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Enough Whining About Primary Care

Colinson72x721Colin Son -- My student loans are forcing me to contribute to the primary care crisis. And with that facetious remark, I initiate a rather controversial discussion.

Let me be clear that I’m a firm believer that primary care is in a crisis in America. There is no doubt that U.S. medical graduates are choosing to go into primary care at rates lower than in previous years.

Many primary care physicians believe that the main factors influencing this trend are primary care’s comparatively poor earning potential plus students' rising educational debt. I’ll be quite frank, I’m profoundly annoyed by this essentially unsubstantiated claim. And it is a persistent claim, even around the medical blogosphere.

It is so pervasive that it has become accepted as fact. What is a little depressing is that these are physicians leaping to this conclusion -- physicians trained to look for evidence of causality. No matter how obvious the association between student debt and specialty selection may seem, the causality simply is not there in the sum of the evidence.

In September, JAMA published a research letter by family physician Mark Ebell. It was a near repeat of a study he had done in 1989 (Ebell M. Choice of specialty: it's money that matters in the USA. 1989;262:1630). In both cases, Dr. Ebell found a statistically significant correlation between a specialty’s median income and its percentage of residency spots filled by U.S. medical grads.

Talk about circumstantial. To draw the conclusion that debt is influencing specialty choice from such removed observations is dangerous. And yet, that is what some have done. One of my favorite medical bloggers over at Medrants was certainly guilty of such in a post on Dr. Ebell’s publication: duh - money matters in specialty selection. MedPageToday, a major online medical news outlet, also gave the study’s conclusions some credence.

My point isn’t to disparage the JAMA study. But the way it was held aloft, despite its obvious leap in conclusion, is a sign of the more systemic problem.

A cursory literature search reveals that few other studies have found student debt to be a statistically significant factor in specialty selection. In the same issue of JAMA that carried Dr. Ebell's study, another study failed to find that connection for general internal medicine. Other evidence to consider: a huge study published in 1999 in the Journal of General Internal Medicine found that, over more than three decades, indebtedness was never a statistically significant factor for female medical students in choosing primary care versus a medical specialty; a 2006 survey published on Medscape General Medicine found that students' debt level did not significantly influence their specialty choice; and, the June 2006 edition of Minnesota Medicine included a study done by a fourth-year medical student that showed the debt burden of students at the University of Minnesota’s main campus did not significantly influence career choice.

I’m not trying to present this as a comprehensive look at the data. But it is representative. I stand by my claim that the sum of the evidence favors the conclusion that medical students are largely not picking their specialty based on their debt load.

In fact, becoming a primary care physician remains a good investment compared with most other career options, even with an average indebtedness of $140,000 for students with debt. Yes, you lose some years during training when you could have been saving and investing. Educational debt means devoting more of your income towards paying off loans and less towards something more meaningful like retirement. Those factors certainly add up, but not to the extent some physicians make it out to be. The choice of specialty has never been simply, largely influenced by debt or future earning potential. It has always been multi-etiological.

That's certainly true for me. I came to medical school thinking I wanted to enter a field where I could work with my hands. But any thought of primary care died when I entered my clinical years in medical school. In my experience, I met only one happy primary care physician. If I were to listen to all the primary care physicians I know, or who I read in journals and online, I would think it was the apocalypse for primary care.

Granted, there are problems with America's lack of focus on improving primary care. But do they warrant the state of fear being spread by the primary care community? Why would any medical student want to enter such a downtrodden, depressing community?

I rarely hear about the rewards of a primary care career these days. Yet despite the widening income gap between primary care and specialists, and the horde of patients each primary care physician is expected to see, there must be some good left in practicing as a primary care physician. I think we need to start talking about that and do less externalizing of the reasons why medical students aren't choosing primary care.

The privilege of practicing medicine should be cheered and cherished. This whining about the state of primary care and medicine in general are just too much for me to take. I’m going to sit back and marvel at the career of caring for patients that stretches out in front of me.

December 26, 2008 in Colin Son | Permalink


Wait til you start practicing as an attending physician and you will see the reality of the situation. The core of the problems is that medicine is a business and the winners in this situation are the CEOs and stockholders. I love to practice medicine but it has gotten to the point that at every turn I have to fill out a form to submit to a person who has no medical insurance for their approval. Enjoy the freedom from these paper pushers while you can. It only goes down hill from there.

Posted by: Frances Chavez, MD | Dec 28, 2008 10:23:33 AM

I have been a solo family practice physician for about 9 years. I am happy in my career choice. I agree that many family doctors are unhappy. Some of this can be from group disparity, where the younger doctors are paid a fixed and low salary and have little input into the care of their patients.

As a solo doctor, I usually work at least 50 hours a week, but I work for the patients and myself. I don't have unrealistic quotas, and I don't have to worry about production bonuses. I have input into the care of my patients and control of my salary. I make over $200,000 a year and enjoy seeing my patients in the office and in the hospital. As a smaller practice, I can spend more time caring directly for my patients instead of dealing with the administrative hassles of my colleagues in group practice. I keep my overhead low, currently around 37 percent.

The majority of the primary care doctors in the area appear to be unhappy. Most of the doctors are sponsored by a large nonprofit Medicaid corporation or the local hospitals. The monthly and quarterly meetings, which require production to keep your job, have caused a lot of primary care doctors to leave my practice area. A key to primary care is to know the good and bad points about it, prior to going into primary care. To me the patients make it worthwhile.

Posted by: solo doc | Dec 28, 2008 10:25:24 AM

A big reason for my move from full service primary care to urgent care was the loss of control over patient load, emphasis on chronic disease management and micromanagement of the practice by quality assurance wonks. The money was OK, and I think you are right that dollar signs don't drive career choices, but as more medical students are exposed to primary care docs like me who are angry about how primary care is treated in the general scheme of things, they are going to move into other areas that (for now) involve more autonomy and bigger paychecks.

Posted by: Dan MD | Dec 30, 2008 7:14:11 AM

As a medical student I have a poor impression of primary care as a practice model. I want to be able to heal people myself not refer them to another doctor to be treated. I don't want to hand out chronic prescriptions to patients while begging them to eat better and stop smoking for the 90th time while there is still little improvement. 8 years of medical education is a lot to be diet coach. I think FPs need to be scraped, and reincorporated into internal medicine/pediatrics/emergency medicine, with PA/NP taking on the role of medical home administrators, and expanding the infrastructure of emergency departments, urgent care facilities, and retail clinics.

Posted by: Ed Stevenson | Dec 30, 2008 10:16:46 AM

good for you! glad you brought this up. i work in a large academic medical center, and finally after six years have good primary care. mine assumes i'm intelligent, doesn't do constant nagging, and looks at me as well as lab values. she has also helped me get rid of a couple of painful chronic conditions, one of which was a zebra. after having her for two years, i would pay attention to anything she says. did i mention she's a DO, and our administrators here are trying to get to a zero DO clinic staff? the MDs i tried at first stereotyped me, didn't listen to what i said, and provided cliche diagnoses that weren't accurate. she's a real doc, but statistically is an exception. although she refers out appropriately, she's not just a referral robot. i feel badly for patients and also for students who like primary care because i think it is seriously broken.

Posted by: anne vinsel | Dec 30, 2008 2:06:08 PM

I just finished a family medicine rotation - I used to be a personal trainer. To be honest, I almost felt like my knowledge as a trainer was enough to handle family med patients. Everything boiled down to diet, exercise, BP, and smoking. You don't need med school for that.

Posted by: kj | Dec 30, 2008 2:09:44 PM

Primary care should not be compared with other career options as that isn't the point. The point, as you hinted at, is the disparity in income between primary care and specialization. What do you expect medical students to do when they have mostly similar education (K-12, College, Med School, Residency) yet have to choose between helping people every day and helping people every day plus an earning potential of $10 million more over a lifetime? Talking about the rewards of primary care is a minor point when waiving around that kind of financial incentive.

Posted by: James | Dec 30, 2008 2:11:54 PM

I want to practice primary care. I don't see what others are so afraid of. I don't want to do family medicine per se, my hope is to do med peds. I prefer to be able to go more in depth than colds/flu and telling everyone to exercise more, drink less (or not at all), and stop smoking. While I prefer to go more in depth, I don't want to go so far as to lose the ability to practice the entire scope of medicine.

Posted by: Justin | Dec 30, 2008 2:21:58 PM

Mr Son,

I like where your're coming from as far as expecting academic rigor from the statements made, as well as the fact that you still hold your ideals. I am a fourth year also going into primary care, and hopefully primary care leadership/revitalization. More of us need to step out and establish the right from the wrong in the current system, and get policy makers moving to improve quality of life for us and care for our patients. If you'd like to continue the discussion, please contact me at lekupe@yahoo.com

Steve K, MSIV

Posted by: | Dec 30, 2008 2:28:24 PM

I have no problem with dismissing the debt issue. Physicians are simply maximizing their private utility. Some place great importance on primary care; some place importance on earnings. Whether debt load is included in their utility, or its relative influence among other factors is unclear. It could simply be that as the relative increase of specialty income to PC income increases, private utility will drive physicians to specialties, especially given that behavioral studies have shown that humans consider relative gains more important than absolute gains, i.e., earning 50,000 when others earn 25,000, is better than earning 50,000 when others earn 100,000.

Posted by: David | Dec 30, 2008 2:30:55 PM

Don't you think you could have phrased your argument - especially the title - a little more tactfully?

Posted by: random dude | Dec 30, 2008 2:32:03 PM

While recently interviewing for a family practice residency, many of the points raised by your article came up in my interview. There was much discussion about the discontent in family practice; also, one of the third-year residents indicated they were still one-quarter million in debt even as they neared completion of residency. One of the interesting debates in the U.S. Congress right now is whether residents should be eligible to defer debt repayment while in residency training. One incentive for getting new residents to go into primary care would be to allow this deferment for primary care instead of specialities.

Posted by: Mikael Langner | Dec 30, 2008 2:47:43 PM

The issue is partially money, but the core problem is working for a bunch of uneducated insurance company fools (or worse) who will tell you how to practice medicine, and insist you see 10 or so patients per hour. As far as Medicare and worse Medicaid patients go, you'll not be paid enough to cover expenses AND they'll make you jump through lots of paper hoops to get permission to treat patients.

That doesn't work worth beans, since to do good medicine it takes about thirty minutes to an hour of history to really do any good, since nobody seems to come with the true clinical question they have, and everything is sufficiently interrelated (i.e. diet, exercise, work, lifestyle and such) you'll need time to sort it all out. Otherwise, as mentioned above, you'll be stuck pleading about diet and exercise, and compliance with meds for the 90th time without any success, which is more an exercise in magical thinking than the practice of good medicine.
So, you get a choice: Bad medicine but pay from the insurance company, good medicine and get your butt kicked from the insurance reimbursement lists, start your own cash on the barrel head practice, or do sub-specialty training.

Or you can be a saint, I know a few who are, and do primary care as best they can, but they're not doing too well; too many long hours and not enough sleep or much of anything else other than medicine, of course.

Posted by: OldMD | Dec 30, 2008 2:49:57 PM

I love the guy that said FM should be scrapped. Thats hilarious. I would be willing to bet that he has never lived in a town with population under 20,000. Just a guess.

I would argue with one point in this blog however and that is the idea that the income gap is widening. I am not certain this is true. If there is some data to prove this, by all means post it. I percieve a narrowing of the gap, both in a decrease for medicare compensation brackets for procedures and specialty consults and an increase in compensation for the basic primary care office visit.

Also, what about the studies out of New Hampshire that showed that for every specialist that is injected into a population the mortality increases? Or what about the fact that the MORE that one pays FM's, IM's, Peds, OB/GYN's, and especially Psychs the lower the overall cost of medical care becomes?

Just some thoughts.

Posted by: Joshua | Dec 30, 2008 3:02:57 PM

wahhhh!!! he wasn't tactful... wahhhh!!! hahaa great article Son!

Posted by: Joppa | Dec 30, 2008 3:12:43 PM

You're kidding, right?

Response to: "Don't you think you could have phrased your argument - especially the title - a little more tactfully?"

Posted by: Patricia Brown | Dec 30, 2008 4:28:07 PM

You physcians can leave the Primary care patients to the Nurse Practitioners, They would gladly welcome those in need of care... If we could get more backing and support from physcians nationsiwide.. it might help lessen the burden on the already overstressed PCP.

I agree with Dr Chavez... sadly enough medicine is poorly run business...with the focus on financial gain instead of healthcare... and the ones that truly suffer are the providers and patients

Posted by: NPAmy | Dec 30, 2008 4:43:53 PM

The legal system needs to be fixed before any progress can even be attempted in the healthcare system of this country.

Posted by: | Dec 30, 2008 4:57:23 PM

Really? It's enticing to throw primary care-seeking patients into the Minute Clinics and other pseudo-physician nurse breeding grounds because they really will work for much less money.

For now.

Let nurse practitioners move into primary care and they'll soon be clammering for specialty practice and pay, less hours, and all with little to no call or responsibility - and they'll be serving it all up with the education of a Master's degree.

The problem with primary care isn't medical school debt, it's the necessity to see too many patients too quickly, it's the upcoming Medicare payment slashes, and surely the ever increasing litigation rate plays a substantial role as well. What's the result? PCP's work too hard for too little money.

Solution? Slay the insurance companies, punch the Department of HHS in the face for allowing ANY Medicare cuts, and burn down every medical malpractice law firm in the country to the ground. Primary care solved.

Posted by: Wonks | Dec 30, 2008 5:15:22 PM

I think its absurd to even submit that income/debt doesn't play a part in it. I'm a 2nd year med student. We've had several students at my school join the Army (Health Science Professional Scholarship) after watching more than $5000 in interest pile up in one year on their loans. In fact, the out-of-state students will incur more than $320,000 debt WITHOUT the interest by graduation (tuition is $50,000 + room/board/books/etc. ~ $30,000 leading to an annual budget of $80,000 x 4 years). The numbers I've seen thrown around in this hilarious blog don't even come close.

Of course, other minor things like Board scores, GPA, and availability of residency slots play a role as does personal preference. Since we've dramatically increased the number of medical students in the US, maybe someone should get working on more residency slots so we have somewhere to go when we graduate. Just a thought.

If you'd like some real facts about physician income levels, check the AAMC website for the study that states physician income has been essentially flat since the early ninties. Correct me if I'm wrong, but since the graph isn't adjusted for inflation, they've actually LOST money. Where did all that money go? Well, SOMEONE had to take a pay cut so the CEO's can make 7-digit incomes, and the stockholders receive record dividends for their investments. Lets steal from those greedy physicians...

Cejka and associates tracks physician compensation and publishes an annual summary on their website, if you wish to check the earnings acceleration in specialties vs. primary care. More expensive procedures equal more income.

The loss of autonomy is our own fault for physicians participating with attorneys to second guess another physician in malpractice cases. Now, due to the battering the profession has taken, you have insurance pukes that may or may not have a high school diploma, telling a physician what he/she can and cannot do in the best interest of his/her patient.

There are also low-life physicians working for the insurance companies-see the documentary "SICKO". These physicians are using their opinions to guide policy for the company, and prevent covering expensive illnesses.

The only logical solution is a federal action to halt all the lawsuits against the drug companies, the physicians, the pharmacists, the man in the moon, and the next door neighbor's dog. That might stem the acceleration of earnings by attorneys.

Posted by: Ted OMS-II | Dec 30, 2008 5:26:55 PM

How many of these people posting have lived in a small rural community where PCPs have a daily impact on their patients lives. I am currently a PA student and look forward to the day that I can practice in primary care in the hopes of being half the provider that the PA who took care of me from 1-21 was! I understand medicine is a business, but it's a business of people. Yes primary care involves a lot of education- with the American movement of obesity and chronic conditions health education is dearly needed.

Posted by: idahopa | Dec 30, 2008 5:35:24 PM

wahhhh there's bad people in my profession! just be glad you aren't in law school.

Posted by: | Dec 30, 2008 5:37:25 PM

I live in a rural community, and my primary care doctor doubles as my gastrointestinologist, pediatrician, ear, nose, and throat, and host of other specific needs. He even has a surgery room for minor stuff like lacerations, stitches, and the like so we don't have to drive 45 minutes away to go to the emergency room. Not only has he and his partner been our overall doc, but the few times I've had to be referred, I trusted his judgement completely. He was the first doctor I have been to that listened to my random but reoccurring symptoms and made a diagnosis that took care of a problem I had been misdiagnosed for and suffering for ten years. The other specialty docs (5 of them) couldn't be bothered with listening or asking questions that might seem outside of the box. We know them, they know us, and we get seen without an hour to an hour and a half wait. It would be a sad day when primary care disappears. Then urgent care docs will probably be forced into the role of primary care.

Posted by: Deb | Dec 30, 2008 6:04:55 PM

The main reason that fewer med students are going into primary care is that much of their training is done in highly specialized tertiary care facilities, and many of their attendings are staunchly discouraging them to go into primary care, in favor of entering subspecialties (usually the particular subspecialty of the attending's liking). Whether it is because of fear of competition or what not, it seems that many subspecialists discourage primary care. Fortunately, my alma mater medical school had a dedicated and proactive family medicine department that tried to really expose students to the rewards of family medicine and primary care. Unfortunately, many schools may not have such dedicated family medicine departments, and some schools do not even have a family medicine department. Thus, the closest exposure students get to primary care is internal medicine and pediatrics. However, even in these fields, subspecialization is HIGHLY encouraged. In fact, none of my internal medicine or pediatric resident friends are going into primary care; EVERYONE I know is specializing.

Let's face it; the majority of medical care is handled out in the community, not in the tertiary specialty referral center where many of us are trained. Some people erroneously think that primary care deals with only coughs and colds. I strongly beg to differ; in fact primary care is the most intellectually challenging field compared to all the other specialties that I rotated through as a med student. It requires a level of diversity of thought and management unheard of in other subspecialties.

As a family medicine resident, I often have to don many different "hats" in a day of clinic, moving from a complicated CHF/diabetes/renal insufficiency case to a 1 year old with bronchiolitis to an athlete recovering from a medial meniscus tear to a sebaceous cyst removal. (I'm not sure that the guy who is a personal trainer that commented on the blog would be able to do that from his training as a trainer--maybe you were simply not paying close enough attention on your rotation.) Many of the subspecialists I have worked with just refer patients to other subspecialists, and before you know it the poor patient has an endocrinologist, orthopedist, gastroenterologist, dermatologist, and otolaryngologist for problems that could sufficiently be managed by a family physician.

People often cite primary care physicians being unhappy, often having to deal with paper work and other non-medical things. A bit of a news flash however to those of you that are not yet practicing...EVERY practicing physician, no matter what their specialty, has to deal with some amount of paperwork and non clinical scutwork. If you think you're going to go into surgery and ALL you have to do is show up in the OR scrubbed up and ready to go, you are sorely mistaken. Even in anesthesiology or radiology, you will have lots of dictations and papers to sign off on. The unhappiness of physicians dealing with this stuff is usually a function of the efficiency of their office personnel; in other words, are you as the doc stuck doing all of the paperwork or do you have good office staff to do it for you.

Sure, primary care could use better reimbursement, but you definitely won't be starving as a family doc or other primary care entity. Maybe a private jet won't be in your future, but who cares? So even though primary care gets a bad rap from your clerkship attendings, I would encourage students to remember why they went into medicine in the first place. For me, the answer is simple; it was to take care of patients of all makes and models. Primary care offers you the opportunity to do just that. And to the ever enlightened KJ, I DO need medical school for that.

Posted by: mehul | Dec 30, 2008 6:19:16 PM

We do need more primary doctors that are critical thinkers out there. There are too many that don't listen or think outside the box. I'm an RN and have watched and questioned and been put down for questioning doctors. I have seen the majority out there, even in their specialty - treat the symptom, not the cause. A friend has been having outbursts of "ulcerative colitis" a few times a year and getting worse. His GI doc gives him a cortisone suppository regimen, not working, no labs drawn...goes to ER and gets placed on abo Flagyl and Cipro...sort of getting better...took 6 hours of my researching to confirm he may have an issue with chronic giardiasis or may be getting exposed to it via the half-cooked razor clams he eats at times. No MD has ever brought up to him it could be that and he's continued on this inflammatory path for years, never questioning the docs. I graduated in 07. How the hell could I put it together, but his primary and GI doc didn't even consider it and talk with him, question his diet or anything. We need more MDs who care and think outside the darn box! God bless those of you who do.

Posted by: Rachel | Dec 30, 2008 6:50:35 PM

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