10 Secrets Of Primary Care Physicians

The latest SmartMoney list of insider secrets and unpleasant truths is just as bleak as every other news item about health care these days, starting with the fact that a primary care doctor—”someone to coordinate your health care, help choose your specialists and be the first to diagnose just about any problem”—is getting harder to find, and fewer med students are showing any interest in the (comparatively) low-paying profession: “the number of primary-care internal medicine residency positions dropped by more than 50% in the past decade.”

They suggest that for basic illnesses, it might be both faster and more effective to try a walk in clinic—there are about 460 across the country now, but that number will jump to 4,000 over the next two years.

Walk-in clinics are… run by nurse practitioners, who diagnose simple maladies, like strep throat or flu, and provide prescriptions, medical advice or referrals if the problem is beyond their scope. These clinics have caught on in part because they’re fast and don’t require an appointment, says Steven Cooley, a physician and CEO of SmartCare Family Medical Centers in Denver. They’re also cheap — $40 to $60 a visit, versus $150 for a doctor or $300 for an ER visit — and many take insurance.

But perhaps the most disturbing fact is that the PCPs out there are probably least able to take on senior citizens as new patients because of how unprofitable they are. They often have complex medical conditions that take longer to diagnose and treat, and yet Medicare doesn’t pay much more than what the doctor would be able to earn on a 15-minute checkup of a healthy patient.

“It is fiscal suicide to go out there and say, ‘I am a geriatrician,'” Robinson says. “You get the patients that require the most time that pay the worst.”

“10 Things Your Primary-Care Physician Won’t Tell You” [SmartMoney]
(Photo: Getty)

Comments

Edit Your Comment

  1. BigNutty says:

    It took me a long time to find that “perfect doctor” that accepts my insurance and answers every question I have about my health.

    Walk in clinics are going to make it easier and more affordable for many more people who don’t really need a doctor. If they stay open 24 hours we could solve a lot of the emergency rooms economic problems of caring for indigents with no way to pay.

  2. timmus says:

    It’s taken me a long time to find a perfect doctor, period, and I usually pay cash. For a profession that pays so well and has such an astronomically high technical level, the profession seems to have an astonishing number of dumbasses and rotten apples. Yay for consumer-oriented sites like ratemds.com. Ideally I’d like to see a universal Amazon-type system of ratings for doctors, then maybe we’d see the good doctors recognized and a return of professionalism to this career field.

  3. DoktorGoku says:

    Actually, I’m really glad to see an article like this on here.

    I’m currently a second-year medical student here in the US (at a nice school, thankfully, getting my MD), and we’re already supposed to be focusing on a specialty to examine/pursue very soon.

    The remarks about geriatric patients are, unfortunately, completely on target- and there’s really not very much to do about it. Because of this, my school has started integrating the Geriatrics curriculum in everything we do- I believe the idea is to make each and every one of us capable for caring when the patients come up.

    However, with medical school debt skyrocketing (especially for private schools, like mine), I know that plenty of my colleagues have already stated, quite openly, that they’re going to try and get rid of the debt ASAP- even if that means catering to a particular population.

    One thing I’ve learned, though, is that you really should go to a Quick Care or Urgent Care center for basic stuff- it helps free up the ERs and generally makes our lives easier, heh.

  4. bohemian says:

    We have some nurse practitioners who are better doctors than some of the doctors.

  5. timmus says:

    Actually I guess I came off kind of abrasive but I’ve got a sore spot for doctors that disappear before you can talk to them, surly waiting room staff, and doctors that push whatever the pharmaceutical reps are pushing. I’ve had far too many doctors try to prescribe serious stuff like Strattera for simple ailments.

  6. RvLeshrac says:

    Just another sad commentary on the modern world when doctors care more about money than caring for patients.

  7. RvLeshrac says:

    @timmus:

    You didn’t come off abrasive enough. See above. When doctors actually give a damn about more than the size of the patient’s wallet, it shows.

  8. Shadowfire says:

    @RvLeshrac: When you look at the costs of medical school, and take into account how smart most of these doctors are (and thus should be earning lots of money), not only should that be expected, but we should be mostly happy about it.

  9. MrEvil says:

    I’ve been with the same PCP since before I was born (he was my mother’s OBGYN through both her pregnancies). He’s not too far off from retirement, at least far before I shuffle off this mortal coil. I am REALLY dreading it when he retires, though I hope he can find another physician to take over his practice.

    I think another problem in all this isn’t so much med students not giving a good god-damn about patients unless they have money. Its more about the expenses of medical school. I think most med students carry a six figure student debt when they’re finally practicing medicine. They hate having that mortgaged on them in perpetuity so they’ll pursue a field that will get that debt paid off ASAP.

    Like it or not, the lack of primary care doctors will eventually lead to some level of government subsidy to get people into the field, just like teachers. Rather than a regular payout, it may amount to student loan forgiveness programs funded by state government.

  10. Major-General says:

    @Shadowfire: Yes, but a lot of them aren’t particularly smart. I have a friend who is basically in med school because that’s what he wanted to do and worked his but off in class for that.

    And spent three years getting him to apply for medical school. He just didn’t get the concept that it was better to apply early rather than by the deadline…or even after it.

  11. mattpr says:

    An article that claims to address the secrets of primary care, but fails to address the problem of physician reimbursements (as low as $7 for a check-up), is pure crap in my opinion.

    Bottom line: there is very little incentive for a med student, who’s spent 4 years and nearly a quarter of a million in tuition, to go into primary care.

  12. ideagirl says:

    @timmus: I agree. I am going through that right now, I had to take a stack of studies and info on various meds to my doctor to even make him consider prescribing something that MIGHT work, even though what I am taking doesn’t work. Why? Because what I want him to prescribe is a generic that is not being pushed by drug reps.

  13. monolithic says:

    “According to a 2007 study, it took new patients in Massachusetts an average 26 days to land an appointment with one. Why? Fewer med students are going into primary care: Interest is so low that the number of primary-care internal medicine residency positions dropped by more than 50% in the past decade.”

    That’s DEFINITELY far from the truth. The simple reason is because people in MA are REQUIRED BY LAW to have insurance before the end of the year or they lose their state tax deductible. So if you’re required to have health insurance why not use it? Thus it creates a huge influx of people making it harder to get appointments. It blows my mind how the state REQUIRES me to spend MY money in a way to suit their needs. I go to school in New York so why would I benefit from having MA health insurance? I’m claiming NYS tax residency now, MA is a giant cluster fuck.

  14. lincolnparadox says:

    If you want good primary care, look for a DO. Osteopathic schools are pushing family care hardcore, and teaching their students the listening skills they need to be effective and the gerontology they will need for the next 50 years.

    DOs have a bad wrap because California tried to have them banned 50 years ago. DOs are as qualified as MDs. The only difference is their philosophy.

  15. Boberto says:

    I’ve been an RN for 15 years and what always surprises me is the time an MD spends listening to a drug rep as opposed to listening to a Patient. They do so because there is tangible financial benefit. The pharma industry is in the most dire need of reform. Consider; More money is spent on marketing than research of drugs, 6 drug reps for every American and the overall emphasis on the palliative rather than curative.

  16. trollkiller says:

    I thank God I have a great Doctor. He employs nurse praticioners that are better than most GIs. I think the best way to tell a good doctor is to look at the reference books in his office. If they are pristine, go somewhere else. If the spines are all broken and they look like they have been used, you have found a doctor without a God complex.

  17. jodles says:

    i still go to my pediatrician who checked me out of the hospital (i’m 20). it’s a pair of doctors and some friendly nurses who wear animal print scrubs. i get a lollipop after each visit and i get to read hi-lites magazine (it’s too bad i don’t fit on the slide and in the little maze-pit anymore)! i love going to the doctor…it’s a dream!

  18. reykjavik says:

    So let me get this straight: With all the great schools out there, and all the education and information that exists in the world today, and with more people having access to all that data and education than ever before in the history of the world, we’re supposed to be perfectly content going with “doctors” who are less educated and with less experience??????

    Why aren’t people demanding even MORE educated doctors and HIGHER quality professionals? Instead everyone wants less because it’ll save them ten bucks. In todays world with the access that humans have to top quality higher education, the fact that the future of medicine will be relying on nurse practitioners should be a disgrace to modern humanity.

  19. XTC46 says:

    @jodles: hi-lites is awesome.

    I wish my doctor still gave me a lollipop :(

  20. XTC46 says:

    @RvLeshrac: you pay back 100k+ in student loans plus day to day living expenses on a 30k salary. Doctors don’t even make good money right out of school and usually go even further into debt. They put a lot on the line financially to TRY and be a doctor. What if in the end they decide its not for them, or they realize they aren’t good enough. Its a risk, and for that they should be paid well. Not to mention its not something everyone can do and the liability they have to deal with.

  21. nardo218 says:

    The situation with seniors is obscene, but I support the clinics. Why should a student go to school for ten years to treat sore throats and infected fingernails? There’s a lot more education options for people wanting to go into the medical industry than their used to be; it’s not medical school or bust. And why should patients pay an enormous copay to get a little piece of paper to get the steroids for what they know is poison ivy? These people can fill a hole in our society’s system of increasingly advanced medical science.

  22. Elviswasntmyhero says:

    Physicians for a National Health Program

    The Physicians’ Proposal…

    “We endorse a fundamental change in America’s health care – the creation of a comprehensive National Health Insurance (NHI) Program. Such a program – which in essence would be an expanded and improved version of Medicare – would cover every American for all necessary medical care.”

    http://www.pnhp.org

  23. darkclawsofchaos says:

    its scary what these people are like in school, I’m a pre-med student, so I see scary stuff in lab where close enough makes the grade. In organic chem, some people got everything backwards or confsed, true its damn hard, but some mistakes are just beyond belief

  24. trollkiller says:

    @Elviswasntmyhero: What we need is for the self pay patients and the insurance pay patients to pay the same amount. It would be a lot easier for most people to come up with $50 than it would be $140.

    I can think of no other industry where the insurance company pays less than a self pay customer.

  25. madrigal says:

    whoa 12 minutes? I went to a new doctor with a sprained ankle that i had sprained 6 weeks prior. she saw me for maybe 5 minutes, and then asked me a few questions while halfway out the door.

  26. TangDrinker says:

    I’m puzzled why my co pay for the doctor is $30, $50 for visiting the ER, and $60 for a walk in clinic (which, by the way, are being built into nearly every new shopping center in Charlotte). I’d think insurance would push the walk in clinics more -especially for the run of the mill stuff like colds and the flu.

  27. stanfrombrooklyn says:

    I haven’t been to a doctor in 20 years since I was a freshman in high school. I figure I’ve spent personally or my company has spent over $100,000 on health insurance for me of which I’ve not used a penny.

    I’m pretty sure that rash will clear up on its own.

  28. Charles Duffy says:

    @trollkiller: It’s not necessary to pay full rates even without insurance, if you know how to negotiate or have someone who can do that on your behalf.

    I happen to be in the latter category: The founder of my company is an ER doc. Before we had health insurance, he would personally negotiate down his employees’ medical bills — including mine when I was in a motorcycle accident once on my way to work. I got an itemized list of where the charges were coming from (if I’d known the hospital was going to charge so much for a pair of crutches, I would have refused them and let the wife buy some from CVS), and a reasonably steep discount.

  29. Syrenia says:

    @lincolnparadox: Seconded. The best doctors I’ve ever had have been DOs.

  30. mattpr says:

    Primary care physicians receive reimbursements from insurance companies as low as $7 for visits at their offices.

    But hey, it’s easier to blame those money grubbing doctors and drug reps!

  31. cashmerewhore says:

    @xtc46:

    I used to work at Highlights. Great company, great magazine, shitty job (telemarketing).

    I had a perfect doctor. But I’m also a pushy patient. I will schedule my specialist visits before I even see my doctor (I know my complaints are beyond their scope). They will give me my referral paperwork, I submit it. I get in to my specialists in a month or less.

    Unfortunately my PCP (a DO) had some issues with the office she was working with (they didn’t renew her contract), so she has gone to a university student health clinic…which means I had to find a new doctor. I see her next Wednesday.

    The only benefit of having so many specialists: I’ve been able to survive without a PCP for months, less one midday urgent care trip for a sinus infection.

  32. mattpr says:

    @cashmerewhore:

    I think you hit on one of the major problems plaguing PCPs. Patients are increasingly seeing specialists.

    The reason I dislike this article is that it does not address the 3 major problems plaguing PCPs:

    (1) Decreasing insurance reimbursements (I know I sound like a broken record but this is absolutely CRIPPLING PCPs)

    (2) Increasing malpractice burden and liability relative to specialists.

    (3) Patients initially seeing specialists instead of PCPs. While this seems unrelated at first, it has consequences. If the specialist can’t diagnose the problem (as it may be outside their specialist), they get turfed either to another specialist or a PCP. By the time the patient gets to the PCP they have already been to several physicians and the problem has likely gotten worse.

  33. @MrEvil: “Its more about the expenses of medical school. I think most med students carry a six figure student debt when they’re finally practicing medicine.”

    It’s the same reason it’s difficult to get lawyers to serve the middle class or the poor — student loan debt is simply too high. My dad graduated from a top-10 law school in 1975 with $3,000 debt, and that was “high.” I graduated from one with $60,000 debt in 2004, and that was bottom-of-the-barrel LOW. We have friends with $250,000 in debt. We have friends who went to STATE SCHOOLS with $80,000 in debt!

    At a certain point the professional schools are going to have to adjust and deal with these problems, or the professions are going to price themselves completely out of the market. It’s even getting difficult to get lawyers to be JUDGES because the salaries can’t pay enough to cover their student loans!

    Alternatively, the medical lobby will have to stop blocking PAs and LNPs and CNWs and the rest of the alphabet soup of well-trained nurses+, who are eminently capable of providing basic patient care at a lower cost, from practicing freely.

    Something’s going to give, and since I’m guessing it won’t be insurance costs, medical school tuition costs, or drug costs, it’s probably going to be the MD-monopoly. (Which I think will have both good and bad points; I’m not anti-doctor. And I love my primary-care MD, but before her I had a primary-care PA whom I also adored.)

  34. Cerb says:

    @timmus:
    The problem with a consumer “Rating” system for doctors is that, and I say this in the nicest way possible, most of you don’t know quality care from a hole in the ground. Studies have shown that a warm, outgoing physician will get the highest approval ratings from his patients regardless of his skill level. He might be the most incompetant doctor on the face of the planet, but hey – he’s nice!!! It’s kind of like if I were to try to rate a nuclear engineers work, I have no background in nuclear engineering, so how could I possibly rate him on anything beyond his personality?
    @syrenia:
    Your best docs have been DOs? Well, that kind of backs up the point I made above. Not to disparage DO’s, which for the most part are very competant physicians, but the fact remains that DO schools require little more than a good credit score to get admitted.
    @darkclawsofchaos:
    Who cares if people get organic chem mixed up? Organic chem has absolutely nothing to do with medicine, period. After you take your MCATs, you will never see it again, period. I would hardly damn some poor premed to incompetance because they can’t read a spectometer.
    @RvLeshrac:
    Don’t care about the patients? Are you kidding? Most of us wouldn’t be in this profession if we didn’t care about the patient. However, caring about the patient doesn’t mean we have to martyr ourselves economically. We spend a ridiculous amount of time in training, work ridiculous hours, and get in ridiculous debt for our troubles (my final medschool debt will be around 200k, which is on the low end of the spectrum). And then to top it off, many of our patients view us as rich people who’ve been fed with a silver spoon (I grew up on foodstamps). Many people come in to medschool hoping to go into Primary care, only to run into the reality during training that being a PCP means you will get little respect, money, and will find yourself getting pushed out of the way by NPs (who, while being very good at primary care, ARE NOT physicians, and will miss many signs we are trained to see that could be indicative of deeper pathology).

  35. Proof that what I’ve been saying for years is true:
    Interest is so low that the number of primary-care internal medicine residency positions dropped by more than 50% in the past decade.
    According to one study, the income of primary-care doctors, adjusted for inflation, actually fell by 10% between 1995 and 2003. “Students are not dummies,” says Pho. “They graduate with $130,000 in debt; why should they go into primary care?”

    Any candidate that claims that they will improve health care but doesn’t say that they will increase funding for schools and scholarships is a damn liar. There aren’t enough nurses and doctors and the ones we do get have too much debt to specialize in areas that don’t pay the most amount of money.

    Nothing anyone can do about the state of health care in this country will do any good unless the cost of becoming a medical professional goes down and the number of medical professionals goes up.

  36. Cerb says:

    @Rectilinear Propagation:

    I agree with everything but would like to point out that 130,000 is extraordinarily low amount of debt for a medical graduate these days. I attend an average to low priced state school at shell out over 40k a year (tuition+living expenses). If you attend a private school or a DO school, you can double that.

  37. waxigloo says:

    @mattpr:
    Nail. Head. Couldn’t have said it better.

    PCP need to get reimbursed for the time that is spent organizing the specialists so that the patients care is cohesive. There was a great article in the December Atlantic about the fact that: we have too many doctors; the doctors we have are all specialists; this means there is no one to make sure we are doing generally fine; our healthcare suffers and ends up being worse than countries that have far fewer specialists.

    People like cashmerewhore demand to see a specialist when it is a waste of money and time. Do you really need an ENT specialist when your throat hurts? No. Who has to look at the results from the specialist to determine further action? Your PCP. Does he get reimbursed for doing that. No. That’s a big problem.

  38. scarletvirtue says:

    @mattpr: I go to a PCP, but I also go to a couple of specialists for problems that they can’t easily resolve – asthma (a prior internist told me that it was just “mold allergy”. A mold allergy that kept me awake wheezing, apparently.); and epilepsy.

    The PCP can easily handle everything else for me, and I’m fine with that.

  39. Nemesis_Enforcer says:

    From the perspective of somone who worked for a Health Insurance Co. this PCP crisis is also due to the Health Ins. rules. They require you to see a PCP before seeing anyone else. But there are fewer and fewer PCP’s around, so the few that are around end up getting hundreds of patients and are so swamped it takes weeks or months to get an appointment.

    Especially in sparsly populated areas, normally your PCP has to be within 30 miles of your address. Thats 30 air miles not geographic miles. We would have to do adjustments at times up to 80-90 miles farther because there were no PCP’s close enough. My own PCP takes about 3 weeks before you can see them, luckily my medical group has a urgent care center nearby and the co-pay is the same as a Dr. visit. I normally just go there unless its something long term or chronic. It’s easier and faster, also my Dr. can view my records for trends when I do see him.

  40. cashmerewhore says:

    @mattpr:

    I don’t seek them out. I know what the office is capable of, and if I need a specific test I will schedule that appointment prior to the appointment with my PCP for the referral. (Most recent example: I need an asthma workup. While scheduling my PCP appointment I asked if that was something they could do in office. It is not. I contacted a pulmonologist friend and she informed me of an opening in a colleague’s schedule. I called and took it).

    I will continue to see my PCP for as many things as I can because it’s cheaper (for both me and my insurance) that way. If I ran to my ENT every time I had a sinus infection I’d be broke.

    (But I also don’t run to the ER unless I know it’s also something my doctor can’t do and I need immediate xrays…)

  41. the_wiggle says:

    @syrenia: DOs can be just as money focused as MDs. I’ve dumped plenty of both over hearing one to many times, your insurance doesn’t pay me enough to spend more time with you coupled w/a fistful of largely irrelevant samples.

    The problems seem to be legion: tuition/time investment too high, insurance payments too low, liability fears, incompetence, and yes, patients who MUST be seen for every little thing & MUST have a pill of some kind for the same.

    Good luck trying to get this mess cleared up. Unless there’s a sudden epidemic of common sense on all parties parts, ain’t going to happen.

  42. the_wiggle says:

    @mattpr: specialist access is there for a variety of reasons & needs to remain available.

    too many PCPs couldn’t correctly diagnose their way out a paper bag resulting in wasted time, $$ & services for things easily id’d correctly the 1st time & treated correctly the 1st time by the appropriate specialist.

    other PCPs be they well intentioned or just $$ focused fiddle about trying to diagnose or treat things they are simply not qualified for instead of being honest up front & insurance companies w/pathetic payments &/or demanding PCP gateways just encourage that idiocy.

    throw in foolishness like MA on top of things, often people are going to the specialist as that’s the only place they can get an appointment in a reasonable amount of time which is crazy.

  43. mattpr says:

    Internists are just as qualified to diagnose an ailment as any specialist, arguably more so. Internists receive the same length. In fact, many physicians whom we consider specialists (cardiologists, for example) do the SAME residencies as PCPs and have the same diagnostic training. The difference is that specialists have education in performing procedures.

    However, based on how medical education is structured PCPs have (or should have) the same diagnostic capabilities as a specialist.

    This problem begins and ends with insurance repayments. PCPs get shafted by private insurance companies and carry a significantly malpractice liability (since the burden falls on them regardless of how many specialists a patient sees). Fixing these two things will solve the problem.

  44. XTC46 says:

    also, please remember that doctors dont ever actually get paid everything they have owed. My accounting teacher was the accountant for a large hospital as well as a few small doctors offices and for the hospital she said they expect to never see ~30%-40% of the money they are owed. Doctors offices are lower, but still significant. Its stuff like this that makes trips to the doctors so expensive, we are subsidizing those who don’t pay.

  45. starlightmica says:

    @mattpr: No, not as qualified to diagnose any ailment as a specialist. Many common diagnoses, yes, but for other problems, the state of the art moves far too quickly – the treatment of HIV is a good example PCP’s that aren’t up on it haven’t the foggiest idea to begin.

    The basic PCP training varies as well – internal medicine used to be 3 years of mostly hospital inpatient care of adults, and family medicine spending time with both children and adults with rotations through orthopedics and obstetrics. Specialty training is 2-3 years in addition to residency, geriatrics being on the shorter side. Procedures, yes, but learning how to manage the more challenging conditions, too.

    One of the big challenges with geriatrics is treating fallout from the medical problems, such as lack of mobility, inability to drive, medical & financial decision-making when dementia such as Alzheimer’s sets in. How can you see a senior citizen in 15 minutes when it takes that long for them to get in and out of an exam room, and expect to be reimbursed fairly when Medicare is about to swing a 10.1% reimbursement axe for 2008? Beats the heck out of me.

  46. StevieD says:

    @stanfrombrooklyn:

    At least you only have a rash. I have this dripping problem, but I am sure it is nothing.

  47. AW99 says:

    @Cerb: Ah, got to love that doctor mentality that they are smarter than everyone else. Sorry Cerb, all three NP I’ve seen could kick the ass of the PCP I’ve had. And do you know why they were better then the PCP, because those NP actually worked as nurses longer than the fresh out of med school PCP even trained as interns. I rather have an experienced NP over a young PCP. The NP actually listens to me unlike the PCP that treats me like I am an idiot.

  48. trollkiller says:

    @Charles Duffy: Unfortunatly not all of us have an ER doc to defend us. Thankfully I have a great doctor, no negotations neccasary. (forgive the spelling errors)

  49. Valhawk says:

    People have this preconception of doctors as rich greedy people who don’t care about patients, it sickens me.

    Both of my parents are doctors. My mother has to work insane hours sometimes as many as 13+ a day 5-6 days a week when not on call. The stress level is incredibly high because they have to see people at their worst when they are sick and irritable.

    If you want better healthcare then lobby for Tort Reform and Medicare Reform, because these issues are driving doctors away from the field.

    Oh and to the Nationalized Heathcare people, your plans are unrealistic and would create a far worse situation then we have already.

  50. ceejeemcbeegee is not here says:

    All I know is that when I switched from an HMO to a PPO, the wait for an appointment went from a 2 weeks to “how soon can you get here?” The Dr. spent much more time with me, answered all my questions, and even gave me her cell number for emergencies.

  51. alice_bunnie says:

    @waxigloo:
    People … demand to see a specialist when it is a waste of money and time.

    Every specialist I have been asked to be referred to has not done me any better than my DO primary care doctor. I am Type II diabetic and after 3 years of poor control (my fault of course) I thought I might get better management with an endocronologist. What I got was a bunch of classes for diet control which I knew backwards and forwards anyway (just didn’t follow well) and pawned off to a PA. I went back to my PA at my DO’s office and I’m on the same meds and finally got my diet act together.

    I went to a gastroenterologist for some bowel problems, got a colonoscopy and a “I don’t know what’s wrong with you, a $3000 bill, and come back in 2 weeks”. Why come back in 2 weeks if you can’t do anything? Forget that, I’m going back to the PA at my DO and I’m just going to forget about all these specialists anymore. :/

    My PCP gets pretty good reimbursement from what I can tell from my EOBs; especially since I’m not seeing him, I’m seeing his PA. And he’s double dipping because he charges a “physicians visit” for the day I come in for blood draws for the lab work and gets the copay from me both days, too. And, every time I’m there, a drug rep is there with some goodies for his staff.