7.13.2007

Choosing a specialty -What about Primary Care?*


Q: Primary care is extremely challenging. "Is it also like this in other areas of medicine?"

A: No. I don't think so. The two main issues that concern all doctors, regardless of their specialty are 1) income, and 2) lifestyle.

Income means how much you make for your time and energy (Do you spend an hour talking to your patient and get $50, versus, you spend an hour doing a high-tech procedure and make $3000). Just really try to visualize this scenario to appreciate its meaning: $50 vs $3000, in your hands. Which one do you pick. See the difference?

Lifestyle means whether you will be able to care for yourself, your loved ones, and your other interests throughout your life. Are you able to go to sleep at night, without thinking, "I might need to go into the hospital at 3am, to deliver a baby," or "I might be woken up to see a patient in the ER in respiratory distress." Do you want to sleep with a pager next to you, like a time bomb that might go off at anytime, at which point you have to leave your cozy bed and your lovely family, to drive to the hospital to care for the patient? Many of us have hobbies. Are you able to knit, work out, read, garden, plus care for your family, on top of having a career? If you have to do calls for 30 years, every 6th night, until you are an old woman, it gets pretty old. One rule of thumb, which is a general concept, is that your lifestyle has to do with what kind of disease processes you are treating. If you go into a specialty where the disease needs to be addressed on a moment's notice (a baby and mommy in labor, or a ruptured brain aneurysm), you are going to have deal with the call and the lifestyle issue, because you and your colleagues in the same specialty will have to share calls to deal with emergency no matter what time of the day it is.

If you go into a specialty where the disease can wait (allergy, a cancer-looking mole, a deck of slides of non-emergent pathology specimen) until the next business day, you are going to have a better life style. If the disease can wait, you can have banker's hours, and live a normal life. Another way to have predictable hours is to work in a specialty where one doctor is just as good as another doctor--i.e. no continuity of care. For example, you can work shifts as radiologist, or ER physicians. You work your ass off for 8 hours, and you go home. This type of lifestyle may be more amenable to flexibility of your life. You can work as many or as little shifts as you like (if you can negotiate it in your contract). You can work in California this month, take 3 weeks off, and then go work in Oregon next month.

Q: "My question is: WHAT area of medicine DO YOU SUGGEST? For sanity, for family, for salary?"

A: Since I am a primary care doc, I can only comment on what I think are better specialties, and I welcome doctors from these specialties to shed some insight if they disagree.

For lifestyle:
Dermatology
Allergy & Immunology
Pathology
Occupational Medicine
Physical and rehabilitation medicine
Ophthomology
Radiology
Plastic cosmetic surgery

But if all you care about is the actual amount of dollars that you make regardless of any other factors:
Neurosurgery
Invasic Cardiology
Interventional Radiology
Orthopedics
Gastroenterology
Urology
ENT
many of the surgical subspecialties

Neither (bad lifestyle, bad pay):
primary care - internal medicine, family practice, pediatrics
Obstetrics & Gynecology

A bit of both (depending on your practice)
Emergency medicine
Ophthalmology
Anesthesia pain management
some of the surgical subspeciaties
some of the medical subspecialties.

And, special mention, anything that is minimally invasive yet procedurally oriented is going to be HUGE. Example, the art of open vascular surgery is now slowly being by encroached by radiologists who can thread a wire up on someone's blood vessel and repair the damage by using stents, making a tiny incision through the groin, versus an open procedure. So, another general, basic concept is that how well-compensated you will be, depends on how much you "cut" people. The more cutting and fixing you do with needles, catheters, scalpels, the more money you will make--especially if you can fix something permanently by operating on it: like a hip replacement. Even better than that is if you can do a procedure that most people want but do not need: like lasik surgery, or cosmetic procedures. You can crank out many of these, and get paid by patient's out of pocket CASH.

So a good basic rule of thumb to remember is the following. The more you talk to people in medicine, the less income you'll make. The more you cut people in medicine, the more income you'll make. The smaller the cut you can make to achieve the same result, the more income you'll make. The less you have to depend on insurance payment, the more income you'll make.

A note about general surgery: they have complained to me that they are the "primary care" of all surgery specialties, and some of them are struggling. ER dumps on them all the time. They get called day and night to evaluate vague problems, like tender abdomens. I think general surgeons have it pretty hard. They have longer residency years, but they really don't make significantly more money for the time and effort.

OBGYNs have it pretty hard too. All the malpractice threats, and the terrible hours. Perhaps someone else can comment on these specialties.

Q: "What area is not completely scrutinized by this frankly jacked up system?"

A: None.
Every area is scrutinized by the system. In order to understand why this is the case, you have to understand how the doctor's work is paid. The concept of the third party payer must be addressed. In America, the doctor usually receives a payment for his/her work, not from the customer, the patient herself. The payment is received through the insurance company which is tied up with corporations, and the government. Because money is actually disbursed by the insurance companies such as Blue Cross/Blue Shield, or the US government in terms of Medicare and Medicaid, these third parties (the first and second party being the patient and the doctor) control how much doctor gets paid.

So the one who hands out the money controls the system.

The purse-holder decides how much the doctor is to get paid, how fast the doctor is to be reimbursed, what type of paperwork the doctor has to fill out in order to get paid, what kind of fee negotiation the doctor can have with the insurance company, what procedures are considered acceptable, what kind of patients the doctor can afford to see, which drugs are approved, etc. All of this is regulated. The final translation is that it impacts how you practice medicine. This is what we mean by "loss of autonomy." Essentially, because someone other than the patient pays your work, the third party that pays you tells you how to do your job. So every doctor who is paid by the third party is affected by regulation and scrutiny. I need you to understand this concept.

Again: whoever pays you, is who manages you, and who controls how you doctor your patients.

How does this happen? -prepare for a rant- The person who pays you, decides how much they will pay you, which affects your income, which affects how you treat your patient, which in turn affects your lifestyle, which ultimately affects your life, period. The doctor, say the plastic surgeon who does cosmetic surgery, who is paid directly by the patient out of pocket (i.e. not through insurance), is less under the scrutiny of the system, because the surgeon is not being reimbursed by the third party. But even doctors who do not accept insurance, are affected by the system--because the system sets up an industry "standard." For example, if the third party is saying that your UCR (usual, customary, reasonable) fee for a an angioplasty is $1000 (a factitious number), you will have a hard time to say that you are going to charge $2000 for doing the same procedure as Dr X down the street.

So in that way, as long as the system of regulation exists, every doctor is affected just more or less in degree. I cannot stress this concept enough. Who pays you, controls how you practice your craft. This is what we mean by "losing our autonomy." We no longer decide for ourselves and our patients. Other people tell us what to do, how to do it, where to do it, how much to do it, in our own profession! And yet when something goes wrong with the patient, it is our fault. The individual doctor is first to blame--not the system, not the insurance company, not the lawyers, not the government, not the patients. We pay out of our own malpractice insurance to compensate the patient. So there you've got a deadly combination. We have very little power in controlling our working environment, yet we are held liable for mistakes or errors in the system.

The loss of autonomy, in the setting of the constant threat of malpractice is very suffocating and demeaning, not to mention chronically stressful. This is why in a recent survey of doctors (I forgot whether the survey was for all docs or just primary care docs), 66% of them said they would not advice their children to go into medicine. Sounds benign? Well, think of this analogy. Say you go to an internet site to decide on a hotel choice. If 66% of the guests at a particular hotel say that they would not recommend staying in this hotel, would you want to go ahead and book a room in this hotel (if you had other choices)? Probably NOT! Unless you were stupid!

Well, you may be saying by now, "don't patients control how you practice?" Not really. Patients are not the ones disbursing the money either. So they have no power. Moreover, they are clueless about how to navigate within the healthcare system. They can't force the insurance company, for example, to pay more to the good doctors, than the bad ones. Patients are the sacrificed lambs in the system as well. And I am sympathetic toward patients. They pay their monthly premium, month after month. But they have no control over how the money is spent. They have no control over the Medicare Fee Schedule, either. The current health care system is so opaque that patients and doctors really have no idea how our money, 1.7 trillion dollars a year, is spent. That is trillion, not million or even billion. Trillion.

Example 1. Patients will take out a credit card loan to pay for a $6000 dollar breast augmentation job, but they will not want to pay one more cent than when they have to for a life-saving bypass surgery. Patients feel that healthcare is a given right, not a want. They expect top-dollar service, but would rather not pay for it. Is it their fault? Maybe yes, maybe no. But I can see their point. I see that ordinary citizens are already paying lots of money into their health care premium. In fact, many people choose a job because it offers health care coverage. These working class folks pay, month after month into their health insurance premium. No wonder they don't want to pay anymore.

I think it's not so much that money is not there, but that money is poorly managed. Many people who have no real contribution to the healthcare delivery are benefiting from healthcare spending, e.g. million dollar salaries given to insurance company CEOs. If you thought a plastic surgeon making close to a million dollar a year is a lot, wait until you see that the CEO of United Health last year got over 80 million dollars in salary and stocks. But, we live in a capitalistic society, and CEOs are paid based on how much money they can make for the company so the stockholders can all benefit. The CEO's job is not to promote health. His job is to milk as much money of this quarterly earning income as possible. So there you have a conflict of interest at hand.

Example 2. Counseling patients about obesity can avoid costly health problems down the road. Yet, the insurance industry will pay more for the doctor to perform angioplasty (a couple thousand dollars ) for heart disease as a result of obesity, rather than for obesity counseling (two hundred dollars tops) to prevent the disease itself. Why is that? Well, you do want to make sure that you attract the brightest people to do these invasive procedures. You can't just not compensate the doc who is doing angioplasty handsomely. Do you want to make angioplasty so cheap so that any joe off the street will want to do it? Don't you want the best and the brightest to do invasive procedures? But who is to say that counseling about obesity to prevent heart disease in the first place is not equally important. So what do you do? Do you pay the angioplasty guy as much as the counseling guy? Ummm. Tough choice.

Remember how we just talked about this: whoever holds the purse, tells you how to do your work. Well, then you have to ask yourself, "what is the motive of the purseholder?" If the purseholder was the patient, he would want the best medical care possible for his money. But remember I said that in this country, although the money comes from patients, it is the insurance company that holds the purse? Well, being for-profit insurance companies, their motive is not to promote health. The CEO of the insurance's only motive is to stay competitive as a business, to be cost-effective, to cut cost as much as possible. His goal is not long term health of those insured. His goal is to make the company as profitable for his company during his tenure there. It is a very short sighted goal. The two goals: profit and healthcare are mutually exclusive. Health care costs money.

You may say that, "wouldn't the insurance company want to keep its insured healthy so that they don't have to get expensive procedures down the line?" In order to understand what is at stake for the insurance company, we must look at the way insurance works in our country. One of the biggest problems is that we do not have universal health care system, where the risk of cost is truly, and justly distributed amongst ourselves as a nation. The original concept of insurance is so that risks are equally distributed across a group of people who pool together their resources to deal with catastrophic costs.

But the way our nation's insurance system is set up is really screwed up. If you don't work, you are not insured. If you don't continue the insurance, you are not insured in 5 years. You may be insured with company y today, but be insured with company x the next year. Insurance companies cherry pick the most desirable of insured people, and try to drop them as soon as they become "expensive," with "pre-existing conditions," or when they become old, defeating the very purpose that the insurance was put in place in the first place. Because we do not have a universal health care system where patients' risks are distributed longitudinally over the life-time where diseases often take decades to develop, what kind of incentive does the insurance company have in providing counseling for now, for benefits that may not happen until 50 years down the line when the patient is no longer on the panel of the insurance company, but now at the age of 65, becomes a problem that the government has to worry about. Everyone over the age of 65 has Medicare, a problem that the government has to deal with? How many of us have the same insurance policy for 50 years in length, for the insurance company to make it worth their while to provide counseling?

Example 3. Can you imagine the political battle that has to be won in order for the insurance companies/government to reimburse top dollar for preventive counseling? There are multibillion dollar industries (drugs, devices, catherization labs, cardiologists, hospitals, even fellowship training programs) that are built based on the results of obesity. These are powerful forces that would be impossible to dismantle. If there were less obese people in this country, and less heart attacks, do you think the advertisement of Coreg (a drug used in treating heart disease) would be a cash cow for GlaxoSmithKlein, a pharmaceutical giant who brings in the profit by the millions for its profit holders? I hope these examples will open your eyes to see the reality of healthcare, the complexity of it. -end of rant-

Q: "Does pediatrics fall in this same category of PCP - and does the caution "do not pursue this field" apply?

A: Peds, geriatrics, internal medicine, adolescent medicine, family practice, and according some people, psychiatry--all fall under primary care.

Q: And the puzzling thing: if most physicians are so underpaid, how come over 75% of the parking spots in the physicians parking garage at the hospital I work for are fancy luxury cars??

A: Ah, this is my favorite question. What about those fancy cars in the physicians' parking lot. Specialists are still making high income. It is not uncommon, for example, to find interventional radiologists to making over $300,000 a year, GI, path and dermatology docs making $200,000, or neurosurgeons and cardiothoracic surgeons making upwards of $400,000. When you make a million every 2-3 years, these super-specialists can afford to buy mansions and luxury cars. Plastic-cosmetic surgeons can make over $600,000 a year, partly because patients pay out of pocket. Since hospitals are now housing only acutely ill patients who need procedures, fewer primary care physicians are parked in the physician parking lot all day, as compared to the disproportionate number of surgeons/proceduralist who are over-represented in the parking spaces, because they are doing procedures in the OR/cath/radiology suites all day.

Primary care doctors make about $150,000 (pediatrics even less), and the figure is not keeping up with inflation. If you look at the math, the so-called debt repayment programs or even military sponsored programs do not come close to what super-specialists make. How much you make may depend on how long you have been in practice. Many of these fancy car drivers are over 45 years old. It may mean that they have worked like a dog for the last 15 years of their lives, making that income to buy extravagant things. Many cardiothoracic and neurosurgeons work 60 hours a week. Men work longer hours then women. The question you want to ask yourself is, do you want to work like a dog for 15 years neglecting your children and your loved ones?

Of course, the type of practice you are in also determines how much income you make within any given specialty. Are you in an inefficient practice, where overheads (rent, hiring of personal, equipment, billing short come) steal money away from your pocket, or are you in a good practice where everything is working like a well-oiled machine. Are you the owner of the practice, who gets to pocket all the extra profit as generated by your employee physicians, or are you the employee physician who is working for the owner physician. Your patient profile (also called payer-mix) makes a difference as well. Are most of your patients well-to-do, and well insured? Or are most of your patients old, uninsured, immigrants, and poor? You may have idealism to go into medicine to help the latter group, but when you realize that you are working like a dog, or you are doomed to shop at K-mart for the next decades, you’ll think twice. Especially when you see your colleagues drive away in the wind in those sports cars, carrying expensive bags, their debts completely paid off. Are you a investor-owner of a medical facility, or even a hospital? Do you own the real-estate of where healthcare takes place?

Lastly, it depends on what kind of medicine you practice within your specialty. You can run an assembly line practice where you are churning out 40 patients a day, seeing each patient only 15 minutes per visit, generating in more income from your “productivity,” vs. being someone who chooses to spend time with patients. If you were a surgeon, you can operate on twice many cases, for example, to double your income, than someone who takes more time to care for patients before and after the operation.

So your income level depends on these 5 factors:
1) What specialty you are in
2) How long you have been working
3) What kind of practice you are in
4) How hard you want to work
5) How much corner you are willing to cut

Q: So what are we suppose to do? Are you telling us not going into primary care?

A: You've got two options.
Go into primary care but only after you are fully informed, and are willing to take the risks and make the sacrifices. Do it because you feel passionate about the specialty regardless of its difficulties. Do it because you feel it's the right thing to do. Do it because you believe in it. Do it with joy and pride even if it means that you are going to be in debt longer and will have to drive a beat up car, when your colleagues are driving Mercedes. Do it even if your higher earning colleagues think that you are the loser and the sucker at the end of the barrel. But better yet, design a primary care practice that minimizes the non-sense. But believe you me, this very labor-intensive and time consuming...to the point it may not be worth the tremendous personal sacrifice.

The second option is don't do primary care.



more insight to 'choosing a specialty' in future posts
*This was written from input of other doctors. Thanks doctorhope.

82 comments:

Ten out of Ten said...

"The more you talk to people in medicine, the less income you'll make. The more you cut people in medicine, the more income you'll make."

Awesome. I loved the entire post.

Pseudo_Doctor said...

Talk about an eye opening post....great write up

Anonymous said...

This was well written but rather one sided. You don't back up your assertion that PCPs have bad lifestyle, which in my experience they certainly do not. In fact, the last study I saw had PCPs working about 44 hours a week with surgeons closer to 60. Contrary to what you would gather from reading the blogosphere, the general surgeons are really the ones with something to bitch about currently. I guess they just can't get through writing a blog post without getting paged for an appy.

Rob said...

Wow.

This is a tour de force. Excellent post! I am most impressed by your candor. As a "thinking" physician, I agree that you must choose this lifestyle with care. I love it, but I have lots of reasons not to.

Thanks.

Rob

ER doctor said...

Anonymous wrote: Contrary to what you would gather from reading the blogosphere, the general surgeons are really the ones with something to bitch about currently

***



I agree, the post does actually recognize that general surgeons have it tough as the "primary care of surgery."



This post (plus comments) further demonstrates the hardships of primary care.


http://medrants.com/index.php/archives/3284

Anonymous said...

Dear Anonymous who talked about "the study I read about PCPs",

You are a clueless and apparently don't interact with general internist s or primary care doctors. Although I agree that general surgeons are the true martyrs (and heroes) of our healthcare system, PCPs are a close second.

10 years ago there was a push for primary care so many intelligent well meaning people went into it. Now they are opening up "day spas", or buying smoothie franchises, anything to actually be reimbursed for their time and risk.

I did primary care for 5 years and fortunately was able to sneak back into a fellowship. I wake up smiling everyday because I know I won't have to fight the good fight for the next 30 years. Do anything you can besides primary care, even if it means occupational health, derm, path, endocrine, whatever. Then if you feel an altruistic pang, go do habitat for humanity every weekend.
b

Anonymous said...

Of course, despite calling me "clueless" you provide no data in favor of the argument that PCPs have a bad lifestyle. Perhaps it's because... they don't. Yes, they make less than most other physicians, but they also have shorter training and shorter work hours than most.

Dr. Smak said...

Hold the bus. "Do anything you can do besides primary care."

I totally disagree.

What I totally AGREE with is EM physician's point, which is go into primary care only if you know what you are getting in to. If your objective is to whiz your Mercedes convertible into the Club parking lot for a round of golf every Saturday morning, or at least those that you're not off to the seaside condo, don't choose primary care.

No job is perfect, and primary care sure isn't. But it's not the Deliverance that many make it out to be.

I live in a middle class neighborhood, drive a 4 year old Subaru, and shop for my kids' clothes at Target and Kohl's. (I usually hit Ann Taylor for myself.) But, I'm home to get my kids off the bus three days a week, and I haven't missed a holiday with my family for 4 years.

I can do without the Mercedes.

http://drsmak.blogspot.com/2007/07/why-i-chose-family-medicine.html

Thanks, EM physician for a great and realistic post about pros and cons.


And I do agree with everyone else - general surgeons are getting shafted.

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SHEIKH said...

Of course, speaks for me, a "clear" does not provide information on the claim that the PNP a bad life. Maybe it's because ... they do not. Yes, they are less than most other doctors, but they also have less education and work fewer hours than most.


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Mrk said...

This was well written but rather one sided. You don't back up your assertion that PCPs have bad lifestyle, which in my experience they certainly do not.
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