Myths devalue the image of primary care

After an exciting and challenging day of caring for patients and teaching students, a third-year medical student on his family medicine rotation says to me, “I really like what you do, but I just cannot afford to go into family practice.”

I realized that by “afford,” he was referring not only to finances but also to the expectations of his parents, friends, and medical school. After spending 35 wonderful years as a family doctor, I have been “dissed’ by a kid who wants to become a dermatologist.

So I am of two minds. Part of me is fulfilled by being needed, loved, and respected by my patients.

Over time, they have increasingly looked to me to diagnosis, advise, reassure, and guide them through a complex healthcare environment in which few others offer them help. Another part of me sees that what I do is increasingly devalued by forces outside the exam room ― those who pay for health care, those who question the “medical necessity” of each test I order or drug I prescribe, and those in medicine who are more likely to know a procedure’s CPT code than a patient’s name.

We are in this position because we have failed to define ourselves, instead allowing others to perpetuate myths about what we do. The first such myth is that what we do is easy. Nothing can be further from the truth. In about 15 minutes, we are asked to treat a long list of chronic problems (e.g., diabetes, obesity, hypertension), resolve a few new problems (eg cough, headache), address preventative health recommendations (eg, smoking, flu shot), integrate the psychosocial issues that impact the patient’s health, and figure out how to get it all paid for by an insurance company using codes that don’t really match either my patient’s problems or the care I provide. Oh, and by the way, can you look at this rash and fill this prescription for my husband? Recent research has shown that an average primary care visit is 50% more complex than a visit to a cardiologist and five times more complex than one to a psychiatrist. So no, it is not easy.

The second myth is that it requires less training than other medical specialties. This has resulted in some assuming that primary care can be left to “midlevel” clinicians. While physician assistants and nurse practitioners can work effectively in primary care settings, it is a mistake to believe that they provide equivalent care to patients with complex problems, and we have suffered by the wide acceptance of this assumption. OR techs can work effectively in an operating room, but no one suggests that they replace surgeons.

A third myth is that all we diagnose is colds. Patients present with a vast sea of undifferentiated complaints. Most of these are diagnosed in primary care. After all, most patients’ cancers are diagnosed before the patient gets to the oncologist, and someone has already figured out that the problem is renal before a visit to the nephrologist. For a cardiologist, the biggest diagnostic dilemma is really whether the patient has or does not have coronary disease. There are, in fact, few medical specialties other than primary care where the doctor doesn’t know the disease before opening the door to meet the patient. And many common complaints are complex. Consider for example, “I’m tired all the time.” Does the patient need a TSH, a cardiac echo, an SSRI, or a little time and reassurance? Sorting all this out is beyond the talents of the endocrinologist, cardiologist, or psychiatrist. It requires a good family doctor.

A final myth is that we function as “gatekeepers.” The image here is that the good stuff is behind the gate and family physicians are barriers blocking patients’ access to it. This obnoxious concept was perpetrated by managed care organizations, which did a great deal to misrepresent the value we bring to healthcare. My goal is to match the right patient with the right treatment at the right time. In this day of unnecessary heart caths and back surgeries, patients need someone they can trust to have their best interest at heart.

These myths and others have resulted in devaluing the image of primary care at a time when it is needed most. Thirty million Americans will be added to the insurance rolls by 2014 and state Medicaid budgets will go broke. It did not have to be so bad, but my student became a dermatologist instead.

Paul Fischer is a family physician who practices at the Center for Primary Care.

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  • Leslie

    “This has resulted in some assuming that primary care can be left to “midlevel” clinicians.”

    But it is often left to them.

    And they don’t mind.

  • http://fertilityfile.com IVF-MD

    A lot depends on the perception of value as per the mind of the patient.

    Dr. Fischer, I get the sense from reading your post that you are an excellent caring doctor. Some patients will appreciate that a great deal, but still there will inevitably be others who have zero appreciation. How can we tell?

    Imagine your patients and how familiar they are with the quality of your care and how much they value seeing you over a random FP doctor. Now let’s do an experiment and offer all your patients $1 per visit to switch from your care to that of the random average FP down the street. Perhaps 99.9% will stick with you, while the least loyal patient takes the money and switches. Now let’s up the stakes to $10 per visit and see what happens. Then to $100 per visit. I’m sure you get my point.

    Whatever price point would get a patient to switch is a good measure of the value of your service in that patient’s eyes. You can be pretty proud of yourself if your patients love you so much they’d pass up $1000 per visit just to stay with you.

    The next question is how much money would it take to convince a patient to switch from seeing an FP to seeing nobody at all! THAT is a good measure of the perceived value of FP care in the minds of the patient.

    Of course this imaginary model I describe is a distorted reflection of what’s happening in real life. Patients have come to believe that healthcare should be free. Therefore the myth you describe is exactly that, a misperception that because healthcare (especially FP healthcare) should be free, that it therefore has little to no value.

    As sad as it may be, patients do not believe that auto repair, cable TV, steak dinners, gasoline or breast augmentation should be free. Therefore, they value it more than they do things like primary healthcare or government education. It explains a lot.

  • buzzkillersmith

    Dr. Fischer’s eloquent post completely misses the point. The med students don’t care about those myths. Hello, it’s the money.
    I have been a family doc for 22 years. I will not be financially able to send my kids to the best colleges that their academic achievement would warrant because of money. My subspecialists colleagues are not in this situation. No myth, reality.

    • http://futureoffamilymedicine.blogspot.com mdstudent31

      My parents were not able to send me to the most prestigious university/college. Neither of them are doctors nor do they both make close to the amount of one family physician combined, whose income is in the top 5% of income earners in the country.

      They took out loans to help pay for undergrad and I paid the rest of the way – for my Masters and now for my Medical Degree, accumulating over $300k of loans in principal. Thanks to the Direct Federal Consolidation Loan and Public Service Loan Forgiveness program, I am going to work in public service/not-for-profit, make 120 consecutive payments on an income-based payment plan and have the rest of my loans forgiven after 10 years. This will help while paying off all of the private loans I had to pay off.

      I’m not going to have a huge house or a luxury car, and may not go on extravagant vacations with my family – but that’s ok. Are we worth more as family physicians? Yes. Will it change? Maybe, but in the spirit of being realistic, I’m not planning on it. We’ll take it one day at a time, invest wisely, and make the best of the situation.

      • buzzkillersmith

        Best of luck to you. But you’re only one person. The real issue here is how to ensure an adequate supply of PCPs for the population. It’s the money, medstudent. If that is not solved, isolated idealists will not get the job done because there aren’t enough of them. Google MH Ebell residency fill rates to look at the data.

        • http://futureoffamilymedicine.blogspot.com mdstudent31

          Well familiar with this data and then some. You are right that isolated idealists will not get the job done. It’s the pseudo-realists that get pushed away from primary care when told they can’t afford to practice primary care – and,relating back to the article, that is a myth. It is definitely the money – but the money is blown way out of proportion. The average family physician makes money.

          http://www.census.gov/prod/2002pubs/p23-210.pdf
          According to the US Census Bureau persons with doctorates in the United States had an average income of roughly $81,400. The average for an advanced degree was $72,824 with men averaging $90,761 and women averaging $50,756 annually. Year-round full-time workers with a professional degree had an average income of $109,600 while those with a Master’s degree had an average income of $62,300. Overall, “…[a]verage earnings ranged from $18,900 for high school dropouts to $25,900 for high school graduates, $45,400 for college graduates and $99,300 for workers with professional degrees.

          With these income-based loan payment systems and with a decent salary (3-4x the avg US salary for college graduates and almost double those w/ professional degrees), I don’t think family doctors are starving. I may not be able to save enough to pay cash for my future kids to go to college either – though I will be able to help and they will be able to take out loans the same way I had to.

          • buzzkillersmith

            You still don’t get it, young med student . The correct analysis here is based on opportunity costs, not on the average salary of Americans. An argument based on the latter is a variant of the “just price” argument demolished by Adam Smith and others centuries ago. You need to think of other people how they are, not how you think they should be, and not how you happen to be.
            On average, a med student leaves several million dollars on the table when he or she goes into primary care. You say that the money is still good. True, but irrelevant. What matters in predicting medical student behavior is the foregone income, not what some joe with a master’s degree makes.

  • Angela Caffaratti, MD

    Leslie,

    Do you think nurses or physician’s assistants are naive. They will also follow the money and choose less work. In my area, they work in specialists office, following protocols to order lucrative procedures. They are great business for specialists, and primary care offices can’t afford them. This is a reflection of market forces at work and not intended to be a slight. Until the system changes and we are paid to work together for everyone’s good, it will be this way with rural exceptions.

  • Phil Colby, MD

    In my area, family practitioners make as much, if not more than subspecialists via lucrative full risk HMO contracts. Of course to get onto such a panel takes several years, but several make 7 figures a year.

    Also, a number of family medicine doctors also perform minor procedures in the office which are often fee-for-service and can be quite lucrative. Just as with anything, it’s what you make of the profession. As an employed subspecialist, I will never make nearly as much as they do (which is fine by me).

  • Will Melahn, MD

    No one else can do what we do. Take anyone but a competent, comprehensive generalist and put them in a community health center and they will be ill-equipped to survive the first hour, and the patients will not be helped. The tension is that we as generalists espouse comprehensive care over time with attention paid to biopsychosocial issues, yet we “crank” out the volume in visits and do not practice comprehensively enough when compared to our peers in the EU and other better performing countries. If we could practice what we preach, the students and more pateints, and payerswill come to see the value of our role. We are, in effect, a public trust. We must live up to it.

  • http://blaggieplaggie.blogspot.com Yolanda (Blaggie Plaggie: Babblings of a Mommy Doctor)

    Physicians may be undervalued, but nevertheless, we do make decent money. At what point would someone consider their salary just compensation? When it comes to money, the comparison game never ends.
    Ultimately, we all made the decision to go into medicine, whatever those decisions are based on. I knew full well the likely range of my salary when I committed to becoming a general pediatrician. I knew that it would be at the lower end when I chose to work at a community clinic. Sure I would love to make more, but I am still doing FAR better financially than many of my non-medical peers, and that’s even with working part-time. So I appreciate Paul’s point that we need to encourage medical students to look past some of these myths and complaints regarding primary care as a career. It is possible to still live the “good life” — the question is not just what you will make, but what you define as the good life, and how wise you are financially. I have friends who make more than me, whether it’s a medical or non-medical field, but they aren’t necessarily more financially secure. Ultimately, money isn’t everything. It ain’t shabby, but it isn’t everything. If money is everything for you, then you probably should consider a different career. I still love my job. That is worth a lot to me. Primary care isn’t for everyone, but hopefully we can still help encourage those who do have a heart for it beyond the degree of compensation.

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