I am a board-certified family physician who left family practice for urgent care.
As strongly and passionately as I believe in primary care, I have no desire to go back to it—at least not at present.
Family practice is in shambles.
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Indeed, it’s at the center of the biggest Humpty Dumpty in the world, the US healthcare system.
As the well-known nursery rhyme goes:
“All the king’s horses,
And all the king’s men,
Couldn’t put Humpty Dumpty,
Together again.”
The problem is that while everyone knows instinctively and scientifically that we need a healthcare system that is based on primary care and preventive medicine, the system that we now have is still fragmented beyond repair—just like poor Humpty.
Payors and the government have shifted—dumped, in fact—all the responsibility onto primary care.
Family doctors I have spoken with tell me that they are overworked and under-supported to the point where they feel like exsanguinated zombies, drained of all morale. They’re fumbling and stumbling through the night of day, searching for any shred of succor—even a hastily eaten free lunch offered by a pharmaceutical rep.
Pediatrics and family medicine have long been at the very bottom of the totem pole in terms of salary. But big-hearted primary care doctors have persisted because they believe that serving their patients and communities is more important than the prestige and financial gains enjoyed by sub-specialists.
Here’s an example of the inequity: A cardiologist in America today can expect to earn $410,000 a year…an orthopedist, $443,000…a family physician, $207,000….a pediatrician, $204,000. [1] In many parts of the country, a family physician would be lucky to earn even $160,000 annually.
Please pass the promethazine. Knowing how hard PCPs work day in and day out, this salary range is so shameful that it makes me want to vomit intractably.
But it’s not just about the money.
It’s about the increasing patient volume and complexity of care, the rapidly metastasizing administrative burden and the relative lack of support facing family physicians as they go to work each day.
Most family medicine offices are open 8 am to 5 pm, Monday through Friday. That’s what patients see—and what the recruiters tell you to lure you in.
But the doctors working in such offices put in countless more hours. Not only that, time spent at night working on notes, reviewing labs or refilling prescriptions for their patients is all uncompensated time. Then there’s shared call, which amounts to even more uncompensated time.
In fact, divide the average salary of a family physician by the number of hours he or she works each year, and you’ll probably find that burger flippers at McDonald’s earn more. Mind you, I say this with all due respect to McDonald’s burger flippers.
To say that primary care physicians are squeezed for time these days is a grossly negligent understatement. They are squeezed tighter than organic oranges at a California juice bar. To make matters worse, the growing shortage of primary care physicians leaves fewer of these doctors to go around, so patients expect much more of them than ever before.
Put yourself in the patient’s shoes for a moment. Let’s say you just got health insurance for the first time in years because previously you couldn’t afford it.
You scan your health plan’s panel to try to find a primary care physician still accepting new patients—a real needle in a haystack. Finally, you find one. But now you must wait three to four weeks or longer to get in for your first appointment.
Once the day of the appointment comes, you walk into your new PCP’s office and find it populated with many other patients in the same boat as you are, and that boat is taking on water. After filling out many forms, followed by a wait of two hours or longer, you finally get to meet your new PCP.
“Hi Doc,” you say. “I couldn’t afford health insurance for the past six years. But I need you to check my high blood pressure, diabetes, thyroid condition and asthma. Bad, I know, but I’m a smoker—somehow, I managed to afford cigarettes.”
“I also need pain pills—something that sounds like Oxyclean—for my fibromyalgia and rheumatoid arthritis. I’m allergic to Ibuprofen, Tylenol, aspirin, Toradol and Tramadol. Will drinking kale shakes every morning help me lose weight? Your MA said my BMI was double my age and I’m only 26.”
And so it goes.
But truthfully, urgent care is not without its own problems. As an urgent care doctor, you have no control over how many patients walk in the door during a given shift, nor when they walk in.
In my experience, if the urgent care stays open until 8:00 pm, chances are excellent that many patients will pile in at 7:45 pm or 7:50 pm, even though you’ve been open since 8.00 am that morning. And guess what, Doc? You’re not leaving until the last patient is seen and cared for, no matter how long it takes.
You have 10 minutes or less to see each patient, some of whom need more than a quick Z-Pak or shot of Ketorolac. You may have some complex lacerations, displaced fractures, anxiety meltdowns or acute chest pains thrown in there, too. Not to mention that during cold and flu season, patient volume increases dramatically and it can get pretty intense in urgent care.
And, of course, during just one urgent care shift, you are exposed to every infectious disease known and a few not yet characterized by the CDC.
On the bright side, once you walk out the door at the end of an urgent care shift, you are done. You can have a life. Or rather, you can achieve a better “work-life balance,” the current buzzwords used to recruit doctors these days.
Not so in family practice With family practice you have no life—and flipping those burgers at McDonald’s can start to look inviting. Mighty inviting, indeed.
