Why I Left Primary Care, Part 4

In the earlier posts in this series I discussed my reasons for choosing a primary care specialty, the problems I encountered while practicing primary care, and considered some factors which might draw me back into the field.  In the final post in this series, I've pulled together a few tips for young doctors considering a primary care career.

I realize these posts have focused on the failings of primary care as a career but I don't want to send the message that doctors should avoid or abandon primary care.  There are darn good reasons for staying in the field, such as

• Primary care doctors are needed everywhere, and even if doctors abandon the field as a form of protest they will then have to find primary care providers for themselves and their families, and believe me this is getting hard to do in Rural.
• None of the current problems in our health care system is going to improve unless we have excellent doctors working on the front line of medicine.
• Primary care medicine is terrifically rewarding if the conditions are right.  You get to see really wonderful patients continuously over time, through good times and bad, and you have the great privilege of being present at some of the intimate transitions of life.
• If you are well-prepared and extremely well-organized, primary care offers the chance at an excellent lifestyle with time for outside interests and family.

Having said all of the above, I still believe potential primary care docs should go into the field with their eyes open.  The suggestions below are in no way meant to be a fool-proof guide to a successful primary care career, but they form a sound starting point and represent everything I wished I'd known when I was starting out.

1.  Advocate for better primary care reimbursement.  I'm guilty of neglecting advocacy, but with a new administration in government we need doctors to speak up for themselves in whatever plan for restructuring is finally developed.  Join your specialty organization and keep up with your local medical society, follow health policy news and write to your political representatives.  One of our surgeons is involved with the California Medical Association and he says we need more voices from primary care doctors, describing the challenges we face.

2.  Perform a careful self-assessment of your goals and preferences.  In other posts I have written about the need for more education in personal financial planning during medical school and residency.  For now, young doctors are on their own for developing a financial plan.  I encourage everyone to sit down and brainstorm their ideal lifestyle, then evaluate how realistic it is against the likely earning potential within primary care.  Questions to ask yourself:

1. Where do I want to live and practice?  Investigate real estate prices in these areas.
2. How many days per week do I want to work?  If you are hoping for a part-time career in the future, calculate projected annual income for that scenario and plan accordingly.
3. What kind of hobbies and leisure activities do I want to enjoy?  If you enjoy travel, extreme sports, theater, art collecting--all of this costs money.  You will have to make choices.
4. If married, will my spouse work?  What are our plans for a family?  I think people fail to acknowledge the financial impact of having children until after the children have arrived.  In high cost of living states such as California, the impact of a one-income household also must be considered.  I know one couple whose relationship is significantly strained due to financial stress with one of them at home. 
5. If I have children, how much do I expect to contribute towards their education?  Will I want them to attend private schools?  What about university tuition?  I think everyone wants to pay for their children's education but most financial advisors instruct clients not to do so if it means neglecting retirement and general rainy-day savings.  Your kids can apply for financial aid, but no one will give you a loan to pay for your groceries when you are eighty.
6. How good is my health?  If you have any health conditions which might limit your ability to work full time or beyond a certain age, you need to factor this into your financial plan.
7. When do I envision retiring?  The old concept of retiring at age 65 is rapidly deteriorating as sixty-somethings find they must stay in the workforce longer in order to fund retirement.  If you have any ideas about retiring younger than 65, start saving aggressively now.
8. How secure are my parents' finances?  Most families don't sit down and discuss finances once the children have reached adulthood, but this is a critical time for open communications.  You won't want to see your parents in the poor house if their finances collapse, and contributing to their care and well-being must play a part in your financial plan.
9. What are my profoundest dreams?  If you want to achieve something outside of medicine, don't exclude it from your plan--save for it!  Make sure you have the money to achieve your goal so you don't have to steal from retirement savings or go into debt to reach it.

Primary care medicine pays enough for a comfortable lifestyle, but it won't give you enough for unlimited possibilities.  If you want to have a large family and educate your children privately, you probably won't be able to work part-time or retire at 60.  If you want to travel or indulge in costly hobbies, you should seriously consider limiting the size of your family.  If your parents are aging or in poor health, you should ask them about their financial status, because they may need your assistance in the future if you want to ensure quality in-home care (this will be the subject of a future post).  Needless to say, I would abandon any ideas about sports cars, mansions, and Wednesdays playing golf.

3.  Involve your family in discussing plans for the future.  Your spouse and your parents should know what your hopes are for the future and what their role might be within them.

4.  Consider a loan repayment placement for the first 2-4 years in practice.  Federal loan repayment will provide $25,000 per year for a two-year commitment at a health professionals service area (HPSA) site. Thereafter, if you continue to provide services at the HPSA, you can re-apply for $35,000/year for another two years, and if you love your HPSA site, you can stay on and apply for $15,000/year until your federal loans are paid off.  Remember these amounts are tax-exempt, so they are worth proportionally more depending upon your tax bracket.  The chance to reduce your educational indebtedness adds greatly to the salary your HPSA actually pays you.

5.  Investigate any potential primary care job carefully.  One mistake I think all new primary care specialty grads make is underestimating the strength of their position in the job market.  Most of my peers worried about getting a job and didn't take the extra step to investigate the jobs they were considering.  Some of these suggestions might test your comfort level but they might well be worth the effort:

1. Ask how the providers at your potential clinic site share responsibilities for each other's patients when one of them is on vacation or out of town.  Pay attention to any moments of hesitation or carefully euphemistic  responses.  Make it clear that equal sharing of responsibilities is important to you.
2. Most clinics will be installing EHRs in the near future.  Ask where the clinic under consideration is in this process and how confident the providers are with using it.  Ask if there have been any problems interfacing with other local organizations (hospitals, etc.)
3. Ask how the clinic processes requests from patients.  How many triage nurses work within the practice?  Does the clinic have protocols for doing low-acuity tasks (UTI triage, INR adjustment)?
4. How many rooms does each provider get to see patients?  How many medical assistants?
5. Ask to speak to individual providers privately, or communicate with them via email after your interview day.  Providers within a clinic are eager to recruit more help but they are also motivated to find people who are likely to fit well within the group and who will be happy in the system, so they are actually going to be pretty forthcoming about the strengths and weaknesses of the group.  At least I am when candidates interview at our FQHC.
6. Ask to speak to doctors outside the clinic--ER docs, consultants, etc.  This requires diplomacy but your clinic should have a few people they know well and who should be happy to answer questions.  To these people you can ask--diplomatically--about the clinic's reputation within the community, and what their opinion is of how well the group practices together.

All of these suggestions require you to be assertive and invest time outside the limits of a regular interview day.  I wish I'd thought of delving deeper into my job when I was interviewing, and I would happily have tested my limits in order to know what I know now.

6.  Once you've found a job you like, negotiate conditions carefully.  Most HPSA clinics don't have much room for negotiation, but you should know the details of the offer and how to maximize them to your advantage.  Where there is room to negotiate--NEGOTIATE!

1. What is the benefits package?  There's usually a 6-month honeymoon period before these kick in and they should include health/vision/dental, a TSA program funded from your own contributions, and some kind of employer-funded plan such as profit sharing if you are working for a HPSA site.  
2. Time off and funds for CME.  Ask what the maximum is and if this is prorated in any way if you do fewer than 9 clinics (36 patient-contact) hours per week.  I would insist you receive the maximum no matter what your schedule ends up being.  HPSAs get the doctors they deserve if they don't invest in their ongoing education.
3. Moving stipend.  This should be flexible and I would ask for 100% of your moving costs.
4. How many patients are you expected to see per clinic (half-day)?  Expect a convoluted answer, but 8-12 is typical in a HPSA.
5. How is productivity rewarded?  Some places, like my HPSA site, give you a certain amount per patient seen over a minimum number, averaged over the total number of clinics done in a month.  However, you are much better off with a productivity system based upon RVUs.  This will reward you for seeing more complex patients, who will take you more time to see.
6. How much administrative time is paid by the clinic?  Is this pro-rated in any way?  The maximum schedule I think a PMD should agree to take on is 8 clinics/32 patient-contact hours per week, with the remaining 8 hours dedicated to administrative tasks (finishing notes, reviewing labs, filling out paperwork, authorizing refills, returning phone calls, etc.)  I think all 8 hours should be compensated, but my clinic only paid for a maximum of 4 hours per week.  I would negotiate for full compensation, since 8 hours is hardly enough to get all the administrative work done on 32 patient-care hours every week.
7. If you have any vacation plans during your first year at work, make sure everyone knows before you sign your contract.  Ask how call schedules and holiday schedules are determined.

There's probably many other items deserving of negotiation but these are the ones I wish I'd addressed when I signed my FQHC/HPSA contract.  The main thing to remember is that you don't have to accept all their terms, you can ask for a bit more and everything you succeed in negotiating for yourself increases your actual compensation.  

7.  After the contract is signed, prepare yourself before the job starts.

1. You should get at least one medical assistant who is assigned to you.  I never learned how to work closely with a medical assistant at my chronically-understaffed residency clinic, so I never realized how much a good medical assistant can streamline a doctor's practice.  Talk to your residency attendings and community doctors about how to optimize your doctor/MA relationship once you start your job.  
2. Decide what, if any, limits you will place upon patients entering your panel.  Will you issue medical marijuana cards if your state permits them?  Will you manage chronic pain patients?  Are there any limits to the types of medications you will prescribe?  Familiarize yourself with the concept of a narcotic/benzodiazepine contract?  What about stimulants such as Ritalin?  Finally, how will you approach the needs of a patient with complex chronic illnesses?  Expect to test your limits, but don't turn into one of these primary care doctors who won't take on a patient with lupus because you won't bother to look up the latest in management in the disease.
3. Brainstorm ways to manage patient expectations.  Consider writing up a handout on what can reasonably be expected in a 15-minute visit.  Look at examples of narc/benzo contracts as mentioned above.  Ask yourself how you will help prioritize a patient's list of questions.  These are the kinds of things that influence your daily life as a primary care physician, so it pays to think about them ahead of time.

These suggestions are only the tip of the iceberg.  I'd be interested to know what other tips other primary care docs would add to the above.  There is so much you can't possibly know until you've done the work for a while, just imagine what it might mean to a young doctor to know ahead of time.  Chime in!

Comments

[nj]

i havent even started med school and these are things i constantly think about and research. everyone tells me i shouldn't plan or think about my life 20 years from now and instead focus on actually getting into med school first. but i feel like i must other wise there is too much uncertainty in my mind.

[dragonfly]

Thanks for this. It was being placed at a practice which fulfilled those 6 criteria really well that first made me think seriously about primary care. Good to have points to think about.