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Students: The future is in primary care

Posted Oct 21 2008 12:51am
An anonymous student asks:

I'm a third year medical student in Charleston, WV. I'm having a tough time deciding what to be when I grow up. "Do what you love." Is the most common comment I get. This is a problem for me because so far I've loved everything. When I started medical school I was set on family medicine or general internal medicine. I still think I'd be happy with either of these options. However, sometimes I feel it might be a mistake for me not to specialize so I will have a more valuable skill when I finish. . . .

I have a small family (wife, one daughter) and plenty of loans. I feel a little discouraged by the reimbursement disparity between general practice and specialty practice. Do you think this pay gap will get even wider? What do you see as the future of primary care medicine in America?

I am a contrarian on this issue, but I believe that the professional satisfaction that can come from being a primary care doctor will come to be enabled by an increase in salaries and better working conditions for those professionals. Here's why. As payors in the health care system face more and more financial pressure (either from employers or government legislators), they will seek to maximize the value of dollars being spent. PCPs are uniquely situated to deliver the goods for them.

Today, PCPs are dramatically undervalued and underpaid, relative to specialists. Fewer and fewer people are becoming PCPs. Yet, they remain the most trusted source of information for patients. (See, for example, page 12 of the recent Blue Cross Blue Shield survey on how consumers make health care decisions in Massachusetts.) Besides being trusted, PCPs are the gateway to the health care system, and they are needed to determine the most efficacious diagnostic and treatment paths for patients.

The current rub is that PCPs get to spend 18 to 20 minutes with each patient because the fee they are paid for visits is so low that they have to see many patients each day to make a living. There is no way they can do a really complete job, much less focus on prevention and wellness. In contrast, we see the assertions of doctors in so-called concierge practices who have more time to spend with the patient, asking personal and family-related questions, doing more physical diagnoses, and focusing on prevention and wellness. They claim they can actually reduce the downstream costs of specialty and hospital care.

Now, you might rightfully say. Prove this with a case-control experiment. I will not try. I will simply assert that common sense suggests that if PCPs are given more time to spend with patients, they will be able to do a more thorough job at prevention and diagnosis, with obvious downstream benefits. If you are Medicare, Medicaid, Blue Cross, or any other payor under pressure from those who send you money, sooner or later you will skew your reimbursement system to enhance this segment of the medical profession and encourage more, rather than fewer doctors, to become PCPs. You might, by the way, tie those salary increases to improvement in quality metrics. This recently happened in the United Kingdom.

Assuming I am right, our Mountaineer friend still has a dilemma. How long will it take for this transition to take place, and will he starve in the meantime? I do not know, but I am guessing that he will see the shift begin by the time he finishes residency training and accelerating thereafter. So, my advice is "Do what you love." Marcus Welby, MD would be proud of you.
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