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So why do people not like primary care?


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This scares me because primary care and urgent care were my two main fields of interest.  I have shadowed two primary care PA's and liked what I saw.  The clinics were both privately owned.  Primary care interested me the most because I am interested in basic health promotion.  Urgent care interested me because it seems similar to primary care but emphasizes urgent medical problems which is where medical science has obviously made great strides.

 

The only other specialty that interests me is psychiatry but I don't know much about it.  It interests me because mental health and pharmocology is extremely extremely interesting to me.

 

Seems most people on this forum are in emergency care which does not interest me much.  I don't need daily adrenaline rushes and tend to like boring stuff that other people don't like.

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many primary care offices have this unfortunate intersection of patients/conditions:

high volume/low acuity. pt every 15 min. all stuff that could be treated at home with chicken soup and tylenol during flu season, etc

argumentative patients(want abx for colds, etc)

fibromyalgia/chronic pain/psych pts

pts wanting to go on disability inappropriately

drug seekers

lots of preauthorizaations, referrals, endless paperwork, etc

pts who refuse to quit smoking, stop drinking, stop drugs, lose weight, eat a better diet, exercise, etc

 

of course you see this in other specialties too, but generally you only see them once and send them back to(you guessed it) primary care to deal with them.

oh, all of the above with more hrs and significantly less pay than many specialties.

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many primary care offices have this unfortunate intersection of patients/conditions:

high volume/low acuity. pt every 15 min. all stuff that could be treated at home with chicken soup and tylenol during flu season, etc

argumentative patients(want abx for colds, etc)

fibromyalgia/chronic pain/psych pts

pts wanting to go on disability inappropriately

drug seekers

lots of preauthorizaations, referrals, endless paperwork, etc

pts who refuse to quit smoking, stop drinking, stop drugs, lose weight, eat a better diet, exercise, etc

 

of course you see this in other specialties too, but generally you only see them once and send them back to(you guessed it) primary care to deal with them.

oh, all of the above with more hrs and significantly less pay than many specialties.

how significantly less of pay hourly wise?  I live in California where the average is $51/hr or $107k.  But I always said to myself that I didn't mind taking the lower paying jobs that others considered "boring" like primary care where it seems to be more counseling and small procedures as opposed to big time procedures like ortho or something.  I didn't know they had demanding hours though.

 

Dermatology also interests me but for a very specific reason that I imagine is not really related to the duties of a physician assistant in derm.

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I love primary care

Took me a few different jobs to figure this out

 

If you do just the simple stuff it stinks.... boring

 

BUT you truly control the care given to patients, I rarely if ever send anyone to endorcrine, or pulm, I like those fields and manage most my self. Also holds true for Ortho and somewhat for cardio.

 

As well this is NO REPLACMENT for a strong PCP when someone is sick - everyone else only answers their specialty, but PCP has to figure out what it is, then send it off to a specialist to rule in/rule out...... no other speciality is like this.

 

As well if you are bored in primary care you are just lazy - - their is literally no end to what you can learn and pretty much do. All the way up to minor office based surgery and the like......

 

PCP got killed by insurance companies (whose payment rates are set by a board of specialists) as "simple medicine" and the specialists wanted more and more for their procedures.... the end result was a crappy system..... with no PCP influence. I think this is changing now as my local PCP offices are down to 15--20 patients a day and time to have a life

 

 

 

ER and Urgent care are also great fields, but I hate being sick, and when I am in those fields I get the cold of the month just about every month or two.... yuck....

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many primary care offices have this unfortunate intersection of patients/conditions:

high volume/low acuity. pt every 15 min. all stuff that could be treated at home with chicken soup and tylenol during flu season, etc

argumentative patients(want abx for colds, etc)

fibromyalgia/chronic pain/psych pts

pts wanting to go on disability inappropriately

drug seekers

lots of preauthorizaations, referrals, endless paperwork, etc

pts who refuse to quit smoking, stop drinking, stop drugs, lose weight, eat a better diet, exercise, etc

 

of course you see this in other specialties too, but generally you only see them once and send them back to(you guessed it) primary care to deal with them.

oh, all of the above with more hrs and significantly less pay than many specialties.

 

This.

 

I also find many primary care offices to kill their providers and to be poorly run, for the most part.

 

After 4 years in primary care, I'm now happily working in a specialty where I see crazy things that I didn't know exist. I'm not stressed out at all here, I'm treated with respect, and we have qualified staff in the important positions (an RN office manager and a MBA business manager). I also completely lucked out with the doctors I work for. They're awesome, flexible, and are considered to be some of the best in their field. We also do cutting edge research here and I'm a sub-investigator.

 

I'm very fortunate to have found this position and would absolutely leave the profession before I ended up back in primary care.

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Primary Care for me right now:

 

Too much to do. 10 min sick visits (hear chest pain)

26 a day expected in 8 hrs

Patients who don't want to participate - just give me a pill, I don't want responsibility

Would you like fries with that Happy Meal?

Developing health prevention is a farce with 10 min appts, few resources and no support

NO RNs

EHR and meaningless use sucking up all your visit time

Preauthorizations to fart, breath and provide basic medical care

ZERO time to teach diabetic patients much less manage them

Again, no support - bare bones staff and no RNs

BAD mgmt at private solo level

Oppressive admins in corporate

Lots of IM in FP but no time to handle everything

Polypharmacy

Fibromyalgia

Chronic Pain

Deductibles, copays and unrealistic expectations from patients - wants to come in once a year with an A1c of 9....

 

Currently killing me and my desire to continue in FP much less medicine

Until or unless FP/IM is seen as the complex SPECIALTY it is - run

And the current administration in govt isn't going to help us......

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From a Canadian standpoint, I got out of family medicine because I was being used and abused...because the work never really ends and it was hard to leave work at work.  I was salaried, so paid for my 8 hour day and nothing else, even if things went over, which they did usually in one way or another.  I'd often be charting over lunch, catching up on labs, doing letters, etc.  I saw folks q 15min, with no nurse or MOA, so had to do my own vitals, paperwork for lab samples, POC testing, etc.  Most patients on my list were older with complex medical issues, so time was needed for them.  I also never got to personally bill for things docs here get to under provincial health regs - so WCB, disability, insurance, legal forms, driver medicals, etc all got paid to the health region (allegedly bounced back to my clinic in annual budget increases).  As an example, I raked in about $13K in my first 6 months there for Class 1 Driver medicals - at $50/head, that's busy.  Because I was seeing folks q 15 minutes (a bit longer for MH or minor surg) and I don't like to talk and type, I had a lot of working lunches or charting at home on my remote access to the EMR..without OT.  I'm not even going to get into taking calls after hours about my care home residents. 

 

In EM, I now go to work and go home - if I have to take extra time buffing up someone for hand over or taking longer to stabilize them, I get paid for it.  I also get more time off - something I kind of value as I get older.

 

$0.02 Cdn

 

SK

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@Ventana, so how do you deal with the negative aspects of primary care?  Do you have a really good job? Do you just try to see the positive side of things? Like OP, primary care interests me but I'm worried because of hear so many bad things about it

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I practiced primary care for most of my 31 years.  I found it fascinating and very rewarding.  I also made a lot of money in primary care.  All the arguments above why people did not choose primary care can be found in different specialties.  You will end up where you belong regardless of the high 6 figured income of our specialty PAs.  It will just feel right.  I enjoyed being the gate keeper and because of the broad range of knowledge required in primary care, I think it is the hardest specialty.  I also liked the relationships I formed with my patients over the decades.  Just my thoughts.

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I love primary care

Took me a few different jobs to figure this out

 

If you do just the simple stuff it stinks.... boring

 

BUT you truly control the care given to patients, I rarely if ever send anyone to endorcrine, or pulm, I like those fields and manage most my self. Also holds true for Ortho and somewhat for cardio.

 

As well this is NO REPLACMENT for a strong PCP when someone is sick - everyone else only answers their specialty, but PCP has to figure out what it is, then send it off to a specialist to rule in/rule out...... no other speciality is like this.

 

As well if you are bored in primary care you are just lazy - - their is literally no end to what you can learn and pretty much do. All the way up to minor office based surgery and the like......

 

PCP got killed by insurance companies (whose payment rates are set by a board of specialists) as "simple medicine" and the specialists wanted more and more for their procedures.... the end result was a crappy system..... with no PCP influence. I think this is changing now as my local PCP offices are down to 15--20 patients a day and time to have a life

 

 

 

ER and Urgent care are also great fields, but I hate being sick, and when I am in those fields I get the cold of the month just about every month or two.... yuck....

 

 

 

This is is why I love primary care. I'm everyone's specialist and pretty much just refer out for lack of equipment, surgical indications, or subspecialty care.

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I would be OK in Primary Care if volume weren't the mantra and I could see a reasonable number of patients daily.

It would be good if I could actually do real medicine with education instead of drive through approach.

 

Today we got a ding from an insurance carrier stating we overprescribed antibiotics in 2015 and they might drop us from their Preferred List. 

 

It was 5 patients - I did not see any of them. The insurance used criteria of 3 or less days of symptoms. NO IDEA where they go their info but each patient had symptoms greater than 2 weeks, concomitant diabetes in one, asthma in one and failed prior treatment in another. Only one was even questionable.

 

So, the idea that an insurance company will drop us from coverage because we are "bad" based on someone's inadequate review and probable lack of knowledge - I don't want to practice that way.

 

So, yep, I am cranky and tired and working hard and not paid enough and it follows me everywhere and goes home.

Problem is - I CARE. 

But the reward of doing a good job and the right thing is not overriding the negatives at this time.

 

Even PA independence won't help me with this crap.

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many primary care offices have this unfortunate intersection of patients/conditions:

high volume/low acuity. pt every 15 min. all stuff that could be treated at home with chicken soup and tylenol during flu season, etc

argumentative patients(want abx for colds, etc)

fibromyalgia/chronic pain/psych pts

pts wanting to go on disability inappropriately

drug seekers

lots of preauthorizaations, referrals, endless paperwork, etc

pts who refuse to quit smoking, stop drinking, stop drugs, lose weight, eat a better diet, exercise, etc

 

of course you see this in other specialties too, but generally you only see them once and send them back to(you guessed it) primary care to deal with them.

oh, all of the above with more hrs and significantly less pay than many specialties.

 

This, ^^^, all true.

 

I like the variety in primary care and the fact you are mostly an independent provider making your own decisions. Most primary care PAs see their own panel of patients. I also do a fair amount of office procedures.

 

This list above, however, is all true and is why primary care tends to suck the joy out of you. Really what does it for me is SICK VISITS. I hate them, hate hate hate them. Where I work, our organization has fostered this culture of seeing people for any and every complaint, no matter how trivial, ASAP. While this benefits some, on the provider end it usually amounts to about 2/3 of your day being taken up by people with cold symptoms for 2 days. Things that absolutely do not need to be seen in a clinic.

 

I'm paid fairly and I have great benefits. But I'll be honest with you some days, during cold season especially, I do not enjoy my work. I am actively looking to bridge to another specialty.

 

So I'm not discouraging you from trying it, OP, you may love primary care. Maybe you are made for it. Just ponder our advice. Students think we're all jaded but really this aint our first rodeo.

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This, ^^^, all true.

 

I like the variety in primary care and the fact you are mostly an independent provider making your own decisions. Most primary care PAs see their own panel of patients. I also do a fair amount of office procedures.

 

This list above, however, is all true and is why primary care tends to suck the joy out of you. Really what does it for me is SICK VISITS. I hate them, hate hate hate them. Where I work, our organization has fostered this culture of seeing people for any and every complaint, no matter how trivial, ASAP. While this benefits some, on the provider end it usually amounts to about 2/3 of your day being taken up by people with cold symptoms for 2 days. Things that absolutely do not need to be seen in a clinic.

 

I'm paid fairly and I have great benefits. But I'll be honest with you some days, during cold season especially, I do not enjoy my work. I am actively looking to bridge to another specialty.

 

So I'm not discouraging you from trying it, OP, you may love primary care. Maybe you are made for it. Just ponder our advice. Students think we're all jaded but really this aint our first rodeo.

What are some of the procedures one would do in primary care?

 

what are some similarities and obvious differences in the daily work of urgent care vs primary care?

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Mole removal, punch biopsy. Maybe small lipoma excision.

 

Cryotherapy warts, AKs.

 

IUD placement and removal.

 

Maybe circumcisions.

 

PAP smears, colposcopy, cryo to cervix, maybe LEEPs 

 

Joint injections. Hardly ever viscosupplementation based on insurance.

 

Sometimes removal FB from eyes, subungual, relieve subungual hematomas.

 

Repair small wounds, debride small burns or wounds. 

 

Ingrown toenail - wedge resection with phenol ablation. 

 

Closed treatment aligned fractures - maybe - if you have right equipment and easy access to xray and follow up and you know how to cast in proper position with a good and not dangerous cast (a personal pet peeve of mine)

 

Urgent Care and Family Practice can be MILES apart in that in FP one is supposed to have an ongoing and preventative relationship with the patient - if the patient comes in and follows up and is compliant. Urgent Care is treat and street - no delving into when mammograms or paps were done or colonoscopies. Minimal attention to chronic meds in urgent care. 

 

In FP you expect to see the patient again, have compliance and improvement. In UC - see patient, advise, treat, send back to FP.

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@Ventana, so how do you deal with the negative aspects of primary care?  Do you have a really good job? Do you just try to see the positive side of things? Like OP, primary care interests me but I'm worried because of hear so many bad things about it

 

Heeee heeee funny you ask

 

Was at a high volume practice earlier---- left after 30 patient days, and 84k per year..... grossed 84k and got a $500 christmass. Bonus when I brought in just under 300k to practice..... up and left when ownership was not ever going to happen

 

Opened my own practice - realized it is darn hard to run a profitable practice - gross about 200k, take home about 1/2 that - but to much time working

 

So off to a state job to work a defined schedule (took a doc slot and pay) and now I run my own deal with a medical director that helps when asked...... these jobs are out there, just have to look and be ready to jump!!!!

 

I now have an institution which I am pretty much solely responsible for. Life is good.

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Several problems with primary care.

1. They are mostly run by Nurse Managers who report to Hospital Management. You have someone without medical training who listens to patient complaints and walks to your office for an explanation. Medical decisions are documented in the notes. This tactic is subtle harassment. I see it applied in multiple locations.

2. If you don't have any control, you will be assigned all of the town's patient's with chronic pain problems. If you treat pain with multiple modalities that don't necessarily include opioids, you will become the target of harassment by Hospital Management. Patients will complain. The hospital wants zero complaints no matter how that is achieved. Stand your ground and get threatened by management or leave. The problem is nearly universal.

3. Patients show little respect for Primary Care providers. This is not about being a PA. Doctors feel it too. If you owned the practice or had some control, you would simply dismiss patients who don't have a mutual respectful relationship. It is better to do better medicine for fewer people that lesser medicine for more. 

4. Pay is abysmal for the work being done. Too much of your work product is being given away for free. Patient phone calls are expected by management but you don't make money at most places. The winner is the patient. The loser is the provider. Emails don't make money for the provider. Administrative overhead doesn't generate revenue. In a perfect world, a cash based business based on time spent is fairer than the current mechanism. Patients have no grasp of costs. 

5. Too much diagnosing but little managing. Apart from the basics (htn, lipids, diabetes), most patient see you to get a referral. Then the primary does all the grunt work to send the patient to the specialists and all the clean up work after he comes back from the specialist.

6. Smoking and alcohol and illegal drug use and obesity. I believe the health care is a limited supply. If we care about outcomes, we should abandon or refuse the patient who won't take steps to improve their health. 

7.Too many unemployed people. This isn't true in a lot of places but if you work serving the indigent, you will see that patients have nothing to fill their days with. The live empty lives on the government dole (Social Security, Medicare, Disability). Most of it is fraudulent but you have to take care of them. It grates on you after a while.

 

So, in a perfect world, Primary Care would be awesome. Just carefully select patients whom you agree to treat, advise patients that you frequently dismiss for noncompliance, expect payment in cash for duration of time, charge for all services (records review, prescription refill, email responses, phone calls) just like lawyers, don't have non practitioners manage the firm, don't accept insurance, don't treat chronic pain, don't write for chronic benzos, don't write for stimulants. Some doctors have started practices like I have just described. They call the Direct Primary Care Model.  Send the benzo and stimulant seeks to Psych. Send to opioid seeker to Pain management. Get back to practicing medicine.

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Heeee heeee funny you ask

 

Was at a high volume practice earlier---- left after 30 patient days, and 84k per year..... grossed 84k and got a $500 christmass. Bonus when I brought in just under 300k to practice..... up and left when ownership was not ever going to happen

 

Opened my own practice - realized it is darn hard to run a profitable practice - gross about 200k, take home about 1/2 that - but to much time working

 

So off to a state job to work a defined schedule (took a doc slot and pay) and now I run my own deal with a medical director that helps when asked...... these jobs are out there, just have to look and be ready to jump!!!!

 

I now have an institution which I am pretty much solely responsible for. Life is good.

was that 84k before or after taxes?  What decade and what state were you in?

 

how do you "run your own deal" in a state job.  I understand most state workers are payed better and have better benefits and hours than comparable jobs in the private sector.  But what exactly is your job?  Do you work for the prisons?

 

 

by the way, this thread is making me question my life decisions.....       -_-

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was that 84k before or after taxes?  What decade and what state were you in?

 

how do you "run your own deal" in a state job.  I understand most state workers are payed better and have better benefits and hours than comparable jobs in the private sector.  But what exactly is your job?  Do you work for the prisons?

 

 

by the way, this thread is making me question my life decisions.....       -_-

 

 

84k salary - mass   a few years ago

 

I am responsible for a clinic and health care in a facility.  Get full bennies, and a pension!  no to prison, yes to correctional facility with a very supportive management (paramilitary, self insured, challenging practice environment(but I like it))

 

no insurance companies

no prior auths

no ICD10

no meaningless use

no no shows

people actually want to see me or the sign a refusal

 

practicing medicine and loving it   

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50% of the FP I did was somehow related to Anxiety/Depression.  It was just defeating....I like UC much better.  Treat'm and street'm.  After they come back for the 3rd time in FP for the same thing...then what?  I just found it very unrewarding.

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Over 85% of all psychiatric drugs are done from a PCP point of care. 

With so few psychiatrists and counselors and poor insurance coverage and patient unwillingness, it can really wear you down.

Something like 65% of all patients carry a psychiatric diagnosis.

 

It is a big load to try to carry as a PCP in FP or even IM.

There is no magic pill and that's what folks want.

Counselors are hard to find sometimes and patients won't spend copays on that or it isn't covered or there is  30% coinsurance, etc etc.

 

So, again, if the practice was limited to about 16 a day and I had support staff of adequate training and licensure - I could handle it without becoming a psych patient myself. 

 

Alas, that doesn't exist.

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There are so few primary care head shrinkers where I work that any time you consulted them for something, you could only consult them for a diagnosis - they tell you what was wrong and how best to manage it, fire off a note back to you +/- a prescription, that they'd expect you to manage (hmmm - thought they were supposed to be the brain drug experts, not me, but I digress) everything.  As noted, ~ 65% of all patients have a primary psych diagnosis that has to be ether managed by as well as their other health issues, or at least kept on top of.  Downside is that, especially with PD's, everything eventually will revolve around that Dx.  Fact is though, if I wanted to become a shrink, I'd have gone into head shrinking - this isn't something that should be dumped back onto the primary care provider, as if the person is in to see you for their psych issue, they take up time...and even if they aren't, odds are that it'll creep back into whatever brought them there in the first place.  Lose/lose for you and whoever is up next in your appointment list, especially if you're fee for service.

 

SK

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What are some of the procedures one would do in primary care?

 

what are some similarities and obvious differences in the daily work of urgent care vs primary care?

 

Lesion removals, skin biopsies, toenail removals, lacerations, burns, animal bites, splinting, etc.

 

Not much. Urgent care is all walk-in and you dont have an "inbox"; that is, a list of labs to f/u on and patient callbacks, emails, etc. The acuity in urgent care is probably slightly higher, but most people just use urgent care as a pop-off valve when they cant get into see their PCP. People walk in to our clinic all the time despite the big red sign that says "no emergency services." The main difference is I have a schedule of patients for the day, but again, anyone can walk in and jump into an open slot or walk in 5 minutes before closing and I have to see them. 

 

If it were up to me I'd see injuries all day. You can seldom do anything for sick visits, and chronic conditions are just that---chronic. There is no solution, only symptom mitigation. People expect you to have all the answers and to make them better. But half the time there is no answer. And aside from the very few people who are actually self-motivated, I'm not going to give them a pep talk and outline what they need to do to get healthy. They dont want to hear it, they just want you to fix it.

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Over 85% of all psychiatric drugs are done from a PCP point of care. 

With so few psychiatrists and counselors and poor insurance coverage and patient unwillingness, it can really wear you down.

Something like 65% of all patients carry a psychiatric diagnosis.

 

It is a big load to try to carry as a PCP in FP or even IM.

There is no magic pill and that's what folks want.

Counselors are hard to find sometimes and patients won't spend copays on that or it isn't covered or there is  30% coinsurance, etc etc.

 

So, again, if the practice was limited to about 16 a day and I had support staff of adequate training and licensure - I could handle it without becoming a psych patient myself. 

 

Alas, that doesn't exist.

 

 

Exactly, and that was my point.  Over 50% of my practice involved some form of psych issue and I was given about 7 min per patient and in some cases less then that (double booked).  I really felt that I was doing those patients a disservice.  Hence, I left Family Practice.

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