Nov 9, 2009

Primary Care: The Best and Worst Job in Medicine

Shawn the medical student asked Doctor D:

As a medical student, I am constantly wondering what type of physician I will become. So my question is, what kind of doctor are you, and how did you decide that field?
Doctor D is a Family Medicine doctor. He chose this career because he is a glutton for punishment! Actually, D chose Family Med because he likes people much more than he likes the technical aspects of medicine. As a jack-of-all-trades doctor I can usually help anyone no matter their age, gender, or medical history, but my knowledge on any specific subject is limited. I can sew up lacerations, give end of life care, deliver babies, prevent future illness, and educate people on how to handle most common medical problems. I did this because I enjoy working with human beings and want to help people with their physical needs.

Should you choose Family Medicine as your specialty you will be constantly looked down upon by other physicians. Even though you probably store more knowledge in your brain than any other doctor, specialists assume you are slow-witted because you don't know as much about their particular disease of choice as they do. You will make much less money than other doctors because insurance doesn't think keeping someone healthy is nearly as worthwhile as doing big tests and procedures. You will constantly be pressed to see more patients in less time because the reimbursement for your work is continually dropping.

After his training Doctor D chose to work in a community health clinic to provide primary care for underserved patients. He absolutely loved his job and the amazing people he cared for. He also learned to hate the medical system and the bean counters that were constantly pushing him to cut corners on patient care. In the end the bureaucrats won and Doctor D quit that clinic rather than choose to hurt the patients he cared about. He is currently working odd shifts as an ER doctor in a tiny hospital in the middle of nowhere to pay the bills till he returns to Primary Care. He blogs about patient-doctor relationships because he misses having patients of his own and still has those crazy ideas about "helping people" with his medical knowledge.

Of Course there are days Doctor D wishes he would have never signed on to be a general doctor (or a doctor at all for that matter). But when I realize I can help nearly every person that walks through my door I am certain that I chose the right career. Family Medicine is one of the most frustrating and rewarding paths in all of medicine. I advise med students to seriously consider general primary care—it is the fullest embodiment of the ideal of doctoring—but only select it as your specialty if you are certain you will love it, because it will probably get harder for primary care doctors before it gets better.
Wow, that was a touchy-feely post! I'm afraid Nurse K is failing to make a good hard-ass ER doc out of me. Quick, someone ask a question that will awaken my god-complex angry doctor side!


MLee said...

"Wow, that was a touchy-feely post! I'm afraid Nurse K is failing to make a good hard-ass ER doc out of me. Quick, someone ask a question that will awaken my god-complex angry doctor side!"

Hmm... had to think for a bit.... What is your response when a patient comes in and says, "doc, my finger hurts if I slam it in the door, my left leg itches when i get poison ivy, nope not itching now, but it will, and my back hurts every since I got hurt about 20 years ago, only dilaudid works for this 10 out of 10 pain....
that sould bring out your god complex :)

Doctor D said...

Ahhh, yes I can feel the ER doctor rage and indignation returning. Thanks Nurse Lee!

HugeMD said...

It's OK to be touchy feely. I understand. Bailed on primary care, too, to do urgent care before I burnt myself to a crisp. I wish I could find a sane enough, well-paying enough primary care job to make it worth going back... Love your blog and what you're doing for people.

Doctor D said...

Thanks HugeMD! I wouldn't say I bailed. I'm just resting.

The touchy-feely side of ER is that I'm actually around to see Little D grow up. In Primary Care I think I saw other people's kids more than my own sometimes.

Christine said...

Doctor D - It is so refreshing to hear a doc (or any clinician) whose views about primary care are not completely negative. I'm a 2nd (clinical)-year PA student, and when I tell people that my plan has always been to do family practice, I get looked at like I am completely insane. "It doesn't pay." they say. "No one will respect you." they say. Well, I'm gonna be a PA, so I don't anticipate loads of respect... and sure, I could make a lot more money doing CT surgery, but I think I would hate it. I worked as an MA at my school's family practice clinic during my undergrad, and I fell in love with the clinician-patient relationship and the huge potential for good there. It's what I found most appealing about medicine. Touchy-feely or not, I appreciate your perspective.

Doctor D said...

Excellent thoughts Christine. It's always hard to be an idealist who wants to serve humanity. Humanity will always let you down from time to time. We should serve people because we care about them not because of the appreciation we may get.

Whenever I start a Primary Care pity party, I am reminded of my friends who chose to be teachers and police officers. They work just as hard as me with far less respect or reimbursement. I have nothing to complain about. They do what they do because it matters.


Dr D just be yourself, you don't have to live up to Nurse Ks bad ass reputation. Being mean and bitter and downing her patients doesn't look attractive(she does write some great stuff though).

I have had my G.P (family Doc) for over 20 years and wouldn't trade her in. Although since this surgery I tend to get flicked back to Urology all the time due to the nature of my health issues.

I have always believed even if a Dr has a bad bedside manner if their medical skills are truly awesome it cancels out the mean side.

If they are useless at their job, but have a great bedside manner then its easier to deal with them however you may never get well.

If you are good at what you do, have empathy/ understanding and actually try to understand the patient as a whole then you are an all round great Dr (no sucking up.

General Practice physicians are supposed to be the Drs we all go to before Hospital is needed, I believe preventative care is always the best, if preventing medical disasters by taking time to know your patient and educate them on healthy lifestyles or disease management, then your more important for the general patient population than the Ambulance at the bottom of the cliff.

Anonymous said...

Thanks for explaining what a family medicine doctor does. I've always been a little puzzled. Other sorts of medical practice are defined by categories like age (pediatrician), body part (cardiologist), or disease (oncologist), but I couldn't figure out why a doctor's area of practice would be defined by a social unit (family) and vaguely wondered if a "family medicine" doctor preferred or expected to have all the members of a family be his or her patients and would get to know them both as a family and as individuals. You sound like the sort of doctor everyone needs and hopes to find. I'm glad you are out there!

queenofoptimism said...

Just want to say thanks. I'm not a sarcastic health professional, just a public servant, and I respect your choice a great deal. As a patient to many doctors, I wonder how some of mine are comfortable with not developing a realtionship woth me to the point that they can't remember anything about me from one appointment to the next.

K said...

Is it common for family practice physicians to practice in ERs? I thought most hospitals only contracted ER docs nowadays.

Doctor D said...

I have heard quoted (although I cannot find an authoritative link to back this up an a quick Google search) that only about 40% of ER jobs in the US are filled with Emergency Medicine trained physicians. Of the additional physicians I would guess that Family Physicians make up the largest percentage of the others because we have a very broad training.

The big urban super-ERs will likely have all ER boarded docs, but the smaller rural ERs in my area are almost exclusively staffed with Family Medicine doctors. Smaller hospitals are barely getting by and Family Medicine doctors are significantly cheaper than ER docs. We sort of expect not to get big bucks. We can handle 99% of what comes in the door, and the rest we stablize and ship to the big ERs.

If you want to do ER your whole life or work in a large urban ER then obviously ER residency is the career for you, but if you want the ability to work ER at some point in your career or do ER shifts on the weekends while running a primary care practice it can definately be done in Family Medicine.

Anonymous said...

I'm an RN,BSN that recently removed myself from a BSN-to-DNP program from a big university. I did so, because I am already trained to do what it is I would like to do and didn't see the point in spending more money to work in a seriously flawed system. I want to help people optimize their health. I have family members and friends that call me daily to ask me questions that their doctor's office didn't have time or care to answer. I feel like a nurse-of-all-trades. One thing that is the same, regardless of the environment is...patients want to be heard, understood and they desperately need to understand their medical conditions and need help modifying their lives accordingly. How do we make that happen in today's health systems? I feel like we're at the corner of despair and major positive change...what do we do?

Anonymous said...

He absolutely loved his job and the amazing people he cared for link. He also learned to hate the medical system and the bean counters that were constantly pushing him to cut corners on patient care.

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