgement either for or against Ben’s decision. I merely am suggesting that I think he will choose a physician’s opinion vs yours which would seem logical, wouldn’t it?

    • Ben M2

      Hi Dr. Igowic,

      I REALLY appreciated the breakdown you just gave there. That was very helpful, and thank you for taking the time to post it here. I think that does sound like a ton of work, and it sounds like it sucks. I especially appreciated your earnings estimate. What worries me most is not being solvent with my finances. That would be unacceptable to me. But at this point in my life, I think I’ll be able to deal with earnings that are lower than they should be, as long as I can provide for my family and live a relatively comfortable life. My feelings may change later in life, but I hope not.

      As for all of the paperwork and haggling with insurance crap that you mentioned, I think I can handle that. Before I got into med school I thought I would be making other people’s food for the rest of my life (the economy really is in a bad way), and doctoring will certainly beat that. The system is wrong, and medicine is messed up, but I think I’ve counted the cost for me, and I think I’ll be fine.

      It’s these reports of making $37,000 a year that scare the hell out of me. I cannot support a family or pay off loans on that income. I would probably join the army or something in that circumstance.

      I very much hope that your new career works out.

      • dr-im-getting-out-while-i-can

        Hi ben2,

        much thanks for the note. yes, i hope my new career works out too.

        in regard to what you wrote: “But at this point in my life, I think I’ll be able to deal with earnings that are lower than they should be, as long as I can provide for my family and live a relatively comfortable life. My feelings may change later in life, but I hope not.”

        YOU WONT be able to provide well enough for your family and live a RELATIVELY COMFORTABLE life. thats the point of everyones message who knows what they are talking about (not everyone who comments on this blog does). you will be able to provide a LIFE for your family but on an Fam Med docs salary COMFORTABLE wont be in the equation. if you have student loans, a spouse, kids, kids education to pay for (like college), a house, & your RETIREMENT, disregard RELATIVELY COMFORTABLE out of the equation, ok? you will live, but NOT comfortable. not even relatively.

        yet, you are already verbalizing doubt when you say, “My feelings may change later in life, but I hope not”. your real concerns are there. LISTEN TO THEM.

        ben, dont change places with me. do NOT go into primary care.

        nevertheless, in whatever your choice, respecting whatever you decide, i wish you so much good luck, all that i can muster.

        Dr. Igowic (gosh, i sorta am liking that name- it fits how im feeling in this segment of my life)

  • jsmith

    Harrowing stories, all.
    The big picture:
    At bottom, actions speak louder than words. American society says it wants primary care docs, but its actions, such as how it pays us and how it makes us structure our work, say otherwise.
    Don’t become a PCP, Ben M2. America does not want you to become one. It would prefer that you become a radiation oncologist.

  • guest


    I’m sorry, but how do you get 14 years for your 4 year PGY training? Its 4 years for college (pre-med), 4 years for medical school, 3 years for residency, and (in your case) 1 year of fellowship. That’s 12 years, not 14.

    If you took 2 years off or required 2 extra years to be accepted into medical school, that shouldn’t be counted for your medical schooling.

    • dr-im-getting-out-while-i-can

      I completed a 4 yr non-science undergrad degree in Psychology. After I completed that I immediately returned to do the 2 yrs of science required to apply to med school.

      Gosh, you almost sounded rude in your doubt. And I most certainly will count it towards the long journey I took to become a board certified family medicine physician, thank-you.

  • Anon


    You said above:

    “What worries me most is not being solvent with my finances.”

    “I think I’ll be able to deal with earnings that are lower than they should be, as long as I can provide for my family and live a relatively comfortable life.”

    Now that we have established that you are indeed motivated by money (like all humans are, no need to apologize for it) I think you need to educate yourself on the basics of home finance.

    Taxes come first. That’s income tax (federal and state) and payroll tax (7.9% if employee, 15.8% if self employed). Don’t forget about sales tax, here in my county in California, 9.75% on everything I buy except food.

    If you have $100,000 in student loans @ 5% payed off over 20 years, the monthly payment will be $660. That means you will have to earn about $1300, then pay the tax man his cut then pay your lender. So the first $16,000 you make will go to pay off your student loans. If you have more, you can do the math.

    Please do not think that the only 2 career paths for someone intelligent and hard working enough to get into medical school are food service or primary care physician.

    There are many public school teachers where I live that make the $110,000 per year salary that Dr. Igowic cited above. With 15 weeks vacation and a guaranteed retirement at the same salary when they turn 60! And while you are taking 7 or so years out of your life accruing debt, they are paying off their mortgages. And they don’t have to set aside 10 or more percent for retirement. Providing for your family doesn’t mean just paying the bills. It means being present and available and spending time, quality and otherwise.

    Don’t buy the myth that primary care doctors are the only doctors that have long term relationships with their patients. This is actually common to all specialties. And with the way employers change insurance coverage, even if your patients wanted to have a long term relationship with you, they often can’t due to insurance contracts (Kaiser, etc…) and the like.

    If you seek employment, your employer will tell you how many patients to see per hour and whatever you agree to at first will change with the employer demanding more hours, more patients for the same pay. Do you think you could do a good job of primary care seeing 4 patients an hour? What about 5 or 6? It won’t likely be up to you anyway, just show up and go from room to room. And when you run an hour or more behind, that means your lunch “hour” today will be 10 or 15 minutes because it’s starting again at 2 PM.

    At least you won’t be able to say no one warned you.

    • Matt

      “There are many public school teachers where I live that make the $110,000 per year salary that Dr. Igowic cited above”

      Where do you live?

      • CommonSense

        I would like to know as the teachers where I live cap out at $51,000 with a Master’s degree. I can assure you education is not even remotely hard compared than medicine, however teachers are continually under many of same pressures – heavy handed government reforms without their input, overloaded classrooms (35 – 45 1st graders in one room), parents that simply don’t care. So, it’s not all the bed of roses. I do find it interesting that all the teachers I know what their kids to be doctors.

        In regards to student loans, I have had several high school students who wish to find a career in family medicine, pediatrics, etc. After telling them of what they will face, (for a student coming from an improverished situation $100,000 looks like a big chunk of money), I tell them to pick up a teaching certificate or minor in business while they are in college. Upon undergraduate graduation, I tell them to work 3 years, live in mom and dad’s basement, work a side job and finally after their undergrad loans are paid off and they have six-figures saved in the bank, apply to medical school. The problem that I find is that most doctors while very book smart often lack common sense.

  • guest


    I’m sorry, I wasn’t trying to be rude. However, I feel that you are adding unnecessary years to the total; the non-science degree was not necessary for medical school. According to your reasoning, if I had gotten a BA in Art (no pre-med courses) then obtained a MA in education (2 years), then 2 years to finish the pre-med requirements then I would have done 4 extra years. Its not correct to add those years as your medical schooling. However, the 4+4+3=11 minimum years of schooling IS a lot for the payoff. If the Merritt-Hawkins surveys are to believed, primary care doctors still do pretty well even while accounting for loan debt and opportunity cost. Unfortunately, I’m not as well-versed with primary care compensation figures but do have a good idea of certain specialist compensation numbers…

    • dr-im-getting-out-while-i-can

      dear guest
      you wrote:
      “If the Merritt-Hawkins surveys are to believed, primary care doctors still do pretty well even while accounting for loan debt and opportunity cost”.

      if primary care docs were doing “pretty well”, then there wouldnt be so much problems recruiting residents into the residency programs. in the 1990′s there were over 3000 residency programs and now there are only over 2000 programs. the reason is they are closing cuz lack of interest on applicants. 30% of the docs in primary care are foreign graduates- not americans (of any race- please dont make this about that)- cuz americans dont wanna do it. this past year, 9% of the residency slots in fam medicine went UNFILLED, by americans OR foreign grads. you couldnt GIVE THE SLOTS away. the word is out: primary care sucks. please dont attend to Merritt-Hawkins as they dont measure the issue we are discussing: primary care pay sucks and we are leaving.

      so i am at a loss to read you write im doing “pretty well”. believe me, if i was doing “pretty well” or wasnt but saw a hope for improvement, i wouldnt be leaving fam med. but the reality is nothing is going to change. which is sad.

      and like my name says, im out. but i do hope the pay raises alot. society needs primary care docs.

      oh, and much thanks for clarifying about not being rude. i was glad to hear it. :)


      PS to guest: and im still gonna count my academic and professional journey to becoming a board certified fam doc to 14 years. :) :)

  • Roberta

    The same situation is true for psychotherapists: many love the field but get low pay, getting lower all the time, mounting insurance company paperwork, many practitioners leaving the field and discouraging others from entering. Managed care is trying to turn healing into profit-making for CEOs and shareholders, with services provided by manualized technicians.

  • Roberta

    Managed care companies take their chunk of the patient’s premium for medical care, then carve out mental health care to yet another managed care company which takes their chunk of the premium leaving half or less of the premium for actual mental health services. Managed care, often non-therapists, decides how many visits a patient can have, related to diagnosis, they conduct patient reviews to cut off services, and they do not respect standards of care. and professional ethics in our field. Professional judgment by the practitioner does not count in managed care.

  • Anon


    I live in a county in Northern California where the sales tax rate is 9.75%. I didn’t say all teachers make that pay but many do with 20+ years experience, CE credit and if they teach a 6th class. Those with only the time and CE make about 100K. You can do your own research from there. If I told you where it was, I wouldn’t be as Anon as I want to be.

  • guest

    The salary surveys that I see show primary care making roughly 180-190,000 a year. However, I’m not sure if this is only reflecting the compensation of a specific subgroup of primary care doctors. In that sense, even while accounting for loan debt, it is a relatively solid level of compensation for most americans. (even those with 7 years of post college experience)

    The fact that those residency positions are being filled with IMG’s and FMG’s (and avoided by US graduates) does not mean that the compensation is poor. However, it IS poor relative to many specialists. I know that radiologists are making roughly 350,000 gross for full-time workers in the US. Orthopedic surgery also does well; EM is pretty good financially considering its a 3 year residency. If the differences in compensation and professional satisfaction are great, it doesn’t matter how well primary care pays. Hypothetically, if family doctors made 300,000 gross/year for 40 hour weeks while anesthesiologists made 500,000 gross/year for 40 hour weeks then most students will choose anesthesiology. This is just looking at the choice financially, not from a personal-interest point of view.

  • Allen Bishoff

    Net income and after-tax income are mutually exclusive and I wouldn’t doubt that after-tax income for most FPs is very low. It is a shame that the specialty of family medicine (or primary care for that matter) is one of the lowest paid but that is the system. The system has created a dependancy on the insurance company and its price models. It is, in my opinion, a system that is without control meaning you are either going to join them or jump ship. Whyare large hospitals getting larger and Why are pharmacies popping up all over the place and yet the trusted source for our health care is struggling and wants out?!? In fact, those larger associations and your representatives have NEVER been able to make this a workable system.

    In our firm I’ve found great interest in cash only medical practices. In fact, interest is growing and done right can free you from a life of slavery to the insurance model. There are between 500 and 1,000 cash only medical practices and I’m not talking about the conceirge model nor the plastic surgery / Lasik sites; these are FPs who we have helped. It may not be for you but may be worth a look to find a firm to provide you an analysis of your options.

    I was at a conference recently and noticed how many administrators and physicians were only interested in a better way to navigate the system rather than placing some energy on changing the business model or driving more productive revenue through the doors. Call me recalcitrant but traditional compliance with the system has proven ineffective!

    • Max Power

      I agree with this. I think that the main reasons physicians are so hesitant to abandon a third-payer model is; 1) Safety – with insurance companies you are going to get paid little, but you have an endless supply of patients. Go cash only and you have to be a good business man and a good clinician. 2) Altruism – doctors have had the “profit = bad” paradigm hammered into their brains since pre-med. Even docs who don’t have a problem making a good living, are squeamish when it comes to advertising and marketing their services.

      The more I look into it, the more I am convinced that changing our business model is the only way the industry can survive. Of course the biggest obstacle is governmental regulation and whether our philosopher-kings will permit us to practice free of their shackles.

  • Bob Blumm

    The retail health care clinics have proven the validity of changing the paradigm. The mainprincipals who have received their cash on buyout were smart Doc’s who saw a challenge and rose to the occassion. Strong feelings require action not waiting for the next foot to fall. I have afriend that spent five hours in the Ehospital between 11 PM and 4 AM on three asthmatics for the sum total of 54.00.
    What in God’s name is wrong with this?

Most Popular