I have been in practice for 15 years, and most of my colleagues hate primary care. (Remember, I come from a cohort of internists, the ones that should be the defenders primary care!) In my rovings as the ExtraMD I still do some primary care, to keep me honest, and to remind me how hard primary care is. Here are 9 reasons why most of my doc pals don’t do primary care:
1. The pay stinks. Consider this, my fellow refugees from primary care,: the average primary care physician in the U.S. earned $183,332 in 2007. A nurse anesthetist makes about $160,000 per year. (Think about the differences in school and training, as well as life style.)
2. Coding is really fun. Just to perk you all up, starting October 11, 2010, there will be a brand spanking new ICD, the ICD-10! According to Medical Economics October 3, 2008 (page 17) ICD-10 will have about “10 times the number of codes as ICD-9″.
3. You are a hamster on a wheel. The average physician spends just over 50% of their office time with patients, with 25% of their day taken up by answering calls and writing refills and reports.
4. You are a shrink. Here’s what it’s like in the trenches: “Even conscientious physicians …face many obstacles in delivering mental health services to their elderly patients who are depressed and suicidal.” (J Am Geriatr Soc. 2007;55(12):1903-191. And it’s not just the elderly that are depressed, “reliable estimates suggest that symptoms consistent with depression are present in nearly 70% of patients who visit primary care providers.” (The Journal of the American Board of Family Practice18:79-86 (2005). Hmmm, how much time can a physician spend with a depressed patient and get paid for it? Yes, you can code for counseling, but gosh, a colonoscopy sure pays better!
5. Insurance companies make life miserable. A typical primary are office has several staff members devoted to teasing out the tangled web we call health insurance. How much overhead does this add?
6. It’s not good mind candy any more. One of my favorite things about medicine is the diagnostic puzzle. Those days are limited to viewing episodes of “House.” Rather, we are mangers of chronic diseases, trying to find joy in motivating patients to change. (We are not well trained to motivate behavior change, but should be!)
7. You got an MD, rather than an MBA. Primary care medicine requires understanding the intricacies of practice financial management, insurance companies, marketing, HR, and ambassadorial level negotiating skills. Last time I checked, this wasn’t included in the standard medical school curriculum.
8. The environment is hostile. Patients have been fed a steady diet that physicians are uncaring sharks. We spend a fair amount of time dealing with patient anger, and more time yet dealing with re-education. Patients do have real grounds for complaints about waiting times, rushed physicians and lack of continuity of care, but this just adds to why physicians hate primary care.
9. A lot of stuff is unfixable. We’ve come a long way, baby, but we can’t fix everything. As a physician I want to make it all better, and patients certainly want it too! But I can’t, and boy is it frustrating.
So, keeping with my philosophy that if I complain about something, I should have ways to make it better, my next post will be on practice level AND global ways to make primary care better. (I will have to do a lot of thinking on this, so send me some comments to get me started!!!)