To Med Students Considering Primary Care


Dear Student:

Thank you for your consideration of my profession for your career. I am a primary care physician and have practiced for the past 16 years in a privately-owned practice. (At some point I intend to stop practicing and start doing the real thing. It amazes me at how many patients let me practice on them.)

Anyhow, I thought I’d give you some advice as you go through what is perhaps your biggest decision regarding your career. Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices. It is the final choice that is, well, final. What are you going to do with your life? ”Being a doctor” covers so much range, that it really has little meaning. Dr. Oz is a doctor, and he has a very different life from mine (for one, he’s not the target of Oprah’s contempt like I am – but that’s a whole other story).

Here are the things to consider when thinking about primary care:

1. Do you like talking to people who are not like you?

Primary care doctors spend time with humans – normal humans. This is both good and bad, as you see all sides of people, the good, bad , crazy, annoying, funny, and vulnerable sides. If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don’t do it. The single most important thing I have with my patients that most non-pcp’s don’t have is relationship. I see people over their lifetime, and that gives me a unique perspective.

2. Do you prefer variety over predictability?

Every room I walk into is different – often vastly different – from the last. I could be walking in on a crisis or a stable recheck. The person could be elated or crying. They could be 90 years, or 2 days-old. They could have something wrong with any system, and it could range from mild to life-threatening. I’d go nuts doing the same thing every day, be it looking just at skin or just dealing with the kidney. But some folks do better with routine and a lack of surprise, they don’t want their days to be unpredictable.

3. Do you need to be in control?

Primary care is not about control. Those primary care doctors who try to maintain control of their patients are both unsuccessful and unhappy. Relationships are not always predictable, and much of what PCP’s do depends heavily on the patient’s “cooperation.” I put the word in quotes, because the word implies that the doctor’s agenda is more important, an implication that I reject strongly. PCP’s are part of “team patient.” Our job is to help them, not direct them. We give them our expertise and they make the final choice. Surgeons, on the other hand, don’t consult the patient when operating; they don’t depend on patient compliance as they cut a person open.

4. Are you a people-pleaser?

The flip-side to #3 is that a PCP must always practice good medicine – even if it makes people mad. You have to learn to say “no” to people who seek drugs, who want an antibiotic, to drug reps who want you to prescribe their products, and to insurance companies that want you to work for free. We are not co-dependents. We don’t base what we do on the reaction we get from patients. Often we are the only ones with the opportunity to tell them the hard truth about lifestyle choices or about their future health. I deal daily with the consequences of people-pleasing PCP’s, who addict their patients to drugs, who create antibiotic resistance, or who give in to drug reps and give expensive prescriptions where cheaper ones are better. Please don’t choose primary care if you are a people-pleaser.

5. How important is social status?

PCP’s have an interesting paradox in their social status. In the eyes of the public, we are the ones who earn less money and so must have gotten worse grades than the cardiologists and dermatologists. In the eyes of those same specialists, however, good primary care doctors have a very large amount of respect. We are actually the ones who run the medical show, using specialists when we think it is needed. We need to know 90% of all specialties, and also know when we are in the 10% we don’t know for each of them. I often get “I could never do your job” from my colleagues. So if outward social status matters (like what kind of car you drive or how big a house you own), then don’t choose primary care. I am not saying that PCP’s don’t have a good income (98% of my patients would like my income), just that my outward status is not nearly that of the surgeon who operates only on left ring-fingers.

6. Do you like puzzles?

The term “gatekeeper” got applied to primary care via our friends in the HMO’s, and that term has haunted our profession since. Good primary care is not simply triaging people and sending them to those who can offer real care. Some PCP’s do that, but they are both lazy and unambitious. I do whatever I can to keep people from the specialists and out of the hospital. I need to know when to send them, but I also need to know what to do before I send them. This endears me to my consultants, as I am sending only patients who need their expertise. I know orthopedists will give an anti-inflammatory and probably order physical therapy for shoulder problems, so I do this before I refer the patient. 80% of my patients avoid orthopedists this way, and the ortho docs know my consults are not usually fluff.

But the real challenge of primary care is the fact that I am usually the first to see a problem. Specialists get sifted problems – I have already thought the situation through and so they get the left-overs. I don’t usually send people to specialists for a diagnosis, I send them for a specialized treatment for the problem I have diagnosed or strongly suspect. I am the quarterback, the manager, the lead singer, the director of the symphony orchestra.

7. How patient are you?

I have to confess that I was not a beacon of patience when I started practice. That being said, I have learned that one of the most powerful tools in medicine is waiting. We get to see the big picture. We see people over months, years, and decades, and watch the progression or deterioration of conditions. I find this most satisfying. People who were suicidal ten years ago are now cracking jokes and are productive citizens. One of the biggest mistakes a PCP can do is to value intervention over waiting. We are caretakers of the big-picture. Surgeons do their job in a few hours, radiologists in a few minutes, and oncologists in a few months or years. But PCP’s do their job over the lifetime of the patient. To me, that’s a plus, not a minus.

8. Are you compassionate?

Again, this is something that has developed over time for me, but the seed of it was there early in training. Primary care is about “care” – in all of the definitions of the word. We care for people because we care. It does matter to us that people are hurting. There is a degree to which primary care is a calling or ministry, not just a job. There will aways be a necessary detachment we have from our patients (for our own sanity), but a PCP who is simply “punching the clock” is both sad and dangerous. You need to be able to listen and see things from people’s perspective. You are their doctor, and they are yourpatients. The possession is emotional, it is one of caring. People judge PCP’s on how much they like them and how well they feel listened to.

There is much more to say (read the rest of my blog, as well as other primary care blogs such as Kevin MDMusings of a DinosaurJill of All Trades, and DB’s Medical Rants for a more complete picture – sorry to those I left off, there are many other good ones). Any specialist would tell you that a very good PCP is incredibly valuable. I love my job, as do many of my colleagues. I want more PCP’s, but I only want you in my field if you’d raise the average. We need good PCP’s.

Come join the fun.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

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13 replies »

  1. You state that you have a better, deeper, and longer lasting relationship with your patient than specialists do. I’m not sure you can claim this. I’m 28 and have been seeing my neurologist twice a year since I was 16. This is often more than I see my PCP. My neuro manages things that my PCP cannot. He spends, at minimum, 30 minutes per visit with me. We have a fantastic relationship. Saying you have better relationships with your patients than PCP’s do is a blanket statement. If a patient needs a specialist for a period of time longer than a year, chances are they develop a very good relationship with that MD, too.

  2. I can’t thank you enough for writing and posting this. I’m starting my search for NP programs and really struggling between acute and primary. My whole career thus far has been acute cardiology and I so LOVE the heart, but lately as I consider furthering my education, with an interest in serving those in need, I feel a draw to primary care. I’ve been resistant to it, because of the seeming lack of acuity/variety and lack of respect from my fellow medical professionals and the public. On the other hand, I love to teach and impact the lives of my patients through relationship. You have encouraged me to swallow my pride and embrace primary care as a field that offers the opportunity to make lasting, compassionate changes.

  3. Simply awesome! I totally agree with you Dr. Lamberts. I have observed these things when I was observing the practice of a primary care physician. The variety of cases that you get to see everyday and the trust and long-term relationships that you create with your patients throughout the years are the main reasons why I will go into primary care training next year (if get matched)! Kudos!

  4. This piece is dead on! I have been in Primary Care since 1989 and have gotten immense personal satisfaction from it. Unfortunately, I have suffered financially. I have spent the last 15 years at an FQHC and my income is stagnant. I now have 2 children in college and am leaving Primary Care for Urgent Care and a 40% increase in income.
    But the reasons above are all of the reasons I chose FP and stayed with it until now. I am moved to tears everyday when I have to say goodbye to my patients for the last time. Many of them have cried too. I have become a part of their lives, watched their children grow (and they, mine), their parents pass on, etc. It was a tough decision to leave. I hope to be able to go back at some point after my 4 kids have gotten through college (2 now, 2 more in a few years).
    I agree with the first commenter that you should share this with medical schools and student publications. Bravo!

  5. @Craig… that is sad. True about the paperwork, but really I think patients respect PCP very much…I don’t work in primary care, but the patients I see value and respect their PCP. I would have to say it might be the sub specialist who lack the respect for PCP. I am sorry you are so disheartened.

  6. @Nurse Practitioner,
    Thank you for your kind words, but I think we romanticize primary care a bit much. Whether it is in the ER, clinic, inpatient ward, surgery (yes, I’m still first assist for surgeries at least weekly), nursing home, home/hospice calls, or the occasional precipitous delivery and infant resuscitation, I stare at the fact that 90% of my actual work time can be done better by someone with a 2 year business college degree. The vast majority of my time spent is in generating paperwork. Patients do not respect us, and this is why. Our positions are not secure, and this is why. We have to face facts and get to retraining for another field (just as soon as the student loans are paid off…).

  7. Primary Care Doctors are of the pure Heart because they make the sacrifices that Specialist chose to Forgo. The Carear Choice of Specialist has placed Income above that of the nobility of Helping others.For a Majority of those who measure sucess is the Income that is generated.
    My primary Docter says the only reason why specialist make so much more money is from the Toys that they work with.The Real Heros are not the specialist that deals with Narrow slices of anatomy but it is the Primary Doctor that is at the Front of emerging Challanges. The Low profile and underpaid Primary Doctor has a more profound understanding and Hands on Challenges than most Specialist that provide Mediocre Medicine.

  8. I very much enjoyed this post and I think primary care is the heart and soul of medicine. I am very grateful to all our primary care physicians, they are not dead man walking and think they are irreplaceable, yet it is not for everyone. It takes someone very special with more than just intelligence to make a great primary care doctor. I can tell you have that.

  9. Why would you encourage medical students to go into primary care of any sort? I do my best to discourage them. I will be lucky to retire from this profession, if I am not replaced by physician assistants and nurse practitioners first. I think physicians in primary care are walking dead. I am 40 years old, and I am making my escape hatch.

  10. I’m not a doctor and a not a student (in the formal sense anyway). But I very much enjoyed your post and hope it encourages more able people to choose primary care as a profession.

  11. My grandson is now 16 and starting his junior high school year. He’s talking med school. I don’t know, Keenan.

  12. I really enjoyed reading this piece as well! And I totally agree with the anonymous comment above that this would be a useful piece for medical students everywhere who are still considering which path to take in their careers. I think soon-to-be doctors need to hear more commentary such as this from practioners already in the field. All interesting points to bring up. Thanks for your insight, Dr. Lamberts!

  13. This is really, really good. I hope it gets picked up by some med schools–it’s a really well written and well thought out encapsulation of what a good primary care provider does, and their absolutely critical (but under-appreciated) role in the system.
    Seriously, you should submit this to some med school newspapers or something. It’s great.