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My partner is a PCP / Family Doc. I had no idea until I met him just how damn hard it is to make a living as a sole practitioner Family Doc.

It’s ridiculous and exhausting. The paperwork. The legal risks. How long it takes to get paid and the ridiculously low amounts that are reimbursed.

But he loves it. He spends time with his patients. He will pore over literature trying to help a patient. He calls in scrips at all hours of the day and night. He takes limited vacation and is often on call for patients even still. No time to actually go to the doctor for himself if he needs a specialist but ironically many of the local docs send themselves and their families to him.

Thank Goddess for his staff. They believe in his mission to provide quality care over a persons lifetime.

He told me this week about a little boy, now 15 or 16, that came in for a checkup and he remembers him as an infant and all the visits in between.

The business part for a PCP doc...good grief. Is there a group or non profit that is working on programs to support the next generation of docs? I am flabbergasted at how little education there is (the business part) for docs starting their own practice. Even if you buy a practice...it’s still a business with legal, accounting, IT, HR, operations and marketing demands. (Note: I am also a business owner and my company actually supports starts ups as they launch. We set up a lot of their business practices and create a roadmap ie strategy for their first three years.) I have been helping my sweetheart think about his practice differently, like a business, and have seen him get to almost break even over the last six months. If only he had business training - something, anything - as part of his med program. Its mind-boggling. I have been thinking about petitioning the SBA to provide better support for Family Docs, especially smaller practices.

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Thank you for this amazing well thought out post. I’m few years out of residency, and tried it against the stream, and started working as an internist. Your post resonated so much, and after a busy week, it was much needed motivation. I love my job, and I didn’t feel like that during my med school years, and during training especially in inpatient. I would question as to how the chronic diseased patients ended up so sick in the first place, and I felt that a lot could be easily prevented if their PCP, tried to be proactive, rather than just refer or do the bare minimum.

I love the tremendous variety of conditions, and integrating mental health with physical health. I sometimes find myself blown away by the outcomes of their making better choices in nutrition, sleep and stress. Knowing them over many months, and following them frequently, has helped me to diagnose them effectively.

Today was one of those days, where I saw a rare connective disease patient, a metastatic malignant melanoma patient, whom I diagnosed on his first visit, a septic arthritis to be sent to ER, and diagnosing an adult ADHD patient.

Yes, there is a lot of BS paperwork, prior auths, documentation, and a lot of specialist dumping of problems, but the feedback and gratitude I get from them once they start getting better, is just truly priceless. That’s the only thing that helps me sleep at night, for a job well done!

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okay, adam, will you just marry me??

substack after substack i say to myself, this man has it right! he's saying what i've been thinking for years. this one is at the top of the list.

i once worked with a family physician who was one of the smartest docs i've ever worked alongside. she was a brilliant diagnostician and referred only when she knew she was out of her league. the world was a better place when she was practicing. we need more of them. and she made plenty of money....but that was a bonus for her. her drive was patient care and figuring out their malady. and she was beloved by her patients.

so you sparked a fire in me to comment. thank you and i hope your recruitment brings them back!!

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I feel like one of the biggest contributor is Obama care and ACO’s. They give us these arbitrary “goals” like lead testing or (PFTs) with asthma (which I find not helpful in the pediatric population), to either give us a reward or penalty if we accomplish. It’s exhausting to have administrators tell us how we need to meet these metrics which have no meaningful improvement in outcomes.

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The concept of shortage has elements of exaggeration or half truth.

-Population is aging and as people live longer, there will be a need for PCPs.

-US, Japan, EU and UK birth rates are below population replacement age. Therefore at some point, population will decline or is already declining (Japan).

-There are plenty of MDs. But few people want to live in rural country.

To have an excess of MDs is a bad idea as:

-They get lower pay

-Large number of NPs that graduate every year will be allowed one day to have their own solo practice

-High cost of medical education

To graduate MDs and NPs like a factory is good for local politicians and for the business of universities but, current demographics suggests that they are eating tomorrow's lunch.

Economics has a strong principal named "reversion to the mean"; it is as strong as gravity. If a factory overproduces, it decreases production next year. If supply of MDs is too high and demand falls, the number of students will decrease. But as you can not "delete" MDs and NPs, reversion to the mean could take decades.

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May 28, 2023Liked by Adam Cifu, MD

As someone who started as a sub-specialty resident and then switched to being a primary care physician for the last 30 years your thoughts really resonated with what my experience has been. Having been a teacher of medical students for most of that time has allowed me to show them what joys and fulfillment there is in being a Primary Care Physician. I am always happy when they tell me that they are pursuing a primary care residency and often tell me that part of their decision was based on time spent with us. It is a start but I really believe that for us to turn the US healthcare ship around we need to have at least 45% of our docs being in this area. I can hope and do what little part I can. Thanks Adam.

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Shared on Facebook. I hope a lot of folks read this. I love what you said, especially, about being a "diagnosis specialist". Brilliant. But all your reasons make great sense. Thank you.

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May 27, 2023Liked by Adam Cifu, MD

GREAT POST. Becoming a primary care internist is CERTAINLY a worthy venture! And then — there is family medicine, with EVEN MORE of a primary care focus (with all the advantages noted by Dr. Cifu — plus MORE ... — :)

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I am a non medical person who has struggled to find a PCP for various reasons. I'm fortunate to live in San Francisco so I can't even imagine how difficult this must be for others in smaller towns. I lost my favorite PCP (who in my opinion saved my life or at least emergency surgery when she said the amount of antacids I was taking was not normal. I had never thought twice about it. Low and behold I find out I have multiple stomach ulcers. I will forever be grateful to her for that) to "concierge". So even though she is still a PCP one has to cough up thousands of $ a year for the privilege. As one can imagine living in the Bay Area there are plenty of people willing to do so.

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May 27, 2023Liked by Adam Cifu, MD

I, too, am a primary care internist. I ALMOST went into pulm/cc. Thankfully, the Lord led me down the path of GIM. I absolutely love it. My favorite part, as cliche as it sounds, is the people. I am thrilled to truly know my patients. My ultimate goal is to be the best diagnostician in my area. However, an equal goal is to know my patients as well as possible. I learn little things about them like favorite restaurants, what crops they grow, where their kids are going to college, etc. That morphs into big things: how much a parent's death effected him/her, a sentinel post-op complication 5 years ago, how long they stayed in the NICU with a newborn grandchild. I have become a counselor to them, which was a happy surprise when I realized I would be doing that. A LOT. Some of the best medicine I practice is when I'm speaking to them at their most vulnerable points.

I'm their advocate...I pride myself on being very creative in getting meds or imaging modalities covered. I'm their gateway to the medical industry...my rolodex of worthy consultants is ever a-changing (but to the benefit of my patients). I'm even called to be the only educated person they know...I had someone schedule an appointment with me to read legal documents for them (yep, I'm a rural doc)!

The glitz and glamor is with the specialists, but the true rewarding and fulfilling side of internal medicine is primary care.

Thanks for this, Adam.

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May 27, 2023Liked by Adam Cifu, MD

Fantastic column, Adam, thank you! These are exactly the points I emphasized frequently with my medical students, encouraging them to consider a career as a general internist, though few made that choice. We are very much an endangered species.

A few additional points. Relish being a thoughtful thorough bedside clinician, listening attentively, performing a proper physical examination as you were taught in medical school, ordering tests rationally, thinking through differential diagnosis, becoming a trusted colleague and most of all, developing lasting relationships with patients you’ll know, care and advocate for over your entire career. In the end, those personal and professional relationships are priceless.

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May 27, 2023Liked by Adam Cifu, MD

Being a primary care physician is absolutely not what I imagined being a doctor would be like. My father worked at NIH for many years (as an RN, not an MD), and I spent ample time there researching my own health problems as well as out of general interest. I expected that being a doctor was about trying to find a niche that no one else was filling and fill it. I'm used to hearing from the world's leading expert on this disease entity or that treatment modality about how they're going to change the world, and I don't know how you can be the world's leading expert on any such thing while also treating whatever comes in the door. My expectation of a career in medicine was to have either a private practice or an academic clinic where it says on the door: "I treat X, Y, and Z conditions, and I offer A, B, and C treatments" and to have patients referred or self-referred to said office.

So my current residency which has me working part time in primary care is a bit of a bummer. I'm noticing with fellowship in sight that my passion for that part of my job has dropped off considerably. And I don't even have to deal with RVU's!

I get the fascination that comes with a truly unknown differential, but that doesn't seem like a huge portion of what I do on a day to day basis. I grew up watching House, that was fun (if often inaccurate), but a lot of what I see now is chronic disease management and preventive care, which is guideline-driven and not that interesting. The more interesting part of my job is serving as a translator to patients and families who haven't gone to med school and don't understand what's happening.

I'm a chronic pain patient. I went into medicine to offer an rational, integrative, non-interventional approach for people who are suffering with chronic pain and the associated mental health issues. My perspective has been and remains that if you broke your arm, or you want to get pregnant, or you have COVID, I'm not the man for the job. It certainly clashes with what the profession wants of me, but I think humility is a virtue that medicine underrates. I wish I knew everything, but I don't and can't and won't. That's why we specialize, in medicine and in life.

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May 27, 2023Liked by Adam Cifu, MD

What a wonderful piece. Sensible Medicine, and especially pieces like this, has really helped rebuild my trust in doctors post-Covid. Thank you for that.

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Amen, yes, hallelujah. Primary care medicine is about caring for the whole person - mental, physical, behavioral, social-emotional. It’s the best job there is.

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I have great respect for people who are willing to do things like this. I don't think I could put in the energy to help people in bad moments like this.

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You'd have the insiders view, Doc, but my observation has been that primary care practices used to offer their physician-owners a place in their community that the corporate-government assault on private practice has virtually destroyed.

I was deeply saddened when the practice that helped me through many hard times over several decades, was finally crushed by a vertically-integrated corporate system and the physicians surrendered and became employees practicing under the thumb of predatory corporate administrators.

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