The road not taken

Pity the beleaguered primary care physician. Low pay (in comparison to those in loftier specialties), increasing loads of paperwork, little respect.

The Times has a marginally interesting article on the subject today. There's not a lot of there there, but it includes a couple of points worth mentioning.

First up, there is this reminiscence of a remarkable medical student.

When it came time to choose specialties in our last year of medical school, most of us thought Kerry would do what every high achiever and even the not-so-high achievers were already doing: line herself up for a coveted spot in one of the prestigious subspecialties, a field like dermatology, orthopedics, plastic surgery or radiology.

But Kerry wanted to become a primary care physician.

Some of my classmates were incredulous. In their minds, primary care was a backup, something to do if one failed to get into subspecialty training. “Kerry is too smart for primary care,” a friend said to me one evening.

The perception that the smart students will take advantage of their academic standing to pursue subspecialty training is pervasive. This creates the converse impression that primary care providers aren't that bright. Obviously my experience is not dispositive, but (contra this belief) most of the primary care providers I know (certainly in my field of pediatrics) are quite bright, and entered the field because they simply wanted to, not for a dearth of options. (Not me, though. I'm dumb as a post.) I've known many providers who had subspecialty certification, but chose to work in primary care offices providing both primary and subspecialty care. (My particular subspecialty of adolescent medicine occupies a nebulous space in which it is a board-certified subspecialty, with exams and fellowships and such, but still considered primary care. Sadly, being thusly dual-boarded does not increase my earning potential, though it does improve my chances when searching for jobs.) Primary care affords the benefit of getting to know your patients well, and forming a quality physician-patient relationship. It won't pay the rent, but since most of us went into medicine because we wanted to help people (at least, that's the theory), it is something to be valued.

However, the question remains -- why do so many people go into the "prestige fields," such as radiology, ophthalmology, anesthesiology and dermatology (tritely described in the article as "the ROAD")? Again, I should mention that I know many people in some of those fields who managed to get there despite being... maybe not MacArthur Fellowship material, let's say. As with any other profession, success does not always directly correlate with smarts. But many of the very smart, dedicated students at my school did go into those fields. Why?

Obviously, there is the question of money. The ROAD specialties are all procedure-based fields, and thus pay very well. This answer is rather obvious. We are, after all, living in a material world. (Sorry. Couldn't help myself.)

Just as importantly, though, there is this:

In addition, with fewer doctors and more patients, as well as little reimbursement for the specialty’s growing administrative aspects — filling out insurance company and health maintenance organization forms, making telephone calls and writing e-mail messages to coordinate care with other caregivers — primary care physicians end up working longer hours than doctors in other fields just to make ends meet and fulfill patient care responsibilities. Moreover, while pressing and acute care needs arise routinely in patients with high blood pressure, diabetes and heart disease, there are rarely calls of the same urgency among patients with, for example, a skin lesion.

In other words -- lifestyle. Docs in the ROAD fields see their patients, and go home. With the exception of anesthesiologists, who are sometimes needed at odd hours for emergency surgeries, most of these providers can head home at night without worry that they're going to get dragged out of bed for some emergency. As someone who routinely has to haul his carcass out of bed to attend dead-of-night deliveries or admissions, this is no small consideration. I don't know if I would have gone into a different field if I'd known how much that aspect of things sucks (short answer -- a lot), but I'd probably answer the question more definitively if asked while driving to the hospital at 2 AM in February.

Cutting down on administrative costs and changing the way we reimburse for medical care would go a long way toward putting the bloom back on the rose of primary care. But I don't know if the lifestyle benefits of subspecialty care can ever be fully accounted for, and thus there will probably continue to be a pull toward those fields for competitive candidates.