KevinMD writes a whole lot about the “death of primary care,” why medical students aren’t choosing it (this is evidenced by the fact that most Internal Medicine residents choose to go into a sub-specialty as opposed to practice General Internal Medicine). And I hate to say it, but I’m not planning to go into primary care, either. It seems like most of the time he focuses on the money and income disparity:

While a family practice doctor often works long days and endures crammed waiting rooms for $155,000 a year, dermatologists average $197,000 — and many don’t work even five days a week.

And he’s not wrong on that end at all. Most of us are leaving med school with at least $100,000 (let’s read that again: AT LEAST ONE HUNDRED THOUSAND DOLLARS ) of debt. But for me at least, that’s not the kicker. It’s a lot of money. But so is $155,000 a year. If I practice as a doctor for the rest of my life, I’ll pay it off eventually and still live a much more comfortable life than most people.

He also focuses on the time committment: long hours, lots of paperwork, no reimbursement for making phone calls, doing workman’s comp evaluations, etc. Again, this sucks, but most jobs suck like this to some degree. I still he’s missing the keystone here. And I wasn’t sure what it was until I read this piece that he linked to, about a woman’s wonderful experience with health care when she moved to Belgium :

I was also pleasantly surprised when she offered me an appointment the next day—and I was greeted by her promptly and had an unhurried consultation without having to fill out any paperwork. Instead of endless forms, she simply listened while I talked, jotting an occasional note on her laptop.

A typical doctor’s visit always includes filling out paperwork, updating your medical history, submitting insurance information and waiting, waiting, and waiting to see the doctor, who is normally overworked and visibly frazzled by the incredible pace and hours he/she is expected to keep.

After 18 months in Belgium and multiple checkups, I have yet to fill out a single form, let alone the scads of paperwork I had to do in the US at every single visit. All of my medical tests have been given by doctors; in the US specially trained technicians or nurses administer tests and the results are reviewed by the doctor later.

My family doctor here in Belgium normally spends a half hour with me (compared to less than 10 minutes in the US). My cardiologist spends nearly an hour with me. My perception has been that the doctors here are conservative, cautious, and thorough in their approach, something I appreciate as I deal with more medical issues than ever before.

This, folks, is what we’re missing from primary care.

Look, medical students are for the most part still very optimistic, caring, no mortgage-paying people who are in this to help people, not to make buckets of money (we could have easily joined our I-banking counterparts if we wanted money). I will tell you right now, if the practice of internists (general internal medicine) consisted of 30-minute appointments where I felt like I could get to know my patients and establish a relationship with them, I would become an internist in a tachycardic heartbeat. And I know I’m not alone. We’d be banging down the doors, gunner-ing like crazy to get these positions. Even if I still had to deal with the paperwork, still had to spend more time away from my family or my hobbies, and still got paid less, I’d choose internal medicine hands down.

Because honestly, for medical students, Clinton was wrong—it’s not the taxes, it’s the lifestyle, stupid. We want to get something out of this medicine thing besides just money. We didn’t go into this to have a job, we went into it to have a profession. A calling. But if you don’t give us the option of a lifestyle where maybe you have to work a little longer, and yeah, maybe you get paid less, but the humanitarian and emotional and helping-people benefits are amazing—well, uhm, yeah, I guess I’ll just take the money like everyone else seems to be doing (or at least find another profession that offers a little more balance).

All we hear about (maybe it’s because we read too much disgruntled KevinMD) is how much malpratice costs, how we sued for anything we screw up on, how reimbursement sucks, how HMOs suck, how we have to work overtime without any pay, and by that point, the job listing doesn’t sound so great.

Not to turn all single-payer on you, and I realize this is just one woman’s story, anecdotal and all, but I honestly believe that a big part of the problem is our system. It’s so mind-numbingly complex and wasteful (administratively and diagnostically) that by tolerating the system for so long, doctors have allowed it to become 15-minute office visits with reams of paperwork. They’ve allowed it to come to the point where some people are choosing to get their care from a stranger who works at Wal-Mart or Walgreens. Again, no system is perfect, but I truly, truly believe that reforming our health care system will improve so many of these problems with primary care (and health care in general) that it seems like almost a no-brainer. Would you honestly not take a pay cut in exchange for less paperwork, less overhead, and lower malpractice premiums?

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