When students are deciding on specialties they’d like to pursue, they often talk about “The ROAD” or “The ROAD to Happiness” also known as the fields of Radiology, Opthalmology, Anesthesia, or Dermatology.
Medical and PA students are not known for being stupid. They’re well aware of the mountainous debt and years of sacrifice it takes to become an MD or a PA. So it’s no surprise when the majority of new grads gravitate to the higher-paying and supposedly more respected subspecialties.
What makes The ROAD so popular?
Income, for one. Medscape’s 2020 Physician Salary Report has radiologists leading the ROAD bringing in an average of $427k a year. Ophthalmologists bring up the rear at $378k. Now, this isn’t to say that physicians on The ROAD make the most money. No, that honor went to orthopedic surgeons with an average annual salary of $511k. Radiologists and ophthalmologists came in 5th and 10th overall.
Job satisfaction on The ROAD is also important. For example, of over 25 medical specialties represented, ophthalmologists had the least amount of their day spent on paperwork and administrative tasks at 9.8 hrs per week. In fact, ROAD physicians represent 4 of the 6 specialists with the least amount of busywork.
Job satisfaction on the ROAD is so good, in fact, that 89%-95% say they would choose their specialty again if given the opportunity. Compare that to internists at 66%–that’s not nothin’.
The ROAD to Happiness Passes Through Primary Care
It’s no secret that we are fans of primary care at The PA Doctor. In fact, we think PAs were born for primary care and are vastly underutilized overall, especially PAs with doctoral training in primary care. But at our core, we’re just big fans of primary care and being medical generalists.
The American Academy of Family Physicians (AAFP) reports that the “specialty of family medicine was created in 1969 to fulfill the generalist function in medicine, which suffered from the growth of subspecialization after World War II.” This is especially interesting given that the first class of PAs graduated from Duke University just two years prior.
The AAFP goes on to say that family medicine specialists, “provide personal, front-line medical care to people of all socioeconomic strata and in all regions of the United States.” Front-line medical care means that primary care providers (PCPs) are often the first to diagnose and treat everything from acute illness to terminal chronic disease.
PCPs, including both physicians and PAs, are the first and principal point of contact for concerns big and small. While some PCPs are so overwhelmed that they resort to referring out any unusual or complicated case, it is not a requirement and sometimes it leads to fragmented care and worse outcomes. In fact, a 2005 study suggests that well over 100,000 deaths a year could be averted by improving access to primary care services.
According to the Institute of Medicine, a core component of primary care is the “sustained partnership[s] with patients” and “practicing in the context of family and community”. PCPs see their patients as more than a diagnosis but the product of their surroundings, home and family life, and their personal beliefs. The PCP probably treats other members of the family and knows their situation well and how it might have evolved over time.
A Fork in The ROAD
Primary care isn’t for the weak of heart, though. Specialist physicians earn an average of $100k more per year than PCPs. Yet PCPs spend 60% more of their time doing paperwork than ROAD physicians and only 54% feel fairly compensated compared to an average of 60% of ROAD docs. Only 70% of family medicine docs would choose their specialty again compared to an average of 93% of those on the ROAD to Happiness.
But where would specialists and subspecialists be without PCPs? Many insurance companies require that a primary care provider evaluate a patient and generate a specialist referral… if appropriate. I see this on a daily basis. Well-meaning patients will make an appointment just to request a referral. Most of the time, however, I can address and resolve their concern in my own office.
It’s also not uncommon to see a patient in follow-up after a specialist consultation or hospital discharge only to have to rearrange their medication regimen or revert to a prior therapy. I also see too many specialists either offering the same treatment to everyone or turning the patient away if their particular problem appears to fall outside of their narrow scope of practice.
Now, this isn’t meant to cause offense. PCPs could never do it alone. We need those with specialized skills and focused training. I am so grateful for the surgeons, nephrologists, and others that I have on speed dial. I’m especially grateful for those who see medicine as a calling, rather than just another job.
PAs in Primary Care
Today, only one-third of PAs practice in primary care. Female, Hispanic, and older PAs are more likely to work in primary care, similar to the trend of medical students that end up becoming primary care physicians.
Up until the 1990s, most PAs practiced in primary care. As of 2010, only 30% of PAs were on the front lines with the majority now joining the ranks of secondary care. A similar proportion is found among physicians. Though designed for primary care, the same forces that weigh on primary care physicians weigh on primary care PAs.
Don’t Be a Hammer
65 million Americans live in areas where there’s a shortage of primary care providers. The total physician shortage is expected to reach 122,000 by 2032. There is more than enough work to go around and PAs are uniquely qualified for the job.
The Kaiser Commission on Medicaid and the Uninsured advocates for the increased utilization of PAs in primary care as a solution to ever-increasing shortages. A 2011 paper stated that PAs “perform as well as physicians on important clinical outcome measures, such as mortality, improvement in pathological condition, reduction of symptoms, health status, and functional status.” They also report that patients are extremely satisfied with PA-led care. Labor costs per visit are also better when care is provided by non-physicians.
In It to Pivot
Almost all PAs, regardless of where they end up practicing, are initially as generalists. This has made them especially flexible during the COVID-19 pandemic. Assuming they were laid off first…
For the benefits of higher PA utilization in both primary and secondary care to continue, they need to be able to practice at the top of their license. States across the country are starting to recognize this, but it’s not without opposition.