Monday, November 14, 2011

Why There are and Will be Fewer and Fewer Primary Care Doctors

     Of necessity, because "man is an economic animal" the different providers of medical care will have different opinions of any payment plan. Internists, psychiatrists, plastic surgeons, anesthesiologists, dermatologists, general surgeons, heart surgeons, orthopods, urologists, oncologists, interventional radiologists, just to name a few of the divisions of medical specialties. We should also add the question of solo or group practice (many fewer solo practitioners today), and practice as private entities or as  employees of a hospital. The happiest doctors, of course, are the plastic surgeons and the dermatologists who do plastic dermatology (Botox injections, Restalen injections, etc.). They are not covered by any insurance plan, so they bill the patient directly,  have  no insurance forms to fill out, and they are free to charge whatever the traffic will bear.

     The internist, who does no procedures (except for the occasional EKG) can only charge for his time, much as psychiatrists and pediatricians do. Medicare pays me three times as much for a rigid sigmoidoscope which takes only 5 minutes (and I could teach you to do in two days) than it does  for a 15 minute office visit where a lot of diagnosis but no procedures are done. This is precisely why we are graduating fewer and fewer primary care physicians-----not only do they get paid less, but they also spend a lot of un-reimbursed time requesting permission for MRI's, or for a different drug, etc. Even if an internist drops out of all HMO's, Medicare and medical insurance plans, he/she will still be bombarded with requests to change brand name drugs to generics, or have to call up to find out why payment was refused for the drug he/she prescribed for the patient, or for the dosage.

     Every month I am offered a  chance to "increase your bottom line" by taking a weekend course in Botox injections and later, collagen injections. The Botox injections have to be repeated every 3 months, because otherwise the neuroparalysis wears off and the face sags, so you have an annuity from this patient of $300 to $500/every 3 months. I am also invited to take weekend courses to learn how to use a laser in my office to remove/reduce leg spider veius. Again, this makes a lot of money but does nothing to increase the amount or quality of primary care.

     A colleague of mine was lecturing to a group of 100 new physicians, all under the age of 35 about the intricacies of electronic billing systems. He asked for a show of hands of those in primary care. NO ONE'S hand was raised. This is terrible. Of course, if you want to make money and have a life then you don't want a specialty with night and weekend call and telephone calls at home and (sometimes) uncontrollable hours. Today about 50% of medical students are female. Following the above guidelines, if they want to be able to schedule their time and also have the time and a clear head to raise a family, their favorite specialties are (and I am NOT being misogynistic, just reporting the facts):
     1) Dermatology (Botox, Restalen injections, Moh's surgery, face peelings, etc.)
     2) Psychiatry---definitely pick your own hours.
     3) Anesthesiology---no calls at home, and you are usually home before 3PM so you can welcome your children home from school.
     4) Radiology---again few if any emergencies, no calls at home, no Sunday hours
     5) Pathology-----dead bodies and chemical tests will never call  you after hours, very low malpractice premiums, almost no weekend hours, no night hours at all.
     6) Emergency Room----can be exciting and challenging, but well-defined 8 or 12 hour shifts, and  when you leave you leave with no worries and no one calls you back.
     7) Allergist---almost no emergencies, charge for all office tests and injections, virtually no phone calls at night and only occasional Saturday AM office hours if you so desire.
     8) Geneticist----just counsel parents and prospective parents about disease linkages and inheritance and penetrance probabilities, again few night calls and no emergencies or weekend hours.
     9) Plastic Surgeon for beautification----again tons of money and few if any night calls or  weekend hours.

There was a book published about one year ago by an author who followed Dr. Craig Smith, the Chief of Cardiac Surgery at Columbia-Presbyterian Medical Center around for six months, and described his days, his work, etc. (Dr. Smith operated on President Bill Clinton, among others.) At the end of the book the author stated that Dr. Smith grossed $2 million, but the top grossing dermatologist at CPMC grossed $3.5 million. We all see where the goose that lays the most golden eggs is, and it is most definitely not in the field of primary care. So unless you are totally in love with the field, the odds are you will not enter it. I might also add that I raised three children and put them through college on my income as a solo internist. I do not net enough today to do that, so I cannot in good faith advise medical students to go into primary care unless they are independently wealthy, and that is a shame and a pity.


  1. One reader reminded me that if a med student has enormous loans then there is no way to afford to be a primary care doctor.

  2. Unless he/she has taken a 4-year scholarship from the armed forces and has agreed to serve in them or an Indian Reservation for the 4 years of medcial school plus whatever years they are allowed in residency. If you have money, this is the best deal.

  3. A front page story in the Sunday July 29, 2012 edition of the NY Times decries the coming shortage of primary care physicians. It points our that if an additional 30,000,000 people get health insurance under Obamacare, there will never be enough primary care doctors to take proper care of this influx. The article also reiterated that the only specialties in which there is a current excess of doctors are dermatology and plastic surgery.