Posted by: notdeaddinosaur | June 12, 2012

You Don’t Have What it Takes

I figured it out! I realized what the basic, underlying, fundamental problem is with medical care in this country.

The problem is that it’s too expensive and often isn’t very good, but that’s clear.

The reason medical care in this country is fragmented  and overly expensive is that there is a perverse inversion of the correct ratio between primary care and specialty physicians (should be significantly greater than one, instead of significantly less). That, too, is perfectly clear.

But what is the reason for this ridiculous state of affairs, where specialists outnumber primaries 20 to 1 instead of vice versa? Most people point to economic disparities, with towering specialist incomes dwarfing that of primary care, due in large part to the perverse payment incentives for “doing something” (ie, procedures) instead of thinking about, talking with, and counseling patients.

I don’t think that’s it.

Here it is:

95% of American medical graduates don’t have what it takes.

Primary care is medicine in its purest form. Family medicine, pediatrics, general internal medicine; primary care, defined as the generalist physician caring for a patient (as opposed to an organ system or a disease) over the long haul, is what medicine is really about. It’s hard. It’s challenging. But it is rewarding in a more deeply authentic way than any other field of medicine.

The rewards offered by the specialties are more immediate, but they are also short term and finite. It’s no wonder that they attract graduates without the emotional stamina required for primary care.

Most of them try to tell us that we’re the dumb ones; the bottom of the class; the ones who don’t have what it takes. This is nothing but projection on their part. Grade ranking in medical school is a meaningless fiction. You have to be the cream of the cream of the crop just to be admitted. Once you’re in, you don’t suddenly become dumb. Besides, the essence of medical school course work is geared to passing the three steps of the United States Medical Licensing exam. Once you’ve passed those, you’re licensed. That’s all it takes. All the other evaluations and grading schemes that reward top performers with dermatology and ophthalmology training slots are nothing but exercises in meaningless memorization that contributes nothing to caring for actual patients.

I suspect that more students start out having what it takes. It’s too bad that so many of them lose the passion for real medicine as they progress through training, and end up settling for the pursuit of one or another tiny sliver of knowledge that they’ll never fully achieve anyway. Between the inherent challenges of primary care and the naysaying peer pressure, I suppose it’s inevitable.

But it’s still wrong.

Primary care is awesome! The only reason so few people choose it must be that 95% of American medical students don’t have what it takes.

Do you?



  1. I was talking with a co-worker in clinic just last week on how we are the brightest of the bunch because we have to be. We have to know everything about everything and about every organ system. We have to navigate the systems of the body as well as we navigate the systems of our community. Primary care is hard and it should be! It is not a cop out and it’s certainly not a place to “settle”. We work hard to stay abreast of every change our professional societies recommend and it has to be a primary care doc that makes the decision to refer – the specialists don’t make (and can’t make) that decision for us.

    it’s the best job in the world.

  2. Good post, but it’s still the money!

  3. Found you through DocBastard, following!

  4. People don’t do primary care because #1 It’s hard. #2 It pays terrible. All these kids have loans and math skills, so there you are.

  5. I think there is some other stuff at play here. I am a fourth year, about to start the match process, and I have constantly gone back and forth on FM. In fact I am still not totally sure about it, even this late in the game and so I am going through the process of gathering the materials for two fields, should I change my mind.

    Yes, it is hard. And it is scary going into a three year training program for fields that seem so very broad; you constantly wonder if you can really do a good job providing such a broad scope of care. Especially when residencies for much narrower fields are almost universally longer, and with work hours getting shorter and shorter.

    And yes, money is an issue, one that primary care is undoubtedly on the losing end of from a cursory glance. But security is also an issue. Now, I am not saying it is a believable thing that midlevels will take over primary care, but when you are this far down the road and up to your waist in debt there is a serious fear of “throwing it all away” on fields that others claim to be able to do with a year or two of online coursework fresh out of nursing school.

    Add to all this the fact that the majority of medical schools are in environments where super-sub-specialization is the norm, and family medicine is non-existent, and things like internal medicine and pediatrics are viewed almost exclusively as stepping stones to a specialty. How many of my attendings on the medicine service actually practiced general internal medicine – None. Same for pediatrics.All were fellowship trained, but did some required time every year on the ward service. Residents are commonly asked by attendings “what are you planning to go into”.

    Woman with trouble conceiving? Not “consult OB/Gyn” but “consult “reproductive endocrinology and infertility”. Patient with diabetes? Endocrinology. Pregnant woman with diabetes? Maternal Fetal Medicine.

    Are the any role models for primary care in most places? Not easily found. And really, it’s hard not to be impressed by the other residents – I mean they know everything about their areas; and the act like other services are blithering idiots for not knowing the appropriate work-up for some bizarre problem in their field. And if you are around any primary care field residents, well then they come up seeming like they don’t know anything; there is just always someone who is better at every individual problem – but not at dealing with all of them.

    And then there is the problem of how primary care is often done in these large teaching areas. I mean, it is kind of easy to cross a field of your list when you see someone who is in the clinic only, and spends 80% of there time referring people somewhere else. There is a short supply of people that really provide continuous and knowledgeable care for their patients, be they in the office or the hospital, in these environments.

    Of course, when you do see someone doing that it is very invigorating. When you work with an attending that sees an issue in the office and you expect him to say “let me refer you here” or “you need to go to the ER” but instead they have the courage and knowledge to say “oh we can take care of that for you”. When they really put in the time to provide total care for their patients, and you see the relief on their patient’s faces when “their doctor” shows up to see them in the ED and assures them that they will take good care of them – and you know that they can and will. That this attending will put in the time necessary to care for their patients.

    Too often primary care is sold to students as “it’s nice and relaxed” or “it’s nice, because you can always refer to a specialist” or “don’t you want to have time for your life outside of medicine” or “we are a very non-malignant program”

    Your best and your brightest don’t want that sales pitch. I really do think they want to be challenged, to be inspired. I was discussing this very thing with some classmates. With some of the current ways primary care is sold I think it attracts the wrong type of person. So those seeking challenge and intellectual stimulation shy away from fields that are often characterized, and even actively advertised, as easy – even when the opposite is true.

    Now suppose you want to have a 9-5 outpatient only practice. Fine, that’s anyone’s prerogative. But suppose you don’t. Suppose you want to do more. Well I think it is the unfortunate truth that it is not an easy task to find a really solid primary care training program for this type of person; and so they may just decide to look elsewhere.

    Sorry, I realize this was incredibly long. But just don’t dismiss students not entering primary care as “them not being up to the challenge”. That may be part of it – and I think it is in a way. But I think there are a lot of other issues at play, and that the way primary care is billed needs to be changed. I think there are students that are up to the challenge, and lots of them. But there are many that aren’t even aware there are challenges to be had, because of lack of exposure and from the voices the specialists that train them, and even the voices of many primary care physicians.

  6. Attracting students to primary care really does come down to exposure to influential role models and seeing the rewards of a family practice first hand while in training. Most medical students never have opportunity to work with an honest to goodness family doctor in a neighborhood clinic or small community, and the opportunities are diminishing by the day as old dinosaurs like myself age and retire.

    They have no idea what it is like to manage care for grandpa who is showing early dementia, grandma who is very stressed and depressed, their daughter, a mom who is struggling with being the middle of the “sandwich” between her failing parents and her acting out teenagers, one of whom has an unintended pregnancy that she intends to keep and raise at home with mom’s help.

    Only a family doc can understand the dynamics in such a complex system and help this family make cost effective health care decisions that will enhance their ability to cope with today as well as for the next generation to come.

    After thirty plus years of being a front line primary care provider for thousands of people, I have no regrets. I was blessed to see quality family docs in action during my early years in training and it made all the difference.

  7. […] You Don t Have What it Takes by Lucy E. Hornstein MD […]

  8. […] You Don t Have What it Takes by Lucy E. Hornstein MD […]

  9. I’m pretty sure I’m offended by this post.

    “The rewards offered by the specialties are more immediate, but they are also short term and finite.”

    Damn right – the difference is that I get to cure stuff. There is very little that is more satisfying than taking out a horribly inflamed appendix and watching the patient wake up without pain. I then get to send him home having cured him. What could be better than that?

    “It’s no wonder that they attract graduates without the emotional stamina required for primary care.”

    Telling a woman that her breast biopsy came back positive for breast cancer is extremely emotionally taxing. But I then get to remove the cancer, follow her through her chemo and/or radiation, and then continue seeing her for follow up for the rest of her life. That’s emotional stamina right there, and implying that surgeons don’t have it is rather unfair.

  10. @DocBastard: Sounds like I hit a nerve. Now you know how I feel when surgeons tried to tell me I was too smart to go into primary care. Hint: the spirit behind this post was to go on the offensive.

  11. @DrDino: I get offended when any doctor tells any other doctor that he or she isn’t smart enough for anything. Except ER docs who (by and large) aren’t smart enough for anything other than triage…don’t even get me started. 🙂

  12. We’ve gone around on this one before, you and I, but I’d still argue that whereas everything you say about family medicine is (mostly) true, and whereas I’m certain (seriously, I am) that you’re one that stays abreast as well as knowing her limits and not like the ones I’ve had to bail out, general surgery is an exception to your characterization of specialities. I had patients and families I cared for throughout my career, and was never one to cut an run. In fact, it’s one of the great pleasures of general surgery: having people consider me “my surgeon,” taking care of a whole range of problems.

    I don’t think it’s a matter of “having what it takes.” For one thing, primary care can always punt when they need to. For another, except for certain not-dead dinosaurs, their call is immeasurably less demanding than that of most surgeons, who, also, can never punt when the excrement is heading toward the fan. I just think it’s a matter of doing what you find best suits you; and whereas I’ll admit that in my younger years, less beaten down by reality and politics, I’ve said some things about family docs that I regret, it’s unbecoming of us all to get too caught up in whose demands are the greatest, whose choices are the hardest, whose mentality is the toughest — and, by implication, the most worthy.

    And with that, I disappear once again into the ethers.

  13. Hey – I haven’t commented for a long time, but I just finished my (second) intern year in FP. And it’s

    1. The money

    2. Dealing with billing and insurance – which is less onerous in a lot of specialties

    3. Being so highly at the whims of insurance, administration,bureaucracy – who will fight me on the HPV vaccine for someone over 18, but futile chemo – nary a word.

    4. Being thought of as dumb by other doctors – all their stories about some dumb ass PCP they rescued the patient from.

    And the one major thing that is starting to scare me and weigh on my conscience is how much I feel that my job is to protect my patients from the modern medical-industrial complex. The ones who want testosterone shots, the back MRIs and then of course useless or harmful surgery, the random cardiac caths, the ones who have gotten 10 CTs in the last 2 years because of their functional abdominal pain in the ED, the ones who want lifetime disability for their whiplash from the minor MVA, the every year mammogram or Pap, the continuous fetal monitor.

    But of course, I’ll never get paid for talking to someone about why less services are better than more – and how badly they can get hurt. And I’ll get accused of trying to cut corners. Unfortunately the American Super Size It mentality has run over into healthcare as well.

  14. What primary care doctors lack is the collective confidence and passion to stand up for themselves. Stand up to other physicians who demean you for not knowing enough, not doing enough. Stand up to the bullying by the Medicare reimbursement committees. Stand up to the bullshit of the insurance companies. Sometimes it’s as little as standing up to media articles that tell you that you need a dermatologist for an acne outbreak or a gynecologist for a pap smear.

    Honestly, your professional organization is doing a horrible job. Or maybe it’s the members who are doing a horrible job of initiating, supporting, and sustaining those efforts.

    To the specialists who are offended–now you know how primary care doctors have felt to be devalued.

  15. As a third year med student with a decision to make soon, much comes down to exactly what Mamadoc stated in her comment: Hard work, little pay.

    In terms of hard work, well most things in medicine are hard. Surgeons work pretty hard too. But they get paid a lot to do so. And the sheer volume of patients and only a few minutes to see each one creates a constant rush and greatly reduces the satisfaction of interacting with your patients. On my rotations, I find myself constantly (politely) interrupting patients because I simply don’t have the time to hear them out, much less hear about their grandkids and hobbies (which I’d like to). And I’m a student! I get more time to spend with patients than the docs do.

    My med school charges $50k per year in tuition alone, with most folks taking out quite a bit more for things like food and rent. Graduating with $250k in debt is routine, and lets not forget that that debt has been incurring interest all along at an average of 6.8%, the least expensive federal loans. This looming shadow is terrifying, many med students I know deliberately don’t check their school bills/statements out of anxiety.

    I wish I understood why primary care docs get so monumentally screwed financially. The laws of supply and demand don’t seem to apply, tons of patients, even more on the way, and a massive shortage of PCPs. I may not have been an econ major, but low supply and high demand should increase salaries, right? This shortage is nothing new, but the market has not corrected by significantly improving reimbursements for PCP’s.

    Narrow (or heck, eliminate) the gigantic income gap between PCP’s and specialists and more students will pick primary care. Not rocket science here. Allow more time per patient and better hours and you’ve got it all, something like dermatology. Not one future derm student I know has the remotest interest in term, instead they are attracted to workable hours and great pay.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s


%d bloggers like this: