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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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39 replies »

  1. 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.

  2. 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 more feasible approach could be increasing loan repayment plans for students entering primary care, while maintaining (instead of increasing or decreasing) the salaries of specialists.
    Critics are likely to question the source of funding for the proposed growth in loan repayment programs. Research regarding the role of PCPs in quality and cost-effectiveness of care gives weight to the claim that increased use of PCPs results in lower health care costs and better health outcomes. To cite just one example among many, authors Franks and Fiscella (1998) reported that patients whose personal physicians were PCPs (as opposed to specialists) had higher perceived health status, decreased medical expenditures, and lower mortality rates. Therefore, it seems plausible that the money saved on government-subsidized care could be put towards programs aimed at increasing the number of physicians entering the field of primary care.
    The main factors to consider in this process will be how to increase the base of PCPs in our system in a timely and cost-controlled manner, and how to do so without exacerbating the growing chasm between generalists and specialists.

  3. 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.

  4. 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 extra income flow to hopefully make a difference in health care outcomes, the buck wins. For the doctor, it was investing into more health care interventions that makes the doctor more effective, even if it does not fatten the wallet. Being seen as a leader and advocate for the public really has been sold out, eh!?!?”
    I am really interested, please explain.

  5. 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 buck versus spending the extra income flow to hopefully make a difference in health care outcomes, the buck wins. For the doctor, it was investing into more health care interventions that makes the doctor more effective, even if it does not fatten the wallet. Being seen as a leader and advocate for the public really has been sold out, eh!?!?
    I am not a business man, and maybe this analogy is too simplistic, but, if you are spending your money on widgets and the ones that are more than 60 time units aged but could be salvaged if the profits were invested to fix or improve them, does the company see this potential? No, in this day and age, it is about numbers, simple and clear. Dump the old ones and make twice as many new ones, even if the plant is malfunctioning in the production of the new ones as the management missed out on the process.
    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.
    Instead here, it will be blood, not oil!

  6. 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 for time spent, you will have some physicians procrastinating, and then produce/worsen access problems.
    When we are talking about salaried docs at MSGs, this does not means “salary for a warm body” only, but salary for a reasonable workload/productivity and reasonable outcomes. If you see e.g. 30 patients at Mayo but you are expected to see 60 per week, your contract doesn’t get renewed if you can’t explain why you need so much time.

  7. 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 one of the defining attributes of primary care: Who does the patient see first?
    I will do emergency surgery when there is no other alternative, but not in any elective situation or even emergency if I can get the surgeon in time.
    Naturally there is incentive to do procedures for larger remunerations. But if there is no longer a belief in medical ethics as a pillar of our medical care, then all of healthcare is doomed to the dustpan of political patronage.
    Dwelling on exceptions rather than the rule is a distraction from and demonization of something that has been great and can and should remain great.
    Medical practices were driven into the financial dark side when payments were squeezed and it became necessary to code for a myriad of services seperately rather than just receive one payment for a global service. Hospitals have been forced into the same gamesmanship.
    Since the 1980s it has been divide and conquer. The once powerful AMA is now a paper tiger. Each specialty society has become more and more aggressive but ineffective in protecting its members. Each in turn has had its ox gored.
    As long as you fixate on cost rather than demand you will fail to reform anything.

  8. 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, or for everything equally.
    If physicians were paid purely for time spent in direct patient care, no matter what they actually do, the only incentive would be to spend more time with patients, and if financial interests were removed, wouldn’t most docs do what they believe is right for the patient?
    This is not the same as salaried. You can be in private practice and you can negotiate your rates with payers, and large differences in negotiated rates will obviously exist. Initially specialists will command more and eventually the sheer scarcity of PCPs will bring increases for PCPs as payers struggle to ensure their customers have access to primary care, which was shown to reduce costs overall.
    Such system can be gamed and it too has weaknesses, but it seems easier to control, less expensive, less stressful for docs and definitely more friendly to patients.
    I’m sure I’m overlooking something because we all know there are no simple solutions. So what am I missing?

  9. 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 out of pocket? I don’t think that’s a good idea, but it is a logical choice. Or do you have a different idea?

  10. 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 for “slave wages.”?

  11. 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.

  12. 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 imaging. Try not getting C spine xrays for a patient with neck pain after a car wreck. Try not getting a CT scan on an old person from a nursing home who fell, bonked their head, and is on coumadin but acting just fine.
    Not too many people are clamoring for a spinal tap for their headache. Try selling one after a negative CT scan. If the patient will let you do it (standard of care for sudden severe headache to exclude subarachnoid hemorrhage) then you do it. If the patient declines, then you do not do it, even though the indications are the same. You cannot force them, at least not yet. I would never want that power. So if the patient clamors for a CT scan, which is relatively not indicated in the docs opinion, but then refuses the spinal tap, which is technically the standard of care, is it because of bad medicine or insurmountable misconceptions on the patient’s part regarding the utility of CT?
    My ethics are just fine.

  13. “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 not follow advice and/or have a 2nd opinion, but that does not mean that a patient gets a procedure just because he/she thinks that it is good idea. That’s in part what all your training is about, remember?
    “But the specialist cannot skip the test; it also is “standard of care”.” Uhhmmm, that depends on the situation at hand. Also note that I specifically wrote that this issue needs to be adressed.

  14. 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.

  15. Dr. E, I don’t usually adhere to anything, that is why I posed it as a question. Mayo does have a stellar reputation and Kaiser’s patient satisfaction seems high. Neither one is cheaper than the rest of our health care, so is their formula working well enough to be copied and expanded? Can it be expanded? Should it be expanded?

  16. MDasHell, I loved the example you used to illustrate your point! Appropo here!
    Ms G-A, talk with some MDs who do NOT work for Kaiser and Mayo any longer, and while you could say that is a biased selection, there are two sides to an argument at least. Why do you adhere that Management’s side of Kaiser’s is the correct one?

  17. This keeps coming up and I must say I am not comfortable with salaried docs, both because of what MD as HELL is saying and because I am not inclined to trust the new breed of physician employer which is bound to emerge.
    On the other hand, how is it that docs at Kaiser and Mayo and the likes are managing to do a very good job? What is the difference there, if there is one?

  18. rbar,
    If your assertion that more patients are misinformed than properly informed is true (which it isn’t), then either you are saying that nothing should be done for anyone ever because doctors cannot tell the truth and nobody ever should pay for healthcare, or we should all work for a low salary from the government and do little or nothing at all (as is true of most government employees) because it is safer and better for the patient most of the time to do nothing.
    If I do ten rectal exams for #150 charge each, five would never pay, 2 would be Medicare and I would get $8, one would be Medicaid and I would get $6 each, and one would be private pay and I would take the contract rate of $50 dollars. That would be $6.40 per rectum. Where is the incentive?
    If a specialist is sent a patient for an opinion, he will do a diagnostic procedure as part of his eval. If the primary care doc had any standing in court he would not have had to defensively send the patient to the specialist in the first pace. But the specialist cannot skip the test; it also is “standard of care”.
    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?
    Each insurance company puts docs through their own credentialling process to allow the doc to care for the beneficiaries of the company. Board certification also is intended to assure that docs are capable and current. If some are unethical that is a problem, but hardly the norm.
    In this debate you must in the end choose someone to believe and trust. Do you want to trust a Maggie or a Lambert with your health?
    You are right. It is not hard at all.

  19. “Why can’t we have common sense in Health care???” As said above by Private Citizen. Well, depending on who’s aspect and definition of ‘common sense’, some say it is in place and others say otherwise.
    You gotta love the commenters here who champion we physicians should take a vow of poverty and then thank these cold heartless bastards for the opportunity to be screwed. And they will just keep on the senseless and clueless banter their perspective is the only righteous and reasonable one, yet, my money is that most if not all the doctor-bashers have never spent a moment, much less a year providing any form of health care as a provider. But, hey, the business model is the only one that fits, eh, you bastards!?
    We realistic and grounded providers know who and what you are after, and any real objective and unbiased readers, read between the lines of these inane and heartless spews of expecting doctors to lose money and have less impact on health care choices, because, it means more money for those who really contribute nothing to the patient-physician relationship in the end.
    The biggest mistake DOCTORS made back in the 1970’s-’80’s was letting health care become a real money making machine and not stepping in front of the greedy non clinicians who just saw another industry to screw.
    Well, last I checked, we still can step up! Or, are most of my colleagues hopeless cripples!?

  20. Thank you for this post. I really don’t understand why a primary care doctor who coordinates so much should be penalized, doctors don’t need to become business people to earn better, they need to do the right thing to earn better. There some doctors who push patients to be seen every month evn for routine refills. Their secretary bugs the patients for follow ups that are not needed. I really would like a place where the doctor does what is right and has no incentive to do more. Every speciality is unique, why shoould there be so much income gap for 2-3 extra years??? Why can’t we have common sense in Health care???

  21. Specialists are a rarer commodity than primary care physicians, which naturally makes them more valuable. That’s not meant to demean the work of PCPs, but the fact that more exist, and the position takes fewer years of training naturally lends to a smaller salary, regardless of the fact that most PCPs are amazing doctors who deserve to be compensated well.

  22. yk, I agree with you that FP still will make a good living, even after a 20% cut. And yet, there is no doubt that, while all physicians are at least reasonably well compensated, some physicians in private practice make a fortune. And unfortunately, this works often to the direct disadvantage of the patients. If you have incentives to do complicated multilevel back surgery because medicare overpays for it, you get surging rates for this procedure, with overall worsening outcomes (I lost the link but can look for it if someone is interested). MD as hell, is this complicated to understand? If you pay per procedure and have misinformed patients (as is rather the rule than the exception in the US), you will get more improper procedures, worse outcomes and waste of ressources. I know that things might look different in your ER setting. But if you got paid, say, 150 Dollar extra for any rectal exam, guess what would happen …

  23. The income numbers in this thread are way low. But it is not for the government to set salary. I work by the unit. Each encounter is a unit. If you place me on a fixed salary, then you fix the number of units i will produce. You may even decrease them. If I work harder then I earn more.
    Dr. Bill Jones has said it quite clearly. Cut the crap.

  24. Ciphertext:
    Really enjoyed your wishful thinking regarding the marketplace if functioning well would correct any inequities. Smith who broght us free market principles states for a market to work, must have many attributes but the one that will never be accomplished in medicine is the asymmetry of product knowledge. The purchaser (consumer) today and perhaps decades to come has no tools to judge value (quality and cost). Many consumers judge by family referrals or bedside manner–trusted outcomes data transparent and validated to Americans may never come for the most complex profession in the world. So, throw away your Utopian answer for something more realistic and achievable.
    Secondly, most health plans are shadowing (following the lead) of Medicare in Policy and payment methodologies since it is considered the “Gold Standard.” Some courts even now have stated if you don’t accept rates at Medicare levels you are price fixing. It makes my head spin. But it is what it is and the profession has done a terrible job of educating the population re: our profession. The “market” rewards herbalists, Chiropractors (yes, many are good back manipulators–), and fortune tellers many times better than a 11+ year higher educated physician, we know then that the market is clueless re: value. This asymmetry of knowledge will long persist. We have allowed it to happen. Look in the mirror…………

  25. The Neanderthals who run our health system ought to spend one year as a first year med student, then 3 mos as an intern with every other to 1:4 before they have any responsibility. In addition we (or they) should find a way to keep actively practicing physicians practicing rather than retiring at age 50-65 when they are physically and mentally still fit. The investment in pcp’s is too great (by the feds who directly or indirectly finance medical education (grants, loans, med school subsidies, etc, etc.) to increase the ROI. It is far cheaper to keep those in the system working than to train additonal PCPs.
    Malpractice is a big issue which keeps older MDs from extending work to part time as they age.
    Reduce or eliminate licensing fees for MDs over 60 or a modified rate for those working part-time. Academies should redce or eliminate dues, fees, CME fees for docs over age 60.

  26. It Aint Just the Bucks
    Yes, compensation is in imbalance and yes I agree that most physicians deserve what they earn considering debt and years of education and responsibilities. But bringing more students into Primary care requires more than additional money that is required to pay off the cost of today’s education. What else must we do?
    1. Emphasize during medical school the critical nature of primary care and the expanded role we wish of them in a better healthcare delivery system
    2. Hold them accountable to be “Holistic” (hate the word)–broader scope–use their talents to the extent of their education, competence, and comfort.
    3. Work on our profession within to neutralize this “cast” system where Primary care docs are considered less than equals to specialists–yes, it is the elephant on the table.
    4. It is not CMS who is generating imbalanced RVUs–it all comes from the AMA dominated by specialty societies. Must find some way to establish parity. The dirty little secret.
    5. Rethink the gatekeeper model and medical home for efficient care–even in a FFS world. Without it, it is a free-for-all for patients, e.g. Medicare traditional.
    6. Educate the populace re: the role of PCPs and the extent of their knowledge/education–influence their expectations of PCPs–not just poorly educated docs there to triage to specialists.
    I became an internist/geriatrician in the 70’s because I liked to solve problems and have a long longitudinal relationship with patients. I thought I would do “OK” financially-but it was not a core value for me. I did this out of interest not intellect. I could have been any specialist if I desired. There are too many barriers for students today to seriously look at being a PCP unless we work on the above and additional barriers + issues of adequate compensation. RobMD

  27. This is an example of where market economics has been tampered with to such a point that prices do not accurately reflect supply and demand. What I did not see in the article was the total number of primary care physicians, or “Family Doctors” in practice (supply). We see, according to the trend, a reduction in the number of M.D.s entering the practice, but no mention of the total number of the supply of M.D.s in family medicine. I may have missed it.
    Insurance companies (via contract vehicles) and the ubiquitous Federal Government via HHS and CMS (via regulations and requirements) have “monkeyed” with the medical marketplace to such a degree that normal market dynamics don’t have the same effect as they would in other market sectors. Ideally, if there were a shortage of primary care physicians then the prices would reflect that shortage. If the article is to be believed, then the influx of additional practitioners of a particular specialty should increase the supply and decrease the average price. It gets too difficult to discuss in a single post how experience differentiates one MD from another and the effect on the market price (presumed effect).
    All of this to say that a well functioning medical services marketplace would correct the “pay” disparities gradually and in a natural fashion. Which allows the market to absorb and process the changes much better than the quick and artificial adjustments made by a government or other regulatory (public or private) instrument. Remove the market regulations, and allow the products/services to be distributed through a more natural supply/demand model.

  28. I agree with ‘yk’. I am a family physician and I don’t see anything wrong with what other specialties make. They take more risk and were in residency/fellowship much longer than myself. They deserve every penny. It seems to me Dr. Pullen you are what they call a ‘hater’.
    Be happy with your choice, as i am, and stop being jealous of your neighbor. They worked harder and longer.

  29. Obviously when the other specialty is highly paid the medical students are bound to choose that. The government and all responsible organizations should give a serious thought on it very quickly.

  30. Ed, you unfairly characterize Dermatology, non-Interventional Radiology and Radiation Oncology (incorrectly referred to Radiation Therapy). In my opinion, all medical fields have their own unique intellectual challenges. As a Radiation Oncologist in a major academic institution, I guarantee you that I work longer hours most physicians. I average at least 12 hours per day, many times 6 days per week. We are in an era of evidence based medicine and you should not be making arguments based on factless conjecture, such as making preposterous arguments that ID, adult neurology or pediatric oncology are more intellectually challenging than lets say adult oncology or pediatric neurology, or more condescendingly Dermatology or Radiation Therapy.
    Further, you fail to mention about residency lengths. How do you ignore the fact that residencies across the board are vastly different. It ranges from the incredible 7 years that Neurosurgeons need to train to 5 years for Radiation Oncology, Diagnostic Radiology and General Surgery to the shortest for primary care (family medicine, internal medicine, pediatrics) which is just 3 years. How do you tie in reimbursement to this disparity in training levels? In your example above, adult neurology is 4 years of residency while radiation oncology is 5. Funny how a “challenging” (ie, adult neurology) residency takes a year fewer to complete(than Radiation Oncology).
    Lastly many physicians, esp in primary care, have been very vocal recently about the threat of medicare reimbursement cuts, how they should be better compensated, how there lives are miserable from paper work, yada yada yada. Radiation Oncologists were facing a 20% in cuts before this was cut down to 5% over the next 5 years. In this current economic climate, crying over 5-21% cuts in salaries of $200k-$400k will not win sympathies from anyone. A family physician making $200k after 21% cut (worst case scenerio which was halted) still will be about $160k. I know people who would sacrifice their left hands for $160k per year.
    Let’s look at the big picture. Physicians are well compensated and this will not change in the forseable future. Even though you wanted to make suggestions on how we could bring more physicians into the primary care, you unfairly characterize specialists as being overly compensated when in fact they experience longer residencies and perform procedures that invariably raise liability risks and costs.

  31. Ok so the only obvious solution is for the government to make monetary incentives for students to enter into primary care. Because lets be honest, there are a lot of other more lucrative options out there for med-students.

  32. Amen!
    This really encapsulates the problem:
    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…It’s a crazy system.
    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.

    Commenter Jay’s response to this is like being shown a globe of the Earth and responding: that can’t be right, the ground underneath my feet is flat. Perspective is everything.

  33. Obviously the way to accomodate the change is to reduce RVUs for procedural care, and bring the pay for equal time and effort for non-procedural care into balance. I thought that’s what was discussed. To move that slowly will make it too late for the situation we are in. This change needs to be done fairly quickly, maybe in 2-3 years timeframe.

  34. Dr. Pullen is pretty much on the mark (radiation oncology and radiology are challenging specialties – actually, which specialty isn’t?, but this is a minor issue). Jay, one could argue about fair pay without end … but with 200K, you are in the upper 3% of HOUSEHOLD income in the US, and physicians do enjoy safe employment.
    The problem is not so much pay differences by specialty, but pay differences for cognitive vs. procedure based medicine. Why is the rheumatologist eager to do joint aspirations, the Neurologist to do EMGs, and the family doc to do minor surgery, i/o doing “normal” patient encounters? To ask that questions means to answer it.
    Re. gradual vs. abrupt change: adjust gradually in 3-5% decrements/increments, and you will be there in 5-10 years, without great disruption.

  35. I am just getting started with practice.
    How? Cut out the crap that PCPs are required to do for free. Cut the crap from insurance carriers who hire gunslinging PBMs to use the PCP as the floor waxer so that its CEO can golf at Pebble Beach. Cut the crap of delaying payments. Cut the crap of abusing my patients in the hospitals, where administrators instill the ring the cash register mentality in its stable of “specialists”. Cut the crap of cheap hospital care with paraprofessionals charading with long white coats as if they were doctors, with a two year education, who call in the specialists. Cut the crap of treating pcps as garbage pickers.
    Cut the crap of selling expensive computerized records and ordering gizmos that cause nothing but aggravation and medication errors.

  36. I am glad you speak for yourself. PCP’s are grossly underpaid. 197,000 is not enough to be a family medicine doctor.

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