By PAUL FISCHER, MD
After an exciting and challenging day of caring for patients and teaching students, a third-year medical student on his family medicine rotation says to me, “I really like what you do, but I just cannot afford to go into family practice.” I realized that by “afford,” he was referring not only to finances but also to the expectations of his parents, friends, and medical school. After spending 35 wonderful years as a family doctor, I have been “dissed’ by a kid who wants to become a dermatologist.
So I am of two minds. Part of me is fulfilled by being needed, loved, and respected by my patients.
Over time, they have increasingly looked to me to diagnosis, advise, reassure, and guide them through a complex healthcare environment in which few others offer them help. Another part of me sees that what I do is increasingly devalued by forces outside the exam room ― those who pay for health care, those who question the “medical necessity” of each test I order or drug I prescribe, and those in medicine who are more likely to know a procedure’s CPT code than a patient’s name.
We are in this position because we have failed to define ourselves, instead allowing others to perpetuate myths about what we do. The first such myth is that what we do is easy. Nothing can be further from the truth. In about 15 minutes, we are asked to treat a long list of chronic problems (e.g., diabetes, obesity, hypertension), resolve a few new problems (eg cough, headache), address preventative health recommendations (eg, smoking, flu shot), integrate the psychosocial issues that impact the patient’s health, and figure out how to get it all paid for by an insurance company using codes that don’t really match either my patient’s problems or the care I provide. Oh, and by the way, can you look at this rash and fill this prescription for my husband? Recent research has shown that an average primary care visit is 50% more complex than a visit to a cardiologist and five times more complex than one to a psychiatrist. So no, it is not easy.
The second myth is that it requires less training than other medical specialties. This has resulted in some assuming that primary care can be left to “midlevel” clinicians. While physician assistants and nurse practitioners can work effectively in primary care settings, it is a mistake to believe that they provide equivalent care to patients with complex problems, and we have suffered by the wide acceptance of this assumption. OR techs can work effectively in an operating room, but no one suggests that they replace surgeons.
A third myth is that all we diagnose is colds. Patients present with a vast sea of undifferentiated complaints. Most of these are diagnosed in primary care. After all, most patients’ cancers are diagnosed before the patient gets to the oncologist, and someone has already figured out that the problem is renal before a visit to the nephrologist. For a cardiologist, the biggest diagnostic dilemma is really whether the patient has or does not have coronary disease. There are, in fact, few medical specialties other than primary care where the doctor doesn’t know the disease before opening the door to meet the patient. And many common complaints are complex. Consider for example, “I’m tired all the time.” Does the patient need a TSH, a cardiac echo, an SSRI, or a little time and reassurance? Sorting all this out is beyond the talents of the endocrinologist, cardiologist, or psychiatrist. It requires a good family doctor.
A final myth is that we function as “gatekeepers.” The image here is that the good stuff is behind the gate and family physicians are barriers blocking patients’ access to it. This obnoxious concept was perpetrated by managed care organizations, which did a great deal to misrepresent the value we bring to healthcare. My goal is to match the right patient with the right treatment at the right time. In this day of unnecessary heart caths and back surgeries, patients need someone they can trust to have their best interest at heart.
These myths and others have resulted in devaluing the image of primary care at a time when it is needed most. Thirty million Americans will be added to the insurance rolls by 2014 and state Medicaid budgets will go broke. It did not have to be so bad, but my student became a dermatologist instead.
Paul Fischer is a family physician at the Center for Primary Care in Augusta.
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Nice commentary, Paul. Medical students are starting to get interested in primary care again. University of Chicago had 11 of 106 students match in family medicine last year and another 7 this year. That is more than the previous 10 years combined! And the new Medical Home Model, if implemented with team care and highly efficient systems can improve primary care physicians income considerably and improve quality and patient satisfaction at the same time. (See Peter Andersons work) I think we may be entering a new era of enlightenment; there is hope!
http://www.jabfm.org/cgi/content/abstract/24/1/6
Gen Surg has the same problem as primary care and that is why everyone is going into a surgical specialty. As to the 7 years, it is not appropriate for medicare to pay a physician more just because of the educational inefficiency of their training. If you want to be a vein surgeon, go spend 6 months learning how to do it and skip the irrelevent first 6 years of sugical training.
Thank you! Great stuff. Hope it has salutary results.
I’m glad you linked to this NY Times article. The comments there are worth reading as well. It’s just so sad that primary care is considered less intellectual and less stimulating than other fields. It is simply untrue. It is at least as intellectually rich as any field of medicine. And every field of medicine has its bread and butter that sometimes gets boring. Think of the endocrinologists’ endless diabetics, the cardiologists’ endless heart failures, the dermatologists’ endless eczemas. I am almost never bored in my practice. Patients with mere “colds” are rare, and are usually a welcome break in an otherwise very demanding day.
I hypothesize that economics are big factor in students’ and residents’ choices against primary care, even beyond the problem of school loans. Viz: if primary care were the highest paid field, there would be lots more competition for primary care residencies. The competition is what makes it seem as though those who get in to those residencies are the cream of the crop. The tables would be turned. Colleagues would say, “why are you going into dermatology? Aren’t you smart enough for primary care?” When I was in residency, one of my mentors was surprised to hear that derm residencies were hard to get into. Apparently that wasn’t the case a couple of decades before. When I told him they were competitive, his reply was an incredulous, “skin?”
Shouldn’t we be calling it “medical home-maker” now?
As a pediatrician I have worked with many other primary care physicians, and I think that a attribute that distinguishs PCPs from “specialists” is their “tolerance of ambiguity”. That element may even be more influential than anticipated income. A revered surgical professor of mine once pointed out that “the urologist or opthalmologist has only about 8 or 10 steps to choose from in trying to resolve a patient’s problem.” The PCP is faced, of course, with almost limitless options in oder to determine the seriousness of and then the cause of the patient’s symptoms. The excellent PCPs can proceed without transferring too much of his/her own uncertainity and anxiety to the patient or patient’s family.
> I am getting screwed.
MD, are you getting screwed by the government or is the government getting screwed by your nephrologist friend? Of course you pay taxes — maybe the right answer is “both”. I think you should be MD as Hell at the guild’s RUC that divides the pie this way…
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Enjoyed the post! You might check out this article I just read in the NY Times yesterday. It’s a similar story, and includes some of the reasons why med students are reluctant to enter into private practice. http://www.nytimes.com/2011/04/02/health/02resident.html?_r=1&adxnnl=1&pagewanted=1&adxnnlx=1301951823-7MazJCoYO5cD1hmMyvAKNg
reference is JABFM 2011, 24:6-15
My nephrologist friend has a personal jet, a helicopter, an ex-wife, a present wife. He is very smart and works hard. I apparently am an idiot for doing what I do for what I get from the same government that pays him enough to own a jet.
I am MD as HELL for a very good reason…. I am getting screwed.
Sorry John, but that is not true. Care is not governed by profit, it is governed by money. For profits want more, goverment/non-profits never have enough. Either one is a “third party payer” who will restrict care in some way and who is unwilling to reward primary care without attaching so many strings that the reward gets lost in the administrative shuffle. Patients are increasingly irrelevant in this game except to provide data points that the pencil pushers can use to harass the providers.
Primary care is the critical path. And while several of your observations are exact, there is also a miss here. Much of the problem has been with the way healthcare has been “managed” by the insurance companies. Until we get to a not-for-profit governing body, the care will always be governed by profit. As your student was also governed by profit. If we order more labs, if we prescribe the new brandname… The list goes on. Healthcare needs a revolution.
John McElhenney
http://twitter.com/#!/health4change
Wonderful point about the term “gatekeeper.” I am going to make a point of never using that term again, except in quotes.
Interesting,
I had a similar discussion with a medical student who stated “I really love surgery but I can’t afford the 5-7 extra years of training and 60++ hour work weeks with overnight call every 4th night that is required to maintain a practice.”
Outstanding article. I’d love to know your source of the relative complexity of primary care visits, compared to cardiology and psychiatry. Thanks for this article.