Stuart Sutton: Supplementing the primary care income

The following is a reader take by Stuart Sutton.

The U.S. Dept of Labor says that the number of people working 2nd jobs is the highest in 15 years. The motivation is, as would be expected, not just more income for enhancement of lifestyle, but a need for such to stay financially afloat.

There is often debate about whether doctors are paid a reasonable amount for their work. This is especially true with primary care, which, for many reasons has been less well reimbursed than other specialties.

But, are these claims of inadequate reimbursement legitimate? The decision by a doctor to add on hours of clinical work outside of his or her usual practice would seem a valid surrogate indicator for the adequacy of reimbursement.

In this discussion, I’m not concerned with the decisions of residents, fellows, or those who are just starting their practices when income is expected to be low and such work decisions are commonly encountered. Nor do I include the decision by a physician to simply expand their previous office hours in order to see more patients to enhance their income.

Rather, I am questioning whether the typical reimbursement for the work of a practicing primary care physician can be considered appropriate when that physician feels the need to add on work outside of regular office hours. This includes such activities as nursing home coverage, weekend hospitalist duty, or hours at an urgent care center. Such decisions equate to taking on a “second job” to make ends meet.

I could not locate any research on this issue with searches on PubMed. Anecdotally, neither I nor other moonlighting physicians to whom I spoke can recall any physician specialty participating in this activity other than primary care physicians.

Sermo, an online physician community had several prior discussions regarding moonlighting. Most of those discussions were populated by primary care physicians. A survey I conducted there confirmed that a majority of those who choose to moonlight (other than psychiatry where the activity is still psychiatric care in a non-office setting) are primary care physicians. (70% primary care with 30% divided among OB/GYN and medical & surgical sub-specialties). Although not an original query, among all the respondents, a quarter added in the answer that they “value their free time too much to moonlight.” This would seem to confirm the sense that such extra work is undesirable though sometimes necessary.

Primary care physicians may be more likely to moonlight because they, unlike other specialties, have more time available to do so. This seems unlikely, however, since adding on more office hours would be a far more efficient technique for enhancing income. Alternatively, primary care patients may only be likely to utilize the services of such physicians during limited hours of the week. This would leave other hours in which a physician could still work, but would have to seek other venues in which to earn additional income. Certainly, many moonlighting opportunities seem relatively well suited to the broad based skills of a primary care physician.

In either case, primary care physicians seem to be disproportionately in need of additional income sources. As with other workers, this need is driven by current financial stresses and not by a desire for additional lifestyle enhancement.

Ultimately, if any sympathy is elicited by tales of average Americans who have less time for their families because they need to work 2 or more jobs, then the same consideration ought to exist for moonlighting primary care physicians.

In this regard, the personal sacrifices are the same for the physician as they are for the Wal-Mart clerk.

Stuart Sutton is an Internal Medicine physician.

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