My husband has been a primary care doctor for some 30 years. A graduate of HMS who did a 3 year residency in a fine NYC program and who has a PhD from an Ivy League school, and who is associated with a leading large hospital group, he remains working all the time for pay that is 1/3 or less than his specialist colleagues. He left private practice some years ago because he could not make a living after paying off his loans, his 4 staff (2 of whom just dealt with paperwork) and his two offices, and still have money left over to support his family. At the time 85% of his billings were controlled by third parties. He tried bringing in a younger partner, who gave up after a year and went to work for an insurance company. His partner’s wife realized that there would be no decent family life or compensation continuing as a primary care doctor, even with a very busy practice. My husband is always working, and when he is home, he is bringing home work. The women in the practice, even those working part-time so as to have time with their children, cannot balance their lives to their satisfaction. Each year there are more demands on my husband’s time from the practice, more push to see more patients, continued week-end coverage, and take home pay that is equal to or less than that of 24 police officers in our suburban relatively affluent community. I have seen on our street foreign trained doctors who went into radiology or anesthesiolgy(?) because they did not speak English well, yet they earned 3 times what my husband was paid. As a spouse, I would not recommend any medical student pursue a career as an internist.

So, today’s segment focused on primary care docs complaining about “not getting paid.”

Um, exactly how much do they make? Are they starving? I doubt it. I suspect that they’re making a living wage.

I can understand someone needing to earn enough to pay back school loans, but if they’re just complaining about not getting rich, I have to say that sounds pretty whiny.

Plenty of us do stuff at work that’s not technically paid, including working hours of overtime in the office and at home.

If I got paid for everything I did at work that’s not “official” my salary would probably double.

And I doubt that I make anywhere near what the average doctor makes. (And, yes, I had my share of school loans to pay off, too.)

I know there are many, many other issues contributing to frustration among the medical community. Some of my best friends are docs and I’ve heard an earful over the years.

But when you guys do a piece like this that’s so focused on money, it just sounds like “gimme,gimme, gimme.” Kinda unattractive.

But thanks for exploring the issue.

MJ

While some do complain about money that has never been a complaint of mine – I am paid well and live well

We have, as a nation, been reluctant to address the base issues – total costs – how and why we spend so much and how we can limit these costs, physician and other provider hours, the paperwork load, the sheer numbers of patients to be seen – the pressures placed on us by hospitals and insurers.

In a perfect world I would see patients in the hospital in the morning, see clients in the office in the afternoon, have dinner with my wife and children in the evening. Further I would not spend one in four nights on call – at least one of every four calls with very little to no sleep.

No one – in any job – has it easy today. I know that because I see those people – I could not stand at a factory job 11 of 12 hours a shift – and tolerate it more than a few days. I could not work all day outside in freezing weather or inside in hot and humid conditions.

Addressing our looming crisis will take thought, guts, determination – and involve some very hard decisions and choices. I hope we have the courage to make them – otherwise we will see over the next few years extreme shortages of many types of providers in many areas of the country – nursing homes may be particularly hard hit as will rural areas.

This morning I heard a piece by Rachel (Gotbaum?) on a new idea in primary care practice i.e. primary care physicians seeing patients in groups. I was appalled. What about privacy? What about senstivity to persons who do not want their ailments shared with a group of people whom they do not know? The physician seeing the group said it was a good learning experience for the patients. Yuk!

Evidently, sensitivity to the “caring” aspects of healthcare is an attribute that has been left behind. I witnessed such insensitivity yesterday at a major teaching hospital in Boston where a group of patients awaiting surgery at 6:30 a.m. were treated like cattle hereded into a small waiting space waiting for a nurse or assistant to stick her head into the waiting room and bellow the name of the next patient to come for surgery. Each person was just another number, just another eye, ear, nose or thoat that neede work.

It appears that in this era of hurried disconnected numbness and lack of privacy, the warmth of “caring” in health care is gone.
Healthcare is just big business.

This show never put docs on the defensive to answer some of the tough questions, like, exactly How much money do you think you should be making? I wager the speakers who used your forum to piss and moan about how overworked and underpaid they are would hem and haw and not own up to the fact that they are still earning, on average, in the high six figures after taking into account their expenses. We need, as a society, to determine how much doctors should be paid as we move to universal coverage because there is no way ultimately we can afford a pure reimbursement scheme with no salary limitations, as happened and as nearly bankrupted Medicare until some (minimal) limits were put in place. Over the past 20 years some modifications have been made to reimbursement schemes to give parity to primary care docs and recognize the value of time spent talking, not just medicating, patients. (See the relative value scale developed by Medicare economists). If docs just want limitless incomes, they need to change professions; become hedge fund managers or corporate CEO’s.

Every person deserves the right to dream about their future and to believe that if they work hard in their chosen profession, they can excell to a place where they can achieve whatever their personal goals are. What PCP’s are losing is this dream. My husband is in medical school. I work one full-time and two part-time jobs to keeps us afloat while he persues his dream of helping people. He would like to be a Primary Care doctor, but we find ourselves having to choose between his career path and whether or not we will be able to do every day things like have children or buy a home someday. It is one thing to look at charts and numbers and decide that doctors are just greedy, which some are, but not most and not PCP’s. We don’t want money for a sports car, we just want to be able to believe that he could spend his life dedicated to helping people and earn a fair wage for doing so.

oh, for pete’s sake. The answer is so simple. Pay off the debts of recently graduated doctors if they contract to practice primary care medicine for 10 years. You’d have a continuous stream of young doctors who could afford to practice primary care medicine. Who’s to pay for it? how about Bill Gates sponsoring a couple of doctors or Michael Bloomberg or the head of Walmart, etc, etc., etc. Why do they all set up fancy foundations with high priced administrators? What’s the matter with paying out directly to those who use the money?. Instead of having a toilet named after them in some performance venue, they might like to sponsor a doctor, how’s that for a worthwhile memorial. Why do we make it so hard?

Hey, aajay – interesting idea!

Maybe we could also have headbands made up so that each doctor could be identified by her/his patients and health professional colleagues as:
“This doctor brought to you by Walmart” or
“This doctor brought to you by Microsoft”

Thank you, Pat Brennan, for expressing so well my horror at the group visits. I can’t think of a single way this could benefit patients. Further, it seemed to me that the doctor in the group addressed the mostly older patient in a rather condescending manner, as if he were a kindergarten teacher leading Show and Tell. I actually heard this piece twice today, hoping that I had misheard — that what team practice really meant was that a primary care doctor and a team of specialislts would develop a coordinated care plan for each individual patients. Great comments here!

Rachel, just listened to your show [ fri. nite ] and it was brilliant… thanks so much for the heads up about it when you were in last! You were wonderful!! kudos…

Thanks for presenting this complex problem so well in just an hour. I am a practicing Family Physician, and unlike the many interviewed in your story, I truly enjoy the diversity and challenges of my job as a rural physician in Alaska. There are great jobs as a primary care doc out there, you just have to look a bit harder.
Regarding pay: in primary care, we are not underpaid. I do believe however, that many specialists are overpaid- some of the charges for procedures are obscene and unjust.
The crisis in our health care system is complex, but we must address it. I do believe it is possible to deliver high quality, cost effective medical care if we make the right choices. It will require that all of us give something up-some doctors will make less, patients will have to demand less, the insurance industry might have to go away (single payer system, anybody?). To pretend that this isn’t so will only perpetuate and worsen the problem.
And on that cheerful note, have a great day!

I caught part of this show Friday night. Please make it available via podcast!

Two determinants impacting primary care today, as well as other specialties (including my own, ob/gyn) are physician expectations of the workplace as determined by physician age and by physician gender. Through my reading and interactions with people in other disciplines, it appears to me that, for better or worse, people entering medicine now and for the past several years, do not place as high a priority on work in general and seek more “balance” in life. Today’s young physicians – as well as their contemporaries in other fields – would rather spend more time pursuing non-vocational activities, such as family time. Additionally, with the entry of large numbers of women into medicine, interest in medicine as an all-consuming profession has further declined, as the traditional role of the woman in the family unit has not changed much in the last 40 years. With few exceptions, the female physician of today is still expected to be the mother we knew from the time before women entered the workplace in large numbers, thus giving her multiple fulltime careers. The end result, and we see this poignantly in ob/gyn, is a trend towards shorter, more controlled work hours, less frequent on-call assignments, shift work, fractionation of care continuity, subordination of the doctor-patient relationship, reduction of commitment and loyalty to a particular practice, and ultimately a more frustrating experience for the patient. In the end, there will be a marked reduction in lifetime work output from today’s physicians and this will contribute to the current primary care shortage.

This documentary did an amazing job of outlining some of the complex reasons why emerging doctors don’t become primary care providers, not the least of which is medical school debt. But don’t let it escape your attention that most emerging health care providers face similar debt loads without the promise of future massive salaries.

I’m graduating in August with a Doctor of Physical Therapy degree, the same 6-figure debt faced by med students, and a starting income of around $50,000 (if I’m lucky). Based on current projections and continuing cuts in reimbursement rates, it seems likely that my income will max out well below that enjoyed by my MD colleagues.

I’m not overly intersted in money – I knowingly took on this debt in order to gain the skills and experience to follow my passion to help patient improve their level of physical function. Yet it sure would be nice to pay off my debt before I retire (I’m currently 38). And if PTs could join the National Health Service Corps (alongside MDs, Nurses, Occupational Therapists, etc.) I’d gladly serve in an underserved area of the US for 2 years to earn some gov’t-funded debt relief – but PTs aren’t currently eligible.

My point is that almost all health care providers graduating in 2008 enter the working world with massive debt – and not all of us have the same income potential as MDs. It’s no wonder there’s a growing trend in health care in which more and more providers make career choices based more on imcome than on providing high-quality, evidence-based care.

As a specialist (in Anesthesia and Critical Care Medicine) I need to give my 2 cents worth. Firstly Primary Care is not the only stressed medical profession, all doctors are working harder and getting paid less and less.

There is a healthcare crisis is occurring in American ICUs that have inadequate specialist coverage, and are seeing dramatic increases in service demand. Increases in Primary care supply will not prevent the continued need for the high tech specialist services that are continually being developed, and patients will continue to want the best care available whatever the cost. The only way forward is to educate patients about preventive and cost effective healthcare, and ration care (a frightening concept here in the US) at some level.

The UK experience shows that it is possible to provide good basic healthcare to all, and still provide adequate tertiary care to those that really need it.

Hi HR – you can get a podcast of the documentary through this link:

http://www.wbur.org/listen/podcasts/

Then choose “WBUR Daily News Update.”

The 3 parts are posted separately. The full one hour documentary will be up tomorrow.

Thanks for listening!

As a third-year medical student, I see first-hand insight to the growing problem America faces. I admit that a specialist profession would allow me the benefits that any of the new Doctors want: More family time, more income, less debt. However, before we fix the Medical school problem we need to focus on the whole. The residencies are NOT expanding, and in some specialties, they are shrinking. Loans are outrageous. And the US insurance it horrible. We need to stop putting band-aids on the wounds of America’s health care.

Well, I can comment on how much primary care physicians make and how much they work. We get paid, not very well, for seeing patients. I spend about 40 hours a week doing that. I spend another close to 40 hours making phone calls and doing paperwork. So that’s 80 hours a week, every week. Based on a hourly rate, I get paid maybe $20/hr for my work after I pay my staff and other overhead. Plus I work weekends and holidays and nights for no pay. I have $150,000 in student loans. No spouse to help pay it off. No inheritance to pay it off. I bring home less than $100,000 a year. I am reasonably well paid, but I can’t afford to buy a condo where I practice medicine. I certainly could not afford to send a child to college. I do not have an IRA or a 401K and after I pay $3000 a month to my student loans, I don’t have any money left to put aside for retirement I certainly wouldn’t say I get a “massive income”. And my income is only going to go down, not up, as the insurance companies pay less and less, while expecting me to do more and more (more prevention, more education, more screenings).

So I think a lot of things have to change. Most people won’t work 80 hrs a week for $20/hr when they can get paid more to work less by being a specialist. If people want primary care doctors, they are going to have to subsidize us so we can afford to buy homes where we practice, and afford to send our children to college. Otherwise we are going to choose specialties that allow us to buy homes and save for our children’s education.

That doesn’t mean I should be paid $500,000 a year. I’m not doing this to get rich. But most attorneys, for example, get paid a great deal more per hour than I do, and every minute they spend working is billable, and they can start getting paid as soon as they pass the Bar. I had to spend another 3 years working for minimum wage before I could even start to get paid $20/hr.

I am actually fairly well paid for a salaried Family Physician, I am the only bread-winner in my family, I have no pension at work – I am fully dependent on myself to fund my own retirement (?Medicare, yes, IF it still exists when i am ready for it), and I take home less than a six figure salary. I take umbrage at the comment above that states we are all making something in the high six figures. I serve on the Board of my state Family Physician organization. I know of many doctors in private practice who are making less than $60,000 per year and others that are putting second mortgages on their homes or borrowing from their retirement savings just to keep their offices open since they serve a rural community and and without them there would be nothing.

Furthermore, the point of the salary discussion is the differential between primary care and specialists that is driving very highly indebted students into specialities and away from primary care. Every high quality cost effective health care system in the world is based on a primary care system as its base.

I am a clinical psychologist and am particularly interested in the lack of access to mental health care and services. Access to primary care physicians will have an impact on behavioral health care since some managed care contracts require PCP’s to act as gate keepers. Also, referrals to behavioral health providers often come from primary care physicians.

In particular, are there studies that focus on the problems associated with American’s access to behavioral medicine?

The problem is simple. The doctor incomes are metered out at a fixed price per procedure and the pricing of everything else in medicine is sky’s the limit.
The solution is simpler.
Get rid of insurance as a cost center
Pay doctors enough per procedure to have sufficient doctors. Make medical education free for primary care doctors if they get pretty good grades.
Provide universal single payer healthcare so collections cease to be an issue.
Offer no alternative to this solution.
The problem will solve itself.

The trend to use nurse practitioners in primary care practices (as well as specialties) has been evolving for many years. Nurse practitioners(NP) have been providing care revolving on health promotion and prevention in rural and underserved communities for years. Studies have shown that nurse practitioners can double the number of patients that a practice can handle. The team approach is a great idea. Shared visits for people with similar issues is a very interesting concept that has great value. If patients do not want a shared visit, they can opt out. NPs now have the option of a clinical doctorate in many parts of the country. NPs are filling the need for primary care. Doing well child exams, immunizing children, health care teaching, promoting healthy behaviors, taking a whole person approach…are all part of the role of the NP.

I currently practice in a prediatric diabetes clinic where most of the patient management is shared by the Endocrinologists and the NPs. We use a team approach that consists of provider, RN educators, social worker, dietitians and psychologist. Most everyone is salaried as we are in an academic institution.

Ms Gotbaum, Thank you for doing the piece, it is timely and interesting. It explored solutions, good work!

Elena Calhoun,PNP, Milwaukee, Wisconsin