Marcus Welby and the relentless growth of specialization

In the very first episode of the TV series Marcus Welby, MD, our hero delivers an after dinner speech to a group of young interns. As he’s introduced, he hastily scribbles the title of his talk and hands it to the hospital director: “The future of the general practice of medicine, if any.” The year was 1969.

In his introduction, the director somewhat tactlessly remarks that many “eminent specialists” have addressed the group in the past, but tonight they have a general practitioner.

After acknowledging this, Welby continues:

Don’t apologize, You’re right. That’s what everyone thinks. Tell me, doctors, are you a specialist or a GP? Or sometimes they say “or just a GP?” But of course we are specialists. And our specialty, like any other, has certain advantages and certain disadvantages. The money is good, but you have to work three times as hard for it. But you people know all about that.

Since you’re about to choose your specialty, you’ve been amassing information about each. Psychiatry, we know, is practiced sitting down. Dermatologists don’t make house calls.

General practice is performed standing up, sitting down, outdoors, indoors, wherever there’s illness. And that means everywhere. Because, gentlemen, we don’t treat fingers or skin or bones or skulls or lungs. We treat people. Entire human people …

… I hope some of you will go into general practice. For if you don’t, where will a patient turn who doesn’t know that he has an orthopedic problem? Or a neurological problem? Or a psychiatric problem? Or a nutritional problem? But who only knows that, in lay terms, he feels lousy.

I’ve been told I’m a dinosaur, simply unwilling to become extinct. Maybe I am. But perhaps you’ll remember that one of these after dinner chats was given by a moldy old fig, with overtones of megalomania. And that he almost convinced you to go into general practice. You’ll remember it, and you’ll look at your beautiful wife and your two beautiful cars and your beautiful barbeque pit and for maybe three seconds you’ll be sorry you didn’t take his advice. But then, a beautiful breeze off the ocean will restore you to sanity. And you will have missed a hell of a lot.

The relentless growth of specialization

Specialization in Western medicine began in the early 19th century, once the practice of medicine changed from balancing the humors of the body to diagnosing diseases in specific organs. By the late 19th century Americans were traveling to Germany to study the latest clinical discoveries. The US medical market was highly competitive — before the reform of medical education in 1910, anyone could hang out a shingle regardless of qualifications. So offering a specialty – obstetrics, ophthalmology, otolaryngology – as part of a general practice provided an edge.

Specialization grew relentlessly. In 1931, fewer than one out of five doctors was a specialist. By 1969, there were more than three times as many specialists as general practitioners.

Some of this increase was stimulated by forces outside the control of the medical profession. For example, doctors who served in World War II were classified into graded categories. A certified specialist was paid more and given a higher rank than a general practitioner who may have had more experience. The GI Bill (1944) provided four years of subsidized residency training, including a living allowance, increasing the number of specialists. This may have been a well deserved reward for those who had served their country, but it had nothing to do with the health care needs of the 1950s.

The promise of the sixties and seventies

Things began to look up for generalists in the 1960s. The term “primary care” was introduced in 1961. Following the creation of Medicare and Medicaid in 1965, the Folsom report recommended not only that every individual should have a personal physician, but that the status and income of those physicians should be comparable to that of specialists. Two American Medical Association reports in 1966 endorsed board certification of primary or family practitioners. In 1969, as Dr. Welby was giving his speech, the American Board of Family Practice was established.

Students who chose family medicine as a specialty in the 1970s were inspired to change the medical culture. The Public Health Service Act of the 1970s, along with private foundations, provided explicit support for training general internists and pediatricians. The Health Maintenance Organization Act (1973) encouraged the rapid growth of HMOs, which tried out the idea of primary care physicians as gatekeepers to specialists. But patients were used to exercising free choice and created a consumer backlash. The subsequent history of primary care has been cyclic and rocky at best.

The future of primary care, if any

Few physicians today seem satisfied with the current state of medical practice in the US, whether they’re classic “specialists” (surgeons), subspecialists (pediatric oncologists), or general specialists (family medicine, general intern, general pediatrician). Our patchwork health care system of competing private enterprises is difficult to control or reform. Primary care physicians in particular complain that there’s too little time to care adequately for patients, too much bureaucratic paperwork, and – just as in Welby’s time – lower incomes.

If one of today’s young and idealistic doctors gave an after dinner speech on “The future of primary care, if any,” she could still find some grounds for optimism, however. It might go like this:

Our current health care system was created at a time when most patients suffered from acute, often infectious conditions that needed immediate attention. That is no longer true today. The majority of our patients have modern “lifestyle” conditions: diabetes, obesity, coronary artery disease, lung cancer, strokes, chronic degenerative diseases.

In the past, it made sense to organize health care into subspecialties that would treat acute, current conditions. But the health of our patients has changed. By the time a patient needs an oncologist, a cardiologist, an endocrinologist, or a surgeon — in many of those cases it would be fair to say that medicine has failed that patient.

What we need today is to recognize the crucial importance of integrated primary care systems, as well as public health policies that acknowledge and address the social determinants of health. We must provide financial incentives that attract and reward high quality primary care practitioners – and give them the time they need to care for their patients. Our goal could then be to empower our patients and give them hope that they may never need to see a specialist.

Jan Henderson is a historian of medicine who blogs at The Health Culture.

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  • Future of Family Medicine

    Saw this post originally on The Health Culture and loved it! Glad to see it here and hope it sparks some good conversation.

    Family Medicine Rocks!

  • jsmith

    Primary care is indeed useful to society. But consider this:
    Option 1 : 170k per year, 50 hours of work per week, seeing anyone that walks through the door.
    Option 2: 300k per year, 50 hours of work per week, seeing anyone that walks through the door, as long as the case is in your specialty.
    What’s your choice, young medical student?
    I recently read a hurtful but somewhat amusing crack from an ER doc, in Oregon I think it was. “If someone is smart enough to get into med school, they’re probably not dumb enough to go into primary care.”

    • CSmith MD

      Retainer fee of $75/patient X 2000 patients
      Option1 : 320 K
      Option2 : 300K

      • jsmith

        Sounds like a plan, Csmith. Please elaborate on how we can all start doing this.

    • Jo

      What solo primary care physician makes $170K??? Those that make that much must be employed by a larger group, hospital or large clinic.

  • soloFP

    I am into season one of Marcus Welby. Dr. Welby spends hours with just one patient and charged in 1969 dollars only $12 for a visit. The visits were all cash/check; no insurance companies and no Medicare. Dr. Welby would go in on surgeries, a practice that ended, now that Medicare/Insurance companies do not pay primary care docs to do this. Dr. Welby was a classic general practiioner, including delivering babies, taking out tonsils, and doing almost all routine parts of medicine. This also has ended with the specialists and litigation. Labs were done in the office, and xrays were read by the primary doctor. With the poor reimbursement, labs are done in bulk by national laboratories, and xrays rarely are read or done in the office. That $12 equates to about $74 in 2011 money, yet the average office visit is only $56 under the current system. As docs, we work more hours for less money and patients get less for the dollar. I’m not sure with all the technology that medicine has really evolved in the last 2-3 decades.

  • Fam Med Doc

    To all med students undecided about their residency plans but considering Family Medicine:

    I was once in my mid-20′s. Idealistic & hopeful for a bright future in Primary Care. But I was wrong. Family Med is as bad as everyone says. I’m getting out of primary care within the next 2 years. Kinda sad because we need more primary care doctors. And I’m decades still from retirement.

    Don’t switch places with me. Go into a better paying & respected specialty.

    You don’t believe me now, but you will.

    Good luck.

    • family practitioner

      Although it hurts me to admit it, Fam Med Doc is right. Any attempts by the government to improve primary care will be too little too late. We have lost. A generation from now, we will be completely replaced by mid-levels.

      • Jo

        Mid-levels do NOT go through residencies. They use other Physicians in the middle of their clinical settings to “watch and learn” and do very little clinicals during their externships (I know as we have had them during training in our clinic, some cannot even create a sensible visit note). NPs are not even governed by a Medical Board, but are governed by the Nursing Board, yet they are given prescribing status and in some states are able to practice without physician supervision. We are losing the great diagnosticians, patient educators and advocates of primary care physicians to a less than average trained practitioner.

    • jsmith

      What are you going to do, if you don’t mind me asking?

      • Fam Med Doc

        Pain Management. Cash only, thank- you. No checks or insurance. Debit/credit cards ok.

        And no, I’m not afraid of the DEA. I do good conservative pain management with good documentation. I consulted a lawyer who specializes in defending docs who get in trouble with the DEA & he helped set things up med-legally to protect me. I know so much about pain management i no longer refer pts in my primary care practice to pain management because i can do it myself. Believe me, I’ve trained well. Also, I have no problems kicking out someone out of my practice I suspect diverting narcotics or with a dirty u/a. And I’m not intimidated by demanding, obnoxious pts. I have my ” no” button well trained.

        So this year I’m opening my clinic. Worked with the interior design construction company (literally last nite!). My new office will be ready in just a few weeks. I’m excited. And hopeful.

        And you know what? It’s a real joy to take away peoples pain (in an appropriate medical fashion- many docs can’t or won’t do it right).

        Wish me luck.

      • family practitioner

        We will still have jobs, either as supervisors of midlevels or pcps, on the same level as midlevels. There is already a push in certain circles to shorten the time to train primary care physicians, thereby reducing the cost, ie 3 years of medical school instead of 4. The irony is that we need longer, not shorter training.

        I am in my mid-40′s and already feel like a dinosaur, being slowly squeezed out of private practice while still trying to maintain full spectrum family practice (no OB). The dinosaurs took years to become extinct, one by one; like them, we will just slowly fade away, and be replaced by midlevels, not other physicians.

    • mdstudent31

      You’re right, I don’t believe you now… and probably never will.

      I refuse to listen to “noise” generated by disgruntled primary care physicians who “advise” medical students to pursue specialization and avoid primary care at all costs.

      This is the type of negative energy that fuels my passion for primary care even more. Just another chip on the shoulder to truly make a difference in our communities, and most importantly, with our patients.

      Looking at the current rate of specialization and lack of desire to go into primary care, I do not know where this whole “aww idealistic medical student” thing comes from. It seems like this is something of the past, created by previous idealistic students who entered into primary care as the profession changed without knowing what it would change into. It is understandable why the current state of medicine would lead to dissatisfied physicians – but how much was done to prevent it? Medical students already know the answer.

      Currently, I believe medical students are more realistic and, as previously stated in rates of specialization, are not idealistic but realistic in expectations with idealism as a goal for where health care should be. Medical students entering into primary care should know by now what they’re getting into and the challenges that primary care physicians face. Additionally, we’re going to continue to use our idealism to fuel our drive for patient care and health care delivery. Why? Well, we were not left with much choice.

      We may be on the endangered species list, but that was the result of our predecessors’ reluctance to go to the forefront of medicine. Instead of staying ahead of the game, creating our pathway to where healthcare should be going, we were placed “on the menu”.

      I refuse to be on the dessert menu and will continue advocacy for primary care, not only for the survival of this specialty, but for the well-being of our patients.

  • ninguem

    Train to a specialty, and do as much primary care as you want.

    My mother goes to a Hematologist/Oncologist. She has no disease related to that subspecialty. He’s her primary care physician. He runs the hospital’s cancer center, but does as much primary care as he can accomodate.

    Last I checked, he did do a IM residency.

    • stitch

      Great idea, I know people who did that, but in some places there are insurance companies who won’t reimburse specialists who do primary care.

      It also takes a fair amount of dedication to keep current both in primary care and a specialty. Kudos to those who choose to do so.

      • ninguem

        I know a few nationals of India, moved to England, trained to the level of fellow of The Royal College of Surgeons. They preferred to be in the USA, so they came here and retrained to primary care.

        Talk about overtrained. On the other hand, I know they’ll do a real good job with that skin biopsy.

    • Jo

      Is he also board certified in primary care?

  • doctormom

    To upcoming physicians: You spend a lot of your time at work…no matter what profession you go into. Therefore, go into something that you love and feel pulled to do. We need good primary care and good specialists, and if you go into what you love you’ll be good. If you like the diversity and love the idea of taking care of a whole person instead of a body part – then go into primary care. If you love living in a rural area, you aren’t going to make a living as a left eye specialist – go into primary care. I don’t love the paperwork, but do you think specialists don’t have that too? I don’t make as much money as a specialist and would wager that I work a lot harder/longer than a lot of those wonderful doctors – but I am living just fine, thank you. I’m on call a lot. I don’t like the pucker factor when I’m “it” when the car wreck/MI/hunting accident/whatever comes in our ER – but I know I am doing what I can out here and can make a difference. I am a wife and mother of three (12,10, and 5). I am a family physician in the middle of the midwest in a small town. There are many of us out here that should be more vocal about our love of our life. For those that are in the trenches and aren’t happy – make a change like the physician above. Do what you love. Life is too short. I love being a family physician.
    Michelle Turner, MD
    Miller, SD

    • Fam Med Doc

      Dear Esteemed collegue Dr Turner,

      Good points. Being professionally satisfied is very important. In medical student education this should be, as you well stated, reinforced as they process & decide what field to go into. But in my opinion, one part of that education that is not presented enough is the atmosphere & lifestyle & consequences of choices. You seem professionally & personally happy and that is great. For real. But I have concerns for others who might not share your circumstances. Specifically: single parents. You are fortunate to have (PLEASE FORGIVE MY ASSUMPTIONS- it’s just to illustrate my point) a husband that also works. But now imagine your family living off JUST your income because of divorce, death, or disability of your spouse. With a divorce rate near 50%, this isnt so far-fetched. Or imagine you are a male & you & your partner want one parent to work in the home which means NO second income. You should agree that in this scenario, financially it’s much harder to make it on a primary care salary. You & I have worked (dammed) hard to get where we are & now provide an essential contribution to society as physicians. We want the same things: live in a decent home in a safe neighborhood, put our kids thru college & save for a retirement. Knowing how much specialists make & the increased difficulties you would have in achieving the above listed goals will be frustrating to watch. Back to my original point of medical student career guidance: this observed professional frustration can erode the joy one has for primary care.

      I know. I was once THE poster-boy for Primary Care. I was similar to the mdstudent31 in enthusiasm. In medical school, i could NOT wait to get into Fam Med. Hopefully i was not as abrasive & know-it-all as s/he came across (and also not be so obnoxious as to BLAME the current primary care docs for all it’s problems- wow this med students attitude is impressively adolescent in nature), but my joy faded once i was out in the real world as my heart & soul was burned by helping so much for too little in return at the risk of my future. It is this erosion of professional excitement that is entirely possible that unfortunately is not discussed enough with medical students.

      And now I’m slowly walking out of primary care. Neither I, nor my collegues in med school would have ever DREAMED I would come to this place.

      I am proud to know I have such a collegue as yourself who is making a difference! I wish you & your family well.

      • doctormom

        We ARE a single income family. My husband is wonderful with the kids and plays in a band on some weekends. (And if you know THAT business – he doesn’t make any money when he covers gas/food and occasional room – but he gets the self gratification of doing what HE loves.) Don’t get me wrong. I am very frustrated at times. It can get bad when I focus on all the BS at work – but is better when I focus on what I love to do. I’m just afraid all students EVER hear is about the sucky parts of the job and not the good parts. I don’t live high on the hog – but life is good.

        • Fam Med Doc

          Sounds great! For you. You have made it work. And that’s to be commended.

          But, the cost of living (especially buying a home) is FAR less in a small town than in the urban setting. Since you are no longer anonymous, I won’t ask you the square footage/monthly morgage payment you have, so we wont be able to compare, but we know the cost of a home where you live is significantly lower. But most people don’t want to live in a small Midwest town (no offense, I’m glad you are happy there) & could not (or at least would find it very difficult) AFFORD to do what you are doing in the urban setting of the united states. That’s my point: if a med student someday wants a “nuclear family”: a home, save for their retirement, & put their kids thru college, a Family Medicine salary in the urban setting (where MOST people live) WONT be enough. You will have to live in less desirable (or dangerous) neighborhoods in order to buy a home. You will probably be unable to afford private school, due to the low salary, so your kids will be in public schools- not the best option in many of the US public school districts, EPECIALLY where you buy your home- remember it’s a less than desirable neighborhood. Yes, it can be done financially but it will be a financial struggle. You say you “don’t live high on the hog”, but your lifestyle would be much less in the urban setting. Would you agree? To maintain your current standard of living, if you lived in an urban setting your husband would have to work. Would you accept/like that? Would your professional satisfaction go down? Important questions, especially for the med students reading this.

          I know I’m saying a lot of “what ifs”, but they occur commonly.

          And that’s the issue. As one works in Fam Med in the urban setting, you will see your specialist collegues live a MUCH BETTER LIFE. They drive nicer cars, go to amazing vacations, have bigger homes in better areas. Their kids are in private schools That’s how it is. I see it every day. And that’s not going to change anytime soon. And that’s frustrating. Initially not so much, but over time quite a bit.

          To the med student thinking bout primary care- I hope this helps. In my past, I was really similar to mdstudent31- I LOVED LOVED Fam Med. Still do, believe it or not. Its an amazing priveledge to be someones Family Medicine doctor. But I won’t risk my families future. And I’m (just) young enough to make the change. I’m behind financially, but I hope to catch up some. Won’t do it on my current salary in Fam Med.

          Dont change places with me. Don’t go into primary care.

  • Molly Ciliberti, RN

    I remember the days of Dr. Welby, MD, because medicine wasn’t big business with the vultures know as medical insurance companies skimming off as much money as possible for themselves, denying care and paying too little for actual healthcare. The problem with “specialists” is no one “owns” the patient so everything is done in individual boxes that sometimes overlap and can lead to conflicts but no one is responsible for the whole patient. We have more and better technology now, but not better healthcare and I suspect not better medicine or nursing (my field). There are times when I long for the good old days.

  • Christopher Gregory

    Our American health care system is failing – both financially and in the fundamental quality of care that is both judicious and practical. The reason for the steadily declining health of our system is a lack of direction that should be provided by the physicians who are best suited to view their patients as whole persons and who can diagnose/treat and refer when necessary based on both familiarity with their patients and an understanding that “more” (worry, diagnosis and treatment) is not always going to do better for the patient and is certainly not going to do better with the limited, shrinking resources we have for all of the overspending and excesses we experience.

    The culture of American healthcare must change, starting in the minds of young men and women contemplating careers in medicine, young men and women in medical schools and young physicians making final career path choices. Likewise, the attitudes of medical educators amd institutional medical schools must change and accord primary care medicine the respect it so richly deserves. Finally, the financial elements of primary care should be reorganized so that primary care physicians are reimbursed better for their time and the intuitive skills necessary to perform the roles of front-line practitioners.

    If we don’t correct the relentless path toward specialization and the dwindling numbers of PCPs, we will come to regret our indifference and apathy about a glaring, critical need in our health care system.

  • Jan Henderson

    Sandeep Juahar, author of Intern: A Doctor’s Initiation, published an essay in the NY Times recently on the sorry state of medical practice today. He argues that managed care – the response to the expense of Medicare – turned medicine into a money-grubbing profession where doctors bilked the system: “I’ll scratch your back if you scratch mine.” Doctors abandoned their professional core values. Instead of doctors being pillars of the community, medicine is now just another profession, full of practitioners who are insecure, discontented and anxious about the future.

    I think this is an exaggeration and, perhaps, a projection on Juahar’s part. And the discussion here throws light on what’s really happened. There is an older cadre of physicians, inspired perhaps by the Marcus Welby image, who decided on their medical focus at a time when family medicine in particular was promoted and supported by both government policy and social ideals. Only after they had established their practice did they learn that the game had changed. But newer generations of doctors begin their practice with their eyes wide open.

    Individual doctors will choose what they practice based on their values. Those who choose high-paying specialties are at least choosing medicine over finance. I think it’s a bit premature to say, as Juahar implies, that becoming a doctor is no longer a noble aspiration.

    More on the Juahar piece at

    • Christopher Gregory

      I have a hard time with such a generalization , i.e., “those choosing specialties are at least choosing medicine over finance.” Are you saying that they are choosing a career in medicine (in any specialty) over a career in finance (working on Wall Street)? Or are you saying they are making a decision to practice a specialty without regard to the high incomes that specialists earn? If it’s the latter – puh-leeez! A lot of doctors have told me they made their specialty path decisions based on money. Let’s not discount that the lure of a high income has an influence. I asked the daughter of a good client of mine (a pediatrician) why she was becoming a dermatologist. The good money was on her A list.

      I don’t have a problem with free choices of specialties – it just concerns me when specializations lead to over-utilization and higher costs. A young doctor certainly has the right to look at a financially rewarding career – especially when one considers the amounts of debt that pile up for medical educations and the years of living close to the vest before establishing a practice and an income.

      But let’s not make all choices purely noble.

      • Jan Henderson

        Sorry, I didn’t realize that would be confusing. Of course, I meant the former. No matter how high-paying your medical specialty, you could earn much more in finance. Individuals choose medicine because it satisfies their values — like being able to save lives.

        We’ve been living in a highly materialistic, consumer society for over a century, so no one expects any profession – other than the priesthood – to disdain the things that money can buy. But I think Juahar is right when he points out that the medical profession loses the respect of the public when there is financial dishonesty.

        The money issue is deeper than dishonesty, though. Medicine is a unique profession. The pubic – patients – would like to believe that clinical judgments are not influenced by financial considerations. For most of the history of medicine, this was the ethical ideal. Managed care health insurance reversed that ideal. When it comes to considerations of how much doctors earn, I think the taint left by managed care still lingers in the minds of the public.

  • imdoc

    Two competing concepts I hear:
    The public, as patients, desire empathic altruistic doctors who put economic interests aside and provide consistently good care (Marcus Welby image). Always advocate for the individual patient.
    The public, as consumers, desire medical service providers with good business acumen to control costs and overhead, be cognizant of cost implications of care, and be able to balance diverse complicated payment schemes from public and private payers. Be reflective of service models in other industries, since medicine is now ‘no different’ and the idea of a professional is obsolete. Be an advocate for societal needs.
    The term that comes to mind is cognitive dissonance…

    • Jan Henderson

      Nice summary and, perhaps, all too true. It’s really unfortunate that medicine is regarded, from an economic perspective, as just another industry. We’re talking about life and death here. Of course, cars and airplanes are about life and death, too, but that’s not the same thing.

      What we think of today as practicing medicine will need to take on entirely new contours in the future. It won’t happen abruptly, but it has to happen.

  • MyFamily Health Guide

    I love being a family medicine doctor! I find it sad to read colleague’s discussions about leaving the profession — sad, but understandable. I’ve been fortunate to have trained and worked in a medical school (SLU) and residency (UCSF/Sutter Santa Rosa) where the primary care culture was very strong. And I felt truly lucky to be living in Sonoma county and practicing such an emotionally satisfying career.

    But the finances are actually much harder than I had realized way back in medical school, and now I honestly wish that a medical school financial aid counselor had given me a serious heart-to-heart talk, with detailed financial projections, about my earnings potential as an FP. If I had seen a nice Excel graph about my inability, in my 40′s, to barely pay for a car, much less a house mortgage, then I may seriously have reconsidered my specialty. The crushing student loan debt these days is absolutely criminal.

    And yet, after all that, I do absolutely love going to work every day, and how many people get to say that? Not enough…

    • Fam Med Doc

      You make my points very well. I’m not convinced medical students hear this argument enough while they are in med school. Many in Family Medicine would not have chosen that field if they then heat they knew now. In your 20′s one just doesnt believe than income will make such an impact on job satisfaction, but it does. You & I older now, & know better. Sure we love what we do. But we would both love to buy a home, to be better prepared for our retirement, etc.

      You and I are in exactly the same position, different cities in America, but similar experiences. The sad reality is the pay imbalance between primary care specialty care will continue, either with or without Obamacare.

      Medical students need to hear this.

  • Jo

    The difference is around 3 million over career between primary care and radiology and the gap increases with other specialists. Also the income for primary has stayed almost flat for 25 years with a huge spike in income for specialists over the same time period. Also most hospital associated specialists have subsidy from the hospital for salary, equipment and overhead. Large groups and hospitals “share costs” for everything from lobby furniture to syringes. Also AMA states syringes and other supplies used for “surgeries or procedures” can be seperately billed for in the “surgical tray”, but that the supplies used in primary care to take off a basil cell CA or dress a wound are “bundled” into the primary care E&M code reimbursement.

    Unless primaries unite and define themselves well and begin to push back, the AMA, government, hospitals and specialists will not give anything up in order for primary care to survive. They would rather hire NPs to do psuedo primary care in specialists offices and even take more of the pie-this is not being cynical, it is happening now.

    Also hospitals who are now seeing that the government will give money to ACOs or CIs they are now playing nice with the primarys but stack the deck in their and the speicalists favor so that the primary vote can always be overridden.

  • Fam Med Doc

    Dear Jo,
    Yes, the difference in income over an entire professional career between primary care & specialists is staggering. Medical Students need to be aware of this.

    In regard to the hospitals courting the primary care docs: OMG, yeah, I have personally started to see this in my community. But you are right: they want to only manipulate the process with the subspecialists so they continue to maintain their high income, to the exclusion of primary care.

    The reality is the “ACO” project is to some degree another FALSE promise held above the heads of primary care doctors that this will finally increase our revenue & pay primary care docs. Do you actually believe Aetna, Blue Cross, or MEDICARE is actually gonna INCREASE our revenue? These promises have occurred before to primary care only to be broken in the end. There is NO extra money to redistributed to us PCP’s. With the current federal budget deficit, increase in retiring seniors & it’s accompanying increase in health cost, anyone who thinks there is going to be an increase in PCP pay is delusional.

    The current low salary of primary care will continue, under any revision of healthcare administration devised by Democrats or Republicans.

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