by Tara Weiss and Seth Cline
Monday, July 19, 2010
Don't go into family practice if you're in it for the money.
When Ted Epperly entered medical school in 1976, he did so with a scholarship from the U.S. Army. In return he committed to serving for four years in the Army after graduating from the University of Washington. It meant he wouldn't have the crippling student loans that burden many new doctors, so he was free to follow his dream of becoming a family practitioner instead of a cardiologist, the more lucrative specialty he was also considering.
"I didn't have large loans, so my choice became about what I wanted to do," he says. Today he is president of the American Academy of Family Physicians. "As I went through school I realized I loved the continuity of care that primary care physicians can offer. I could see patients through their whole lives. Since I didn't have large loans to pay, I could do what I wanted and have a calling. It became a no-brainer."
Not many doctors have that luxury, since the average medical school student owes $140,000 in loans at graduation. That's a major reason not many doctors are becoming primary care physicians: They earn the lowest salary of all physicians, according to the medical search and consulting firm Merritt Hawkins & Associates' 2010 Review of Physician Recruiting Incentives.
At $180,000 for pediatricians and $175,000 for family practitioners, primary care providers make an awful lot less than the typical orthopedic surgeon, who makes $519,000, or a urologist, who earns $400,000, according to the Merritt Hawkins data. That disparity has contributed to a serious shortage of primary care doctors. The American Medical Association predicts a shortage of 35,000 to 40,000 primary care physicians by 2025.
Why do primary care physicians make less than specialists? One reason is they simply don't bring in the same amount of revenue per doctor, according to a Merritt Hawkins survey of hospital revenues. The 114 hospitals that participated in that survey reported that primary care physicians brought in an average of $225,383 less per year than specialists, between 2002 and 2010.
One reason for that is the medical profession's fee structure. Medicare and private insurers cover medical expenses based on valuations provided by a committee of the American Medical Assocation that assigns every medical task a "relative value unit" based on the skill and expertise required to perform it. If your work as a doctor expends more relative value units, you generally end up earning more, so the committee's assessment is very important.
"The group that sets the standard for this is composed of doctors, mostly specialists," says Phil Miller, vice president of communications at Merritt Hawkins. "Some people say because this group is made up of mostly specialists, they weight their own work more." The committee doesn't rate the primary care physicians' face-to-face interactions with patients as highly as procedures that specialists perform, so primary care physicians end up earning less.
Family practitioners earned $16,000 less in 2009 than certified registered nurse anesthetists, registered nurses who have worked in the field for at least one year and then return to school for 24 to 36 months to qualify for a master's degree. That's a lot less training than the four years of medical school, one year of internship and then residency you have to go through to become a primary care physician.
"You're talking about twice as much money to be a specialist, a better perceived lifestyle and more time off," says Tommy Bohannon, senior director of development and training at Merritt Hawkins.The AMA predicts that the shortage of internists will get worse as baby boomers age and require additional medical attention.
The AMA and the American Academy of Family Physicians are discussing several possible ways of addressing the shortage. They include offering scholarships to students who go into and stay in primary care, and loan forgiveness for primary care physicians who work in underserved areas.
Epperly also suggests distributing National Institutes of Health grants, a large source of funding for public medical schools, based on how many primary care physicians the schools produce. "If your percentage of primary care physicians is low, you don't get as much of that money," he says.
There has been talk of creating more places for students in medical schools, but that would take a long time to have an effect, since those students need not just four years of medical school but also a one-year internship, about three years for a residency and maybe three to five years of regular practice before they reach their full effectiveness. As a result, Bohannon says, there can't be a real increase in supply before about 2030.
Still, getting more primary care physicians out there is crucial for improving Americans' health, Epperly says: "Studies show that if you have a regular primary care physician to go to, your health will be better and your costs will be lower, because the treatment can be preemptive. If I've cared for you for 10 years, you can call about a question and not need to come in. I connect the dots for you for your health care. That's what we're missing in our system."
1. Family Practice
Average salary, 2009-2010: $175,000
2008-2009: $173,000
2008-2009: $172,000
2006-2007: $161,000
2. Pediatrics
Average salary, 2009-2010: $180,000
2008-2009: $171,000
2008-2009: $159,000
2006-2007: $159,000
3. Internal Medicine
Average salary, 2009-2010: $191,000
2008-2009: $186,000
2008-2009: $176,000
2006-2007: $174,000
4. Family Practice with Obstetrics
Average salary, 2009-2010: $200,000
2008-2009: $184,000
2008-2009: $184,000
2006-2007: $159,000
5. Hospitalist
Average salary, 2009-2010: $208,000
2008-2009: $201,000
2008-2009: $181,000
2006-2007: $180,000
