Most medical students don’t have what it takes for primary care

I figured it out! I realized what the basic, underlying, fundamental problem is with medical care in this country.

The problem is that it’s too expensive and often isn’t very good, but that’s clear.

The reason medical care in this country is fragmented  and overly expensive is that there is a perverse inversion of the correct ratio between primary care and specialty physicians (should be significantly greater than one, instead of significantly less). That, too, is perfectly clear.

But what is the reason for this ridiculous state of affairs, where specialists outnumber primaries 20 to 1 instead of vice versa? Most people point to economic disparities, with towering specialist incomes dwarfing that of primary care, due in large part to the perverse payment incentives for “doing something” (ie, procedures) instead of thinking about, talking with, and counseling patients.

I don’t think that’s it.

Here it is:

95% of American medical graduates don’t have what it takes.

Primary care is medicine in its purest form. Family medicine, pediatrics, general internal medicine; primary care, defined as the generalist physician caring for a patient (as opposed to an organ system or a disease) over the long haul, is what medicine is really about. It’s hard. It’s challenging. But it is rewarding in a more deeply authentic way than any other field of medicine.

The rewards offered by the specialties are more immediate, but they are also short term and finite. It’s no wonder that they attract graduates without the emotional stamina required for primary care.

Most of them try to tell us that we’re the dumb ones; the bottom of the class; the ones who don’t have what it takes. This is nothing but projection on their part. Grade ranking in medical school is a meaningless fiction. You have to be the cream of the cream of the crop just to be admitted. Once you’re in, you don’t suddenly become dumb. Besides, the essence of medical school course work is geared to passing the three steps of the United States Medical Licensing exam. Once you’ve passed those, you’re licensed. That’s all it takes. All the other evaluations and grading schemes that reward top performers with dermatology and ophthalmology training slots are nothing but exercises in meaningless memorization that contributes nothing to caring for actual patients.

I suspect that more students start out having what it takes. It’s too bad that so many of them lose the passion for real medicine as they progress through training, and end up settling for the pursuit of one or another tiny sliver of knowledge that they’ll never fully achieve anyway. Between the inherent challenges of primary care and the naysaying peer pressure, I suppose it’s inevitable.

But it’s still wrong.

Primary care is awesome! The only reason so few people choose it must be that 95% of American medical students don’t have what it takes.

Do you?

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • JohnAmy S

    I absolutely love this article! I am currently in medical school and I can’t wait to be a rural Family Physician. People tell me, “you’re smart, so why are you going to be an FP?” My response: “I am smart, that is WHY I am going to be an FP.” ;)

  • Sakina Bajowala

    I fail to see how claiming that your specialist colleagues don’t have “the salt” to perform your job does anything to promote primary care. I have the utmost respect for my primary care colleagues, and encourage each of my patients to establish care with a generalist, if they have not already done so. You’d be hard-pressed to find anyone in the field who doesn’t recognize the enormous value of a perceptive, well-read primary care physician. However, your article essentially labels your specialist colleagues as lazy one-trick ponies. I’m sorry, but why must it be a zero sum game? Is it not possible for both PCP’s and specialists to be energetic, intelligent and committed to patient care? It is exactly this type of divisive attitude that has usurped the ability of physicians in this country to effectively advocate for our patients and ourselves. We were so busy insulting each other that insurance companies, politicians, and noctors took all the seats at the negotiating table. Shame on us.

    Also, I think it’s a little disingenuous to say that your specialty is more rewarding than my specialty. How do you know how rewarding my work is to me or my patients, until you’ve walked in my shoes?

    • Eric Smith

      Would you, as a specialist, continue to practice with as much enthusiasm if your salary was reduced to that of a primary care physician? Would you have even chosen your specialty if you knew it was on the lower end of the salary range for physicians (as is primary care)? If you are lucky to have a primary care doctor who wants to know you as a person, is skilled to handle most of your health and wellness needs, and is happy and satisfied with his job, you better keep him or her, because they are getting harder to find!

      • Sakina Bajowala

        As a specialist (and the owner of my own micropractice, where I see a limited number of patients in order to be able to spend 30-90 minutes with each one), I make less money than many employed primary care physicians. But, my patients and I are happy with the arrangement. If I wanted to be wealthy beyond my wildest dreams, I would not have chosen medicine as a career (nevermind allergy vs. primary care). I chose my specialty because it holds meaning for me personally, it allows me the opportunity to engage in advocacy, and lets me create long-term relationships not just with individual patients, but their whole families. I must say, for certain primary care physicians to say, “I make less money, but only because I’m a “thinker”, am more compassionate, have higher emotional intelligence, actually CARE about my patients, and have more stamina to boot! You only make more money because you’re a greedy proceduralist.” is incredibly insulting to those of us who also work very hard to improve the health of our patients. It’s time to get off the high horse.

        • http://twitter.com/JamesFPMD James Biggerstaff

          Congratulations on being able to practice at a leisurely pace. BTW, are you a member of a 2 doctor family? Are you the sole breadwinner for your family? Perhaps it’s time for YOU to get off YOUR high horse! While you’re basking in self-satisfied smugness at your carefully constructed micro-brew practice, those of us in primary care have to work for a living. We don’t have time to drink your Koolaid. Your statement that you make less than many employed PCPs is probably the most offensive statement on this post! You make what you make because you CHOOSE to. Those of us in Primary Care scramble to make what we make because we HAVE to! There’s a huge difference. We have families to provide for and only wish that we had the luxury of practicing medicine as a hobby; a method you seem to have perfected.

    • http://www.facebook.com/kevin.hale.98892 Kevin Hale

      noctors…haha, wow thanks!

  • Sequoia Kam

    I have always wanted to be a surgeon. I grew up watching VHS tapes of open heart surgery and brain surgery. I see the value of primary care, but I am fascinated by the function of the internal body and the highest level of physiology for me is internal surgery. I am still studying to take my MCAT September 11th. I am putting all my notes online at http://everythingmcat.blogspot.com/ I don’t ever see myself becoming a primary care physician. I am a massage therapist and enjoy helping people improve their mental and physical health in that manner. I plan to continue to work with geriatric patients doing massage even after I am a surgeon, but I don’t feel the same about being a PCP. I have to agree in the end, that I feel I don’t have what it takes to be a primary care physician. I don’t think it takes a smarter, better person to work in primary care, but I do think it takes a specific type of person. Maybe someone willing to take more risks, the risk to be wrong. Maybe someone who loves to solve problems instead of just fixing obvious ones. I am not one of those people, who wants to live that life, but I definitely respect them for doing the most necessarily of all medical jobs.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I think it is unfair to say that medical students who choose specialties other than primary care do not have the right stuff. I am a primary care physician and fought for general internal medicine to be fairly compensated for years. I additionally fought for generalists whether family practitioners or internists to be able to perform those tasks and procedures that they were trained to do and capable of doing well based on observation, testing and case reports.
    Students enter the field of medicine because they wish to help people. Along the way the majority come to realize that in order to balance family life and responsibilities, financial responsibilities and lifestyle they may have to choose a specialty that is not all consuming like primary care and that pays enough so that they can raise and educate a family. This does not mean they are any less philanthropic, altruistic or talented and dedicated. It just means they are realistic. Their faculty mentors in many institutions demean ” the local medical doctor ( LMD).” Primary care faculty from the community may discourage students from entering an area of medicine that might require both parties in the family to be full time wage earners to pay all the bills. My colleagues in specialties earn more money than I do because the payment system pays them more and values their skills over my skills. They put in as much time if not more than I do, are as dedicated if not more so and as skilled in what they do as I believe as I am practicing longitudinal care in general internal medicine. They have the right stuff, they just choose to use it within the profession in a different manner. If the author is unhappy with the direction primary care is going then she needs to fight to improve it not pick on her colleagues. They want primary care to do better they just do not want the increase in benefits to primary care to be taken from their compensation.

    • http://twitter.com/JamesFPMD James Biggerstaff

      Yes Steve but keep in mind that you’re having to do all this fighting because your specialist friends are opposing any effort you make to get equal pay or perform procedures for which you are qualified. Make no mistake, you’re fighting them, not the insurance companies. The insurance companies could care less who gets the money, they just care how much they have to pay. And yes, the system pays them more and your specialty buddies have done a great job of seeing that the status quo continues

  • http://www.mywhitecoatisonfire.com/ Lumi St. Claire

    As someone who practiced primary care for over a decade, I must say I found this fairly offensive. Your claim that students “lose the passion for real medicine” implies that specialists are practicing some lesser, devalued form of medicine. I know that when both of my parents were diagnosed with cancer, I was thrilled that they both had specialists (aka oncologists) who were well-trained in their craft and were able to provide them with current protocols and give them both excellent outcomes. Something that I certainly wouldn’t be able to do as a generalist.

  • StephenModesto

    …Thank you Dr. Lucy for sharing the perspective of this societal abberation in the name of the ambition of `professionalism’ versus the aspiration of `understanding’. Your words are refreshing to hear. I am a RN. I had focused my developmment on becoming a generalist for reasons very similar as you write. Ironically, this developed and acquired skill is not reinforced in the currency of the contemporary market. Self-doubt then became the natural consequence…at least for me. Yes, of course it is also a natural consequence that there will be and has to be specialists in all fields. The dilemma seems though that as more and more specialists are referred to the inevitable increasing frequencies of co-morbid complications of pt. care, that the PCP is somehow lost in the conducted orchestration of that care. There are no simple answers to this structured system…as is evidenced by the counterpoints of the other commenters. But I still appreciate your perspective.

  • maribelchavez

    I don’t understand the low reimbursement thing. Can’t you charge whatever you want for your services like anyone else? You offer a valuable service – people with pay for it. This works for primary care. Even your medicare patients can pay for routine services out of pocket. Working for a large hospital group is a trade off – someone else will deal with chasing after the deadbeat patients and the medicare/medicaid stuff and you get whatever they decide to pay you. Otherwise set your own prices; however, you get to deal with the same stuff other private business owners have to deal with.

    • Lucy Hornstein

      You’d think so, wouldn’t you. Problem is that most people in this country believe deep down that they really shouldn’t have to pay for medical care. That’s what insurance is for (though medical insurance isn’t really “insurance” in the actual definition of the word), and someone else (your employer; the government) is supposed to pay for your insurance. Think about it: “Good” coverage is the one that costs you the least in premiums and out-of-pocket co-pays and the like, and covers the most in terms of procedures and visits. Although many doctors are going “cash only” (cutting insurance middlemen out of the doctor-patient relationship), there are still large areas in the country where people will just switch doctors. You’d be surprised how little most people really value (monetarily, that is) good primary medical care.

  • CorpAvenger

    But don’t tell me that you are so unaware of the present day enviornment that you deny that this doc’s basic perception of how the rest of medicine and specialists DO view Primary Care? She is using tongue in cheek almost humor here to “Stick it Back at Them”, all who do put down PCP’s the line of work, training and the like. And being a specialist I bet you can go a lot slower in your similarly designed “Micro Practice” than my wife can in hers living on “Office Visit” E&M codes almost exclusively. Just a few well paid procedures can earn you in a morning more than we can bill for in an entire week most weeks. Yeah, we too love the half hour schedule blocks we have here but at barely $100 bucks or so on average for that at best that does not leave a heck of a lot to pay the rent, the business loan, the student loans, no less keep a roof over our own heads, feed our kids and perhaps afford a few normal things like their sport or creative stuff we really should support and take pride in….
    Not to knock you here, but it sure is a heck of a lot easier to be a values leading specialist than it is to be in any of the “Cognitive Medicine” fields. If and until we pay a completely different fee, about 50-100% per office visit and start having logical things like the correct coding and billing of lets say a CCI Edits, allow primaries to code bill and get paid for an office visit and the extra two well women visits codes (one of my favorite examples of duel sexism, sexist to the patients and the female providers who tend to have more female patients) of G&Q instead of loping them off as “Inclusive” to the CPE or office visit nothing is going to change.
    There was a great article here at KevinMD awhile back about how the choice to pick a well paid speciality vs primary care was almost like an enterence exam, base level intelligence test when you start to consider the differential in pay, hours, call structure, and worse yet similar levels of post med school debt too, who is their right mind would go into primary care under today’s perverse conditions set up to fail and burn-out. Sure you folks all take an oath but I don’t think most of you really considered it an “Oath of Poverty” like that of a priest of what have you. It was supposed to have a positive upside and those of us like my wife and I thought, were openly lied to and mislead by a majority of the generation ahead of her, that instead of being really well off we would be fine with simply be firmly and safely within the middle class and probably on the higher side of that bell curve for that demographic…
    I see my wife deal with elder people with multiple diseases of life or wear and tear starting to take their toll while others are remarkable healthy, or won’t give in and chose to live life as best as they can even as their bodies are not so perfect and without aches and pains… Then young adults with problems and issues, families with husbands who won’t come in enough while they are fairly young to properly treat diseases in their earilest stages to they can be around long enough to bother their grandchildren, wives with multiple role and responibility stress, the kids of all ages, teens acting out or get “Busy” a bit too young and needing to counsel them.
    We are by far the nation’s stop gap measure to keep the mentally ill from falling thru a thousand extra mile wide gaps… We have all sorts of anxiety and panic disorders, mild to moderate Bipolar disorder, eating disorders, sleep problems and the potential cardiac harm that comes with all of that if it is apnea related too. Sprain, bangs, bumps, bruises, modest Dermatology. BTW, my wife is really good at, and nails the Dx on first view almost every time. She could have normal office hours have a packed schedule, not take any insurance at all and we could be done with her school and business debt, practically never an over night call or emergency. I would not have to be in the driveway doing brakes and other fairly involved repairs in bad cold weather or hot sticky weather because we really can’t afford the mechanic or a new car, Jeep (terrible snow and ice here, salt eats our cars alive and between her business and mine and my son’s hockey we have to have a safe reliable 4X4) and so I try the best I can with my love and knowledge of shadetree mechanics to keep us in viable and safe transportation…
    If only she was ONLY a Dermatologist and NOT also a Gerintologist, A Chemical Dependency Specialist, a Psychiatrist, a Marrige and Family Counselor, a Cardiologist, an Endocrenologist, a Urologist, a Pediatrian, a Pediatrist, a wound care specialist, an Orthopedist, an OB/GYN, no less EVERYBODIES Mommy because half of the world can’t miss a day or two of Gym or work without needing a “Doctor’s Note”…. Oh and a Billing and Coding Specialist who is sort of an over glorifed and totally Uncompensated Paralegal, constantly fighting to get every lousy Rx she writes today (yes even tons of the generics, she has very good generic useage so it’s not that either) for meds patients have been on for years… And a few years ago as our last MA needed to leave anyway and money was going down fast, we realized that the totally useles and specfic questions being asked in the end really required the DOCTOR to be the one to speak with these Prior Auth Bozos anyway. 9 out of 10 times the average intelligent person who once knew the game and the system couldn’t answer what was being thrown at them unless the were the care provider and even then, many of our Micro Practice IMP and AC Users, all agreed that they were creating stuff that had no exit and no good answer. It was the most blantant errecting of barriers to care we had every seen to that time.
    Anyway, I wonder how many Radiologists, Orthos, Neuros, Derms, anastasist and the like would gladly switch places with a Primary Family Doctor who has so many BS hoops to jump now with Meaningless Use being forced upon us combined with ICD-10 soon too… And honestly, how good would the average Derm or Radiologist (no picking either) be at “Catching a Baby” in residency, balancing out 5 or 10 different meds for four or five chronic diseases and problems brought about by life, stress, diet, work and living conditions, genetics… and then having to get it all straightened out again after some over rambuncous or under slept and not caffinated resident at the ER just went and undid the better half of two years of work and trust building with a patient to get all of those meds and conditions…. How much would they want to pull their hair out or how fast would they get burned out and start to drink late at night? And to be in unending debt and not take nice vacations, any vacations, drive a bomb not any better really than you used to own back in college or med school?
    No I really doubt that most Better than Though acting Specialists who try to send half of their work like their Prior Auths for their procedures and their chosen meds back to the Primary, some who don’t even take their own call anymore for the post surgery patients.. We have docs (and we are not alone this happens around the country) who have the nurses sign out the post surgery patients without thier notes even being ready or sent to us, have those patients discharged and given instructions to “Call their Primary” if they have any post Surgery questions, concerns or complications…. LIke my wife was using her special powers to see patients here while at the very same time assisting or observing the procedure, surgery and knows exaclty what happened and what was or was not found or repaired or what have you? This is how Primaries are Viewed and Treated, them and their staff, each and every day. We are their Trash Cans, Spitoons, and Scut Workers all too often.
    And if you don’t believe me, simply google all the garbage finally heating up around CMS and its all too close relationship with the AMA and their RUC commitee who have had E&M codes for office visits held steady or even devalued while specialists procedures are give value ratings way beyond anything reasonable way too many times…. 4 chairs held by primary care, and 23 or so held by specialists… is it any wonder Primary Care docs are so looked down upon and mistreated and underpaid and undervalued? I think not…. I think that just about perfectly shapes how even the other doctors and their chairmen and dept heads, mentors and teachers all view Primary Care…. like that almost bum like, unshaven blue collar, divorced uncle who you have to invite to an occational family gathering or largest functions…. Not lovingly that’s for sure…

    • Sakina Bajowala

      There is no doubt that PCPs have an enormous amount of administratives hurdles thrown at them. But meaningful use and ICD10 will affect all of us. I do all my own prior auths, as I should. There is a code in medicine: you do the scutwork for the therapies you prescribe, and you clean up your own mess. If your local specialists are abusing your wife (who is obviously dedicated to her patients), time to find a new network of specialists. This is where PCPs do have SN element of power – to a large extent, specialists must remain in their good graces to earn referrals. If a PCP called me complaining, I’d be an idiot not to pay attention.

      There was nothing humorous or tongue in cheek about this article. The author was dead serious. In fact, the tongue was quite clearly out of the mouth, blowing raspberries at the rest of us.

      At the end of the day, we all choose what works for us, specialty-wise. It is shameful that cognitive work is undervalued in our healthcare system. This should change. But that means the system is broken and needs fixing, not that all PCPs are God’s gift, and that all non PCPs are lazy jerks.

  • http://www.facebook.com/scottenass Scott Nass

    I am a Family Physician, not a generalist. That term is offensive. I choose to provide comprehensive, full-spectrum care for my patients – there is nothing “general” about that.