To Med Students Considering Primary Care

Dear Student:
Thank you for your consideration of my profession for your career.  I am a primary care physician and have practiced for the past 16 years in a privately-owned practice.  (At some point I intend to stop practicing and start doing the real thing.  It amazes me at how many patients let me practice on them.)

Anyhow, I thought I\’d give you some advice as you go through what is perhaps your biggest decision regarding your career.  Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices.  It is the final choice that is, well, final.  What are you going to do with your life?  \”Being a doctor\” covers so much range, that it really has little meaning.  Dr. Oz is a doctor, and he has a very different life from mine (for one, he\’s not the target of Oprah\’s contempt like I am – but that\’s a whole other story).

Here are the things to consider when thinking about primary care:

1.  Do you like talking to people who are not like you?

Primary care doctors spend time with humans – normal humans.  This is both good and bad, as you see all sides of people, the good, bad , crazy, annoying, funny, and vulnerable sides.  If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don\’t do it.  The single most important thing I have with my patients that most non-pcp\’s don\’t have is relationship. I see people over their lifetime, and that gives me a unique perspective.

2.  Do you prefer variety over predictability?

Every room I walk into is different – often vastly different – from the last.  I could be walking in on a crisis or a stable recheck.   The person could be elated or crying.  They could be 90 years, or 2 days-old.  They could have something wrong with any system, and it could range from mild to life-threatening.  I\’d go nuts doing the same thing every day, be it looking just at skin or just dealing with the kidney.  But some folks do better with routine and a lack of surprise, they don\’t want their days to be unpredictable.

3.  Do you need to be in control?

Primary care is not about control.  Those primary care doctors who try to maintain control of their patients are both unsuccessful and unhappy.  Relationships are not always predictable, and much of what PCP\’s do depends heavily on the patient\’s \”cooperation.\”  I put the word in quotes, because the word implies that the doctor\’s agenda is more important, an implication that I reject strongly.  PCP\’s are part of \”team patient.\”  Our job is to help them, not direct them.  We give them our expertise and they make the final choice.  Surgeons, on the other hand, don\’t consult the patient when operating; they don\’t depend on patient compliance as they cut a person open.

4.  Are you a people-pleaser?

The flip-side to #3 is that a PCP must always practice good medicine – even if it makes people mad.  You have to learn to say \”no\” to people who seek drugs, who want an antibiotic, to drug reps who want you to prescribe their products, and to insurance companies that want you to work for free.  We are not co-dependents.  We don\’t base what we do on the reaction we get from patients.  Often we are the only ones with the opportunity to tell them the hard truth about lifestyle choices or about their future health.  I deal daily with the consequences of people-pleasing PCP\’s, who addict their patients to drugs, who create antibiotic resistance, or who give in to drug reps and give expensive prescriptions where cheaper ones are better.  Please don\’t choose primary care if you are a people-pleaser.

5.  How important is social status?

PCP\’s have an interesting paradox in their social status.  In the eyes of the public, we are the ones who earn less money and so must have gotten worse grades than the cardiologists and dermatologists.  In the eyes of those same specialists, however, good primary care doctors have a very large amount of respect.  We are actually the ones who run the medical show, using specialists when we think it is needed.  We need to know 90% of all specialties, and also know when we are in the 10% we don\’t know for each of them.  I often get \”I could never do your job\” from my colleagues.  So if outward social status matters (like what kind of car you drive or how big a house you own), then don\’t choose primary care.  I am not saying that PCP\’s don\’t have a good income (98% of my patients would like my income), just that my outward status is not nearly that of the surgeon who operates only on left ring-fingers.

6.  Do you like puzzles?

The term \”gatekeeper\” got applied to primary care via our friends in the HMO\’s, and that term has haunted our profession since.  Good primary care is not simply triaging people and sending them to those who can offer real care.  Some PCP\’s do that, but they are both lazy and unambitious.  I do whatever I can to keep people from the specialists and out of the hospital.  I need to know when to send them, but I also need to know what to do before I send them.  This endears me to my consultants, as I am sending only patients who need their expertise.  I know orthopedists will give an anti-inflammatory and probably order physical therapy for shoulder problems, so I do this before I refer the patient.  80% of my patients avoid orthopedists this way, and the ortho docs know my consults are not usually fluff.

But the real challenge of primary care is the fact that I am usually the first to see a problem.  Specialists get sifted problems – I have already thought the situation through and so they get the left-overs.  I don\’t usually send people to specialists for a diagnosis, I send them for a specialized treatment for the problem I have diagnosed or strongly suspect.  I am the quarterback, the manager, the lead singer, the director of the symphony orchestra.

7.  How patient are you?

I have to confess that I was not a beacon of patience when I started practice.  That being said, I have learned that one of the most powerful tools in medicine is waiting. We get to see the big picture.  We see people over months, years, and decades, and watch the progression or deterioration of conditions.  I find this most satisfying.  People who were suicidal ten years ago are now cracking jokes and are productive citizens.  One of the biggest mistakes a PCP can do is to value intervention over waiting.  We are caretakers of the big-picture.  Surgeons do their job in a few hours, radiologists in a few minutes, and oncologists in a few months or years.  But PCP\’s do their job over the lifetime of the patient.  To me, that\’s a plus, not a minus.

8.  Are you compassionate?

Again, this is something that has developed over time for me, but the seed of it was there early in training.  Primary care is about \”care\” – in all of the definitions of the word.  We care for people because we care.  It does matter to us that people are hurting.  There is a degree to which primary care is a calling or ministry, not just a job.  There will aways be a necessary detachment we have from our patients (for our own sanity), but a PCP who is simply \”punching the clock\” is both sad and dangerous.  You need to be able to listen and see things from people\’s perspective.  You are their doctor, and they are your patients.  The possession is emotional, it is one of caring.  People judge PCP\’s on how much they like them and how well they feel listened to.

There is much more to say (read the rest of my blog, as well as other primary care blogs such as Kevin MD, Musings of a Dinosaur, Jill of All Trades, and DB\’s Medical Rants for a more complete picture – sorry to those I left off, there are many other good ones).  Any specialist would tell you that a very good PCP is incredibly valuable.  I love my job, as do many of my colleagues.  I want more PCP\’s, but I only want you in my field if you\’d raise the average.  We need good PCP\’s.

Come join the fun.

13 thoughts on “To Med Students Considering Primary Care”

  1. Another beyond-awesome post. You nailed the dr-pt relationship and it is a relationship, in spite of people who would have us turn it into another transaction. This should be required reading and I hope you recruit a lot of doctors! Gotta say something about Item 5 and social status though–as a patient and a member of the public, I’ve never, ever thought of primary care docs as lesser somehow than surgeons or other specialists. That notion never even occurred to me until I started hearing about a lack of respect/less $ etc in the blogosphere and to a lesser extent, news media reporting on a shortage of docs.
    P.S. Now I’m dying to hear the Oprah story. Will you share it with us sometime?

  2. As a fellow primary care doc who has been in the business for almost 30 years, you’re spot on Rob. Excellent post, as usual.

  3. I’ve been with my neuro for 18 years. Pulmo for 15. Ortho for 16. PCP for 3. My PCP’s keep moving away or retiring! (it’s starting to feel personal!)

  4. Fantastic post Rob. Yo0u have captured exactly the essence of General Practice, what makes it challenging and rewarding.
    I love the bit about filtering, we have usually made the diagnosis when we refer. One of the frustrations of Primary Care is lack of recognition for this skill. I do get a bit irritated when I have handed ‘specialists’ the diagnosis and it gets referred back to me as their diagnosis!

    We are Specialists too!

    I am handing this out to my clleagues at our next peer review. I felt empowered by it


    Kerry – SPECIALIST General Practitioner – New Zealand

  5. I’ve only read two posts – Flat Tire and To Med Students – but I gotta say that I really appreciate your distractible mind.

  6. As a primary care physician and a general surgeon i went to two rotation in internship and finally a year of family practice as they called that in early seventy’s then went to pathology for one year and four years of general surgery before practicing. Knowing the sub-specialties theoretic and practical is in it self entails extra efforts as for myself being very interested in those branches of medicine. I was able to refer my patients to the specialists and be appreciated by them as i don’t have the privileges of doing them myself in any institutions by law. Being chosen by my patients to do surgeries on them i gave them the choice if they ever have preferences/ second opinions if they want that. That is how i do my practice. i agree wholeheartedly with you. Thanks for your nice article. Sam.

  7. Hi Dr. Rob,I am currently a medical student in San Antonio, and I found this entry to be extremely endearing. I was wondering if I could have your permission to post this article on one of our school’s organization website? I am the webmaster for the pediatric interest group at my school, and we thought it would be great idea to post your article on our page for easy access. If you prefer for us to not directly share your article (i.e. copy and paste this letter onto a page of our website) due to any copyright issues, I can completely understand and can comply to your request. If you need more information about my school and organization, please let me know. Thank you and I look forward to hearing from you!

  8. As a medical student considering primary care, what do you think about the Direct-Pay medical practice?
    Thank you,

  9. It’s tempting, but it doesn’t work in the larger picture. I can’t say I would recommend against it, but I do know it won’t last as a long-term solution. I’ve considered it, but would be sad to lose my Medicare and Medicaid patients.

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