Should All Primary Care Doctors Be Salaried?

A reader emailed me some great questions to ponder. The submission in its entirety.

Thank you for your valuable comments and your funny blog. I'm not certain that I understand some things that you are saying. For instance, although few Americans are going into primary care, aren't the FMGs making up the difference? Are you concerned that some FMGs aren't up to snuff? Also, regarding debt, I went to my state medical school just to avoid debt (and it has a fantastic clinical program) and I think students should either get a good aid package from their private school or go to their state school. Also, I hear your concerns about overhead, etc. but these days shouldn't PCPs be employees (as engineers and many other professionals are today) instead of being independent business men? If they were employees as you are as a hospitalist, wouldn't a lot of the problems with overhead be taken care of? I did an MD instead of a PhD Bioengineering and I use the MD combined with my BS Elect Engr/Comp Sci thus I find your writings highly educational. I only wish you and other bloggers had a much wider audience.

First of all. I gotta say, I have a BS in chemistry. And the only thing I remember is that atoms have electrons, protons and neutrons. To be able to use your EE and CS degrees along with your MD is impressive. Congratulations. Do you work as an on call MD for nuclear power plant?

Let's break down the excellent questions you asked:

• Although few Americans are going into primary care, aren't the foreign medical graduates (FMGs) making up the difference? First of all, I don't know the specific data to tell you for sure. I think, my experience has been that many FMGs may work rural primary care to get their visa issues established. However, my experience is that most foreign medical graduates eventually leave primary care and go do fellowships in all different types of specialties. Specialties that pay, relative to exclusive cognitive work, much more money because of the procedural orientation of their fields. Cardiology is a popular field. Neurology. Gastroenterology. You name it. Do I have data to back up that assertion? No. I can tell you in my community there are very few foreign born primary care doctors. There are many procedural specialist trained doctors in my community. I must admit I don't know where their medical school training came from so my assertion is just that. I'm sure some of them trained abroad. So, are FMGs making up the difference? Maybe, but I believe their commitment is only a temporary step towards a long term establishment with procedural specialties. That's my experience. Maybe others can comment differently. Even in hospitalist medicine, the folks that have left our group? Several FMGs who have left to do cardiology and GI fellowships among others. Hell, we even had one guy who went to do GI for FREE, if they promised him a spot. Talk about motivation. You left out one big problem with the equation of FMGs picking up the slack. When a foreign trained medical grad comes to the United States, they have left behind their expertise and training that their country so desperately needs. It is not fair to the rest of the world for the United States to encourage a policy of filling gaps in our medical needs by stealing doctors from other countries. That is just bad karma.
• Are you concerned that some FMGs aren't up to snuff? Nope. Not at all. Foreign medical graduates must pass the same rigorous American residencies to become board eligible in their field of specialty. That means if they want to practice internal medicine, they must pass their internal medicine boards. There are many fine FMGs that are specialists. There are large variations in medical school quality internationally. There are even large variations in quality of residencies within the US. But the standards are the standards. If you pass the standards to practice medicine in this country, you are qualified. And I don't think graduating from medical school in another country has anything to do with it. In fact, I find the work ethic of FMGs often exceeds the work ethic of American trained doctors. That says a lot about America's FREE=MORE entitled mentality. Now, whether FMGs get superior or worse training in medical school, I have no idea. I know by the time they are board certified doctors, they are equal.
• As far as the aid packages go? My tuition at my state institution in the late 1990's was $6000 a semester. Added to living expenses I got out of training with just over $100,000 in debt. Now I'm talking to residents at the private school medical school across the street and I hear their tuition alone, per year approaches $50,000, not including living expenses. Do I think students need aid. Yes. Absolutely. And by the way, I hear that tuition at my medical school is now $12,000 a semester. Doubled in just over 10 years.
• Shouldn't PCP's be salaried? I ask the question why? I guess if you ask the question regarding all doctors some argument could be made both ways . Expect 9-5 hours for salaried employees with no extra effort. I like to call it the VA mentality. Why do more when you can be paid the same to do less. There is no reason why PCPs should be singled out for salaried positions. They are MDs like all other physicians. And the cost structure has more to do with the government's failure to provide adequate payment for PCPs. Instead of placing PCPs on salary I would much rather have entire communities of PCPs band together in giant UBER groups. What was once a whole city of individual practices could now be one giant group practice of 100, 200 500 or more physicians, all billing under the same group ID number. Able to meet insurance companies head on with bargaining power. The same type of power large academic Meccas bring to the table. Unfortunately, to the detriment of sound business principles, physicians are fiercely independent people and would much rather go bankrupt then belong to a large group practice with rules to follow.
• By the way, I am not an employee of a hospital. I am a member of an independent private practice hospitalist group. We do have overhead. And most people, non medical business people don't realize how big a hospitalist overhead is, especially a well run and efficient group.

By the way, I hate the term primary care. It makes it sound cheap. It makes it sound dumb. It makes it sound so superficial. What we do as internists, pediatricians and family medicine doctors is far more than the connotation of primary screening and evaluation. We manage many complicated patients with mulitorgan failure. And many doctors in rural America do it all alone. With no help at all. Some of the best doctors in the world are rural primary care physicians who must treat highly complex medical issues by themselves. Not because they want to but because they have to.

The name primary care has got to go. Perception is 4/5th of the equation.

Another blogger used the word comprehensive care once. I think that is perfect. And I use it often in my blogging.