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Wednesday, May 23, 2012

Why don't doctors want to do primary care anymore?

I really loved doing primary care, taking care of patients in my community in a medical office and in the hospital when they needed that. I practiced primary care internal medicine for over 20 years, first as part of a health care cooperative and then in private practice, and it was very gratifying, never boring and fed my soul. This last year, across the country, almost no internal medicine residents chose to go into primary care. Graduates of family medicine residents were more likely to go into primary care, but many of them, too, chose specialties or hospital medicine. Though family medicine residency positions mostly did fill, over half of them were taken by foreign medical graduates who traditionally are less competitive for residency slots. Why?

An article in the New England Journal of Medicine discussed some of the challenges of being a primary care doctor and some of the changes in reimbursement that are expected to ease the shortage of those absolutely essential regular doctors who take care of real people in health and disease through sizable portions of their life spans. This is the link: http://www.nejm.org/doi/full/10.1056/NEJMp1205537?query=TOC.

So why, if it is such a great job, don't medical school graduates want to do it? Medical school professors teach medical students and residents, and they are our role models. They don't do primary care. They are professors of medicine. We do some work in outpatient clinics as students, but most of our teachers there, the real primary care docs, are pretty busy and when they have medical students, they are even busier because then everything takes longer. So medical students learn that the really important people don't do primary care and that primary care docs are always busy and harried. And it is often true. Primary care docs are busy and harried, and getting moreso because less people are doing it and so they have to see more and sicker patients, and now they need to use increasingly complex computer systems to document visits and since insurance company evaluations of quality are based on proving that in addition to curing a person's rash or counseling them on their failing marriage, we also need to harangue them about their cholesterol and vaccinate them for pneumonia and tell them how to lose weight and quit smoking, and and and... I loved it because I got good at it, but most new graduates are totally out of their element and, compared to specialty or hospital medicine, they get paid pittances.

Various payment incentives are being put forth by private and government insurance agencies which offer a partial solution to the salary problem, but fail entirely to deal with the inherent difficulty in doing the job as it is now defined. These include not reducing payments to primary care docs, while reducing them to specialists (Medicare), increasing pay by 10% (Wellpoint) and paying primary care docs an extra $3 per patient per month as an incentive to see patients (several private insurance companies.) My personal experience going from office based primary care to hospitalist medicine points out how ridiculously too-little, too-late these schemes are. Practicing full time as a hospitalists means working 12 hours a day, seven days a week, every other week. With that schedule I can make what was an entire year's salary in my office job in 5 months. I can also work a little on my weeks off and make more than that. I am really truly not working on my weeks off, plus I can take real vacations without feeling guilty about leaving my patients in the lurch. I don't have to take telephone calls at night when I am not working. The work is faster moving and more intense, with more people threatening to die if I don't do everything right, but that is what I was trained to do.

For physicians to go into primary care it will need to be delicious. It will need to satisfy the very human needs for competence, by having work loads be within reason, for meaning, by allowing us to use our own creativity to solve patients' problems, and for connection by giving us time to talk to patients, colleagues and engage with our families and friends. It wouldn't hurt if it also paid even close to what hospital medicine does.

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