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Specialist Surfeit; Primary Care Paucity

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It's schadenfreude (enjoyment obtained from the troubles of others).  That's where I find myself as I observe the surfeit of specialists juxtaposed to a dearth of primary care docs.

As Dr. Pauline W. Chen said in "Where Have All the Doctors Gone?"—"I [don’t] envy Mr. Obama.... Any attempt to make health care more accessible will be doomed to failure without an adequate number of primary care physicians and a strong primary care system."

Internal medicine is one of the lowest paying post-residency choices with an average annual salary "approximately $5,000 less than the debt most med students carry upon graduation. The average radiologist salary is twice [that]” Medical students are "turned off by the possibility of caring for chronically ill patients, and the amount of red tape and paperwork general internists have to grapple with." Foreign medical graduates seek the subspecialties—no wonder!  Who is going to do the primary care grunt work?

Rubin R, New doctors avoiding most-needed, worst-paid field: general practice [Last accessed 12/8/08].


Compared to other practitioners, those of us in primary care physicians earn less, and we are are pressured more to control costs and improve quality. "With primary care attracting substantially fewer new physicians than other specialties, health systems may struggle to meet patients’ needs as older primary care physicians retire or reduce their clinical workload."

"To address these major challenges for primary care, policymakers and health care leaders have placed increasing emphasis on transforming primary care practices. These efforts have high aspirations to achieve the quadruple aim of improving health, containing costs, enhancing the experience of patients, and improving work life for primary care physicians.4 Evidence has been mixed as to whether and how new models of primary care can achieve these goals.5,6"....

"We believe that more effective coordination of financial incentives between primary care physicians and specialists will also be key as Medicare moves from volume-based fee-for-service care to new value-based payment models.9 Patient-centered medical homes can enhance primary care, but broader provider networks and organizations are needed to align financial incentives and coordinate systems that integrate ambulatory primary and specialty care with care delivered by hospitals and other providers."

John Z. Ayanian, M.D., M.P.P., and Mary Beth Hamel, M.D., M.P.H. "Transforming Primary Care — We Get What We Pay For." N Eng J Med. April 13, 2016 DOI: 10.1056/NEJMe1603778


In a fee-for-service (FFS) system, you are paid for piece-work; there patients were 63% more likely to have surgery than they would if their doctors were salaried.

Bakalar N. "Surgery or Drugs? Doctors' Pay May Influence Choice." NY Times Posted March 8, 2017.

Referring to: Nguyen LL. Smith AD, Scully RE. {Harvard}. "Provider-Induced Demand in the Treatment of Carotid Artery StenosisVariation in Treatment Decisions Between Private Sector Fee-for-Service vs Salary-Based Military Physicians." JAMA March 1, 2017