Wednesday, December 9, 2009

Why Medical Students Should Choose Primary Care - Not for the Reasons You Think

The current generation of medical students are not choosing primary care and instead are flocking to specialty care medicine in droves. Unlike decades ago when the best and brightest often went into internal medicine, the vast majority of students opt for dermatology, radiology, anesthesiology, and ophthalmology. Reasons for doing so include better predictable schedules, work-life balance, and compensation.

While I understand that proponents for more primary care doctors use other reasons to increase the primary care workforce, namely decrease the healthcare cost curve and improve health outcomes, medical students today need more compelling and practical reasons to do primary care.

I'll give three. Information technology / primary care transformation, globalization, and payment reform.

Before delving into the reasons, we must address why primary care is so unattractive to medical students. It isn't because of the relatively low pay of primary care doctors receive compared to other specialties and the high medical student debt that studies often suggest. The real reason is as primary care currently exists there is no sustainable work-life balance. Among gen X and the millenials, their identities isn't defined by their career. Unlike their baby boomer parents who lived and breathed their jobs, the newest doctors have other things to do in life.

This is why becoming a family doctor or internist isn't appealing. During their third and fourth years, students do clerkships or clinical rotations in all fields of medicine, including primary care. They experience first hand the daily struggles current primary care doctors have in administrative hassles, difficulty in care coordination in a paper chart world, decreasing reimbursement, and challenges accessing accurate real-time medical, prescription, and laboratory information. These headaches coupled with the intellectual need to be knowledgeable about a variety of aliments and problems seems too difficult to be a lifelong career.

This is true, if they were practicing today. However, by the time they finish training the world will already being shifting. When they retire thirty years later, primary care will have once again become the desired specialty of choice. Today's medical students are thinking a lot like the executives at General Motors; they are looking to the past - gas powered bigger trucks and SUVs. They should be thinking more like Toyota - hybrid or electric smaller vehicles.
The question medical students today need to ask is, where do they wish to place their bets?

They are extrapolating the future world based on their past experiences rather than envisioning the future.

If all they experience in their junior and senior year is the hurried, stressed, primary care doctor buried under paperwork, missing charts and lab results, and hurdles in communications and handoffs to other doctors then it makes why they choose dermatology, radiology, anethesiology, and ophthalmology.

But the primary care of today already looks very different for some doctors in this country and will be fundamentally different in a decade. As a result, the work-life balance problem actually is a non-issue. Those who choose specialty care will, in the future, be looking for jobs or taking pay cuts to live in especially desirable places.

Here's how the future is already taking shape.

Information Technology / Primary Care Transformation
For those individuals who have an entrepreunial spirits, groups like the Ideal Medical Practice, headed by L Gordon Moore, and Hello Health, lead by Jay Parkinson, allow doctors to practice true primary care. Both concepts focus on the doctor-patient relationship by getting off the fee for service treadmill which values patient volume and medical procedures. Since primary care medicine is a cognitive specialty requiring thought which take time and does not have the procedures that a cardiologist or gastroenterologist has, these doctors can only make a reasonable living by seeing more patients per day.

The Ideal Medical Practice (IMP) gets off the fee for service treadmill by slashing overhead cost dramatically by reducing ancillary staff and other fixed costs like office space to a minimum. Therefore the amount needed to cover the costs is less. As a result, one does not need to see as many patients as before to maintain a practice.

Hello Health works by having patients pay a monthly membership fee as well as direct payment when seen in the office. They generally don't work with insurers but instead get their payments directly from you. The benefit, however, is with the membership fee you can communicate with your doctor online via email or webchat like Skype. If you need to be seen it is often same day. The monthly fees that patients pay for these conveniences pays for the doctor's salary, as a result like IMP, the primary care doctor can spend time with you to figure out how to keep you healthy or get you better sooner.

Medical students however who don't wish to start their own practice can find competitive salaried positions at Kaiser Permanente, Geisinger, and other integrated healthcare delivery systems, as well as other private medical groups in communities that are thriving. Primary care doctors work hard, but enjoy their job, are paid a reasonable amount, and aren't planning on quitting anytime soon.

The experience above already exist today, but only exist in the minority of primary care practices. What they all have in common is the elaborate use of information technology, specifically electronic medical records, a can-do spirit on doing things far differently that what is currently experienced and observed by medical students in their clerkships in primary care, a relentless approach to managing expenses and overhead, and the mindset to always change. As a result, doctors are less stuck on the adminstrative hassles, less frustation on inadequate and often dated medical information, and are able to spend more time on valuable elements they enjoy in primary care, namely fostering the doctor-patient relationship.

As all successful healthcare organizations and systems know, the best infrastructure to deliver high quality medical care at the least cost requires a robust backbone of primary care doctors. With the healthcare crisis in the United States, primary care workforce shortage will be a priority. As primary care doctors embrace, and need to embrace, the technological innovations as well as the business practices, in the cases of those entrepreuners, primary care doctors ability to have reasonable compensation and work-life balance will be secured.

So why are all of these medical students going en masse into specialty care doomed? It's not to say that the United States doesn't need specialists, but do we need as many? The reasons are globalization and new medical advances.

In terms of globalization, other doctors in other countries can do the same level of care for less. Currently elective surgeries like joint replacements and heart bypass can be done at 1/6 the cost in America if performed overseas in foreign hospitals by US trained doctors. Patients report experiences better than what they receive here. The outcomes are comparable. Some employers and insurers in the US send patients overseas, cover travel for themselves and a family member, as well as a small fee to do it. While the numbers are small, patients are willing to go.

With the digitization of radiology imaging and the creation of the internet, MRI and CT images can be sent quickly not only to hospitals but overseas. Radiology costs is about 1/3 the cost and images are being read by doctors in India, Austrialia. While US radiologists relish the fact that they no longer need to take night call for late night emergency room CT scans, they should also worry as should medical students contemplating a career in radiology.

It is only a matter of time, unless US doctors wish to take dramatic paycuts to match the pay of doctors in places like Thailand and India, that many elective surgeries and routine imaging reports are outsourced. Don't believe me? Ask the United Auto Workers or other cities and towns built on manufacturing and factories. They couldn't compete with Mexico or China.

In terms of medical technology disrupting specialty care, one only need to look at cardiothoracic surgery. The number of bypass surgeries for heart disease have fallen since the advent of cardiac stents. The number of cardiac stents done can be lowered with the improved focus on cholesterol management with statin drugs and blood pressure control. In other words, patients can avoid having any surgery done much more than even a decade ago as better medications and understanding of illness has occurred.

Who will manage these new medications and keep people healthy? Primary care doctors.

When laser eye surgery for vision correction started years ago, it required the expertise of a highly skilled ophthamologist. Cost for the procedure was thousands of dollars. Today computer assisted laser machines do the bulk of the work. Cost of the procedure now? Few hundred dollars.

As an overwhelming number of students go into specialty care, simple supply and demand coupled with the expensive elective procedures (and most lucrative procedures) being done overseas, and as medical technology continues to get better, specialists will have no choice but to take paycuts or move to areas perhaps less desirable to make a living.

Payment Reform
While primary care doctors current suffer under the fee for service reimbursement system, it is clear that the United States cannot continue to do so indefinitely. One need to look no farther than Massachusetts, which a few years ago was the first state to have universal coverage for all of its inhabitants. The state failed to address payment reform. As a result, and not surprisingly, costs continue to escalate with no demonstrable improvement in quality.

To address the budget gap, a state commission proposed changing the payment system to one that favors keeping the patient healthy, preventive interventions, and primary care by paying a monthly or annual fee. Insurer Blue Cross and Blue Shield has done just that in an experiment.
As a result, the incentive to increase volume or procedures is diminished and doctors are focused on delivering the most cost effective care.

So students going into primary care should take heart. You are choosing the right specialty for the future. To avoid the traps that your mentors have fallen into, be very picky about where you practice. Want to be your own boss? Want to be an employee? Either is fine. Make sure however that you work at a place dedicated to using electronic medical records not only for charting, but ordering and reviewing medications, lab results, and imaging. Check to see that your compensation isn't significantly died in to the fee for service service treadmill.

Then be thankful you made the right choice. There is no more rewarding experience than having a long relationship with another person which typically only comes by being either an internist or family doctor.


Annie said...

My name is Annie Smith and I am the assistant editor of I am contacting you today in hopes of developing a relationship with your website; we have seen your site and think your content is great. is a purely informational site dedicated to the general Public.

I hope you show some interest in building relationship, please contact me at

Anonymous said...

I think primary care is going to be handled by nurse practitioners and physicians assistants. Family medicine will disappear as it becomes obsolete.

Anonymous said...

"They are extrapolating the future world based on their past experiences rather than envisioning the future."

This is because they are smart. Few will base their entire future on pure speculation rather than by examining historical trends. One does not predict tomorrow's weather based upon imagination, rather, tomorrow's weather is best predicted by observing today's weather, and yesterday’s, etc. It's easy to look back from a position of comfort and security as an established professional and fantasize about how people should think, but it's another matter when you're the student looking forward into an uncertain future.

Davis Liu, MD said...

Looking to the past to predict the future denies reality. Hospital medicine and hospitalists didn't exist until about 15 years ago. Emergency medicine was started in the 1970s. Cardiac stents has changed the practice of cardiothoracic surgeons. Google didn't exist until 10 years ago. International travel wasn't commonplace until deregulation started the momentum.

In other words, past experience is ok for weather prediction, but is only a jump off point and not particularly helpful in envisioning the future.

-boldly|broken- said...

You make some interesting points, but I believe, as an above commenter already pointed out, that the "undercutting" you described as applying to surgeons and radiologists is happening here to primary care physicians to an even greater extent. There is an entire workforce of nurses who have been told that, with just two years of online courses, they can be the equivalent of a primary care physician. The ANA is batting for them, and the government, for now, is believing them.

If you want to talk about GM and historical trends, I'd say that primary care is going, not the route of Toyota, but the route of Walmart. Quality sacrificed for cost, with a large, powerful institution throwing their weight around to secure their agenda.

Current twenty-somethings grew up in the 80's and 90's, the beginnings of the volume overloaded primary care shenanigans that are rampant now. Most of these people did not have a strong relationship with a physician, and as they get older, they will be using the minute clinic and urgent care for their needs. Don't get me wrong, they will complain about it all day, but they wont realize there was a different way, because just as the green movement is growing and people are beginning to reject processed foods, Walmart still reigns over the local grocer. Because people don't care about quality.

Anonymous said...

thanks for your blog. i'm in the middle of FM interviews, a 4th year student. i've had my doubts about FM through and through- having considered all the more lucrative/better-respected specialties in my head, knowing that i am competitive enough for them. i chose FM in the end, in spite of classmates & even attending MDs telling me to do otherwise-- partially because i think, like you, i'm also a hopeful believer in the brighter future to be had in primary care, even for physicians. but at the same time, i see that we could be on the verge of losing a voice in all of this reform, and it truly scares me. the pressure to save money is so strong that even the gov't seems to want to hear what what it wants to hear -- that NPs and PAs are quality substitutes. that we don't need to invest more in FM recruitment, etc.

sadly, the comment above about primary care going in the way of walmart is so true. my friend was just at a walmart conference in arkansas for his work last week, and passionate discussions about providing low cost care at walmart minute clinics is surely in the works. how do FPs play a role in all of this? could you articulate this more?

please keep writing what you're writing. i really hope that we can communicate the message of the importance of *quality* primary care better to the public & to the well-intentioned leaders that often have too many competing voices around them to know the difference between good health reform & a failed system.


Related Posts with Thumbnails