Can Medical Students Afford to Choose Primary Care?

[FutureDoc]

Wondered what folks on here would make of this study.  Stumbled across it while going through a lit review for a manuscript.  The Authors performed an economic feasibility study on median student debt levels and found that primary care is still economically viable.  I thought this matched well with the recent "loan to income" ratio post that got a lot of discussion on the site.

 

https://www.ncbi.nlm.nih.gov/pubmed/23165279

 

 

[Zaphod]

From a quick look at that abstract I'd say the issue is that it doesnt assume the obvious, costs rise and competition from lower paying replacements like PAs and NPs allowed independent practice driving down costs and pushing them out.

IMHO, the shrewd thing for all doctors to do is to avoid all the fields with low pay and low barrier to entry, it just doesnt make any long term sense. Those kind of issues will be first on the markets agenda for cost cutting, that is, it will just slowly happen due to natural pressures without any one major change. Any long term view can see PAs and NPs taking over primary care, and just to be totally blasphemous, will be totally fine and overall good.

[RetiredERdoc]

I seem to recall that a rule of thumb for a bachelor's degree was to not have student loans exceed the first year of income that the degree will bestow. Is there such a rule for grad or med school? Does repayee, etc make such a rule obsolete If you had to pay for undergrad plus med school, it certainly looks like it would be easy to greatly exceed the 189k primary care income.

[ENT Doc]

Two things would make me afraid of this if I were thinking about going into primary care.  The first is that they felt compelled to do this study and are saying primary care is "still" viable.  That doesn't show a trend in a positive direction.  Neither does the growing ranks of the less-well-trained and cheaper PA and NP groups threatening their existence.  The second issue of concern is that this study is from 5 years ago.  Take a guess as to what the current status is - or what it will be in 4 years.

[WallStreetPhysician]

FutureDoc wrote:

Wondered what folks on here would make of this study.  Stumbled across it while going through a lit review for a manuscript.  The Authors performed an economic feasibility study on median student debt levels and found that primary care is still economically viable.  I thought this matched well with the recent “loan to income” ratio post that got a lot of discussion on the site.

 

https://www.ncbi.nlm.nih.gov/pubmed/23165279

 

 

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Absolutely, but only IF they manage their finances well. Taking a few key steps, such as living like a resident for a few years after residency (I call it a "financial fellowship"), avoiding trading (especially short-term trading) in taxable accounts, and investing in low-cost index funds instead of high-expense ratio mutual funds, will put a PCP financially ahead of specialists who don't do these things.

This does not even count avoiding other "stupid doctor tricks" like these, that were posted almost 6 years ago (!) by WCI.

-Wall Street Physician

[FutureDoc]

I like that term "financial fellowship", that has an excellent ring to it.

 

The saddest part of the article came for me when I read down in the discussion section and they stated that the analysis assumed that the physicians acted in an optimal financial way for all scenarios.  Any one of those stupid doctor tricks would blow the scenarios right apart.

[Hoya21]

Do you guys really think that primary care is a dead end for a physician?

I really enjoy family medicine for a lot of reasons and am 90% set on choosing it (current 2nd year). I tend to think that there is no replacement for a quality, board-certified family physician. Especially since midlevels are going into pretty much everything except surgery, I'm not sure I buy the midlevel encroachment argument, but am open to more experienced voices.

[nolamd84]

PAs and NPs won't replace primary care - the role of the PCP will be distinct. Likely the model will blend telehealth, personnel management and cost controls. Iora Health is doing some strong work with the future of primary care and is probably more in line with the future. No more 15 minute visits.

I think its very clear that specialist salaries will likely decline as ACOs and other cost cutting measures start coming into effect. No one's going to be incentivized to do more and more colonoscopies or angiographies and their salaries will decrease accordingly.

Anyway, all this to say that the future is a bit unpredictable and not just for primary care.

[jz]

@Hoya21,  currently lots of the money is medicine flows into management hands.  A primary care doc who includes management of midlevels might be well compensated.

[FutureDoc]

I don't think primary care is a waste at all.  Primary care is probably the most important part of healthcare.  The discussion there was of financial aspects.  We have plenty of primary care IM and FM docs that have done very well for themselves.  The issue really is the absurd inflation of student loan debt.

[Zaphod]

Primary care may still be viable, but thats not the question (its more financial). The question is how many physicians will be needed to manage a primary care population that is more and more going to be managed by NPs, PAs, etc...and some doctors. Do we already have that amount, and what will the pay be for those in it and competing for these dollars? Hard to believe it goes up. The number of specialized referral primary care docs will undoubtedly be a smaller number than the midlevels making up the bulk of the patient facing population.

I think people are fooling themselves if they think there is a single pressure in the world, ie, economic, technologic, etc...that will do anything but replace primary care with cheaper overall options. I know docs like to think when that happens the people will ultimately revolt due to terrible care, etc...but they wont because that just wont happen. Most of the large low hanging fruit has been taken care of, and many medical issues are simply lifestyle choices and a slightly slow diagnosis/referral wont be anything large, frequent, or dramatic enough to cause alarm. Remember that no one wants to pay for it.

Lots of these pressures are also applicable to all of medicine, but primary care will feel it the worst since its the least rigorous and acute and therefore more easily accepting of less trained personnel.

[M2]

PCPs will move into a more risk stratified model, where physician panels move to 10k patients and the MD only sees the highest risk (highest cost) 5% and takes a more proactive approach (ie. sending a RN to the home twice a month, monthly office visits, etc) with them.  Simultaneously managing 4 or 5 NPs who care for the routine care of the remaining patients and consult the MD when needed.  The goal of the PCP will become less about caring for individuals and more about reducing the expenses of their cohort (less ER visits, re hospitalizations).  Companies like Tandigm Health are leading the way with these ACO models.  Basically IBX gives $100 per patient, Tandigm empowers physician with technology and infastructure and assumes risk, PCP and Tandigm share savings (spend $90 per patient, doc gets $5, Tandigm gets $5).

[VagabondMD]

The cost-value proposition is not as good as it may have been in the past, but it seems that job prospects--that it is the ability to be employed with a full panel of patients--remains quite favorable.

[StarTrekDoc]

Yes.  Can teachers afford to be teachers?  Yes.   Can preachers afford to be a preacher?  Yes.

Choose the field that calls to you is my suggestion.  If you're blessed to have multiple callings, then it may come down to financials.

Being in Primary care for nearly 19 years and son of a pediatrician (despite this, had 150k of student loans coming out of Medschool), still haven't found a single fellow doc in poverty or forced to drive a 15 year old beater car.

There's a huge shift in economics toward value-based care.  You can see it in this forum already where fellow highly compensated subspecialists are warning to caution on future income basis.

I know that whereever I go, I will be able to land a good paying job without any issue in a week and have good job security.

Being a US born, US trained Internist in primary care is a RARE bird these days.  Greying of America and boomers will only increase the demand.   The type and level of work is already changing, and would be immensely helpful if you garner some type of basic managerial skills or Process Improvement training cause mid-levels/extenders is definitely going to be a part of the team based care delivery model.   Watson and Google may help information access and CDS, but all ultimately patients want to come in and bounce their searches for long term management off their doc.   Living in the heart of the biotech world, it's still true.  People want people to make the decisions.

 

[Panscan]

StarTrekDoc wrote:

Yes.  Can teachers afford to be teachers?  Yes.   Can preachers afford to be a preacher?  Yes.

Choose the field that calls to you is my suggestion.  If you’re blessed to have multiple callings, then it may come down to financials.

Being in Primary care for nearly 19 years and son of a pediatrician (despite this, had 150k of student loans coming out of Medschool), still haven’t found a single fellow doc in poverty or forced to drive a 15 year old beater car.

There’s a huge shift in economics toward value-based care.  You can see it in this forum already where fellow highly compensated subspecialists are warning to caution on future income basis.

I know that whereever I go, I will be able to land a good paying job without any issue in a week and have good job security.

Being a US born, US trained Internist in primary care is a RARE bird these days.  Greying of America and boomers will only increase the demand.   The type and level of work is already changing, and would be immensely helpful if you garner some type of basic managerial skills or Process Improvement training cause mid-levels/extenders is definitely going to be a part of the team based care delivery model.   Watson and Google may help information access and CDS, but all ultimately patients want to come in and bounce their searches for long term management off their doc.   Living in the heart of the biotech world, it’s still true.  People want people to make the decisions.

 

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How did you have 150k in loans coming out of school if you have been practicing for 20 years?

What were your interest rates?