Dear future practicing physician, choose primary care

Dear future practicing physician,

Choose primary care.  I know all around you there are pressures to choose to become a specialist.  I remember those pressures well.  In medical school, one of my favorite mentors was predicting that after I got a taste of primary care, I would “come crawling back” to him.  I still chuckle about that conversation to this day.  In residency, I remember several seminars for us built around choosing a fellowship and tips on how to prepare to apply, but barely any seminars on choosing to become a primary care doctor.

There is little mystery as to why I did not find more guidance.  Specialists have much higher reimbursements for their clinical services leading to higher wages.  I also recall there being a significant difference in the perception of the prestige of practicing primary care.  Turns out, that prestige gap has been shown in research to influence career choice.

Well, after practicing primary care for seven years now, I am here to tell you differently.  With current measures built into health reform, my partners and I started receiving bonuses this year just because we practice primary care.  I see this as a substantial development.  For decades, payment schemes have been heavily slanted in favor of procedural specialties, leaving primary care physicians to make far less than their specialist colleagues.  Now, there is recognition that primary care physicians can help better control health care spending, and if you haven’t noticed, everyone in Washington, DC wants to reduce health care spending.  This bonus, baked into the Affordable Care Act, is an acknowledgement of a problem and a sign of changes to come.

But you didn’t go into medicine just for the money.  I know you didn’t.  You chose to become a physician in order to be a healer, for the challenge of learning the science of being a doctor, and for the opportunity to make a difference.  I can’t imagine a better description of my day job.

After seven years of practicing primary care, I can’t imagine going back and choosing to become a specialist.  My days consist of solving medical mysteries, guiding my patients through managing chronic conditions, and sometimes just doing my best to provide some comfort from physical or emotional pain.  I know at the end of each day that I have touched the lives of my patients, and this had led to immense career and life satisfaction.

Chris Lillis is an internal medicine physician who blogs at Progress Notes.

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  • Anonymous

    A med student who chooses primary care is voluntarily deciding that he will inhabit a lower socioeconomic class than that inhabited by most of his medical school classmates.  Just sayin’.

  • Anonymous

    What bonuses?  I haven’t seen any and I’m a FP.  If I could go back, it would be dermatology for me, baby.

  • drrjv

    I feel the same way, only I’m a neurologist.

    • Anonymous

      Yup, you guys are in the same hot water as us family docs.  Sorry to hear it.

  • Steven Reznick

    Having practiced general internal medicine for over thirty years I understand the joys of developing long term care relationships with patients and families. I have just received a Medicare primary care bonus which was small but certainly a first. You should go into primary care if you enjoy developing lasting bonds with patients and being their advocate and advisor in health related matters.
    There are many challenges to going into primary care. Hospitals and insurers want you on their payroll taking away much of your independence and creating a massive conflict of interest as to whose interests come first the patient or the institution?   Your colleagues  will treat you like their indentured servants at times. Hospital systems will try and get you to relinquish your skills and training by deciding whether you want to practice outpatient or inpatient medicine exclusively. You will be compensated less and must budget differently and live differently than your colleagues unless you have significant non medicine sources of income. You will need a life partner who understands the difference in your earning potential compared to your colleagues and is willing to help out in many areas.  Trust me it is difficult year after year to sit down for breakfast in the hospital doctors lounge and hear your colleagues discuss meeting for dinner with their families in an exotic foreign locale while you are trying to figure out how to meet next weeks payroll and student loan payments.  Despite this all , if you love helping and caring for patients and developing meaningful professional relationships then primary care is a wonderful specialty

    • Anonymous

      Yes, if you are masochistic, you’ll love primary care.

      Is that what you are saying?Why, over the last 20-30 years, has primary care gotten to the point of having to give these simple excuses–”if you like this, or like that……..?”  Enough of this garbage!  We’ve been duped by the specialists time and again. Of course I like my patients and relationships I have with them.  You don’t think specialists do as well?  Of course they do AND THEY ARE MAKING ENDS MORE THAN MEET.I’m not arguing against you, Dr. Reznick.  I’m just saying that we in primary care should be treated better than we are and it’s time to do something about it.Excuse me now—I have to get on the American Board of Family Medicine website, pay more than $300, and take the idiotic annual test and clinical simulation where I may only learn 2 or 3 new things. I can learn more at Continuing Medical Education conferences and have a more relaxed time—oh, yea, I can’t even afford those anymore.

      • Anonymous

        ” We’ve been duped by the specialists time and again”
        Actually, we’ve been duped by the AAFP time and again. 

        Other specialists have professional societies that represent the interests of their members. 

        We have a society that represents the EHR industry, large insurers, and government agencies. Our bad.

        • Anonymous

          Good point.

    • Anonymous

      Your praise was very faint indeed, Dr. R. That said, I agree with your analysis.

      • Steven Reznick

        Primary care is very rewarding. If it is not the sole source of family income or even the primary source of income then you should consider it. I got off the conveyor belt when I joined SIMPD ( now AAPP) and converted to a concierge type practice. It gives me the time I need to spend with patients with multiple chronic illnesses and it gave me a way to dramatically lower my overhead and costs so that I could afford to practice primary care medicine the way it was meant to be practiced.

        • Anonymous

          So, I presume that you have declined to see a large number of potential needy patients, such as Medicare, Medicaid, Tricare. In concierge, you have the ability to charge what you think is fair, not receive what some insurance thinks is good for them.  I agree with that, but not every patient can afford such care.  

  • Anonymous

    I am a first year medical student at the UW SOM. I think that quite a few medical students are looking at the current need for primary care, and are hoping to meet that need. I know that this is why at least 3 of my class mates are interested in primary care. 

    I myself am currently most interested in ortho or gen surg. We will see though I could fall in love with primary care when I rotate through it. 

    As a side note, I don’t think that monetary remuneration or prestige will play in to my decision or the decisions of my class mates. 

    • Anonymous

      Three are interested?  How many are in your class?

      I admire your interest in primary care.  As someone who has been doing this for over 20 years, I can only say, be very careful in what you choose.  Once you have completed a primary care residency, you can’t go back, unless you are eligible to go on to a fellowship.  Check out the law.  I did several years ago and discovered Medicare would not allow me to go back into a dermatology residency.

  • samson dy

    With regards to wealth, power and prestige, we family practioneers are in the bottom of socio economic class as  health care providers. Although the reality is that we need to be more knowlegiable than every other specialties in order to properly and effectively do triage of coordinating and reconciling patients care with several subspecialties. This in itself is a monumental effort from all the primary care physicians, internist and general surgeons as i am both. ACO should consider us to be on top of all of them. (Accountability Care Organization). My opinion.

  • Terence Ivfmd Lee

    I teach part-time at a state medical school, lecturing to the third-year medical students on my area of specialty (infertility). When I casually poll them on their future career choices, about 20% indicate that they are going into primary care. Many express interest in my field, but when they hear that it’s four years of a OB residency followed by three years of fellowship, they realize the great advantage of getting a four-year head-start on the actual positive-earning portion of their life. If we had a free market, the areas that patients want/need more would be rewarded more. The areas that patients want/need less would be rewarded less. An optimal set point would be reached and be ever adjusting dynamically to adapt to changes.

    • Anonymous

      Huh?  The areas that pts want/need more of would be found optimally?!   Perhaps you should read less of the Wall Street Journal and more the literature on the economics of HC. You really need to do some reading on information asymmetry in health care if you wish not to make such absurd statements in the future.  Google Kenneth Arrow and read his seminal article on HC.  What people want and what they need in HC are two very different things, Dr. Lee.  You should know this.

      • Terence Ivfmd Lee

        Perhaps you can explain the facts as you understand them. I get an inkling of what you are saying that because of information asymmetry, we don’t have a free market. But that’s my point also. We SHOULD have a free market, but we don’t, and therefore there remains a great deal of information asymmetry. In a true free market, one of the problems that would tend to gravitate towords optimal would be improved transparency and information. Right now, there is no incentive for health care providers to do anything about improving the information asymmetry. But in a free market, if the patient wants better information on which to base his healthcare purchase decisions, then someone somewhere will arise to fill the need, whether it be the providers themselves or some ratings agencies.

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