Ladies,
You know, there are SOOO many posts in MOMMD that lament that we, those who are in primary care, are unhappy in our jobs, and yet so many of us are bound by medical school debt so we are forced to work. This experience is shared by many of my colleagues in real-life across spectrums as well.

This is one of the most brilliant scams out there.

Maintain an aura of prestige and competition. Let people fight over a spot in med school. Get people to sign over hundreds and thousands of dollars. Paint a rosy picture about primary care. Match people to it. Force people to provide medical care for hospitals and clinics for little wage for 3 years. After 7 years then indenture people for years to work bound by their growing debt.

I am wondering what you thinking about bringing a class action lawsuit against US medical schools for "falsifying" information to medical students and premedical students about the state of primary care.

When we were students weren't we told that primary care physicians need to possess the skills of listening, organizing, and educating patients. As I recalled, we were told that we'd be the corp of "special" physicians who understand patients in the whole biosocialpsychological context. This is why, students should aspire to match in primary care. There is a disconnect between what academia teaches its students and what real working environment is.

In reality, we are seeing patients 15 minutes a piece. Time to educate, reinforce, listen, organize, document, analyze, etc ARE NOT REIMBURSED. We are seeing 20+ patients a day being responsible for every aspect of patient's medical care, with time to review labs that come out of our staying later, during lunch break, cutting corners as much as we can get away with. In the meantime, patients expect their primary care doctors to practice "perfect" medicine like Norman Rockville's doctors. Or else, they will sue. We all buy million dollar medical liability insurances.

Because of our educational debt, we can't quit. Meanwhile, medical schools accept more med students and churn out more medical residents who are going into primary care thereby reducing our negotiating leverage. Do you see how in the bigger economic scheme of things, we have very little power?

How about it.
Do we have a case?

If there was such a lawsuit, initiated by someone else, how much money are you personally willing to contribute to it to pay for high-profile attorney's fee? I for one know that if someone initiated this lawsuits, I would contribute in the ballpark of $200-500 but I'm not sure if other people feel this way.

Does anyone know how much of such lawsuit would cost?

Even if the case was lost, it would provide media exposure and open a topic of discussion. It might detract premeds and med students going into primary care, which ultimately will lead to some radical changes.

Alternatively, should people form an organization of physicians who go out to tell pre-meds and med students NOT TO MATCH in primary care? Given the 50% of med students are women, would they listen with more if this message came strong and clear from women physicians who are practicing and living the real life?

Like many other groups of disgruntled workers...we should unionize. That way we can make the rules...and if hospitals, insurance companies, clinics, etc. want to play this "medicine game," they'll have to deal with the doctors union. We protect our rights, and our voices are not only heard, but respected.

If we could change medicine just a tiny bit, in significant ways, we would be happier practicing. If we were happier practicing, the debt, time invested, and all the things mentioned, would be worth it.

I think it's more likely that a union would work than a class action law suit. And if the class action law suit is an option...doctors need to organize anyway (even for that to be successful).

Bottom line...doctor's need to unite and fight. There is no medicine without us...we need to flex our muscles a bit, and remind the country that *we are medicine.*

This is a little off topic, but I'd like to sue the lawyers for all the frivolous and truly non-malpractice cases they create!! This is creating terrible work conditions for physicians now. I hardly know a doc who's not being sued anymore. I got dragged into a case right now where all I did was order an xray--radiology misread it and a diagnosis totally unrelated to her visit to me was delayed by a few months, but the patient received appropriate care for it. But she died of something else entirely 3 years later!! Tell me how that is my fault!! My attorney says I'll get dropped eventually, but I am stuck in this case for years now until then.

I find it morally reprehensible in our country the way it is so easy to sue doctors when the patient or family simply isn't happy with the outcome. Greedy, greedy, greedy and no sense of self-responsibility.

I do feel let down by the practice of medicine in our country, but feel it is more due to our government and law system. Maybe if the doctors back in the 60's and 70's had paid better attention to things and maybe unionized back then, we'd be in better shape today.

doctorhope....

I couldn't agree more with your analysis of the scam we all were suckered into. My finance used to talk about that exactly as you wrote. I always thought he was a bit of a conspiracy nut. Now I can see that scam and multitudes of similar others throughout our society and wished I had woken up sooner. It deeply troubles and saddens me. It is quite comforting to read that others are aware of it too and interested in taking action.

In med school, I started stressing over the debt that was accruing. The financial advisors at school always smiled and reassured me that I would be able to pay it off really quickly with my future doctor salary. My tuition was huge and then they gave me only a tiny amount to live off of (so I had to take out private loans). They also seemed surprised and annoyed that I couldn't just call my parents for money to pay rent and groceries etc...

I can't imagine paying this off anytime soon. My loans payments are more than most peoples house payments. Even if I lived out of my car for 5 years, I doubt I would be able to pay this down much. I don't even have kids yet, so I can't imagine how others deal with it. My income is not increasing, but my malpractice and business expences keep going up. I feel terribly trapped.

I would be interested in taking action, but I'm not sure we could win the lay suit your discussing. People do not have much empathy for doctors or understanding of our problems. Even many of the premeds on this website (who interact with us here daily) do not seem very understanding towards our problems and are lining up to go right down the same path we did. Although it does seem they are getting the message to avoid family practice.

naw, don't need to sue the medical schools -
It is really more of a government funded indentured servitude - most especially with primary care. It is the government that loans us the large amounts of money (Stafford, etc.) to attend school and it is also the government that later on has a huge influence in how much we are paid for our services - Medicare and medicaid - and of course, the private insurers continually low-ball down reimbursements toward the government rates. Oh yeah, our residency training wages are also government funded -

CaliMed

Your analysis is brilliant. It IS the government. Wow. I never thought of it that way.

And here I am thinking that the government is the innocent party. I think that way because I get less hassle from Medicare then private insurance companies.

You rightly pointed out the following.

It is the government who subsidize additional funding to medical schools such as mine that labeled itself as a primary care focused school. Stupid me. I should have wondered why there's a shortage of primary care physicians. Duh.

It is the government that helped to defeat the lawsuit of residents against ACGME for the Match. If residents were to earn more, the health care system would go bankrupt.

It is the government that guranteed the loans.

It is the government that sets Medicare fee schedule.

But the government didn't act alone. It is the final result of the big corporations (biotech companies that make invasive procedure related devices), insurance companies, pharmaceutical companies, special interest group (including our specialists colleagues in the AMA) that lobby hard to make goverment make its decisions.

I think the public is totally in the dark and clueless about what is going on. This brings back the story of how the government allowed GM to make SUVs which are nothing but a bigger car built on a truck frame that is not only dangerous but energy inefficient and harmful to the environment. The government caved into the lobby effort of GM, and then GM sells this terrible product to consumers with glorified image of a very dangerous vehicle by multimillion dollar advertisement. Read High and Mighty, a story of how SUV came to being, well written by a New York Times author.

We will never win in this lawsuit. But it might bring an unprecedented awareness to the public and mobilize public advocacy. Do you think most patients know why their internists/FP spend only 15 minutes on the average for a visit?

"Doctors don't listen. They don't spend time to tell me ANYTHING!"

I guess the only other approach is to form an organized effort to tell premeds and medical students NOT to do primary care. Less supply=greater demand=less leverage power. We at MOMMD can do it.

I don't agree with those doctors who say, wow, the shortage of primary care doctors is so bad for the patient. No. That there are unhappy primary care doctors working as such is bad for the patients and the doctors.

We say that we have to take power back. But how?

I personally would be happy with the same salary but seeing fewer patients a day (10 patients in the clinic, or 7 patients as a hospitalists). This is ridiculously low for our census currently, but it would mean that I could provide outstanding care and not burn out even after 20 years of practicing. I can have a life outside of medicine like normal people because with the extra time, I can eat lunch for 20 minutes without interruption, I can keep up with medical journals, and investigate the really tough cases without a diagnosis. I can return lab work and discuss them in detail the way patients like it...It would be an honest 8 hour day.

There is a survey out saying that primary care is picking up as there is more demand. Could it be that it's already happening? Fewer people choose primary care because it sucks? Or more people get old and need primary care? Or has the government once again created a perceived hysteria that we don't have enough primary care physicians, so they can churn them out more as a way to lower our fee?

Calimed is right. The government is the ultimate supplier of primary care doctors. In fact, the system creates a safety valve. All those internal medicine subspecialists in a time of crunch or highly desirable enviornment, can switch to perform primary care--even though they may be very bad at it because primary care is not without clinical challenges.

Suppose primary care picks up and all the physicians are happy, then there would be more people going into the primary care, and the whole cycle of bad practicing environment would start again. The whole issue is with supply and demand. We need to have a check in the system that monitors primary care very closely, and advice premed/med students whether they should or should not go into primary care.

We are not totally powerless. I personally tell people not to go into primary care. We can do that. Or we can ask patients to lobby for us. Too naive?

Doctor Hope,
You are brilliant! I love it. We'll sue for false advertising. I'm laughing all the way to Wal-Mart to spend my latest paycheck. :rotfl: :rotfl:

I love this topic! I agree that it is a government conspiracy, and we were all too overwhelmed trying to figure out which cranial nerve came out of which fossa to consider the future. Now here we are in the future, scratching our heads. How did this happen?? I would contribute $500 to the cause. Sign me up.

On a practical note, I needed sanity in my life. I now charge $25 for non-urgent afterhours calls(refills/just to talk advice/UTI/URI etc). If I send you to the ER I won't charge you. And they pay.
I charge $25 no-show fee.(cancel in 24hrs)
I charge $30 to pierce ears (fun and easy)
I charge $25 phone consult fee (get credit card up front, I use this to manage HTN/ADD/LIPDS etc) for my patients who won't come in and need refills. I just put them in the schedule first thing after lunch and I call them.
I charge $25 e-consult. Can send pictures this way. kinda fun and can do this at home (medfusion)
I charge $5 a page to fill out forms.

The patients grumbled a little, but realized we would all quit if we didn't have some sanity. They are now trained and call is much much better. No more refills to call in while I'm shopping with my kids at Target.
Back to the subject at hand, I think Loan Consolidations should be at much lower interest rates (again, a govenment set fee). And yes my financial guy told me to pay as I go, and don't double pay unless I had a ton of extra money laying around. He said you can borrow for kids schools, but can't borrow for retirement. hmmm. Student loans are such an emotional decision, does getting rid of them make me that much happier? yes! but does it make the most financial sense?
txfp

Hey, txfp, wow! This is the first time I've read of an FP having an established fee schedule for all those generally UNREIMBURSED and time consuming activities that FP's perform! You must not have any significant medicaid, medicare or especially HMO patient population, right?

txfp

Wow. I love your schedule of charges. My practice next!

I believe that one lets people treat the way they treat you. I am so happy to hear other physicians take control of the situation rather than working grumpy, being someone else's slaves, and complaining all the time. Charging for your professional time is the way to go. Which other profession requires you to sleep with a pager and talk to strangers at night with no reimbursement for it?

Well, regarding the original topic. Thank you for "pledging" $500. If 500 doctors (FP, internists, psychiatrists, pediatricians) pledge $500, we would have $250000 for the lawsuit. I have no idea how much something like this would cost. But I've looked at the website started by the residents who were sueing over the NMRP system, and they had over 10 lawfirms across the country representing them. So it sounds awfully expensive. It's too bad that they lost the lawsuit, but it did give way to the 80 hour work week. Hospitals around the country are employing more PAs and RNs to do the scut work that residents traditionally did when they were on call. So there has been progress. I am going to at least try to get in touch with the 3 plaintiffs who brought up the lawsuits and learn a bit more about their experience. Obviously I am doing all this on my free time so it might take a while, but I am determined to at least talk to these people to see if this is a viable idea.

At the end, our "lawsuit" may or may not happen. CaliMD is right--the ultimate culprit is the government. The issue, however, remains: why are primary care physicians unhappy, why are many people getting poor care, and how can we change it? All pathyways that I can think of that created the problem comes down to the principle of supply and demand. I think by far, the easiest thing we can do, is to control supply and demand of physicians. An corollary is that when people made a decision to become primary care physicians, they really had no idea about the reality, but were asked to commit the time and money it required to take on the task.

If it's the problem with supply and demand, and career education, well, we can't do much about demand, but we can control supply, and we can educate. In fact, we can do these VERY WELL.

Think about it. If we can organize as a legitimate and credible organizations of working physicians, who are adults, with or without children, leading real lives after med school and residency, we have a tremendous power in persuading future applicants to or against from our specialty. More then the Dean of Medical School, glossy brochures, academic faculty members, or anyone else with an ulterior motives to persuade people to go into primary care, we have the single-handed advantage to tell people what our lives are like, after medical school and residency, after having accumulated debt, after becoming fathers and mothers to little children, after passing our youth. This is our reality, and we are ready to tell our stories to those people who are in need to hear.

The concept would be the same as the FICO credit rating system. We will gather a bunch of benchmarks, and do Gallop Poll surveys of working generalists, and summarize these results for the lay public to see, on a real-time basis.
This information would be made available for the lay public to see. We can in addition form tasks groups to individually talk with med students, premeds, and residents, letting them see what our reality is really like. When people learn of our working condition, they will not want to join. The fewer primary care physicians, they more we have in terms have leverage within the system. The more leverage we have, the more we can advocate for patients and for ourselves. They can't just fire us and get the next warm body on the street called Stafford. Of course the government can loosen immigration and get foreign doctors on J1 visa, but that might create a public backlash in this country if the public realize that it is going on.

Without controlling supply and demand, we will always be at the mercy of others.

Yes, we have the AAFP, the ACP, the APA, etc, but these organizations are too removed from reality and from patients. They are in fact doing the opposite to what they should be doing. In order to increase membership, they recruit medical students and tell them what wonderful professions these are. These organizations have lots of jargons that most people don't have the time for. They also don't do direct consumer media marketing, which I believe is so critical in getting the message across to the public. If I ran the organization of consumer and physician advocacy, I would make sure that there is a significant percentage of our budget that goes into mass media marketing. Why do you think the pharmaceutical companies and the "1800-med-hurt" lawyers advertise on TV day and night? Because it works!

We need to educate our patients about what really goes behind medicine especially primary care. The most frustrating aspect of my practice is that patients have absolutely NO idea why they get only 15 minutes per visit. They have no idea why records are not available. They are clueless to know which are the good vs the bad doctors. They don't know that hospitals are awarding hospitalists groups that promise the shortest length of stay and the cheapest care per case. Of course patients have no idea how insurance companies play games such that the burden of payment is on the physician. Or, that EMRs are not subsidized and hence medical records are scattered all over the place between doctors, clinics, labs, and hospitals. These issues I feel, the patients must be educated. As a woman, I hate patching up problems with a bandaid, or brushing the dust bunnies under the bed, and I hate disorganization and inefficency even more. I think as women physicians, we can unpeel to the origin of the problem and clean HOUSE.

Great post, Doctorhope! You brought up some truly critical points. The perception of us by the public has certainly been tarnished over the past 15 years in parallel with the explosion of managed care. I think that we need to convince the U.S. population that we are on THEIR side. I found that I constantly had to remind my patients that I was sympathetic to many of their "gripes" about our healthcare system

You seem to suggest in your last post that by encouraging medical students to stay out of primary care that things will improve. One issue that you did not address in that equation, however, has been the ever increasing "substitution" of primary care provided by midlevels over the past decade or so. Some of the health plans on the east coast, I believe, have groups of NP's listed as primary care providers. When I was in group practice, management would often replace a departing FP with a PA or NP. Likely, then, the more MD's stay out of primary care, the more mid-levels will comprise the majority providers of primary care. For the most part, patients are generally pretty comfortable with the midlevels in primary care. In fact, many NP's are viewed as spending more time with patients and having superior "listening" skills. Management likes them, too. What I am getting at here is that I am suspect that a "boycott" of primary care by MD's will lead to significant change in that midlevels will be eager and ready to "step in". What are your feelings in this regard?

Anyway, great post as usual! I am truly thrilled to see these discussions here on MomMD -

CaliMD

Yes. This is a really big problem. I'm glad that we are being critical of our own logic and testing it.

Columbia University is offering a RN PhD track, precisely to produce nurse practioners who are one level above the regular NP status. When a student finish this program, she will have a PhD after her name. You can bet that she will be addressed as a Doctor. And if you think patients are confused about PA, RN, CRNP, or these physician extenders as it is, wait until you throw the PhD and the doctor title into the mix. If you think primary care doctors are miserable now, wait until when there are more people who are willing and ready to do our job.

I am not sure how this is going to work. The only thing that I can think is, saying to these folks, "well, welcome to our world." If RN-PhD, PA, CRNP start to practice independently, they may be forced to deal with the same issues that PCPs are struggling with now. Let patients sue them, let them carry the same amount of malpractice liability (although plaintiff and lawyer may be less inclined to sue a nurse with lower income earning potential than a doctor), let them carry overnight-holiday-weekend beepers, and let them see 15 minutes/patient and deal with the real-life consequence of substandard care. Pretty soon, these folks will realize that this is no bargain.

But there is one catch. I am sure the system will work it in so that MDs will still have to "supervise" these extenders. You know, get our signatures on everything, so that at the end of the day, we are still responsible for the outcomes of a system that we had no saying in creating. To me, that is the worst case scenario.

What can we do? Again, I think we can educate and alert future medical students and residents about this--yet another hazard of primary care medicine.

Despite of what we think of ourselves, primary care providers are seen as people who are the least specialized, but who are willing to do the dirty work of organizing messy medical problems for little money. I am afraid this is the way specialists see us, and this is how the medical industry/government see us. This is why people feel that a PA, RN, CRNP, or the future RN-PhD can replace us easily. In their mindset, how hard is it to treat asthma, obesity, depression, arthritis, GERD, colds, etc? It's not brain surgery.

What non-generalists fail to understand is that in medicine, individual problems are easy to manage, but once you've got multiple problems, the picture become complex and the total picture is not the sum of its parts. Specialists tend to deal with discrete/isolate problems, but generalists tend to deal with multilple problems that requlre multilple medications. Generalists need to figure out how to balance the whole picture. Not only that, many times the patients' symptoms are vague and not clear cut. You can't MRI or CT every symptom, and yet, you have to make sure that you don't miss a migh a catastrophic etiology. You need time, tact, and experience to realize the 5% of cases that are not straight forward. As if that's not enough, so many patients have psychosomatic symptoms or symptoms that present as an atypical syndrome that no one has every taught you in medical school. It's up to you to figure out whether the patient psychosomatic, or the patient has a rare genetic disease that every specialist has missed. As a primary care physican, at least a good one, you need to know a lot--about the advance of many different specialties so you can make some informed recommendations to your patients. I personally think it's harder to keep up with the literature as a generalist than a specialist. For all those reasons above, I think primary care is truly a specialty in itself.

The situation where patients praising RNs are more caring and listening is a familiar one.
I am frustrated by the patient's lack of understanding why that is.

The only thing that I can think of doing is going back to the drawing board and think how we can stop this trend: Educate the public. If we can get a main-stream massive public campaign going, explaining the necessary virtue of having board certified physicians being one's only primary care provider, we may be able to sway the public so that they make informed decision in picking a PCP, and hence, pursuade their insurance companies to provide PCPs. Not only that, we may be able to get patients to understand that you cannot talk about depression, or fatigue, or malaise, in 15 minutes. Patients will need to understand how their health care dollars are being spent, and why PCPs can only spend a limited amount of time to talk.

At the same time, while we are educating the public, we need to educate our perspective medical students and residents the threat of the emerging extender replacement and competition of our livelihood. Let them think thrice before joining this competition of low-cost care.

If we leave this alone to the wills of others, we let things slip right under our nose, and before you know it, we are dispensable, not only from our own competitors who are within our profession, but from other professions who should not be doing the business in the first place.

I disagree with those physicians who say, "Don't they know who we are? We are doctors! We deserve power and respect, damn it." I think the more realistic approach is to say, well, if the pharmaceutical industry, the health insurance industry, the legal industry, the automobile industry, and even the real estate broker industry actively seek consumer support, and government favors, then we need to do the same, and make sure people understand why health care is the way it is, and how it can be better.

By the way, I respect nurses tremendously. I just don't think PA or nurses are equipped to do what we do which requires a very specific type of training and length of experience.

The nursing shortage a few years ago has led way to improved working condition for nurses, and now the nurses are back in force slowly. The cycle kind of just went on its own, with the help of very vocal outcry from the nursing profession. Imagine if we can control the supply and demand of workers in our profession, how much more we get to say how people treat us.

I know I'm not supposed to post here as a premed (sorry) - just wanted to let you know that us premeds are listening - I've known for awhile to stay away from primary care - I've been warned from all angles - I've even had someone tell me to lie to get into medical school - to say I want to do primary care even if I have no intention to do so. I won't lie. Still I was surprised that this person felt so strongly... I guess that he felt that the schools were playing a game and he was just playing along. I would say that we premeds don't dare question the state of primary care - otherwise we are seen as not wanting to "work for the greater good of humankind". Maybe we'd be seen as money grubbing - not willing to be be truly giving. On a side note... physicians seem to be getting less and less respect - I don't usually go around advertising that I am applying to medical school.. but when someone does ask, and I tell them - I feel as though there is a distance created between us. Almost as if they are thinking - "isn't nursing good enough for you? If you really CARED about people, you'd be a nurse. You must be another greedy doc" - ok, so no one has actually said that to me... but I swear I'm picking up weird vibes. Ok - sorry for hijacking the thread.

doctorhope:

Great post, great topic, interesting insight. Have never considered many of the points you, and others, brought up regarding the lies we're told to get us to be PCPs. Have to say, I WAS warned by the physicians I shadowed while a pre-med; 90% said "Don't go into medicine, whatever you do" and this was the early 90s before managed care, pay for performance, etc really took hold in this part of the country. I remember thinking "Well I can do it, they might not be happy but I will be" because that's the competitive spirit, the drive that got us all into and through med school and keeps us going when it seems impossible to put up with more and more and more. Now, $100K in loans later, it's too late. I think I had chosen to put up with the status quo, but maybe not if this post generates more interest and really starts moving somewhere.

Thanks for the food for thought!

GracieThree said,
I remember thinking "Well I can do it, they might not be happy but I will be" because that's the competitive spirit, the drive that got us all into and through med school and keeps us going when it seems impossible to put up with more and more and more. Now, $100K in loans later, it's too late.


Graciethree,
You and I both.
When I was in highschool, I was told by a resident not to go into medicine. Then when I was in college I remember I was told by an older PhD biochemist, not to go into medicine. But guess what, I went into medicine. Somewhere along the line I got the idea that going into medicine is like climbing the Everest. You go for the burn and glory. You prove that you can beat out all the other premeds who are dying to be at the same spot. Boy, if you got into medical shool, you'd be someone. Your parents, friends, relatives would be so proud. You will be important and no one can say that you have not accomplished anything in your life. Think I am crazy? Look at the Premed board to remind us of ourselves.

For reasons that everyone else went into medicine I went into medicine also: stability, salary, prestige, ego, respect, intellectual capacity, competitive drive. On my medical school application, I wrote that I wanted to go into primary care, and I meant it. So I got into a primary care school. I actually chose primary care because it is it the most interesting specialty to me. Unfortunately, no one in medical school ever pulled me aside to say, "psst, stupid, think twice about primary care." I was naive to believe other people didn't go into primary care because they weren't good at it, or weren't interested in it. I thought doctors are doctors. How much difference in lifestyle can there be? Surely, there would be a system so ensure that there are day time, and night time doctors. Does the aviation industry let pilots fly during the day, and then answer phone calls from the control deck that night overnight, every 5 days or so? How bad can it be? Let other people make a quarter million dollars a year, but I was going to live a normal life and be very happy with $150,000/yr.

Now 7 years and $150,000 debt later, here I am, beloved by patients and employers, but wondering what went wrong. You might think that I am a disgruntled employee and am terrible at my job, but the opposite is true. I am one of the most popular internists because I am personable, and spend a lot of effort and time, regularly outside of the pay period, to practice what I believe is the kind of medicine that I or my family members deserve. But it comes to at a price of burn out for me. I am not quite there yet, but I can see it happening a few years down the line. I just keep on wonder, how do I get out of it? How do I go back to being a normal human being again who can sleep every night uninterrupted? How do I have a 40 hour week, with 20 minutes for lunch everyday. How do I not look at the clock and think, gee, how can I cut the patient off? How do I treat patients with kindness and respect even though I know in the back of my mind that they can come back and sue me and ruin me financially? How do I do everything that we are suppose to do according to evidence medicine, but still stick to the schedule of 15/30 minute schedule?

Is it that I don't like medicine? Or is it that I don't like the health care system that dictates how I can practice? I think it's the latter.

I am proud to be a physician. I don't think 97% of patients are asking for ridiculous demands.
I don't need to make more money. If I can see fewer patients a day, I'd be happy. If I don't have to fight with insurance companies and memorize all the rules about billing and payment, I'd be happy. If I don't have to give 40% of income for overhead mostly related to insurance paper pushing, I'd be happy. If I can get compensated for the time that I spend in filling out paper work, and answering phone questions I'd be happy. If I can sit down and talk to patients like a regular human being, I'd be happy. If there is a "no-fault" compensation fund, sponsored by all parties involved, that compensate patients who are harmed through honest human errors during medical care, I'd be happy. If I don't have to keep on working, simply because of my debt obligation, I'd be happy. I am not out to get more. What I want, is a better medical care system where I can deliver high qaulity care, without burning out myself, and without cheating patients and giving them as little as possible.

But none of my wishes are true. $130,000 sounds like a lot of money but so many of us are still shopping at K-mart and Target, wondering whether we would make ends meet. The paycheck after childcare, mortgage, tax, living expenses, retirement savings, and loan payments is not that much. My experience is so prevalent amongst PCPs that I work with, that I think wow, here we are, a bunch of really smart, caring, good-willed physicians who chose to do primary care, but are miserable. Why is that? The more I think about it, the more I realize that partly it was my fault that I didn't investigate carefully when I was younger. Partly, I think the government and academia push this fantasy of primary care on young people. In this way, it is like the credit card company giving out huge loan when you are young and naive, and then expect you to pay back much more years down the line. It is like the government going to the poorest parts of the country and give out brochures about luring young people to join the miliatry. That's fine, but the truth--the bad and good--should be said upfront. Otherwise this is irresponsible goverment and policy. Without advocacy for ourselves, for our patients, and for a control of supply and demand, for transparency of health care spending, the status quo is likely to continue.

Unfortunately, doctors cannot unionize--that's the law.

I'm not sure you're correct in saying that it's against the law for doctors to unionize. I was in a union as a resident. In Los Angeles the doctor's are unionizing...

http://www.aaem.org/unions/launion.shtml

Mya
I am not sure if physicians can unionize. I have been told by several lawyers and colleagues that we cannot.

There is an exception for residents. When I was one we happened to be one of the biggest residency programs that was unionized. But residents are not "physicians" per se? Is there a state by state variation on this issue?

Gotta look into this, but my suspicion is that we cannot...otherwise you would think we would have long ago?

I am so angry and so sad. I have been practicing for five years. And I have never been happy. Oh, there are certain moments that make me happy. But generally, every day, I am unhappy. I absolutely hate going to work every day. I hate nasty demanding patients. I hate that the government tells me what I am supposed to write in my notes or it is fraud that means I could go to jail. I practice a time consuming medicine not well suited to the treadmill-therefore I am a failure because I do not work fast enough. I am being sued by a two patients who are non compliant.

Since I have started practice- I have gained 50 pounds. I look in the mirror and I don't recognize myself. I like my home. My home life is good. I just don't know what to do anymore. I feel trapped by the medical student loans. The rape of medical student loans. I feel trapped and I am struggling to restructure my life in such a way that I am not trapped.

Doesn't it suck?!

Maybe, maybe not. Physicians have historically been a group of people who believe "to each his own." We are not used to working together, and getting polically involved on our own behalf. We are doormats, conforming to HMO demands, governmental demands, etc. Highly professional, high earning people tend not to unionize. Not a Republican way of doing things. We were the employer...not the employee. There was no reason for the older docs to feel the need to speak as one.

Up until recently, MDs were making very good livings...enough to not rock the boat. But now, we're being "raped" and must do something. In Nevada...things didn't change until the physicians walked off the job. Then, this cumbersome "legislative process" and all those "rules" were suddenly nonexistant. We are in charge of medicine...and it is our responsibility to take back control. And, until we do...we'll remain in our bent-over positions...waiting to be...raped again.

The only way to do this is to have one voice. Whether it's the AMA, or some sort of union-type of organization...

...one voice.

we are so not in charge. there are huge industries that are built on the back of physicians. they will pay some of us just enough to keep us quiet. And the rest they will tell if you were only good enough, you would be able to do this. we are glorified hourly workers in the the plant called the hospital. the hospital and the insurance company are all fighting about who makes the most profit off the work of the physician. any physician who has been displaced by a medical management company know of what I speak.

amen, khk, I painfully know about which you speak. Ya know, so many times when I read the words of premeds desiring to be a physician because they want to have "autonomy", authority and be the so-called "team leader" or "boss" - I more than CRINGE. Premeds need to immediately drop their preconceptions about what it is truly like to be a physician these days. Autonomy my foot!

I find it incredibly ironic. That the tone of the practicing physicians and those aspiring to be a doctor are completely opposite. I really wonder if the premeds or doctors to be read the items in this particular forum or find it too depressing to consider. I can amen everyone one various points.

I am truly sorry to hear about your plight. My heart aches for you hearing that your ungrateful patients have sued. It makes me SOOOOO MAD.
I hope you will remember that some people are crazy and plain greedy. You did your best. You are a human being. Your enviornment does not allow you to practice perfect medicine. Bad outcomes happen even despite of best human endavors. Even if it had been, there is no such a thing as 100% perfection in ANY human endeavor. You've dedicated so much of your life to help others. That is an eternally noble calling. I hope you will really know it deep inside that it is not your fault. I will stand by you. I will stand by you. Let me say again. I. Will. Stand. By. You. I want to give you a strong hug, a strong handshake, and let you know.

Yesterday a 90 yo lady with her 50 yo niece came in. At some point, I helped the 90 yo to the exam table, and seeing that she was wobbly, I said, "are you sure you are OK sitting up here?The last thing we want is to cause more harm to you--if you fell, we'd feel very bad."

I am 5'2'', 105 lb, not much bigger than the little 90 year old, but I helped the little lady up on the table. The niece sat there like she was expecting to be served. Didn't move an inch to help.

Then the 90 yo lady said, "why would you feel bad if I fell?" Her 50 yo niece then promptly interjected, "oh, it's because you fell, you can sue her."

Oh man. I wanted to punch her.

I almost lost it. If it had been my own practice, I would have immediately become stern and scary looking, and said, that if a patient even as remotely joked about lawsuits, I'd want him/her out of the practice immediately. But because it isn't my practice, I pretended like it didn't bother me.

Moving on. To the "raping" of doctors by their student loans.

I told my SO that even if we died, and didn't pay our stafford back, the government will have made enough money off our backs. Imagine, getting a PA to do all the work we did in 2 years of medical school, 3 years of residency, how many hours did we work? A regular PA gets paid $75000 a year--times that by three, it is $220,000--what they have gotten out of us during labor in residency--not including overnight, overtime, holidays, and weekends. Minus residency wage of $120000 for three years. The government still made at least $100000 off our backs. No wonder they guranteed the Staffords which bind us further into labor.

Ladies, I hear you. My colleague's group, an excellent group of great docs are being replaced by another group of lesser doctors. Hospitals, Physician Executives, Management companies control the board game. We are the little soldier pieces.

I think we have complained. Everyone says amen to the complaints. Let's shift gear to think what we can do, individually and collectively to change the situation.

The AMA is not our friend. The AMA has many subspecialty interests who are making a lot of money in doing procedural oriented specialties. The woes that I am hearing here belong to primary care (FP, psych, Peds, IM). We need a subgroup and organize. The ACP and the AAFP have led the current situation to develop so they are dubiously reliable.

What can WE DO?

Please contribute here what you think you can do.

I really think we should organize as primary care providers and block supply of future docs. Do you think going to medical schools and premeds forum and discourage people going into primary care is a good idea? I think that is the least costly and most effective way to change our professional leverage. Decrease the supply. The demand will go up. Then when we organize, we have so much more leverage.

Even if we don't succeed, we can drum up some media attention. The way it is now is NO good for patients or doctors. Patients are pushed through a factory, with many opportunities for "mistakes"/redundancy/frustration/inequality/misconception etc.

What happened in Nevada? What was the walk out like? Who organized it?

It't hard to believe that months have passed by. Today, I read a thread by a pre-med wondering about this thread. I wrote my response there because I thought pre-meds, med students, and residents need to be informed before they can join primary care. Please take a moment to read the thread in general discussion and add your thoughts about primary care.

I have been in touch with folks who are actually happy doing primary care. More to come.

This is a really old thread, but I hadn't seen it before.

It's so great to see it because I have thought the same thing. Everyone can sue us; we should be able to sue someone for false advertising/failure to warn, something!

And, I'm a gyn, so it's not just primary care.

I returned to school a year ago to get an MPH and that made me feel somewhat hopeful that I could get out of this, but now I'm having second thoughts about it. Not because there's anything wrong with it but because I'm not doing it out of some burning desire to do public health but as a way to salvage something from my medical training and practice. I'm doing environmental and occupation health which includes built environment issues, so I thought it would be close enough to what I really live - interior design. But I still can't shake the nagging tap on my shoulder about what I'd really like to do. The only thing I really love is interior design, but I didn't pursue that because my dentist father and my mother who was his office manager didn't value that and I was too young when the decision was made to think for myself. Whenever I said anything about doing something creative when I grew up, they didn't say much, but when I said medicine they bought me a car - how's that for positive (or negative) reinforcement? I went into medicine because I thought there'd be stability and a good income and that I'd be intellectually challenged, but that has definitely not been the case. Now, I'm seriously thinking about being brave for once in my life and taking the leap and applying for a graduate interior design degree. I'm scared I'll starve to death before I get anywhere, but heck, there have been plenty of months as a private-practice physician where I don't know how I paid my mortgage, so what's the difference? At least I'll never be on call.

Go for it, DrEthiope. Medicine is only going to get worse if health care reform is passed in its current form.

Did not realize this thread was so old when I started reading it - but yes, this is exactly right! It is soooo refreshing to hear these truths, spoken "out loud"! Yes, the AMA is not our friend. Yes, my patients and family have NO IDEA what is behind the way medicine is practiced today. Thank you, Doctor hope, for talking about it!

I myself have been outspoken about this. During my residency, I was starting to realize I had been subject to this institutionalized "scam". When I was invited to my undergraduate Alma Mater to speak about becoming a physician to a group of premed students, I told it like it was. The crippling loans. The dangerously long hours at work (I actually fell asleep at the wheel driving home from a 36 hour long work "day" in the PICU and luckily veered into the breakdown lane - woke up with traffic coming head on toward me...). I was not invited to return to speak the following year. The administration clearly did not want the students to hear the truth, just their idealized version...

Well I am not sure I can change the way it is. I guess I kind of feel like the old saying about knowing the difference about what you can and can not change. Or perhaps I just lack the energy to try. Anyway, I will continue to tell the TRUTH about the practice of medicine to anyone who asks. And, BTW, I think specialists are unhappy too...

I have two sons. I will discourage them both from going into medicine.

Thanks for the encouragement AnnaM. As I write this I'm preparing to go to my first interior design course tomorrow evening. I've just taken a leave from the MPH cause I don't want to burn any bridges until I'm sure. For some reason I'm absolutely scared to death! I think it's because, for the first time, this is something I really want so I'm scared I won't be good enough, etc. Believe it or not, I didn't feel this with medicine. If they had told me I didn't get in med school, I probably would have felt somewhat of a sense of personal failure, but I don't think it would have been devastating. But, this. It's taking everything in my power not to chicken out, but like I said before, gotta stop being a chicken sometime. Wish me luck!

Good luck to you DrEthiope! Let us know how things go. My daughter is a creative type and I love to see how much she loves what she is doing. She started out wanting to do interior design but ended up switching to fashion design and then an interdisciplinary major between fine arts and theater with the intent to do costume design. I worry occasionally that she won't be able to support herself (wishing she had stayed in interior design), but mostly I just think that she loves it so much she will find a way to make it work.

my sister loves her work in Interior (spacial) design, and has worked on big urban projects and has received awards for her work. get back to us on how things go.

Three Accelerated Architectural Design classes and so far I love it! Of course it's too soon to really tell, but so far so good. It's so much fun. The class is small (only 5 students) so we get lots of personal attention. The instructor is a female architect and a very good teacher. It's so refreshing using the other side of my brain for a change, and it's the side that I think is my strongest side but I was always afraid to pursue something creative. It's taken 20 years and many mistakes to curb the fear. Feels like I'm finally coming into myself at last. I'll keep you guys updated, and I just hope my feelings about this continue.

i hear you kpzr...no one in my family is going to make the same mistake i did. doctors are suffering for so many reasons and it's more apparent than ever now and i think the situation will only get worse. my only saving grace is that i'm a pediatrician and no one will ever be able to take better care of my kids then their pediatrician mommy

I realize this is an old thread and I wish someone had explained this all to me before I decided to match in primary care! Argh! I am trying to cut back, get out, what have you but it's so hard. I am highly trained to do one thing and one thing only. It's so frustrating.

Hang in there. I think things are changing in medicine. And you can seek a position that meets your needs. There is more flexibility than before. It just takes work to find/create it. Once you are done with training you will have more options. Are you going into FP, Internal Medicine, or Peds?

Oh, lol, I am done! I finished my peds residency in 1996 and have been working ever since. I am a mom now to a 3 year old and find that I am just over worked, over stressed and do not have as much patience as I need to. I just need to work less. I would love a part time office, part time admin job but with my current employer that would be impossible.

i totally understand momtonoah and the sad reality is that i have a part time pediatric office job and it still doesn't fit my mother of 2 and hopefully one day 3 lifestyle. the main reason is that being a primary care doctor is a full time job and even though i'm only in the office 3 days a week my patient panel is no smaller than the other full time docs so i just end up squeezing full time patient care/phone calls/paper work into 3 days and get paid much less than i deserve.

the one thing i haven't tried yet is pediatric urgent care/shift work and i wonder if my lifestyle is more suited for that line of work. parents expect a lot from their pediatrician these days so sometimes i feel like i'm going from a mom of 2 at home to a mom to 1000 when i'm at work and it's not fair to anyone--me, my kids or my patients---when i'm stretched this far. i'm guessing i'd be able to detach more from work in an urgent care type situation.

anyone have any experience with this time of transition...going from primary care to urgent care and how satisfied are you?

I have thought about that but the only problem, at least from my perspective here where I am, is that urgent care hours and need is pretty much during the time when I need to be home with my child....afternoons, nights, weekends. I am not sure if that's really much better.