How Can We Encourage Medical Students To Choose Primary Care?

[2012mdc]

That's because our current system is f'ed up.



The only people who think primary care is easy are those who have never done it.

For some reason, they do seem to love hanging out in our forum, though. Go figure.

I do not think anyone is saying primary care is easy, it's difficult but that does not mean other specialties cannot be more difficult/complex.

I understand that FP's often get a bad rep by those who are ignorant but one can be aware of the difficulty of primary care but still believe a certain specialty may be more difficult w/o having disrespect for PCP's. Just because that poster believes rad onc is more complex it doesn't mean that poster thinks primary care is easy

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[deleted87716]

I do not think anyone is saying primary care is easy, it's difficult but that does not mean other specialties cannot be more difficult/complex.

I understand that FP's often get a bad rep by those who are ignorant but one can be aware of the difficulty of primary care but still believe a certain specialty may be more difficult w/o having disrespect for PCP's. Just because that poster believes rad onc is more complex it doesn't mean that poster thinks primary care is easy

Anything can be learned. Wagy's attitude that he could learn to do primary care if he wanted to, but that the average FP couldn't learn radiation oncology because we're intellectually incapable is the part that's flawed. We're all doctors. A few points' difference on an exam doesn't separate imbeciles from geniuses.

 

[JackADeli]

I think we had almost this entire line of conversation in the past few months on this forum...

My comment then was that a good deal does have to do with very poor marketing. Can any particular specialty find/declare reasons why their pay check at the end of the month should be more? Yes.

....plenty of students that know of the surgical specialties and what their income is without much appreciation of the workload involved in obtaining said income. I am certain I can find any number of surgeons that would love their current incomes ~$250-350K/yr with the M-F, ~9-5/6, limited call, and quality of lifestyle practice of many FM physicians. I do not know any PCPs that will accept the 60-80hr/wk, Q3 call lifestyles of surgeons in exchange for their income.... correction, I do know a few that put in extra moonlighting hours and do make upwards of $300k/yr.

My point now as it was previously.... We need to fully educate the students not just about the specialty but what is the "compensation PACKAGE" of the career. ...Continued emphasis on comparing check stubs without context will only serve to hurt efforts to recruit for ALL specialties...

Let's have some truth in advertising...

I am in no way saying the system is correct or that it comes particularly close to free market function...

My point now as before, is that the "class warfare-esque" argument that ignores all factors but the pay stub does not:

1. inform med-students well
or
2. enable physicians to work well together/multidiscipline/mutual respect/etc...

I appreciate that the "dramatic" difference in pay stubs [out of context] makes for good talking points when fighting for a "fair" increase piece of the pie...

...you have this "Mother Theresa" type stereotype being portrayed while simultaneously making all the arguments [more money please] in this thread and others...

Having said all that, I am one that honestly believe FM is a difficult field to practice in and should be full of the best, brightest, and academic excellence in order to do it well. Some programs strive for that but others seem to promote the residency comforts to recruit....

I understand that. The question is will "we" be smart about it? This entire thread (and others like it) is an example of how "we" the amateurs have been played by the pros in politics. It is the old divide and conquer strategy. We have been played against each other...

First, we have PC/FM/etc... excited and actively engaged in using comparisons to decrease the societal value of the other specialties' services in an effort to increase their own...you alienate the other specialties. Then congress, politicians use all your arguments to justify cuts in income of other specialties.

"You" think those cuts will translate to increased income for you...the cuts are consumed by this population, NOT your hope for increased compensation.

"you" complain the pay raise didn't arrive? They then turn around and use your calculations (similar to your comment below) to point out.... you are worth less in comparison to the specialist... that you helped devalue! You have now been played by the pros...

...if PCP's continue to take the perspective that they have to rob peter (specialists) to pay paul, they're never going to get support outside of their own...

EXACTLY. As per my quoted statements above, the argument of PCPs' societal value being politically based on ~devaluing specialist is a political game. In the end the PCPs will not win their raise and only suceed in proving the "misery loves company" dictum.

I believe in my PCP. I don't like the payment structure and/or the governmental contamination of the system. But, I am also tired of people saying "i could be a great golfer like Tiger... I just had other priorities....". I see too many FP/FM residents that failed step 1 or scored very low. They then come around saying it really isn't an indicator of anything.... I see too many say they want the specialists pay but without the on-call and other hours. It just goes on and on.....

But, in the end, when congress or some other body fully devalues the specialists... when pokliticians and FM/FP get convinced that everyone must love FM/PC because it is great and people put in 5-10 yrs of extra residency because they only wanted the money..... well that chicken is going to come home to roost. My choice of specialty was not money, definately not "lifestyle". It was because I was willing to put in the extra years of sacrifice to be able to do the kind of medicine I enjoy. I would NOT have chosen FM at 3yrs residency, less call, less hours, etc for 450K. I just wouldn't cause that is not my bag. So, yeh, like the great one says....~we are just hardwired to not think correctly.... we just don't get it....

 

[deleted87716]

i think the complexity of generating a treatment plan for prostate cancer is far more difficult and merits more reimbursement than an hour of counseling a patient on screening, health care measures.

Do you seriously think that's all we do in primary care...?

rads and rad onc generate a huge portion of their income via the technical component, something that is not available in other specialties as much.

It's no secret that current reimbursement undervalues cognitive work in favor or procedural work. That doesn't make it right.

And, to Jack, I've never met a primary care physician who devalues specialists. The opposite, however, is not true...sadly.

 

[smq123]

My choice of specialty was not money, definately not "lifestyle". It was because I was willing to put in the extra years of sacrifice to be able to do the kind of medicine I enjoy. I would NOT have chosen FM at 3yrs residency, less call, less hours, etc for 450K. I just wouldn't cause that is not my bag. So, yeh, like the great one says....~we are just hardwired to not think correctly.... we just don't get it....

So, do you think that there IS a solution to the lack of PCPs? How else to entice them? Increased reimbursement is not "deserved." Debt relief, according to wagy27 is not "deserved," either. Both of you pay lip service to the difficulty of being in primary care (note that I DO NOT specify just FP; I also include IM and peds), but then pay a subtle insult by saying that they do not do enough complex work to be paid more or to have their debt burden taken away.

So IS there a solution? Maybe we need to start screening medical school applicants for those who would be more likely to go into primary care.... That seems unfeasible, though.

Personally, i think the complexity of generating a treatment plan for prostate cancer is far more difficult and merits more reimbursement than an hour of counseling a patient on screening, health care measures.

First of all, if I had an hour to counsel patients on this screening, life would be so much easier. The fact that you seem to think that as PCPs we have *that much* time to go over these things shows that you do not have a good understanding of the problems in primary care, either.

So, if I DO generate a treatment plan for an elderly patient with end of life care issues, multiple comorbidities, and several social work nightmares, which is very complex and very difficult, I should be reimbursed the same as you would be reimbursed for creating a treatment plan for prostate or breast cancer. But how do you judge that? And who defines complexity? Is operating on an otherwise uncomplicated appy ALWAYS more complex than taking care of a treatment-resistant diabetic who has heart disease and is so profoundly depressed that he comes to the office threatening to commit suicide? (One of my co-residents had a patient like this come to the clinic this past week.)

As for my perspective, I completed an internship where I spent several months in primary care as an IP and OP. While that's obviously not extensive compared to a 3 year residency, it did give me an idea of the scope of the field.

I find it odd to associate primary care with inpatient. The fact that you do illustrates, again, a less-than-clear understanding of the obstacles in primary care.

Secondly, again, the point of primary care is continuity of care. Not exactly something you can attest to understanding until you've done it for more than a few months of required ambulatory care rotations as an intern.

 

[2012mdc]

Do you seriously think that's all we do in primary care...?



It's no secret that current reimbursement undervalues cognitive work in favor or procedural work. That doesn't make it right.

And, to Jack, I've never met a primary care physician who devalues specialists. The opposite, however, is not true...sadly.

1. I have limited experience but it seems to me that specialists do cognitive work in addition to the procedural work. Surgery involved a lot more mgmt and cognitive thinking than I realized but I guess that may be due to the nature of the hospital and its patient pop

2. I've met a few PCP's who devalue specialists. A faculty member at my med school (a pediatrician) was giving a talk about applying to residency and different specialties etc and took a completely uncalled for shot at ortho - paraphrased - "I don't understand why it's so competitive to match, even a monkey can hammer" The lack of respect for another field was appalling coming from a faculty member. Point is there is some disconnect and lack of respect that goes both ways

 

[deleted87716]

as someone who has been a radiation oncologist and acted a primary care physican during an intern, I believe there is far more cognitive challenge in radiation oncology.

I'm glad you find your job challenging. I'm going out on a limb and suggest that as an intern, you probably weren't a very good primary care physician. Most interns aren't, even those in primary care residencies.

Primary care is easy to do badly, but very challenging to do well.

Tweaking somebody's BP meds during radiation treatment doesn't make you a primary care physician any more than ordering an EKG makes you a cardiologist. The whole is more than the sum of its parts.

 

[VA Hopeful Dr]

1. I have limited experience but it seems to me that specialists do cognitive work in addition to the procedural work. Surgery involved a lot more mgmt and cognitive thinking than I realized but I guess that may be due to the nature of the hospital and its patient pop

2. I've met a few PCP's who devalue specialists. A faculty member at my med school (a pediatrician) was giving a talk about applying to residency and different specialties etc and took a completely uncalled for shot at ortho - paraphrased - "I don't understand why it's so competitive to match, even a monkey can hammer" The lack of respect for another field was appalling coming from a faculty member. Point is there is some disconnect and lack of respect that goes both ways

Everybody takes shots at the orthopedists - medicine specialists because the ortho guys seem to have forgotten what nonsurgical medicine they did know (show of hands, who here has been consulted for "manage BP" on ortho inpatients that did swimmingly when you started HCTZ), and surgical specialists because ortho does bear a resemblance to carpentry.

There are lots of folks taking pot shots at other specialties. What do you expect, medicine is full of type A egomaniacal jackasses. That being said, its been my experience that the doctors who talk the most crap about other doctors are the ones who are unhappy with their own lives in some way. Primary care docs that hate on specialists are usually not happy with their career choice. Specialists that hate on PCPs usually resent the easier hours that PCPs work as well as our ability to not see self-pay patients if we don't want to.

 

[bronx43]

Is there something broken in the health care reimbursement system. yes, I agree. The problem is the way it looks now is that the size of the pie isn't going to change and so specialties are going to have to compete to get the biggest slice they can get. As a specialist, I justify my salary being larger than a PCP by the fact that 1) I trained longer than an FP/IM (without fellowship) and 2) I believe the complexity of what I do and procedures I perform are more than that of a PCP

You can justify your higher salary any way you want. It just doesn't mean it's an accurate representation of reality, given the current financial reimbursement model. Only in a free market system can there really be any justifiable statement about incomes for specialties, but since there isn't, your justification is nothing more than your own subjective self-assurance. You trained longer than a non-fellowship FP/IM, but unless you put that into some tangible context, the conclusion you drew means nothing - likewise the complexity of your radiation oncology cases. It's simply rhetoric as there are no objective ways outside of a free market for price determination.

I take the current reimbursement model at face value. It's messed up, and it might or might not change over time. I don't really care. I just find it absurd that people in the highly reimbursed fields (or fields that use multiple reimbursement avenues) speak with such conviction when trying to mentally masturbate and imbue some kind of intrinsic superiority in their work to justify their compensation.

 

[deleted87716]

I have repeatedly asked you what your basis is to challenge the scope/complexity of my specialtiy when you have no experience with it whatsoever. My knowledge of primary care is certainly incomplete but at least I have an idea of the scope.

I've done no such thing.

You're the one claiming to know all about what we do, not the other way around.

What I do know is that medicine is complex, and that being a physician is challenging, whatever the field. There is no specialty that I denigrate, nor do I take kindly to those who denigrate mine.

 

[2012mdc]

Anything can be learned. Wagy's attitude that he could learn to do primary care if he wanted to, but that the average FP couldn't learn radiation oncology because we're intellectually incapable is the part that's flawed. We're all doctors. A few points' difference on an exam doesn't separate imbeciles from geniuses.

I've done no such thing.

You're the one claiming to know all about what we do, not the other way around.

By saying that FP docs could do rad onc if they wanted are you implying that rad onc and FM have a similar level of complexity? Or are you implying the average FP has the intelligence to tackle a more complex field?

 

[deleted87716]

By saying that FP docs could do rad onc if they wanted are you implying that rad onc and FM have a similar level of complexity? Or are you implying the average FP has the intelligence to tackle a more complex field?

I don't think that any specialty is beyond the ability of someone who has the intellectual capacity to graduate from medical school.

We all have our aptitudes and preferences, but none of us are *****s.

 

[2012mdc]

I don't think that any specialty is beyond the ability of someone who has the intellectual capacity to graduate from medical school.

We all have our aptitudes and preferences, but none of us are *****s.

Ok. I can't agree or disagree b/c I haven't had much exposure to a lot of the specialties. But isn't that above statement pretty much implying that you have some sort of understanding of the complexity of a field like rad onc?

Or are you just confident in our medical schools education system?

I find your statement interesting as well as something to think about

 

[deleted87716]

But isn't that above statement pretty much implying that you have some sort of understanding of the complexity of a field like rad onc?

Which part of "medicine is complex" didn't you understand?

 

[Endolas]

The powers that be who define compensation have looked and decided that the treatment planning I am doing is more complex than the planning you are doing. It’s not simply about time spent.

You mean the RUC? A committee dominated by specialists? Shocking.

 

[deleted87716]

You mean the RUC? A committee dominated by specialists? Shocking.

Somebody's been paying attention. Excellent.

 

[JackADeli]

...And, to Jack, I've never met a primary care physician who devalues specialists...

I find that hard to believe.... but I will just take your word for it. I know in my medical school and accross the country speaking to medical students the messages devaluing specialists, etc... is rampant. Much of the commentary through these forums do in fact play the ~class warfare arguments which in themselves go towards trying to increase the value of one side through ~devaluing the compared to side...

So, do you think that there IS a solution to the lack of PCPs? How else to entice them? Increased reimbursement is not "deserved."...

I don't claim to have the answer. But, to continually presume it is "disparity" that keeps medical students from entering primary care seems to me overly simplistic. There is a shortage of general surgeons to.... But, most PCPs I know express general surgeons are paid well or too much. As I stated previously, more money would not have enticed me into PC med. But, I do think there are personality traits and personal motivators to attract individuals that over work, over perform on exams, and all around highly competitive and then choose longer courses of training that leading to ~more rigorous career lifestyles. As stated by others in these forums primary care is easy to do badly and difficult to do well... flooding it with people simply seeking what $250, $350, or $450k with current lifestyle advantages... do you think that would improve healthcare? So, no, I don't have the answer.

...Both of you pay lip service to the difficulty of being in primary care ...but then pay a subtle insult by saying that they do not do enough complex work to be paid more or to have their debt burden taken away...

Vehemently disagree with your characterization in respect to my comments. There are reems and reems of my comments throughout this forum. I don't claim to know the "correct" amount of compensation for primary care. I have not said that PC does not perform enough complex work to be compensated more. I have posed the question repeatedly as to what others think (as opposed to simply feeling) should be a fair measure and/or answer. I don't throw it as an insult when posing the issue of how much aditional training one specialty endures vs another... 3yrs vs 5, 7, 9? I don't pose it as a subtle insult when posing the question about compensation for a physician that maybe works 9-5, 4days/wk with limited if any on-call, almost all weekends & holidays off, etc vs the physician working upwards of 7 days per week, significant on-call, numerous weekends and holidays, etc.... It is not an insult is is an attempt to ascertain what is going to be compensated what amount of ones life dedicated to the career is compensated. That conversation should not be an insult.

 

[bunnymd]

I find this entire debate very refreshing and quite interesting.

It seems that there is a subtle message that we are all as intelligent as the rest because we went to medical school and graduated while passing our USMLE exams. Nobody wants to admit that a high score on USMLE I or II entitles them to a high-paying profession. Apparently, it's just the training and time that is spent on said specialty that entitles somebody to an enviable income.

Well, I've graduated from a U.S. medical school and passed all of my exams without ever failing any test or class. I've also finished 2 fellowships after my family medicine residency. The first was geriatric medicine and the last was palliative care and hospice medicine. Based on time spent in residency and fellowship, I should be paid top dollar for my work and cognitive efforts. This is far from actual reality. My fellowships were entirely cognitive specialities that, incidentally, save insurance companies (including medicare) thousands of dollars. The savings is rooted in reduction of polypharmacy, re-admissions from nursing homes, un-compensated family meetings, etc. Please don't pretend that a procedure or radiation therapy is any more complex than conducting the family meetings and medical management that I engage in on a daily basis. If it were pure cookbook medicine and algorithims, my life would be a lot easier.

I am the physician who interprets many of the superfluous tests and exams that are performed. I am the guy who explains the risks and benefits of treatment. I am the one who does the "hand-holding" and gives (way more often than one would expect) the prognosis conversation to deluded patients sitting in a holding pattern in the nursing home.

Please don't try to compare apples to oranges. There is a huge disconnect between "cognitive" management and procedures in terms of compensation. I'm not crying about reimubursement because I knowingly chose the fields that I pursued. However, I do think that just because you inserted a tube into an orifice, zapped a mass with radiation, or told me to "clinically correlate" an abnormal finding, does not mean that you are entitled to a 3-fold compensation incentive compared to the time I spent with the same patient.

There are massive discrepancies in compensation. Just ask rheumatologists or infectious disease doc's. Time spent in training does not explain this discrepancy.

 

[JackADeli]

...It seems that there is a subtle message that we are all as intelligent as the rest because we went to medical school and graduated while passing our USMLE exams. Nobody wants to admit that a high score on USMLE I or II entitles them to a high-paying profession. Apparently, it's just the training and time that is spent on said specialty that entitles somebody to an enviable income.

Well, I've graduated from a U.S. medical school and passed all of my exams without ever failing any test or class. I've also finished 2 fellowships after my family medicine residency. ...Based on time spent in residency and fellowship, I should be paid top dollar for my work and cognitive efforts...

I am not sure exactly which "subtle" position/comment you refer. However, I will say that in USA in almost most professions work and high performance is financially compensated.... usually in the more work/higher performance = more opportunities/compensation. I agree our healthcare system is flawed in how it compensates. I agree effort and high performance.... i.e. top undergrad -> high MCAT -> high USMLE -> prolonged additional training/residencies -> +/- fellowships should be compensated.... And, yes, generally based on your described path, you should be paid top dollar and be proud to expect top dollar. However, it will always be difficult if "we" enter a room and speak to our years of "sacrifice" and joy and desire to provide "service" to the community and how "Mother Theresa" we are..... then the CEO will say, be happy my son with this token salary cause I know you really do it for the joy of giving.... and he (CEO) and all the other administrators go home collecting the dollars without shame because.... they went into it as a career with a mind on business.

...Please don't pretend that a procedure or radiation therapy is any more complex than conducting the family meetings and medical management that I engage in on a daily basis...

I sense your anger.... Again, as I have said I know PC medicine and PC subspecialty medicine is work.... as I quoted from someone else, PC medicine is far easier to do badly then it is to do well. I will not pretend I am qualified to do PC medicine cause at this point I would be one of those easily doing it badly.

...I am the physician who interprets many of the superfluous tests and exams that are performed. I am the guy who explains the risks and benefits of treatment. I am the one who does the "hand-holding" and gives (way more often than one would expect) the prognosis conversation to deluded patients sitting in a holding pattern in the nursing home...

I am not sure exactly what your job is.... But, The only tests "superfulous" or otherwise that my patients PC physician is interpreting are those ordered by the PC physician. Before someone gets another ant in their anus... let me say I don't refer to the tests as "superfulous"... because I didn't order them and I trust my PC physicians have order them for a reason.

Now, as for my patients, if I order tests and studies.... I actually interpret them (with few exceptions...) and discuss these results with them. I spend a great deal of time in the clinic discussing prognosis, treatment options, multi-modality, multidiscipline approaches, etc... I ABSOLUTELY would NOT send my patient to a PC physician for said physician to explain the risks and benefits of a proposed procedure (that I am going to perform).... in fact, my clinic dictations cite our (patient/family and my) discussion of risk & benefits and the consents also reference our discussions on this point. IMHO.... if your subspecialists surgeons/radiation oncologists/etc... are sending patients to you to discuss risks & benefits about what They plan to do.... they are incompetent. If you are assuming that role of discussing the risks and benefits of treatments you are not trained to provide and/or are not going to be providing.... your stupid. Both situations at the very least are huge malpractice liability issues and, IMHO have some real ethical considerations.

 

[bunnymd]

Jack,

The kind of medicine I perform is primarily nursing home medicine. The nursing home is where a lot of your hospitalized patients end up. They have a good deal of tests ordered on discharge that get followed up by me. And while there may be no superfluous tests ordered on gumdrop lane where you seem to practice, there certainly are plenty of them that end up on my lap.

I have no idea where you are coming from, but I certainly can explain risks and benefits of procedures that I'm not trained to do. I can explain to my 89yo with prostate cancer the risks and benefits of getting a colonoscopy after he got a form letter in the mail from his GI doc's office telling him he's due for his screening. In fact, I spent a great deal of time talking to pts about risks and benefits of procedures I'm not trained to do. I explain the risks and benefits of hospitalization to a frail 95yo who's discharge instructions included; "not a surgical candidate, transfuse prn." No f'ing joke.

 

[JackADeli]

...I am the physician who interprets many of the superfluous tests and exams that are performed. I am the guy who explains the risks and benefits of treatment...

...The nursing home is where a lot of your hospitalized patients end up. They have a good deal of tests ordered on discharge that get followed up by me. And while there may be no superfluous tests ordered on gumdrop lane where you seem to practice, there certainly are plenty of them that end up on my lap.

I have no idea where you are coming from, but I certainly can explain risks and benefits of procedures that I'm not trained to do. I can explain to my 89yo with prostate cancer the risks and benefits of getting a colonoscopy after he got a form letter in the mail from his GI doc's office telling him he's due for his screening. In fact, I spent a great deal of time talking to pts about risks and benefits of procedures I'm not trained to do. I explain the risks and benefits of hospitalization to a frail 95yo who's discharge instructions included; "not a surgical candidate, transfuse prn." No f'ing joke.

1. some... NOT alot of my patients do go to rehab, skilled nursing facilities, and/or long term care facilities. Yes, I try to assure the physicians involved in their care, including nursing home physicians get copies of test results.... but, I explain the results of the tests and studies I order... exceptions being those studies the PC md may ask I order on their behalf so, "I can have that result to discuss/treat adjust when I see them in clinic (i.e. HgbA1c, etc....)". Those might be the tests on discharge I would pass to a PC physician.

2. If I am going to perform a major procedure, I am going to explain the risks and benefits as I am legally going to be liable for "informed consent". I always send correspondence to PC physicians as to what we discussed and what plans may be. I always welcome PC physicians to be involved and provide me with feedback and/or particulars he/she may be privy to about a specific patient.... However, the PC physician taking it upon themself to be "the guy who explains the risks and benefits of treatment".... not in my fantasy "gumdrop lane" or whatever dream world you may perceive. I have seen more then a few situations in which a patient declined surgery because of the "explanation my family/primary/etc doctor gave about risks". I have seen them because they returned six months later with widely metastatic disease and their lawyer wanted me to explain my iopinion as to how appropriate it is for a physician untrained in particular field "x" "talking a patient out of" a potentially life saving procedure.... The conversation/attorney assertions goes something like this... "the patient would have had a chance at a cure or maybe a few more years with their family but Dr. Happy scared them away" or "told them the operation would not help". So, yes, I always include my colleagues in other specialties, especialy the primary care physicians. But, IMHO, in my crazy field of dreams, I think it is insane for any specialist to have someone that isn't trained to provide the therapy to be the one providing the risk benefit conversation.... It reminds me of those "expert witness" physicians giving testamony on subject matter they don't practice.

3. So, if you want the liability of explaining risk benefit of thyroid resection for cancer or colectomy for high grade dysplasia or cancer or esophagectomy for cancer or mastectomy for cancer or adjuvant therapies and you want to follow the PSA or CEA or TSH or etc..... Great, enjoy.

4. I specialize in a particular area of practice. there is vlumes per week if not per day of changing data on treatments, outcomes, do you operate, do you give chemo ad/or XRT up front or after resection. It is tons of material. Maybe you are the DrHouse of nursing homes and are fully read and up to date on the outcomes, benefits, etc... in addition to the vast amount of information a good primary care physician needs to keep up with to be a good primary care. I am not as good as you. I don't claim to be up to speed and as knowledgeable of PC. I surely do not get into risk/benefit discussions of the best meds or no meds to treat a patients chronic illnesses. I do however stay up on what I practice.

 

[lowbudget]

I have seen them because they returned six months later with widely metastatic disease and their lawyer wanted me to explain my iopinion as to how appropriate it is for a physician untrained in particular field "x" "talking a patient out of" a potentially life saving procedure....

3. So, if you want the liability of explaining risk benefit of thyroid resection for cancer or colectomy for high grade dysplasia or cancer or esophagectomy for cancer or mastectomy for cancer or adjuvant therapies and you want to follow the PSA or CEA or TSH or etc..... Great, enjoy.

And? What did you say?

Truth of the matter is that patients get information from all over the place. From friends, family, coworkers, psychics, hairdresser, anyone over dinner who will listen... and their family doctor, in addition to the surgeon. Why is it wrong for me to tell the patient how I perceive it?

See, the key word above isn't "life saving"... the key word is "potentially". And, what's left out was what's the potential that the procedure can be life "threatening"? Patients aren't stupid at least not the ones who ask questions and seek information. Surgeons aren't God. Their word is not final, and they use qualifiers like "potentially" to hedge because no one in this world knows what the outcome will be like, with OR without a procedure. So, why is it wrong for a patient to ask a doctor who has no financial interest in doing the procedure if a procedure is right for them?

"Untrained" is a loaded word and "talking them out" are loaded words. What do you mean, untrained? What qualifications are necessary to validate a patient who doesn't want a procedure done? A pair of functional ears? Why would I "talk someone out of a procedure" if a surgeon thinks it's best, and a patient wants it? Obviously, the case you described is one where either the surgeon can't guarantee a 100% good outcome or the patient wasn't all "bought into" the procedure in the first place. What's my incentive for "talking someone out of a procedure"? Nothing. And patients know this. That's why they come to us to ask further questions.

So, absolutely, family doctors have a role. Patients come to me all the time after visiting with a surgeon about a procedure just to get my opinion. Because, as a family doc, I was there when they were well and I was there when they were sick. I'm the one who diagnosed their cancer and broke the news with the family. It's absolutely appropriate for me to offer my opinion from my angle, my perspective, and provide context.

Don't try to intimidate me or the med students/residents reading this forum that family doctors have no role in patient care with lawyer stories and whatnot. That, we can't do our job and offer advice from the way we see it. How often are surgeons sitting on a witness stand as an expert witness testifying that a family doc was negligent and practicing outside their scope for a patient's decision for not doing a procedure after discussing that procedure with the surgeon and their family doc? I mean, what is there to debate? Statistics & likelihoods?

I tell my patients straight up "I'm not a surgeon" "I'm not an oncologist", but invariably, they say, "we know, but we want to know what you think". With that said, I educate myself with what they're up against. I educate the patient with my experience in the matter and what life's going to be like afterwards from my experience (and I tell them if I don't have no experience in the matter). And, I empower them to make their own decision, to do what's right for them, and live with it.

What's so wrong with that? I always leave the door open that you can die. Why? Because it's true. You can die if you do the procedure. You can die if you don't.

Does it bother the medical community that patients would rather listen to their family doctor than listen to a surgeon, after all that? Do people ever consider the fact that we know what we're doing and maybe we're doing what the patient wants to do?

As family doctors, we have a lot of responsibility to provide accurate information to our patients. This I agree with JAD. But, the truth of the matter is the family doctor is a very important person in the eyes of the patients. If the medical community has a problem with that, they need to get over it.

---> How Can We Encourage Medical Students To Choose Primary Care? We tell them that their patients need them.

 

[JackADeli]

..."Untrained" is a loaded word and "talking them out" are loaded words. What do you mean, untrained?...

So, absolutely, family doctors have a role...

Don't try to intimidate me or the med students/residents reading this forum that family doctors have no role in patient care with lawyer stories and whatnot...

I could go on and on... but I have read enough of your posts to believe you have a little more intellect then your rant suggests...

I have specifically stated PC medicine has a role in participating such care and to suggest otherwise is at best a red herring.. and I dare say you know that.

As for intimidation, again, a red herring, and again, I dare say you know that.

My points and replies were to specific comments by a specific poster:

...I am the guy who explains the risks and benefits of treatment. I am the one who does the "hand-holding" and gives (way more often than one would expect) the prognosis conversation...

...I certainly can explain risks and benefits of procedures that I'm not trained to do. ...

Ask him/her.... But, I stand by the statement, that any specialist FP/PC/Surgery/Gyn is the "guy" that explains the risk/benefit of procedure that he/she performs.... IMHO, it is at best unethical for "the guy" that explains risk/benefit to be someone other then the individual trained to perform and will be performing therapy x, y, z.... you can argue the point if you want and you can deem such a position as "intimidation" if you like... with someone else. With me, such an argument would be a waste of time.

If you missed that point of the discussion, please go back and re-read so you understand what is the point.

 

[bunnymd]

This debate continues to be interesting. I graduated from a residency with very intense surgical training. I have never claimed to have the knowledge or skills of a surgeon, but I did take call for many surgeons during my training and cared for many surgical patients. I was EXPECTED to perform as a "surgical resident" during that time (our attendings' expectations) and consent patients and explain risks and benefits of the procedures for which I would assist, or if I was lucky, be the primary on said cases. Part of the reward for studying the pathology of the patient, stabilizing them in the ED/ICU, consenting the patient, researching pertinent articles and admitting these patients was that I would get to be primary on the case. Granted, I wasn't primary on any "complicated" cases but I was at least the first assist.

If my attendings expected me to consent these patients as a RESIDENT, I believe that I am fully capable of directing an informed conversation about the risks and rewards of surgical interventions that I fully engaged in during training. I have seen innumerable H&P's performed by NP's and PA's prior to surgery where they are expected to do the same. I hesitate to admit that their skills and knowledge base are inferior to mine.

Patients end up in the surgeons' offices typically after they are sent by PCP's. Many times these patients do not even realize they have an option to say "no." If I know a patient's values and goals of care after multiple conversations with them and these goals don't align with the surgical intervention at hand, I will point that out to them. My training demands this.

I deal with elderly and frail patients. Many do not realize that as a result of an intervention they will have to be admitted to nursing homes and suffer serious (sometimes only temporary) decline in function. My job is to explain this to them. You would be quite surprised to know how many times a patient says "hell no" when they actually know what happens in a hospital and the sequelae of events that occur thereafter.

I make a cautious effort to never speak from a place of authority from which I have no merit. There are many times I plead with a patient to pursue therapies that align with their goals of care when their insight is lacking.

If you truly believe that PCP's have no place as an advisory role in the interventions of specialists, then you are simply not informed in regard to our role in health care. I think that you would prefer that we have those discussions with patients prior to their arrival on your doorstep.

The game of lawyer anecdotes can be continued ad infinitum when it comes to the unintended sequelae of procedures performed...

 

[JackADeli]

This debate continues to be interesting. ..

Not really.

...a residency with very intense surgical training...did take call for many surgeons during my training and cared for many surgical patients. I was EXPECTED to perform as a "surgical resident" during that time ...and consent patients and explain risks and benefits of the procedures for which I would assist, or if I was lucky, be the primary on said cases...

Great, and in theory, you told these patients "I am DrX's resident...". And when they had questions beyond they would speak to Dr X. But, you are describing a period of time when you were a resident. Again, in theory, during this intense training period, you would be reading and studying about the pending procedure, risks, benefits, indications, etc, etc..... Much of which has probably changed since you left this finite period of surgical training some years ago.... And yet, I would tell any resident, "No, you are NOT "the Guy" when it comes to informed consent, risk, benefit, indication, etc....". As the primary attending, I am "the Guy". Can I use some surrogates along the process... yes. But that is not what we are talking about and that is not what you were describing numerous responses earlier.

...Many times these patients do not even realize they have an option to say "no."...

then the physician that would be providing n intervention/therapy has failed to provide informed consent. That still does not make "you" or any other physician that is not going to be providing the therapy and/or is not part of the practice that is providing said therapy "the guy" to provide informed consent. My suggestion, instead of thinking your "the guy"... and remembering how ~important you felt as a resident on a surgical rotation... send the patient back to the physician to get properly informed and consented.

...I am the physician who interprets many of the superfluous tests and exams that are performed. I am the guy who explains the risks and benefits of treatment...

...If you truly believe that PCP's have no place as an advisory role in the interventions of specialists, then you are simply not informed in regard to our role in health care...

1...Yes, I try to assure the physicians involved in their care, including nursing home physicians get copies of test results....

2. If I am going to perform a major procedure, I am going to explain the risks and benefits as I am legally going to be liable for "informed consent". I always send correspondence to PC physicians as to what we discussed and what plans may be. I always welcome PC physicians to be involved and provide me with feedback and/or particulars he/she may be privy to about a specific patient.... However, the PC physician taking it upon themself to be "the guy who explains the risks and benefits of treatment".... not in my fantasy "gumdrop lane" or whatever dream world you may perceive...

Again, you are having some significant reading comprehension problems... no fears, you apparently are not alone. I at no point said PCPs have no role and/or advisory part to play when a specialist is going to provide an intervention/procedure/therapy. But, being involved is different then a PC physician telling me or any other physician that he/she "is the guy" that does the informed consent/risk benefit discussions, etc.... apples and oranges that you are now trying to mix.

...The game of lawyer anecdotes can be continued ad infinitum when it comes to the unintended sequelae of procedures performed...

There is no game and the point is only a lesser component of the entire discussion. The bigger issue is practicing medicine outside of one's field/scope of practice and on-going continuing medical education.

Final note... before folks get their thong stuck in a wedgy.... I understand the phrase "informed consent" was not used. That is irrelevant. "the guy" that explains risks and benefits of a procedure is assuming the role of informed consent even if not actually signing the consent form. So, we are talking about informed consent... which is further illustrated when a reply comes back suggesting the patients after discussion with a physician do not even now they have a choice?!?

 

[cali-ob]

I'm not exactly sure how to attract more medical students to primary care. Perhaps the more appropriate question is how can we attract more quality medical students to primary care?

As an FP resident who wasn't a bottom of the barrel med student, and who chose FP after realizing the specialty life I thought I wanted wasn't for me, it's disappointing to see the state of FP recruiting. For example, my program doesn't actively recruit and we have a top medical school associated with us. I feel like we are these sad lonely girls hoping for a date with a cute guy, but so scared we will end up with no one that we just take whatever guy looks our way. Thus the over abundance of poor performing US and carib grads and FMGs many of whom don't even seem interested in FP and are just looking for a way to get into this country for keeps. Its disgusting and pathetic and doesn't help the perception that FP is for low achievers.

By the way the above statement is in now way meant to be a bash on FMGs or carib grads. I'm talking about people who wouldn't be picked up by anyone else because they clearly aren't interested/qualified but get a spot anyway because we (FP) are so damn desperate.

Lastly, quite a few of my classmates went into FP. Many more went into surgery, rad, rad onc, derm etc. Those people were my friends. I don't have any less respect for them now as the dreaded money hoarding "specialists" than I did when we were all studying together, laughing together and learning together.
What's with all the cross specialty bashing? It's so juvenile and kinda reeks of poor self esteem. JAD makes many good points, and I don't believe he's against us. Many of you on this forum are just looking for a reason to argue.

Get back to the point of the thread.

 

[JackADeli]

I'm not exactly sure how to attract more medical students to primary care. Perhaps the more appropriate question is how can we attract more quality medical students to primary care?

As an FP resident who wasn't a bottom of the barrel med student, and who chose FP after realizing the specialty life I thought I wanted wasn't for me, it's disappointing to see the state of FP recruiting...

There are many that will disagree with me forever. I also appreciate there are significant competing agendas/political efforts. I believe these will continue to hurt primary care recruitment.

...It isn't the hours or lifestyle. It IS the work. Each needs to choose a specialty for which the work matches your interests. For me, surgical work is far more stimulating and exciting. I much rather get up at 2 am for a surgical concern/issue then a DKA. That is what it comes down to.

Those that choose their specialties on primarily lifestyle or other considerations are the ones I have met looking for ways out after 5-10yrs or very bitter. i.e. the surgeon that does little surgery or IM does little patient care and tries to be hospital administrator. Most, I speak with did not dream of being an administrator... they just grew to despise their job. They chose wrong.

Let's get real and open our eyes. What is the major component of a physicians day to day lifestyle? It is your job. If your 9-5 portion of lifestyle sucks.... your lifestyle primarily sucks!

I found my IM rotation to be very educational and intriguing. I learned a great deal....

When all was said and done, during medical school, I was impressed with the IM fields. Those that provided my IM education were impressive and exceptional clinicians. However, I also knew it was not the type of work I wanted to do for 20-30 years.

My points as cited above and elsewhere are:

1. you are not going to recruit the best and brightest if your sales pitch is.... you will have a lot of free time outside of your actual job. You need to recruit people for the actual job not the vacation time.
2. you are not going to recruit the best and the brightest if your sales pitch is something like..... ~your residency will be pretty easy and shorter compared to the alternatives.
3. you are not going to recruit the best and the brightest if the loudest message they hear is akin to ~we are victims of the societal healthcare industry, not going to be paid, at war with the overpaid specialists.

I just believe, IMHO, the message/sales pitch/etc... is self defeating. Should physicians of all specialties be paid? Yes, absolutely! But, continued and excessive focus on the dollars as the primary reason for or against recruitment of quality candidates is naive at best. Too many med-students just never learn what a specialty is about. As noted by some, they chose other sub-specialties and then changed to PC when they realized PC was their true interest. I have a friend, top medical school, actually highest board scores out of class ~200. He was sure he wanted ortho. After careful & smart assessment and questioning, he chose PC medicine.

Again, the loudest message I hear from students, physicians, TV, politicians are not messages that would in any field recruit the best and brightest! In many ways, the largest barrier to good recruiting rests squarely on the shoulders of numerous PCPs. The bitterness, the anger, righteous or not is poisoning the water and perpetuates the problems.... again just my opinion.

Ask yourself, "am I selling the job or complaining about what I don't like?". To recruit, sell the job, sell why you love what you do, sell the excitement that gets your juices flowing and wanting to come back in the morning for another day.

I would argue, if you can not find this sales pitch in your job, you are in the wrong job..... be it school teacher, fire fighter, forest ranger, bread baker, etc, etc.... sell the damn job!!!

 

[deleted87716]

Anonymous posts on SDN do not necessarily reflect the actual efforts and message of organized family medicine.

If you want the facts, feel free to visit: http://fmignet.aafp.org/online/fmig/index.html

 

[2012mdc]

There are many that will disagree with me forever. I also appreciate there are significant competing agendas/political efforts. I believe these will continue to hurt primary care recruitment.My points as cited above and elsewhere are:

1. you are not going to recruit the best and brightest if your sales pitch is.... you will have a lot of free time outside of your actual job. You need to recruit people for the actual job not the vacation time.
2. you are not going to recruit the best and the brightest if your sales pitch is something like..... ~your residency will be pretty easy and shorter compared to the alternatives.
3. you are not going to recruit the best and the brightest if the loudest message they hear is akin to ~we are victims of the societal healthcare industry, not going to be paid, at war with the overpaid specialists.

I just believe, IMHO, the message/sales pitch/etc... is self defeating. Should physicians of all specialties be paid? Yes, absolutely! But, continued and excessive focus on the dollars as the primary reason for or against recruitment of quality candidates is naive at best. Too many med-students just never learn what a specialty is about. As noted by some, they chose other sub-specialties and then changed to PC when they realized PC was their true interest. I have a friend, top medical school, actually highest board scores out of class ~200. He was sure he wanted ortho. After careful & smart assessment and questioning, he chose PC medicine.

Again, the loudest message I hear from students, physicians, TV, politicians are not messages that would in any field recruit the best and brightest! In many ways, the largest barrier to good recruiting rests squarely on the shoulders of numerous PCPs. The bitterness, the anger, righteous or not is poisoning the water and perpetuates the problems.... again just my opinion.

Ask yourself, "am I selling the job or complaining about what I don't like?". To recruit, sell the job, sell why you love what you do, sell the excitement that gets your juices flowing and wanting to come back in the morning for another day.

I would argue, if you can not find this sales pitch in your job, you are in the wrong job..... be it school teacher, fire fighter, forest ranger, bread baker, etc, etc.... sell the damn job!!!

Isn't lifestyle a major reason for the competitiveness of the ROAD specialties?

 

[JackADeli]

Anonymous posts on SDN do not necessarily reflect the actual efforts and message of organized family medicine.

If you want the facts, feel free to visit: http://fmignet.aafp.org/online/fmig/index.html

I appreciate that web link and resource....

But again, the ~facts (more accurately, regular experiences) I speak of are what I see. If medical students are seeing strong and positive messages about PC medicine everywhere else.... great. But, the message and marketing I see and hear from numerous PC physicians, TV reporting, TV med correspondents, politicians, and probably most telling medical students is not one that suggests a particularly good recruitment effort is underway. Rather, the loudest message I am hearing currently is that "low pay" and "disparity in pay" are the main reason for poor recruitment. However, we have been around that block a million times.

My post is simply to put my impression and suggestions on how to recruit medical students to PC medicine. I say, if you want to recruit for the best and brightes you sell the job.... not the vacation plan or the negatives. I was not sold into surgery based on hours, lifestyle, or any belief of great pot of gold. I was sold on the excitement of surgery. An excitement clearly seen on the faces of my mentors that had the glow the likes of which I have only seen in a 2nd trimester pregnant lady!

Isn't lifestyle a major reason for the competitiveness of the ROAD specialties?

I can't tell you all the reasons. But if it was purely lifestyle then I believe PC med would see a massive surge. But, again, depends on your definition of what comprises lifestyle. My lifestyle encompasses very long hours of exciting practice in the surgical field. If my lifestyle involved the majority of my waking hours being in a dark room reading mammos and CXRs..... that would be a sorry lifestyle (to me).

 

[deleted87716]

the ~facts (more accurately, regular experiences) I speak of are what I see.

The pleural of "anecdote" is not "fact."

Again, if you're at all interested in knowing what we're actually doing to recruit students to family medicine, visit the link that I previously provided.

Don't confuse recruiting efforts with payment reform efforts. They are not the same thing.

 

[lowbudget]

1. you are not going to recruit the best and brightest if your sales pitch is.... you will have a lot of free time outside of your actual job. You need to recruit people for the actual job not the vacation time.
2. you are not going to recruit the best and the brightest if your sales pitch is something like..... ~your residency will be pretty easy and shorter compared to the alternatives.
3. you are not going to recruit the best and the brightest if the loudest message they hear is akin to ~we are victims of the societal healthcare industry, not going to be paid, at war with the overpaid specialists.

Agreed.

This is not a universal truth. When I was a resident helping out with recruiting, interviewing, and admissions, we were snatching up junior AOA's, 260's on both Steps, class presidents, and overall good people. Interesting people. What tipped you over from into Rank-to-Match was likability, class, social skills, maturity, and passion.

Universally, these kids weren't afraid of going against the grain. Everyone reported some toxic loud-mouth, trash-talking resident/attending at their med school with low budget social skills talking about someone's career choice. But, despite stellar grades etc. they chose (not just) "primary care", (but) family medicine in particular for whatever personal reasons they had.

There are some on SDN who have been talking about recruiting the best and brightest into family medicine WAY before the "crisis" because vogue.

The truth of the matter is, when you're competing against so much noise, the only time the popular press/politicians will pay any attention to anything is when there's a "crisis". The difference between then and now is that back then it was the family docs trying to recruit. Now, it's the patients who are trying to recruit more med students into family medicine.

 

[lowbudget]

I could go on and on... but I have read enough of your posts to believe you have a little more intellect then your rant suggests...

I love me some SDN. LOL!

 

[2012mdc]

Agreed.

This is not a universal truth. When I was a resident helping out with recruiting, interviewing, and admissions, we were snatching up junior AOA's, 260's on both Steps, class presidents, and overall good people. Interesting people. What tipped you over from into Rank-to-Match was likability, class, social skills, maturity, and passion.

Universally, these kids weren't afraid of going against the grain. Everyone reported some toxic loud-mouth, trash-talking resident/attending at their med school with low budget social skills talking about someone's career choice. But, despite stellar grades etc. they chose (not just) "primary care", (but) family medicine in particular for whatever personal reasons they had.

There are some on SDN who have been talking about recruiting the best and brightest into family medicine WAY before the "crisis" because vogue.

The truth of the matter is, when you're competing against so much noise, the only time the popular press/politicians will pay any attention to anything is when there's a "crisis". The difference between then and now is that back then it was the family docs trying to recruit. Now, it's the patients who are trying to recruit more med students into family medicine.

This is very true. I've had numerous patients recruiting me on my FM rotation.

Question - Is the residency you went to considered a top program in FM? Top programs in any specialty attract the best of the best

 

[MOHS_01]

Man o' man, the whole of this thread is truly worthy... from the "mine is bigger than yours" to the "I deserve it" to the "but I worked harder than you" to the "but we are the backbone of healthcare" on and on... same tired old arguments that can reach no conclusion or resolution because they have nothing more than paper thin meritorious underpinnings (at best). Rather than pointing out the number of ways that bronx is correct, I'll leave it be (for I sincerely doubt that many will be open to altering their preconceptions anyway). FWIW, at one point in time or another I made similar fallacious arguments -- then I entered the workforce and started a solo practice...

If you want to entice students into primary care it is quite simple -- find out what motivates their decisions and start by addressing those.... and I do not see how to do this without institutionalizing class warfare within the house of medicine. In fact, considering Medicare's central role in pricing -- and it's quasi-zero-sum nature -- I would virtually guarantee it.

 

[JackADeli]

The pleural of "anecdote" is not "fact."...

Which is why I specified.... we can get nit-picky and distracted as usual if that is your preference. But, it misses the point. Ultimately effective and/or successful recruitment is going to be largely determined by the experiences and/or perceptions of the medical students, i.e. targets of the effort and ultimately the level of talent you hook from the target group. My opinion/impression/anectdote, etc.... suggests to me the current recruitment efforts may need to be re-evaluated. Again, yes, my opinion based on anecdote (and even the forums asking how to recruit...).... as well as data published as to the recruited residents.

...Again, if you're at all interested in knowing what we're actually doing to recruit students to family medicine, visit the link that I previously provided.

Don't confuse recruiting efforts with payment reform efforts. They are not the same thing.

I checked your link the first time.... thus my point in thanking you for it. As to confusing the issues, I am quite aware of the differring issues as I have pointed out and/or inferred here and elsewhere. Again, somewhat of a distractor.... Ultimately, recruiting should consider if other agendas/efforts are competing and/or harming. If so, priorities should be determined and all pending projects adjusted accordingly to maximize the efforts.....

...I also appreciate there are significant competing agendas/political efforts. I believe these will continue to hurt primary care recruitment...

...The difference between then and now is that back then it was the family docs trying to recruit. Now, it's the patients who are trying to recruit more med students into family medicine.

If that is the case, it has gone from a buyers market to a sellers market iun terms of the service PC physicians provide. Thus, PCPs should employ better business models to sell... embrace the concierge, embrace getting paid, etc, etc.... dump the excessive Ghandi/Mother T service and sacrifice sales pitch. Again, without spending too much time trying to hash out and go in circles on the issues of self defeating and/or competing agendas.

 

[deleted87716]

I'm not being "nit-picky," Jack. I'm being concise and specific. You should try it sometime.

 

[JackADeli]

I'm not being "nit-picky," Jack. I'm being concise and specific. You should try it sometime.

OK, sure... You are making clear my statement, obviously it was written in a manner that would confue and/or mislead.... though, I would suggest that if any residency potential recruit failed to understand the statement and/or clarifiers, have them, they are all yours....

Now, glad for your clarifying the point, sure isn't about being nit-picky. Probably the "~" confused everyone. Probably the parenthesis further clarifying confused everyone.

...the ~facts (more accurately, regular experiences) I speak of are what I see...

I obviously did not use perfect wording and so we can distract and focus on that. I guess I could have used ~"the facts of my personal experiences.....". Of course then wait for you to tell me that is the definition of anecdote, etc....

Yep, a lack of concise verbage is the problem... I clearly remember that from previous posts in which what I wrote have been completely ignored, no matter how specific the statement, in order for peoples' interpretations/feelings/assumptions to be the point of debate.... yep spent post upon posts pointing people back to exactly what was stated and etc.... Yes, discussion will be greatly improved if we assure every punctuation and exact and perfect wording is used.

 

[lowbudget]

If you want to entice students into primary care it is quite simple -- find out what motivates their decisions and start by addressing those.... and I do not see how to do this without institutionalizing class warfare within the house of medicine. In fact, considering Medicare's central role in pricing -- and it's quasi-zero-sum nature -- I would virtually guarantee it.

Class warfare? Meh.

The debate reminds me of a classical one: How do we best govern ourselves? How do we best achieve representation when power and money are at stake?

Very similar to the debate during the 13 Colonies. Large populated colonies wanted representation based on number of citizens, while small colonies wanted representation based on number of colonies. In the end, they compromised on both. Inefficient system, but fair.

Our payment system under Medicare underrepresents primary care doctors in proportion to the number of doctors who practice primary care. At the RUC, each specialty sends 1 specialty. That means, a small specialty has an equal voice than a large specialty. And it's easier to drown out the voice of the large specialty if the small specialties band today.

The good news (for medical students) is that this is no secret. That, there is recognition to get better representation for primary care specialties at the negotiating table when they debate the central prices.

AAFP to CMS Administrator Berwick: Consider Changes to RUC
http://www.aafp.org/online/en/home/...ow/government-medicine/20101022rucletter.html

Ok, class warfare? Maybe. It's a struggle for power and money. But, honestly, anything less would be considered un-American.

 

[lowbudget]

If that is the case, it has gone from a buyers market to a sellers market iun terms of the service PC physicians provide. Thus, PCPs should employ better business models to sell... embrace the concierge, embrace getting paid, etc, etc.... dump the excessive Ghandi/Mother T service and sacrifice sales pitch. Again, without spending too much time trying to hash out and go in circles on the issues of self defeating and/or competing agendas.

Wow, it really bothers you that some medical students go into medicine and primary care for this reason.

You know, it's not impossible to maintain high-value services without giving up on service & sacrifice.

Look at Cancer: driven by compassion and personal/family experiences, medical students chase careers focused on the War on Cancer in hematology/oncology, gynecology, surgery, urology, and radiation oncology. Especially pediatrics hem/onc, which is the mother of Mother T. I'm sure every one of these Cancer Fighters have at least been bitten by Ghandi & Mother T at least once to serve and help people; and yet their services remain one of the MOST expensive in the health care system. So much so that insurance companies carve it out & sell supplemental insurance; and even deny those with pre-existing cancers because treating cancer is so expensive.

Service & getting paid are not mutually exclusive nor are they trade-offs.

But, here's to holding my breath that they will pay me as much for giving a Gardasil vaccine as they do for the total cost of treatment for cervical cancer... I mean, seriously. Do you really think it's a failure in marketing, recruiting, and business models on the ground level? Or, maybe something up top is rather messed up?

 

[JackADeli]

Wow, it really bothers you that some medical students go into medicine and primary care for this reason....

Please don't.....

I am trying to discuss issues of recruitment and/or their failures. I have absolutely no problem for folks going into medicine, primary care.... or yes other specialties for altruistic reasons. So, I again say, please don't....

What bothers me is that "we" as physicians allow our altruism to be used against us... Been over it a dozen times throughout.... Getting back to the question of recruitment, one must ask what you want to recruit and accept that maybe, just maybe there is going to be conflict in the objective.

You want to recruit the "best & brightest" then one needs to be honest and clear.... Recruiting based on "some" and/or presuming most do not have some altruism may be problem. To sit back and say ~"poor pay" is the biggest reason for poor recruitment is again, as stated on numerous occasions, is a problem.

So, who does primary care want to recruit? Answer that question and then sell the appropriate "product" to the appropriate "customers". IMHO, use some sound business sense. Physicians, accept "we" sell a good or service and demand compensation and market accordingly. Training programs you want to recruit? Then recognize you want a population to buy what you are selling. You want a certain "clientel"? You adjust accordingly.

PS: 90+% of my practice is oncology

 

[MOHS_01]

...
Ok, class warfare? Maybe. It's a struggle for power and money. But, honestly, anything less would be considered un-American.

You have a very f'ed up view of what it means to be "American" if you consider political rent seeking behavior as a proper metric. Perhaps feudalism... or imperialism... or perhaps instituting a more proper bourgeoisie democratically controlled system is more your cup of tea. Yay numbers. Yay democracy.

 

[MOHS_01]

Class warfare? Meh.

The debate reminds me of a classical one: How do we best govern ourselves? How do we best achieve representation when power and money are at stake?

Very similar to the debate during the 13 Colonies. Large populated colonies wanted representation based on number of citizens, while small colonies wanted representation based on number of colonies. In the end, they compromised on both. Inefficient system, but fair.

Our payment system under Medicare underrepresents primary care doctors in proportion to the number of doctors who practice primary care. At the RUC, each specialty sends 1 specialty. That means, a small specialty has an equal voice than a large specialty. And it's easier to drown out the voice of the large specialty if the small specialties band today.

The good news (for medical students) is that this is no secret. That, there is recognition to get better representation for primary care specialties at the negotiating table when they debate the central prices.

AAFP to CMS Administrator Berwick: Consider Changes to RUC
http://www.aafp.org/online/en/home/...ow/government-medicine/20101022rucletter.html

Ok, class warfare? Maybe. It's a struggle for power and money. But, honestly, anything less would be considered un-American.

After reading this again... you need to slow down, read what you write, and proofread just a little. It is hard as hell to follow fleeting thoughts in broken English.

If you actually employed your own logic using the "13 colonies inefficient, but fair" you would realize that your ensuing complaint does not follow as the RUC largely employs a similar structure.... and that you are decrying a statistical misrepresentation based upon relative population sizes. You are a populated state.

...and I have always said that E&M is underpaid -- whether or not it is undervalued across the board in the RVU system is a much more difficult position to argue, however, given that I see great discrepancy in the profitability of various procedures that I perform. I can relatively rack up doing quick E&M and minor procedures relative to the >1hr reconstructions that I commonly perform. Again, everything is relative...

 

[lowbudget]

If you actually employed your own logic using the "13 colonies inefficient, but fair" you would realize that your ensuing complaint does not follow as the RUC largely employs a similar structure.... and that you are decrying a statistical misrepresentation based upon relative population sizes. You are a populated state.

Meh. I knew the analogy would get lost somewhere.

Help me understand. If FP's are the "populated state"... why is it that I only get 1 vote on the RUC? Shouldn't FP's have more?

And, if primary care only has 5 representatives, *and* if it takes 2/3's majority to pass a measure, how can primary care overcome a 2/3's majority when a measure is clearly anti-primary care?

What Every Physician Should Know About the RUC
http://www.aafp.org/fpm/2008/0200/p36.html

The RUC's deliberations are complicated by the fact that the size of the Medicare payment pie is fixed; a bigger slice for primary care means a smaller slice for surgery, and vice versa. The following quote from Tom Scully, former administrator of CMS, captures the essence of the process: "Essentially, we sit down with [RUC] every year and say, ‘Here's $43 billion and growing, how do you want to [divide it]? What's the relative value of weights between anesthesiologists, gastroenter-ologists, surgeons?' and set the relative values at what the physician community thinks the relative payment should be."

CURRENT RUC COMPOSITION

The RUC has 29 members, each of whom has one vote. Recommendations regarding relative values must be approved by a two-thirds majority. Only five seats are currently occupied by physicians in what the AAFP considers primary care specialties. Those are in bold below.

Chair (appointed by the AMA) CPT Editorial Panel Representative
American Medical Association Representative
Health Care Professionals Advisory Committee Representative
American Osteopathic Association Representative
Practice Expense ReviewCommittee Representative
Anesthesiology (American Society of Anesthesiology)
Ophthalmology (American Academy of Ophthalmology)
Cardiology (American College of Cardiology)
Orthopaedic Surgery (American Academy of Orthopaedic Surgeons)
Dermatology (American Academy of Dermatology)
Otolaryngology (American Academy of Otolaryngology, Head and Neck Surgery)
Emergency Medicine (American College of Emergency Physicians)
Pathology (College of American Pathologists)
Family Medicine (American Academy of Family Physicians)
Pediatric Surgery* (American Pediatric Surgical Association)
Gastroenterology* (American Gastroenterological Association)
Pediatrics (American Academy of Pediatrics)
General Surgery (American College of Surgeons)
Plastic Surgery (American Society of Plastic Surgeons)
Geriatric Medicine* (American Geriatrics Society)
Psychiatry (American Psychiatric Association)
Internal Medicine (American College of Physicians)
Radiology (American College of Radiology)
Neurology (American Academy of Neurology)
Thoracic Surgery (Society of Thoracic Surgeons)
Neurosurgery (Congress of Neurological Surgeons)
Urology (American Urological Association)
Obstetrics/Gynecology (American College of Obstetricians and Gynecologists)
--------------------------------------------------------------------------
*rotating seat

At times, the debate can be vigorous – particularly when a specialty society presents work values that appear obviously inflated. However, the vast majority of work values are approved as presented by the specialty society. RUC rules require a two-thirds majority to approve any recommendation regarding relative values. When specialty society recommendations fail to pass the RUC on an initial vote, they are generally referred to a "facilitation" committee of the RUC (i.e., an ad hoc subcommittee appointed by the RUC chair) to develop a recommendation that is acceptable to both the presenting specialty and the RUC.

AAFP to CMS Administrator Berwick: Consider Changes to RUC
http://www.aafp.org/online/en/home/...ow/government-medicine/20101022rucletter.html

The Academy also asked Berwick to encourage more transparency in the RUC process, as well as a "fundamental change in the composition of the RUC that more equitably recognizes the value of primary care."

Based on previous CMS decisions -- such as the recent redistribution of work values to codes that support evaluation and management services most often provided by primary care physicians -- it is apparent that CMS "recognizes that a high-quality, efficient health care system must rest on a foundation of primary medical care," said Heim.

"Unfortunately, the composition of the RUC does not demonstrate a similar recognition," she added, noting that primary care currently has, at most, five seats on the RUC.

"We would encourage CMS, again as the primary recipient and user of the RUC's product, to insist on greater input from true primary care members of the RUC, consistent with the agency's emphasis on primary care as essential to a high-quality, efficient health care system," said Heim.

 

[lowbudget]

So, who does primary care want to recruit? Answer that question and then sell the appropriate "product" to the appropriate "customers". IMHO, use some sound business sense. Physicians, accept "we" sell a good or service and demand compensation and market accordingly. Training programs you want to recruit? Then recognize you want a population to buy what you are selling. You want a certain "clientel"? You adjust accordingly.

Hmm, yea, sorta, kinda... our business models differ. Simplistically, surgeons sell goods. Family doctors, we sell service.

Consumers want to know how good a surgeon's hands are, how reliable is it, how often does it mess up, and how good does it perform, much like a washing machine or a car. It's very easy to judge a surgeon. Either the surgery works or it doesn't work; and what differentiates you from your peers are your outcomes.

For family doctors, it's different and harder to put your finger on it. It's not about the medicine (which is essentially a commodity). Metformin is metformin. Anybody can write amoxicillin. Because we are in a service-business, our business (i.e. what we "sell") is the relationship, the trust. We are like financial advisors, accountants, and lawyers. We are judged by how attentive we are, how accessible we are, and how caring we are. That's what differentiates us from each other.

I tell med students when they rotate with me is that patients will tolerate an @sshole surgeon because at the end of the day, all patients care about are how good the surgeon's hands are and not good their personalities are.

But not us. Patients have low tolerance for douchbag family doctors. If they can't develop that relationship, they'll bolt. If you don't have it in you to, literally, "take care" of people, don't do primary care.

So, to me, it's ok that we continue to recruit people who are passionate about serving, who are all about being Ghandi & Mother T. I hope we don't stop doing that because that's good business. That IS what we sell.

My personal opinion is that the best doctors are the ones who take a page out of the other person's playbook: A surgeon with excellent hands who's passionate about serving and a family doctor with excellent patient relationship skills who can deliver results. I think we can all agree that these are the medical students we ALL want to recruit.

 

[MOHS_01]

Look -- I'm not a fan of the RUC. I'm not a fan of the RBRVU system. I dislike the AMA, CMS, and most self serving specialty PACs. I would also like to say that setting a goal is great and all, but when the endpoint includes some undefinable concept such as "high quality, efficient" whatever it constitutes an unattainable goal. This is the problem with many, if not most, centrally planned or designed systems -- which seem to be the only kind that committees, including government and specialty societies, can implement. An open ended/non-ending goal is the same thing as a moving goalpost; it is great to say that we need X% of people screened for this or Y% of people counseled for that... but to speak in non-specific and undefinable terms (as is done with most position statements that I read) is really futile.

Consequential decision making committees and organizations evolve into nothing more than political power structures. They have always been exploited, and the RUC is probably no different. I would love to hear the definition and basis of "obviously inflated", by the way, as well as the frame of reference and knowledge base from which the judging party is basing his opinion. That would be interesting indeed.

...as for the constitution of the RUC: what if you were a radiation oncologist? Nuclear medicine? One of many specialties who occasionally get a rotating seat? Try to step back from your narrow vantage point for one moment, rinse that God awful (pervasive) bitter taste from your mouth for one second, and point to any single specialty whose voice is not merely represented -- but carried with such a weight as to be able to force their limited / specialty specific agenda down the throats of the remaining counter interests with ease.... unless you are going to go all conspiracy theorist on us and say that the OB's and surgeons are playing footsie under the table with the radiologists or the derms so that they can inflate their specialty specific codes... in light of the knowledge of the zero-sum nature of RVU changes. Yes, seems not only plausible -- but likely, does it not?

 

[lowbudget]

Look -- I'm not a fan of the RUC. I'm not a fan of the RBRVU system. I dislike the AMA, CMS, and most self serving specialty PACs. I would also like to say that setting a goal is great and all, but when the endpoint includes some undefinable concept such as "high quality, efficient" whatever it constitutes an unattainable goal. This is the problem with many, if not most, centrally planned or designed systems -- which seem to be the only kind that committees, including government and specialty societies, can implement. An open ended/non-ending goal is the same thing as a moving goalpost; it is great to say that we need X% of people screened for this or Y% of people counseled for that... but to speak in non-specific and undefinable terms (as is done with most position statements that I read) is really futile.

Consequential decision making committees and organizations evolve into nothing more than political power structures. They have always been exploited, and the RUC is probably no different. I would love to hear the definition and basis of "obviously inflated", by the way, as well as the frame of reference and knowledge base from which the judging party is basing his opinion. That would be interesting indeed.

...as for the constitution of the RUC: what if you were a radiation oncologist? Nuclear medicine? One of many specialties who occasionally get a rotating seat? Try to step back from your narrow vantage point for one moment, rinse that God awful (pervasive) bitter taste from your mouth for one second, and point to any single specialty whose voice is not merely represented -- but carried with such a weight as to be able to force their limited / specialty specific agenda down the throats of the remaining counter interests with ease.... unless you are going to go all conspiracy theorist on us and say that the OB's and surgeons are playing footsie under the table with the radiologists or the derms so that they can inflate their specialty specific codes... in light of the knowledge of the zero-sum nature of RVU changes. Yes, seems not only plausible -- but likely, does it not?

Well, I don't know what goes on behind the scenes during these RUC meetings as I am not privy to the conversations, the games, and the politics that occur. Nor do I know what the political wherewithal radiation oncology and nuclear medicine has with the RUC.

What I do know is that there appears to be a design flaw prima facie in the RUC's make up. A built-in structural defect. This is well known to everyone, and it has yet to be disputed. I would love to be the off-base conspiracy theorist here, but all accounts point to the contrary.

No matter what your personal opinion is over centralized control over the health care pricing and the mixed public-private medicopolitical economy, the fact is that this is the system we have, it's one that we all work in, and it's not going away any time soon.

What we can do is push incrementally to fix the problem, which to AAFP's credit is what they're trying to do. Primary care can't be the unintended consequence of an inefficient system. No one can afford that, and I think the faster people understand that, be quicker we can move on.

The message stands and it is clear: Medical students -- "It gets better."

 

[MOHS_01]

Kudos for coherency. Negative kudos for the duck and dodge.

OK, champ, explain to me this: what of the representation of those non ABMS recognized specialties who have absolutely zero chance for a seat at the table? What would your opinion be if, say, such a specialty goes through their periodic revaluation review, provides the requested documentation, jumps through the hoops, has their RVU valuations edited accordingly -- all by the existing rules of the game, mind you, and without "undue voting privilege" on the voting body -- only to have CMS go to the "independent" RVU RUC and say "devalue code X - or else". Code X gets arbitrarily devalued at the explicit request of CMS -- contrary to all established rules and procedures. What is your opinion of the justice in that? Now what if code X comprised 50% of your billable services?

PCPs really are not the only group getting assraped by the system, they just have a louder voice to complain.

 

[JackADeli]

Hmm, yea, sorta, kinda... our business models differ. Simplistically, surgeons sell goods. Family doctors, we sell service...

We both sell goods and services. yes, you can try to define yourself as different, either way, in the market place, trying to sell something.... Hence my point about recruiting residents.... each program is in effect trying to sell to candidates in the hope of obtaining the best candidate....

...Consumers want to know how good a surgeon's hands are, how reliable is it, how often does it mess up, and how good does it perform, much like a washing machine or a car. It's very easy to judge a surgeon. Either the surgery works or it doesn't work; and what differentiates you from your peers are your outcomes....

Very, very misinformed at the least and exceedingly arrogant at worst. You aren't going to be practicing if your outcomes are not at least similar if not equal to your competitor. Some patients may ask about "hands". Maybe, they are asking you.... and since you you feel/think it easy to judge a surgeon you give your opinion. However, your statement is very ill informed of what reality is and what patients consistently define as a good surgeon vs a bad surgeon.... What differentiate a good surgeon from a bad surgeon is rarely the issue of outcome and more the issue of the relationship, compassion, communication, etc...

...For family doctors, it's different and harder to put your finger on it. It's not about the medicine (which is essentially a commodity). ...Because we are in a service-business, our business (i.e. what we "sell") is the relationship, the trust. We are like financial advisors, accountants, and lawyers. We are judged by how attentive we are, how accessible we are, and how caring we are. That's what differentiates us from each other...

Yes, your so very special... you sell trust, while... we surgeons only sell hands... Of course there is no concern about trusting someone to put a knife on you or be there when you wake up or gudie you through much of the frightening things associated with surgery. Oh no, primary care is selling trust and relationships. Surgeons? We sell good hands, it's all so easy to judge.....

Again, bewteen-specialty classwarfare, etc.... does not help with recruitment, does not help with multi-specialty working together. The age of defining one group as "cognitive" and the other group as "technicians", which is a facade of saying one group is a doctor while the other group is not, really needs to end. And, yes, someone can declare themselves of great but undefineable value... that is somewhat self serving. Especially, when it is coming from an individual that is at the same time declaring an ease of judge of a different group. If one can not clearly define their value, you are going to have difficulty marketing. It will be hard to market to recruits and hard to market to clients/society. The claims of being different and defining your worth by ~classwarfare esque techniques and nebulous "we're different" approach doesn't work.

 

[Ronin2258]

The question is posed; how do you sell more medical students to go into primary care?

There were several things that killed it for me as a student, despite trying to keep open. I rotated through 4 FM places, (2 academic/military and 2 private practice,) total. Between the 4 places, they unfortunately, collectively killed any thought of making primary care a permanent career for me. As follows:
1. Attitudes from the attendings, who were miserable from some of what is described in this thread. That made me feel unwanted.
2. I hate the idea being in business alone with all the logistics and personnel issues, which seems to be more common in the primary care fields (neither PP Family Medicine doctor was hospital affiliated.)
3. It felt I was never doing enough for the patient in the time allotted. There were a lot of social issues that I felt weren't addressed correctly, despite best efforts. I felt helpless.
4. Seeing the same patients over and over, with no change in their condition due to lack of compliance. Despite the best counseling both the attending and I could do, I felt helpless again. Yet the patient blamed us for not improving their situation. That made me feel abused, questioning my own adequacy.

IF I was still in service, the appeal to being a flight doctor or other opportunities were making it look pretty interesting, just to do something else.

My bills are less than what most of my classmates have by happy circumstance (by third to a half, depending on the comparison.) So money wasn't an issue. I would be perfectly satisfied with the salary average for the field as long as it helped eliminate the debt I do have in a reasonable time, covered malpractice, and left enough to live adequately on. But the above reasons would sap any satisfaction I would get from the job. Hats off to those who can deal with that regularly, you are doing something that had me going to pieces with frustration nightly until the rotations were over.

Set the money issue aside for a moment and ask the question again. Let's also forget I am not as cynical as I am now. Let's say I am a bright, wide-eyed student rotating through your office, 4.0 with a Step I score well over 220, with no leanings in any direction. You have a good chance to sell me on the idea of being FM. What could you say or do to get me to start listing FM programs on ERAS during fourth year?