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The Family Doctor

The number of primary care physicians in the US today is dwindling. Nearly a third of the population lacks access to primary care and those numbers are only going to rise – a shortage of more than 52,000 primary care physicians is anticipated by 2025.

I spoke with Dr. E, a primary care doctor who has been in practice for about 25 years in Rhode Island about the changes he’s seen in adult primary care.

C: We all tend to think that a family doctor and a PCP (primary care physician) are the same thing. But there’s a difference, isn’t there?

Dr. E: Family doctors specialize in everything from pediatrics to adult medicine to obstetrics. A PCP for kids is a pediatrician, and for pregnancies/women’s care, OB/GYN. 

Most adult PCP’s like myself refer to ourselves as general internists. Like family doctors, we have long term relationships with patients, but we only care for adults, no pregnancies or pediatrics. Having a longer-term working relationship with patients is kind of cool.

PCP is a term the insurance companies invented, or even more degrading, “provider”. Both terms downplay our professionalism, and equate us with widget producers. 

C: Why did you choose internal medicine as a specialty?

Dr. E: I liked the variety, and I enjoyed diagnosing. It was something I felt I was good at.

C: After school, did you open your own office??

Dr. E: When I started out, I joined a group of about five5 primary care physicians. I’m with a larger group now.

No one can open their own office anymore. You can join a hospital or clinic or you make zero in your first year and get burned out. Insurance companies pretty much demand that doctors become part of a network.  

C: How much influence do insurance companies have in shaping the way that medicine is practiced today?

Dr. E: As far as policies and expectations, doctors are powerless.  The insurance companies and Federal government are telling us to do a few narrow tasks and calling this “quality”, but I see it as more of a marketing tool and a bureaucracy trying to justify its position than anything else.

To me, being a good doctor has to do with how well you listen and ask questions, and how well you address patients’ problems from their perspective and, more objectively, doing the right thing medically. Think about what you want and expect in a physician.

C: The pandemic made some pretty drastic changes in health care. Have there been any permanent changes?

Dr. E: Telehealth and virtual medicine became accepted and reimbursed. That practice has remained. For anyone with respiratory symptoms, I continue to wear an N95 mask and require masks for patients, though now I tend to take care of these patients on the phone.

C: Let’s talk about the shortage of PCPs in RI. I know people who find it impossible to get appointments, sometimes waiting several months to get in. What’s going on?

Dr. E: To start with, primary care physicians in RI are underpaid so the groups in RI are unable to find physicians. All you have to do is walk over the border and you’ll make $40K more in starting salary. 

I’ll put it this way – usually we have grads from RI Hospital apply to join our medical group. For the past ten years no one from RI Hospital has joined our group. They’ve all gone out of state.

C: Isn’t being underpaid one of the biggest problems behind the general shortage of PCPs?

Dr. E: It’s one reason. Compared to what specialists make, internal medicine pays half or less.

But it’s not just that. There are endless bureaucratic hassles. Computers are not user friendly and half our time revolves around that. Computers make our lives miserable. Also, they all too often don’t interact from one system to another, so often I don’t know what happened with a patient outside my office.

There’s also a shortage of specialists in RI, and that makes everyone’s life difficult. It is very stressful for me to be responsible for a sick patient whose problems are beyond my ability to help them.

C: I always just assumed that any specialist I saw would send my PCP the results of my tests – but unless you ask, they don’t, and even then it’s not guaranteed. 

What advice would you give students who have graduated from medical school and are considering specialties? Would you recommend internal medicine in a medical office here?

Dr. E No.

C: Have you thought about changing jobs?

Dr. E: There’s a tremendous amount of red tape in any job change. It takes 4 to 5 months minimum to go through all the paperwork for licensing, registering with the insurance companies, malpractice insurance, etc. Besides – the whole point of primary care is the long term relationship. That can take 5 to 7 years to develop.

C: RI is fortunate to have you stay. Thanks, Dr. E!