There’s a lot more than lower pay that causes high burnout rates in PCPs (primary care providers).
Note that medical care complexity increasing in recent years puts more pressure on PCPs to be accurate “gatekeepers”.
My father was a family physician (one of the first to be board certified in family practice) and I’m grateful to have a competent and caring internist, who I occasionally converse with about the challenges he faces (currently, many internists are pissed off at the American Board of Internal Medicine and the $$ docs pay for recertification that they feel doesn’t add to quality care).
The U.S. needs to sort out issues leading to PCP burnout before we wind up in a mess like the U.K., where long delays in being able to see a PCP are putting heavy pressure on A&E (Accident and Emergency) departments. Numerous A&Es have been described as being in “crisis” for a long time and conditions seem to be getting worse, with waits of at least 16 hours for patients to be seen, corridors stacked up with patients who can’t get a hospital bed and lines of ambulances containing patients waiting outside A&Es overnight because there’s no room for them inside. It sounds gruesome for both patients and staff.
Just to add my opinion. When I see a patient for a routine follow-up visit, I am expected to address their hypertension, their diabetes, their thyroid disease, their carpal tunnel syndrome and their urinary incontinence. Sure I can refer to a specialist for each but then what is the use of my skills or education? So I try to do all this in the 15 minutes allotted while also dealing with any mental health issues.
The patient states that they wish to see a specialist for say diabetes. I refer them to an endocrinologist who takes the 15 minutes just to discuss the diabetes and gets paid the same or more than I do. The specialist adjusts the medication. At the next visit the patients says “I don’t know why I need a specialist? Their copay is higher and you can handle it just as well”. So now I am responsible for managing the insulin program that the specialist wanted.
That does not include the fact that a lot of what I manage such as hypertension has no symptoms for the patient. An orthopedist can tell the patient ( and they do) that if he has knee pain and back pain he can only handle one and must make another appointment for the other which the patient will do because they are in pain. However, if I see a patient with diabetes and tell them to come back for another visit to address their hypertension I will be lucky if they come back before their medication runs out because they have no symptoms.
I don’t begrudge the specialists being paid for surgeries or procedures I am not trained to do. It just sometimes seems unfair that the primary care doctors do all the time consuming diagnosis, the specialists whip in, get paid much more for a quick procedure then send them back to us to do everything else.
ETA: This sounds like I don’t like what I do. That is far from the truth. There is nothing I like more than going through a patient’s medications and telling them I can give them one pill that will lower their blood pressure, help prevent their migraines and improve their tremor. I like treating the interconnected diseases. It’s just that our health system rewards procedures much more than preventative care.
My site partners and I had apparently missed the memo on it and have just started entering it.
For everyone else, as noted compensation for the basic work we do has not moved much in a long time. This code can get added on top of our sick visit codes for patients who our site provides continuity of care for. Not all payers pay it and it isn’t huge (0.33 WRVU, work value units) but it does represent an effective increase of maybe 15%(?) for the standard sick visit that has not been seen for long time.
It’s almost too much work to add new codes. I noticed that reimbursements are creeping up toward my charges so I have to raise my prices. ( The insurance companies pay the lesser of what they allow or what you charge so you have to keep your prices above the highest reimbursement rate). Also I have to decide whether to opt in for MIPS since I have a small practice and my EHR has inexplicably decided to report measures where 95% compliance only gets me 3/10. At least I’ve never not gotten some extra but the 2.9% cut this year is going to kill me given that all my expenses like IT and answering service are going up. But thanks, I will look into it.
This thread has been quite enlightening for me. Thank you.
I am a career-long government lawyer. I make what I consider a comfortable living - less than reported above as the average PCP income, but more than what most of you report. Prior to my latest/last promotion 13 years ago, I was in a position which today would be hired in as $75k, and would max out at $138k. Supervisors in that job maxed out at $162k.
And that is straight income. In addition I receive contributions towards health insurance and a savings plan, and am eligible for a pension. Several private attorneys earn more than I - tho they often work longer hours, and many attorneys make less than I.
I had always just assumed that doctors made approximately similar income to mine, if not more. I respect folk who have a true “calling” for a particular profession, but personally, I have a hard time imaging why anyone would go through the stress, time/effort, and expense of med school, and the stress and hassle of working as a doctor, if my income maxed out under $200k.
Again - thank you for dispelling my ignorance on this topic. And I agree - you all should be paid more. Just such an inexcusable situation, that so many folk make so much from health care - except for those actually providing the care…
I don’t think the problem is so much that primaries aren’t paid more so much as specialist are paid way too much vis-a-vis basically every other country on the planet.
Primaries still make a really good living in the US versus the rest of the planet, but specialist are paid vastly more so the incentives aren’t in balance.
A huge reason why this is the case is that education in this country is insanely expensive, especially medical education.
It’s all out of whack, education is too expensive and many doctors are just trying to recoup the ivcestment they made on the front end.
I feel like part of the problem is that the US doctor training system is extremely selective and difficult. I mean, it’s basically straight-As, then hope you get into a good medical school, four years of medical school after undergrad, THEN you’ve got to find a residency, and spend a grueling 3-7 years there before you’re actually fully licensed to practice on your own. Being a PA or NP is less, but it’s still a lot of time and money to get licensed.
This is a way to produce very well trained medical providers, but it’s also a sort of gatekeeping to limit the numbers, IMO. And more providers is what we need, not less, if PCP burnout scores are 79%.
I feel like maybe having less emphasis on the MD/DO level providers, and having people make primary relationships with their friendly mid-level providers is the way to go. That way, people won’t feel like they’re getting short-changed by seeing some mid-level instead of the actual doctor. They’ll be seeing their provider, and the actual doctor will be some person who they kick the complicated stuff up to and you see every now and then.
That is a valid opinion. But I would ask what is a reasonable rate of pay given the education and liability involved?
$150k can certainly support a comfortable middle class lifestyle. Especially in a 2 income family. But I don’t think western physicians have ever been thought of as just an “average” middle class profession. I just looked up my local school district and see a number of teachers earning $150-160k. Local police earn up to $140k.
I’m not saying police and teachers ought not earn what they do, but I do not believe they need the same amount of education to enter their fields. And they are eligible for (what I consider) relatively generous pensions at a relatively young age.
Also, I do not believe police and teachers have to have the sorts of grades and test results needed to get into any med school.
Why are you comparing the income of US physicians to “the rest of the planet”, as opposed to other incomes in the US?
Like I said before, physicians ought to earn a greater share of the health care pie. The same way farmers ought to earn more of what is spent on food.
From what little I know about the medical field liability only applies to the reasonable care any professional would exercise in the profession. This is decided by fellow medical professionals who work in the medical field. I think this is a fair standard.
I think the rate of pay primaries currently receive is about right on target, it’s everything else that is out of whack. Education costs, costs for equipment, admin costs, medical mal practice costs. Everything else needs to be reduced so primaries can make a suitable living that’s reflects their massive front end investments.
I think medical costs are already insane and increases them even more to encourage more promaries to do this valuable service would just be exasperating a problem that is already out of control.
Like I said I know this won’t be a popular opinion, no one likes being told they shouldn’t make even more money than they already do. I just don’t think we’re really addressing the heart of the issue by only rates rates for primaries, especially when you consider that few other countries on earth pay doctors higher salaries.
Like I said, your is a valid opinion. I’m just not sure I agree.
I think it can be a challenging prospect to opine what a certain profession OUGHT to earn. Like I said, in an economy where teachers and cops earn $100-150k, it does not strike me as unreasonable that doctors earn somewhat more - say $200-250k.
It is yet one more on a long list of issues w/ the US society that folk are not paid commensurate with their contribution to society. I would comfortably say that a great many healthcare administrators could do with SUBSTANTIAL pay cuts. Not to mention any number of folk in financial services.
I was briefly a public school teacher and I didn’t know many teachers who made 6 figures, not in my state they don’t. The only teachers I knew who made that much were tenured professors with PH D’s. Sadly we don’t value public school teachers very highly. Cops can certainly make 6 figures, 2 or 3 times over with enough over time.
All I think would happen if we raised the salaries of primaries is the price of everything else would also increase proprtionately. In particular the costs of specialists who complete additional training would rise, which is why I don’t think raising only the salaries of primary care physicians fixes the underlying problem. We need more primaries, they do difficult work, but many are dissuaded from doing it because they can make 2 to 3 times more going into other specialties. It’s a escalating arms race that shows no sign of slowing down.
It’s a good idea to say that people should see mid level providers and only kick the complicated cases to the MDs and DOs but IMO that is a sure way to decrease the incentive to go into primary care. You take away all of the benefits of primary care, being able to build a relationship with the patient, comprehensive care etc and instead leave the physician with only the most complicated and time consuming cases. There’s no breathing time like a rash or infection that you can deal with in 5-10 minutes in order to spend more time with the complicated patients. Instead it’s all complicated, time consuming patients with the same time constraints. That is a sure path to burnout.
In my area, you are more likely to see a PA or NP when you see a specialist.The specialists can concentrate on doing procedures and leave screening and follow-up to the non-physician providers. For example, if a patient needs a colonoscopy they will see a PA or NP to assess their risk etc, then the GI specialist just does the procedure.
I’ve got a nice roof over my head, kids through school, comfortable amounts in retirement portfolios … I’m not complaining myself.
And I will offer some thoughts.
Cost of medicine. My suspicion is that our fees are not the major expense. What gets ordered and on the adult side the hospital stays of our patients is.
No disrespect to the many good advanced practice providers (APP) out there but I often see them order and refer to specialists more than is often necessary, and more than a primary care physician would. Mileage may and does vary by individual but it makes sense that less experience and training results in more labs and referrals.
That said I do suspect that we don’t need all the academic portion of med school.
I’m reminded of a historical parallel - the Imperial Japanese Navy before World War II.
The IJN had a strenuous-to-brutal system of pilot training in the runup to Pearl Harbor. It produced probably the best naval air arm in the world at the time, taking large entering classes and culling out all but the best and most dedicated. They were trained well in all facets of their job and their early-war performance, flyer-vs.-flyer, showed it.
But it was utterly unsuited to the demands of a long, large war against similar power. Pilots who went down at Coral Sea or Midway or over the Solomons couldn’t be replaced. Those who survived were kept in the battle until they, too, eventually succumbed, rather than taking the lessons they had learned from the air war and bringing them back to train more pilots, in the numbers that the Pacific War needed.
The U.S., on the other hand, had large pilot training programs that were quite rigorous but not sadistically so (as was the case with Japan). Pilots with success in combat were sent back to the States to train more in what they had learned - and the quality of new U.S .flyers rose accordingly. Since the U.S. had been gearing up for a large, global war since 1940, they were able to expand their pilot corps to accomodate the demands of such a war, and eventually swamped Japan in both quanity and quality. (Other factors in making US pilot trainng better included availability of fuel and training in good/warm weather areas of the country, but I’m concentrating more on the factors under each side’s control.)
I don’t know enough about training of prospective doctors (or burnout of existing ones) to make the analogies stick, but some do come to mind - I’m thinking of practices like scheduling residents for 20-hours shifts or the like, although I understand that has become less common lately. If someone more knowledgeable about it would like to weigh in, I’d love to hear it.
20 hour shifts? Surely you jest! I think the limit now is 24 hours which is not unreasonable. I do believe that following a patient through an acute crisis is helpful. I am not opposed to long shifts as long as there are days in between for rest. The problem comes after training when you are the cardiologist on ER call for a week and get called in three days in a row to do an emergency catheterization. You can’t just say that you only work 24 hours and then leave in the middle of a procedure.
Having hospitalists has made a huge improvement in the lifestyles of many doctors. In some ways the patients get better care since they are treated by fresh, well-rested doctors . However, they do suffer from being seen by doctors who don’t know them. For example, when a patient comes to the ER they just look at whatever medications they were on at the last discharge so they end up on the wrong medications. I know things about my patients like who can’t tolerate certain blood pressure medications because it affects their kidneys. Then they go to the hospital, get restarted on these medications and I have to stop them again when they go home.
I would agree with this, and based on what my PCP has told me, what they really need is less administrative overhead duty. She complains that she’s thinking of leaving the field because she spends an enormous amount of time on paperwork and documentation instead of doing what she trained for, which is seeing & treating patients.
So before we go throwing more money at the problem, maybe just let these people have the satisfaction of doing the damn job that they signed up for.
Also I agree that it’s ridiculous that PCP’s do all of the intake funnel and diagnosis, and then specialists swoop in with a well-understood low-risk procedure and collect big bucks. It should pay more to work in constant uncertainty, figuring out the right approach, and having to nudge noncompliant patients in the right direction. That’s harder than having someone else eliminate all the uncertainty so you can do a well-defined procedure that you’ve done a thousand times.
Even in general practice Peds there are times … my luck of the draw was getting lots of our practice call in the holiday stretch. Most of the time call is a call or two over the night. But 12/30 through 31 was a call every freaking hour that I was trying to sleep. One of the few times that I think “I’m too old for this shit.” to myself. That’s uncompensated time btw. Value added service.
Which circles back to burnout.
I see three legs to preventing it, and decent comp is just one (didn’t mention btw that our CME and board certification costs, thousands of dollars each year, is paid by us too).
@Jackmannii adds the other, which I just bitched about: stress and demands of the work. When I watched The Bear S1 the managing crises seemed like normal to me! Oh it is usually fun as long as it doesn’t overflow the cup … so usually not a problem per se. Lifestyle though of course matters to burnout. Most of the time call isn’t like that. And the office is better staffed for now.
The third though … is feeling like we are part of a greater good. That’s been undercut. Increasingly we are parts of corporate machines more focused on bottom lines than serving the overall community health. Or having to be just to keep afloat. It gets discussed as “moral injury” and it is for many death by a thousand cuts. I deal by just concentrating on the small world in front of me, because the big picture of what I am part of pisses me off too much.
Yes, i don’t think “more pay” really addresses burnout at all, although i suppose it might attract fresh blood to the job.
But expecting a doctor to thoroughly review a patient’s history and needs in 15 minutes? All day long? That creates burnout. Sure, “doc, i just noticed this rash” might be a 15 minute appointment, but if you are managing patients who have any preexisting conditions, surely it takes more time than just looking at the rash and asking about recent changes in environmental exposure and diet.
And as for attracting more doctors … There are a limited number of slots in US medical schools, and it’s very hard for anyone trained outside the US to practice here. Slightly expanding medical schools might improve the situation, especially if the number of seats in specialty training didn’t correspondingly increase.
I wouldn’t say not at all. It’s just that it is only one of the three legs. Feeling underpaid means that both the other legs have to be there or burnout is a sure thing. Thing is the career historically has given us all three: good pay, decent lifestyle, and feeling like you are making a significant positive contribution to society. Score! Now the pay is not as much. The working conditions more stressful. And that positive contribution sense much less than it was. Lots quit during Covid and we are not pulling in enough to replace them and those who are getting tired as they approach 70 …
