Tuesday, May 29, 2012

Why I Didn't Do Primary Care

My first residency was actually in a primary care program so this was obviously a field I was very interested in. But I aborted it. Why?

1) Partially it was a problem with my residency and probably a lot of residencies. Most internists who do primary care spend much of their residencies doing inpatient medicine, out of necessity. My "primary care residency" only different from general IM in that we got one month of primary care per year, which was a mix of clinic and urgent care. Enough to feel comfortable being a PCP? I felt it wasn't.

2) I didn't like the idea of having to know everything about everything, especially in a field where things are constantly changing and patients were getting more and more complicated. I felt like I'd have to be reading constantly just to stay current.

3) People would keep coming up with random complaints that I had no idea how to address, like, "My belly button feels cold."

4) It felt like there was a push to see patients as quickly as possible, yet many of the patients were incredibly complicated. When an elderly patient hands you a bag of 30 bottles of medications and four of them are half-filled bottles of atenolol, just sorting through that alone takes like twenty minutes. I felt like I was being pushed to short-change my patients.

5) The reimbursement is not great and just getting worse. Which means being pushed to see more patients in the same period of time.

6) I didn't want to take hospital call, but I felt like in the areas where I wanted to live, the hospitalist system wasn't established enough to avoid that.

7) I worked with a PCP during my third year of med school. I will never forget this experience with her: She had an upcoming vacation and the whole two weeks I spent with her, she was arranging coverage and sorting things out for this big vacation. How long was the vacation? Four days. Including a weekend.

8) I kept hearing about high rates of primary care burnout and it scared me.

Ultimately, the "hating my residency" thing may have played the biggest part of all. I didn't think I could make myself be miserable for another two years for a field that might also make me miserable. I'm pretty sure I made the right decision by switching.


  1. PS I can't imagine having only 3 months of primary care training and then being expected to be competent as a PCP. Here in Australia GPs receive a minimum of 18 months in supervised primary care practice (after a pre-vocational intern year and a further formal hospital training year in medicine/surgery/ED/peds).

  2. In my Family Medicine residency we did 2 half days of clinic every week as an intern and then 3 half days as a 2nd year and 4 half days as a 3rd year. 1500/pts in clinic in the last 2 years is actually the requirement for FP residency as of 9 years ago(cannot speak to earlier than that or after). 1500 is not a lot, that is true. But no residency training teaches you as much as you learn the first year out.

    The hardest years of training, IMHO, are 1st year of med school, 3rd year of med school, intern year, and first year out in practice with the first year out of training being the most educational. And that has nothing to do with volume.

  3. I had planned on doing primary care for most of medical school, but changed my mind when I started to realize the pressure to see patients quickly, and not actually develop relationships with them. Ironically, now I'm in anesthesia, but I still feel the change was the best one I could have made.

  4. A million years ago I got my primary care through a family practice residency program. I saw some amazing residents there, and if I could have stayed with any of them I would have. Every single one of them was offered a staff position upon graduation, and every one of them left and moved far away.

    At the end of my time there I wound up with a staff doctor and figured out why all the residents fleed -- probably for their lives. The staff doctors were almost all completely incompetent. The office staff were hopeless, though whether incompetent, lazy, or simply short staffed I never found out. I was never able to get a copy of my records from them. You had to ask multiple times to get anything done. It was a nightmare.

    The place has since closed, amongst rumours of lawsuits. It wouldn't surprise me.

  5. I think that's partly why I have chosen (in my head) not to pursue a career as a PCP. I dealt with it at a non-profit facility and I currently see my boss put a lot of pressure on the other girls to make the goal (it's a physical therapy clinic). I hate the numbers game and I don't want to feel like I'm short changing people.

    I do like my PCP though, but even sometimes I feel like I'm ushered in and out ASAP. Even though she's cordial, I've never met with her for more than 15 minutes, maybe not even that.

  6. I am a family doc and while I get that you didn't feel primary care was a good fit for you and appreciate your humor about what you didn't like about it, I do feel like I have to defend my specialty a little as other readers of your blog may be dissuaded from a wonderful specialty. I would strongly recommend that anyone considering primary care do a Family Medicine Residency and not an Internal Medicine one. Family Medicine is better preparation for primary care in general. In my particular residency, we worked in our outpatient clinic 1-2 days a week through all our inpatient rotations and had 3 complete months a year just in clinic. If you don't ultimately want to do OB/GYN or peds, you can tailor your practice once you graduate. I see a lot of women and children but some of the other physicians in my practice don't. There is always going to be the little old lady with the bag of meds (in fact she will pop up in every specialty!), but thankfully when you are an attending you have more say about your schedule and if I have a really complicated patient, I just book them for a longer appointment. As an attending, you also have more experience and confidence and you know your patients better so you get more efficient at seeing even the most difficult ones. It honestly does get less stressful seeing these patients.
    In the 5 years I have been in practice, I have also developed wonderful relationships with my patients. I often see members of the same family across 3 and 4 generations. My youngest patient is currently 6 months old and my oldest is 98. I regularly get farm fresh eggs, fresh produce from the garden, cookies, etc. and when my daughter was born, my patients basically clothed her for her first 3 months. Sure, it has it's frustrations like any area of medicine, but it is also incredibly rewarding.
    The important thing is to be picky when considering positions. There are of course, going to be some pretty crappy primary care clinics, but there are far more good ones and these are the ones to seek out. Most of the residents from my year are in thriving practices and enjoying their work immensely.
    I am in private practice, have call 1:8 with the occasional weekend and holiday manning our small urgent care clinic. I received a lot of support when I had complications with my 1rst pregnancy and had coverage for my maternity leave. Yes, I am sometimes stressed, there is always annoying paperwork to do and annoying insurance companies to deal with, but overall I couldn't picture myself doing anything else. So please, if you are thinking about a career in primary care, I promise there is a bright side!

    1. I may have stuck it out if I'd been in a Family Practice residency.

  7. Wow...I guess after reading these comments I should hang on to my PCP for dear life! Hands down, he's awesome. I write these comments as a layperson and not a med student/professional so my apologies if I get the terminology wrong. Let's see: he is an internist, works for a teaching hospital in a very large urban setting (Chicago), teaches classes, and has residents and students in and out of his office/practice regularly. While I would guess that these tasks/duties are pretty common for a physician who is employed by/affiliated with a medical university, I have never felt rushed, pushed through, or as if I was a specimen for the residents or students to examine. He either obviously loves what he is doing and is very good at it or he's a damn good liar and faker. Either way, I don't care; I feel as if he is an exemplary professional who has the "smarts and the hearts" needed to properly care for his patients.

    1. You should hang on to ANY doctor you like for dear life. I'm not sure why this is such a revelation.

  8. As a graduating fourth year medical student planning on a career in primary care, I agree with you 100% Fizzy that the traditional IM primary care training is severely lacking. A half day of primary care clinic in a 6 day week with maybe 1 month of outpatient elective per year is not nearly sufficient to train a good PCP.

    I would argue though that a lot of Internal Medicine residencies are seriously buffing up their primary care tracks to give you substantial experience and training. GW for example gives you an entire year where all you do is outpatient medicine. Many other programs are creating a 4:1 or 4:2 system, where for every 4 week block of inpatient medicine you have 1-2 weeks of outpatient experience. And IM programs that do decide to have a 4:1 or 4:2 system make all their residents participate, knowing that regardless of what you specialize in, you are likely to have some outpatient responsibilities.

    So, I don't think it's necessarily true anymore that you need to do Family Medicine if you want good primary care training. I'll let you know in three years.

  9. This all seems so strange to me. It seems that our Canadian system, while not dissimilar, is quite different from US training.

    We don't have DOs, only MD schools. Residencies are quite straightforward (if you want to be a family physician, you do a family physician program. If you want to be an internist, ie hospitalist, then you do Internal Medicine residency). It seems more straightforward to me this way. Of course, it may just be because I'm more familiar with our system, but so far I'm quite confused about how it works in the states...