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How Can We Encourage Medical Students to Choose Primary Care?

A Radical Suggestion – Pay Specialists Less

Since 1997 the number of US medical students choosing to go into primary care has decreased by more than 50%. It seems that sources as diverse as the Obama Administration and the Wall Street Journal think that we should find a way to encourage medical students to choose primary care specialties in order to allow Americans to have the best and most cost effective care. This is very problematic when primary care specialists earn considerably less, often 50-70% less than physicians in specialties where most of the revenue is produced by doing procedures. For years when asked about the disparity in physician salaries I’ve said, “I think primary care physicians are fairly compensated. I just think a lot of other physicians are overpaid.”

If you look at the 2009 AMGA survey of physician income it is clear that the pay you can expect as a physician has little to do with how hard you work, how long you train, or how stressful or difficult your work is, and everything to do with whether you perform procedures that are highly compensated. It is hard to think of specialties less demanding in terms of afterhours call, emergent life-threatening care, and overall lifestyle than dermatology ($350,627), diagnostic non-interventional radiology ($438,115) and Radiation Therapy ($413,518) (median salary in parentheses). Compare these to what I’d consider some of the most difficult, intellectually challenging, and demanding specialties: Pediatric Oncology ($205,999), Infectious Disease ($222,094) and Adult Neurology ($236,500). Family Medicine is one of the very few specialties where the first number in the median salary is a 1.

For the annual earnings of one Orthopedic Joint Replacement surgeon ($580,711)  we could have one General Surgeon ($340,000) who operates on the sickest of patients often emergently at inconvenient times, plus a Family Physician ($197,655) and a first year school teacher thrown in for good measure. There are no emergent joint replacements. When a patient with a fractured hip is admitted to the hospital a primary care physician or hospitalist admits them, works for hours to days to get them well enough for surgery, then the joint surgeon operates for maybe 2 hours, spends maybe 1 hour on rounds the next several days, and sees the patient a couple of times in the office for follow up visits. If the patient has post-operative complications, the primary care physician or hospitalist, or maybe an intensive care specialist is asked to manage these problems. It’s a crazy system.

All efforts to change this have been met with intense lobbying efforts from physician specialty groups. The theme is always that we cannot make sudden changes in compensation; things must be done gradually so that it will be fair and thoughtful. Somehow the changes then just don’t happen. Remember the Harvard Compensation Study recommendations.

As primary care physicians we are well paid. It’s just that by dangling the carrot of really high income in front of students, who see that the workload, lifestyle and difficulty of specialty care is not greater and is often less than that of primary care where they can expect to earn millions of dollars less over their career, they have trouble justifying a primary care career choice.
I’ve read lots of articles and posts recently saying changing pay alone will not fix the shortage of primary care physicians. Maybe not, but it is the easiest first step. Increasing primary care compensation a little, and decreasing specialist pay a lot, to bring them close to equal, would go a long ways towards making primary care training more popular. In his post on KevinMD John Horstkamp MD agrees that making pay more equitable is the key to providing incentive to medical students to go into primary care. He suggests we need to pay family physicians 50-70% more. This would suit me nicely. I could live with higher pay. I also know that any proposals that increase the amount spent on health care are likely to be poorly received by legislative decision makers. I suspect a more palatable solution to American society in this era of concern over medical spending may be to pay less for procedures done by specialists.

The rates for payment are set by the federal government. Each year the Center for Medicare and Medicaid Services (CMS) sets what are called Relative Value Units, or RVUs. These determine the compensation for every procedure physicians are paid to perform. Currently the weight on RVUs is heavily weighted towards procedures, and less weighted towards the evaluation and management of health concerns. CMS could choose to change this to make payment for procedures much less. This would functionally bring pay to primary care physicians and specialists closer to parity. Commercial insurers have always quickly followed the CMS determined RVU schedule. Could this happen? Certainly if our legislators have the will to mandate this change by CMS, and the courage to stand up to the lobbyists of the specialty associations it could happen very quickly. The AMA will undoubtedly be opposed to “rapid” change. Primary care associations will take care not to be offensive to anyone. Legislators won’t pick a battle because it is always less than two years until the next election. This makes it unlikely to see this type of change anytime soon.

Legislators will whine that there is nothing they can do to get medical students to go into primary care, because they cannot afford to pay primary care doctors more. Don’t believe them. They just don’t have the courage to make obvious big changes that will be unpopular to some of their supporters.

Now, where can I find a place to hide from my specialist friends.

Edward Pullen, MD, is a board certified family physician practicing in Puyallup, WA. Dr. Pullen shares his viewpoints on medical news, policy and the practice of medicine from a primary care physician’s perspective at his blog,DrPullen.com.

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canada goose expedition parkaUniversity OnlineCecilia MurchAdult Day Carerbar Recent comment authors
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Guest

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University Online
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There are no emergent joint replacements. When a patient with a fractured hip is admitted to the hospital a primary care physician or hospitalist admits them.

Cecilia Murch
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Cecilia Murch

Dr. Pullen brings to light an important issue of compensation disparities. It’s not simply a matter of whether doctors deserve their current level of pay; continuing to incentivize specializations is likely to have a detrimental effect on our nation’s ability to provide effective and efficient health care. Given that the number of medical students entering the field of primary care is rapidly declining, how do we reverse the trend? As Dr. Pullen suggests, closing the gap in pay would certainly influence students’ decisions. Decreasing specialists’ salaries, however, is bound to incite resentment between the two sectors of providers. Perhaps a… Read more »

Adult Day Care
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You know, there is an analogy brewing with the BP spill and health care: ignore the boundaries and safety features of providing responsible and efficacious health care interventions, and there will be a mess.

rbar
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rbar

You misunderstood, my exhausted colleague. When I refer to productivity comparisons, I am talking about docs seeing patients out of the same pool (same specialty, same average complexity). That’s how it seems to work at Mayo (“seems” I never worked there and heard it 2ndhand). I really don’t understand: “The point about profit, which no one who is business oriented can understand is NOT applicable to the health care model, was fairly simple for the physician, until doctors stupidly allowed this model to perverse the system as cancer does: when it comes down to making a buck versus spending the… Read more »

ExhaustedMD
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ExhaustedMD

Gee Rbar, it is so black and white to you, isn’t it? The Doctor who only sees 30 pts, because he gets the pool who are sicker and need more time, does the adminstration look at the quality? NO, sir, they do not, as they are a profit motivated group in the end. The point about profit, which no one who is business oriented can understand is NOT applicable to the health care model, was fairly simple for the physician, until doctors stupidly allowed this model to perverse the system as cancer does: when it comes down to making a… Read more »

rbar
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rbar

Margalit, IMHO, there is nothing wrong with your suggestion, but it’s no huge improvement to salary either. It is very easy to inflate the time spent with the patient (chatting, chart review, more detail) without getting much value out of it. Of course it is much easier to see 50% of patients than average, and claim that one is super thorough (and some slow docs are super thorough, but the question is, do they have improved outcomes? I would doubt that in most cases). Any way, there is rough window of expectation for reasonable “productivity”. If you just reimburse physicians… Read more »

MD as HELL
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MD as HELL

The sheer scarcity of PCPs will give rise to the army of NPs and PAs. NPs in particular can be regimented because of their nursing background. There will be no more PCPs for the same money as specialists. The reason they are paid a lot is because they must be right and perform flawlessly in elective situations. They must invest more time in training and must assume greater liability. Primary care requires different skills than those of a neurosurgeon or a pathologist. It is more time intensive in terms of patient contact hours than other specialties. I believe that is… Read more »

Margalit Gur-Arie
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I am no MD and no Hell either, but I’d like a stab at this. If patients are so misinformed, and they probably are, then having them pay out of pocket is guaranteed to create lots of bad choices, and we know that folks without discretionary income do forgo both needed and unneeded care. So this option is not a good option, unless maybe you make people pay out of pocket for what is blatantly unnecessary. If strong financial incentives lead to performance of services regardless of medical benefits, then perhaps there should be no strong financial incentives for anything,… Read more »

rbar
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rbar

hellMD, it sounds like you rather meant “discretion” or “patient autonomy”. I don’t think that anyone would disagree with you on that. I think we went too far from my main point, which you apparently disagree with. That main point is: if there is strong financial incentives for a medical service/procedure, this service will be increasingly performed, independent of the tests medical benefit. There is ample empiric evidence for that. Diagnostic overkill is part of our rising health care costs. That’s why I am concerned (rather than paranoid) about that. What’s your take? Have the patient pay for their care… Read more »

maggiemahar
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Ed Pullen: You write: “Increasing primary care compensation a little, and decreasing specialist pay a lot, to bring them close to equal, would go a long ways towards making primary care training more popular.” Bravo. Money is relative. Median pay for PCPs is now $175,000. Most would feel well paid if they weren’t comparing themsleves to peers who are dermatologists earnign $400,000. Now, the question is not just where do you go to hide from your specialist friends, but where do you go to hide from those PCPs who believe that working for $175,000, they are being asked to work… Read more »

bev M.D.
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bev M.D.

With the new information emerging about cumulative radiation resulting from repeated and overused CT scans, patients may finally begin to change their minds. This is long overdue, especially in the pediatric age group. In fact, it falls under the “why didn’t somebody think about this before?” category.

MD as HELL
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MD as HELL

rbar, I wrote “The FINAL indication for any procedure is the patient is willing to undergo it.” Emphasis added for clarity. It is not only by demand, although I have people demand a CT scan for their child’s head bonk or an MRI for their headache of brief duration. Try telling a determined mother “no” on the CT scan. Try telling a mother “no” on a CT scan for her child’s abdomenal pain. It is not always easy to do. The radiologist does not order these tests, but the standard of care for many things has evolved to include expensive… Read more »

rbar
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rbar

“Your paranoia over unnecessary procedures is striking. Only the patient can decide if it is necessary. Physicians are in the advice business and offer an opportunity to the patient for recommended care. A smart patient will get more than one opinion. But insurance does not always pay for two opinions. The final indication for any procedure is the patient is willing to undergo it. Do you want that to change?” I am sorry, hellMD, but I find your medical ethics bizarre. Performing medical tests/procedures depend on medical necessity, not on patient preference. Of course, every competent patient is free to… Read more »

pcp
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pcp

I don’t see how Mayo can be a model for the healthcare of the future. They begin a patient population that is healthier, wealthier, and better educated than the country as a whole, and don’t achieve any significant cost savings or improvements in overall health. And they’re beginning to convert their Arizona operations to concierge practices for Medicare patients.