Are Primary-Care Doctors Going the Way of the Dodo?

The problem of inadequate medicare reimbursement is just one more way Capps has failed us--by not fighting for more medicare dollars in this area. She's a nurse who should understand the system better! This is a very good article which points out the dangers of government healthcare (ie, waiting months and months for inadequate medicare reimbursements,) The REFORM we need is insurance sold across state lines plus HSAs. That way, a patient can pay for doctor vistis,either because they have a competitive plan, or their HSA saves them enogh money that they can pay for "maintenance visits."

It's appalling that doctors, who go to school for long years and rack up huge debts are so poorly "reimbursed." No wonder there's a shortage of medical students choosing to go into primary care. This is government's dirty secret and everytime you hear Medicare is working fine yell arrggghhhhh! It's driving THESE good doctors out of busines and out of our town.

THESE are the issues we should be discussing vis a vis health care "reform." A government option that will work as poorly as medicare (does not.) Most doctors I interview say reform is needed. But not a public option (ahem) and not these current reform bills.

Private practice docs are not the only ones having trouble making it. At Sansum, primary care physicians are expected to serve something like 3000 patients and they are getting burned out from the heavy case load and the bureaucratic insurance paperwork load that goes with it. Then they leave and hope to make it in private practice, where they can actually get to know their patients. It's discouraging to learn that the success rate is so low.

My employer provides HMO-type insurance that requires me to stay in-network, i.e. Sansum, and every time I find a doctor I like, they leave after a couple of years. Two of these were Anna Hayes and Anne White, mentioned in this article. Now Eric Trautwein, the best doc I've ever had, is also about to leave Sansum for private practice. Most of his clients who can't go out of network will have little choice of new physicians, other than his replacement, since few Sansum docs are accepting new patients.

At least I'm one of the lucky ones who has insurance, but the present medical system controlled by for-profit insurance companies is not meeting our needs.

This article shows the problem of healthcare being more of a symptom, than a disease.

The underlying issues seem to mired in the same muck that drags down most of the middle-to-lower classes--the increasing cost of living, without regard to its effect on the "poverty line". Basically, as all of life's incidental costs increase, the amount of "disposable income" decreases, and it eventually eats enough that "required (non-disposable) income" is not enough.

Things like increased (malpractice) insurance cost and rent at the top end, and things like the increasing cost of fuel in our country at the bottom, are taking more and more of the US paycheck than they should. Insurance has gone from a good idea to basically a scam industry, rent increases at the whim of the person who was lucky enough to be able to own the property, and fuel costs are an example of a domino-like chain of increasing costs.

The overall point is, that GP doctors, being lower-paid than specialists, fall into the middle-class, and every day that the cost of living increases, they slip down closer to a lower economic class. Even the higher paid are not immune to this effect, but they currently have enough monetary reserve to ignore it for now. There are, however, more people each day, who have managed to increase that economic gap (the *mega*-rich), so that they are *virtually* immune--having enough that they would not be able to out-spend themselves within their lifetime, barring a "fatal" turn of bad luck, or bad choices.

To bring it back to the doctor/heathcare argument, if it were possible for cashflow to be naturally managed, then these doctors could afford to live and work without the ridiculous pressures of having to "make the bottom line", and the practice of medicine would work better for all of us.

The problem of declining wages and salaries is universal across the US, and it is especially devastating when our best educated and highest skilled people are reimbursed so poorly. But we have made a conscious decision to join the third world in the interests of "diversity" and the Green Church, and now we must accept third-world wages as a consequence.

Thanks for writing a very informative article Isabelle. I have fond memories of the excellent GP's who took care of me when I was a kid growing up here in town - Dr. John Cooper and his partner Dr. Holderman, and later on, Dr. Jerome Kay. In those days, I recall appointments could be had easily and the waiting room wasn't chock full of patients in a cattle queue.

Well-said Isabelle Walker! Finally a journalist who understands what primary care physicians are facing and how this affects the people of Santa Barbara and the nation.

Health insurance at its inception around WWII was meant to cover a catastrophic, potentially bankrupting illness or injury. We paid a little for it each year and hoped that we'd never have to use it. We don't expect homeowner's insurance to pay for a bathroom redo or paint for the house and car insurance doesn't pay for oil changes or new tires. It's there for a major event. We pay out-of-pocket for predictable maintenance expenses for everything else in our lives.

Health care insurance has become the equivalent of prepaid health car, and this is an inefficient way to pay for predictable health maintenance costs. During WWII when salaries were frozen, companies rewarded their workers by having health insurance cover more and more small, predictable, health care expenses. People have become accustomed to the best care that other people's money can buy. Many expect employers to pay for health insurance and we're all out of touch with how much it costs to run a medical practice, obtain medications or tests.

Health care is goods and services delivered by highly trained and experienced physicians. No one has a right to the goods and services of others without some sort of payment to the person providing this valuable service. Yet physicians are told by insurance companies how much they can be “reimbursed” for their services. Payment hasn't kept up with inflation and we work more and make less than we did twenty years ago in this system. No one wants to go into primary care anymore. The doctor shortage is real. Health insurance for all is great as long as there is someone to provide the health care for those who are insured. .

The solution is consumer-driven, patient centered care. Health care has been conflated with health insurance when they are not the same. Health care will thrive and patients will be satisfied when they can choose their physicians, make decisions together with the help of their personal doctors and fees are transparent to the consumer.

Get an HSA (Health Savings Account), which is tax advantaged and yours to keep towards retirement savings or use for healthcare. Get a high deductible plan so that you are covered for something major. Pay transparent reasonable fees at the time of service for predictable health care needs, (Pap smears, cholesterol and diabetes screening, colds and flu). Ask for medications from Ralph's $4 for 30-day supply medications. Get the personalized care and service you deserve from a doctor, but be willing to compensate the doctor fairly for his/her time, knowledge and expertise.

Questions? Comments? Please call me, Beverly D. Brott, MD (Board Certified Internist, general care, womens' health)

"The problem of inadequate medicare reimbursement is just one more way Capps has failed us--by not fighting for more medicare dollars in this area ..."
---- maximum

That is a completely false statement. Capps has indeed been fighting to get the medicare payments we deserve in this area. In fact, she co-authored a bill to fix this problem in June:

http://www.house.gov/list/speech/ca23_ca...

And this was reported by the Indy as well:

http://www.independent.com/news/2009/jun...

It is sad that a primary care physician, the gatekeeper to access any and all aspects into the healthcare system, is not only dying but new enrollment is also stifled. The reimbursement model has put the physician into a non-recoverable situation on their own.
SOLUTION, see if the concierge model is right for you. Your reimbursement model patients are seen by an NP or a PA and you select 300-500 concierge patients, on an average which is typically 10-20% of your patient panel, and enjoy quality patient care, better hours and additional incremental income into the practice of $350,000 to $ 590,000. After all isn't haveing a quality healthcare option worth giving up a Starbucks a day?

The concierge model is not the solution to affordable, available health care for all. It may be a good fit for some but we need a viable way to have affordable, personalized care for everyone.

I'd rather pay $60 for an office visit if I need to be seen then pay $1,500 per year to be in a practice plus then pay for services as I need them.

Medical care is between the patient and the doctor. Get the third party insurance intrusion out of that relationship and health care will be more affordable. Doctors won't have to spend on having billing personnel and worry about accounts receivable and tracking all of those details. It's win-win for the doctors and the patients.

"Get an HSA (Health Savings Account), which is tax advantaged and yours to keep towards retirement savings or use for healthcare. Get a high deductible plan so that you are covered for something major ..."
---- BeverlyBrottMD

My employer in Goleta started offering an HSA combined with a high-deductible plan two years ago (a corporate contribution is made into the HSA annually). In addition, we have the typical PPO choices at varying deductible levels.

While HSA's can be beneficial for some people, I would not make a blanket statement as Dr. Brott has. HSA's can be beneficial for younger people or those who have few medical issues. But for those who don't fall in that category, its not necessarily the optimal choice. A casual poll of my co-workers indicated that many of the younger employees favored the HSA while those with young children or older employees favored the PPO.

This begs the question ... if HSA's are of most benefit to healthier people and/or those that make enough money to reap the tax benefits, then why make them a centerpiece of health care? Its an interesting question and those issues have been raised here:

http://en.wikipedia.org/wiki/Health_savi...

Interestingly, some of my co-workers were intererested in using their HSA's as a tax shelter because health expenditures out of the HSA were (at that time) not monitored carefully. Not sure if that's the case anymore.

The Mayo Clinic has a list of pro's and con's to consider:

http://www.mayoclinic.com/health/health-...

As long as one is not enrolled in Medicare, an individual can put $3,000 per year into an HSA. After age 55, an additional $1,000 per year can be contributed. It is yours forever; it's not "use it or lose it" like some medical savings accounts used to be. The amount one can contribute goes up each year.

This money can be used for most medical and dental expenses including acupuncture, massage, fitness consultations, over-the-counter medications, eyeglasses, contacts, dental cleanings, Lasik surgery and long term care expenses and insurance and much more. You've got a check book or a debit card and the HSA accounts earn interest.

The consumer has total control about whether to spend the money or save it. It is of benefit to everyone, not just young healthy people. It should be made available to Medicare people too. They have out-of-pocket expenses.

Would you rather pay $500 a month for an insurance policy with a $250 deductible and no HSA or would you rather pay $150 a month for a high deductible health plan and a $3500 deductible? With the latter, you're covered for a serious illness and you've got $350 per month to put into your HSA...tax free. It's yours. If you need to use it you've got it and if you don't use it it keeps adding up like a 401K.

Here's how a high deductible health plan coupled with an HSA helps someone with chronic medical conditions:

Under a traditional health plan s/he pays $500 per month, has a $250 deductible, has a $20 co-pay per doctor's office visit and pays %20 of prescription medications cost. Let's say s/he has rheumatoid arthritis and is getting expensive immune modulating medication therapy every month.

So after $250 out-of-pocket to meet the deductible s/he pays a monthly co-pay of $20 for each office visit ($240 per year) and pays 20% of the expensive medication each month. These medications can cost thousands but for this example we'll say $2,000. Twenty % of $2,000 times twelve months is $4,800.

Insurance premium of $500/month is $6,000 per year
Deductible is $250 per year
Co-pays are $240/year
20% of medication fees is $4,800 per year.

Not counting the premium this person is paying $5,290 out-of-pocket per year.

With a high deductible health plan that has lower premiums and a deductible of $3,500 and an HSA, his /her maximum out of pocket (not including premium) is $3,500. Once that's met there is no charge to the patient for medications or doctor's visits or health care expenses.

The HSA is the better deal.

East Beach, you must not be in the real world here... I can assure you local docs do NOT feel it's just to be reimbursed less than are other docs in other areas... I realize you don't have much to talk about but try finding something more than Capps' defenses. The woman is failing us. Period.

Any sane person reviewing the above comments should see how ridiculous and un-workable are our current methods for financing healthcare! I've used HSAs over the past 5 years and they've just added yet another layer of denials, paperwork, delayed payments and extra costs to a third-party administrator.

The truth is that most Americans, including doctors & nurses, want a nationalized healthcare system like Canada & Great Britain. Reform is blocked by the special interests and profit-making corporations that benefit from our misery. Thank you to this excellent journalist for a fair and balanced article about the consequences that have resulted in Santa Barbara.

If Primary Care Goes the Way of the Dodo, We’re All in a Lot of Doodoo.

Thank you for an interesting and important article. If we want a healthy healthcare system (one that provides high quality and cost effective health care), we need a healthy primary care system. If we don’t improve the reimbursement to primary care, medical students will continue avoiding it in droves. Only 2% planning to go into primary care… it should be at least 30-40%.
More info here: http://www.psychologytoday.com/blog/stre...

(As for concierge care being the solution… it might be good for people that can afford it. However, if we have trouble figuring out solutions to universal health care and the primary care shortage now, just imagine the problem if every primary care doctor became a concierge doctor… each physician dropping 2/3 of his or her patients).

sbdoc gets it. When you go to school for YEARS (far longer than most people will ever have the discipline to) you DESERVE compensation. When you literally work in an arena of life and death, you DESERVE compensation.

There's a running theme in these comments, Beverly/Arnie/sbdoc - and it doesn't read to me like "for national healthcare." Docs already know that Medicare isn't working. Heaven forbid national "heatlh care."

Heaven help us if America doesn't wake up. Prayers may be all you get.

Excellent article. I am a Family Physician in Santa Barbara borrowing each month to make ends meet. Presently I can no longer obtain any further credit. I borrow because I do not get paid when services are rendered.
Payment is being delayed by all payers. The Federal Gov, Medicare, and all private insurances play their games to delay or deny payment. There are frequent denial due to the complexity of the billing system. Multiple physician IDs such as license, NPI, DEA, Tax ID...Multiple codes must be in place and correctly aligned, ( CPT, ICD, modifiers...). Our politicians need to address these complexities and simplify the process. What I foresee is the end of the Family Physician. Our health care will be serviced by none physician practitioner with a specialty referral network within a large complex clinic environment.

Everyone is missing the bigger picture. Doctors are being forced out of business because lots of people are losing their jobs and health insurance, and the insurers are trying to keep their profits up by delaying payments. Unless we address the underlying issue of a Depression-level economy, the health care system will collapse. Here's a good summary of how close we are to a 1930s catastrophe

"Is Unemployment the Worst Since the Great Depression?"

http://news.yahoo.com/s/usnews/20090827/...

The first step to fixing things is to stop voting for politicians who kill jobs. Don't automatically vote for Lois Capp's daughter when the Progressive machine tries to install her in the House. Don't just vote for something because they have a "D" beside their name, or because they mouth platitudes about the environment. Think about how California's regulatory and tax environment is eliminating our manufacturing base.

A very nice, balanced overview of the current situation by
Ms Walker. As a longtime SB community primary care doc, I have been observing this situation ferment and worsen in recent years. The author touches on Cottage Health System's perspective. CHS seems to think we have a primary care physician shortage. Perhaps they do at Sansum Clinic, but I do not believe that to be the case in the community. Most of my colleagues in family practice, pediatrics or internal medicine can accomodate new patients in a very timely manner. The problem is more about lower reimbursements and increasing costs of being in practice. Rent, medical and office supplies, payroll, utilities, insurance and other service costs (eg, billing service, answering service, bank fees, etc) continue to go up while insurance companies are reimbursing less and sending out payments more slowly. Not a good equation for the business side of a medical practice. Sure, concierge practice is a potential solution for some, but many of us who chose fp, im or peds are not comfortable with excluding patients from our practices because they cannot pay the annual fee.

I have friends/colleagues in primary care practices in other communites. Their local health care systems seem to be far more proactive,tuned in to the situation, and willing to offer assistance (within the legal parameters) than my perception of Cottage Health System. My impression is Cottage seems to have been more preoccupied with what one colleague has referred to as "empire building". In review, over recent years CHS has purchased GVCH; Santa Ynez Valley Hospital; St Francis Medical Center; The Rehabilition Institue; and most recently taken over PDL laboratory. As stated in the article they have been working on merging with Sansum Medical Clinic as well. They have also been preoccupied with their building projects at the hospital campuses. But during this time I feel ,they have neglected the community based primary care providers. And this perception is reinforced by CHS's recent large rent increase at their two medical office buildings near GVCH. Many of the tenents in those buildings are in the primary care specialties. Yes, they have had a couple of recent meetings of the Physician Hospital Allignment Workgroup, headed by Dr Allyn (for whom I have great professional respect.). But my impression there is it is more about a relationship with Sansum, rather than the community based pcp's.

Another aspect of this problem is the effect on the other specialties. As community family docs disappear, so do their referrals to the other specialists and subspecialists. So ultimately this problem also becomes a problem for them as well.

I do not know what the ultimate solution is. I am hopeful but do not expect CHS to become more active in a solution. Even though I do not subscibe to a primary care physician shortage in SB now, if things do not change we are clearly headed in that direction.

One step in the right direction would be a single-payer healthcare financing plan. This will not immediately resolve the shortage of primary-care providers, but it has the following advantages:
1) malpractice premiums would be a fraction of what they are currently, as healthcare costs for the victim would no longer be part of the award
2) billing would be standardized and very efficient. Currently it is estimated to take 70% of a paper pusher for each practicing doctor, for most primary-care physicians this means them and that time wasted dealing with our fragmented and reluctant to pay private/public system is healthcare not delivered (through no fault of their own).
To the degree that we can lessen the financial burden for our primary care physicians we will see an increase in their numbers. Having durable relationships with these providers without financial barriers is key to a healthier population, and only achievable with a single-payer (or single-payer like) plan.

tegrat: excuse me? How would your fantasy work? As "efficiently" as Medicare? (see doctors posts above--get the POINT of the article...)

Sigh...

Tegrat does make some good points about advantages of single payer healthplans. And maximum, I don't know where you get your information from, but Medicare has been way more efficient a program than some of the private insurance carriers! In fact, we are looking into eliminating some private carriers from our roster in favor of Medicare. No, Medicare is not perfect--but it is way ahead of some plans that give us the Blues....

http://www.dailyfinance.com/2009/08/25/t...

Medicare is not sustainable and due to go bankrupt soon. Right now, 4 people in the workforce are what is sustaining the cost of each Medicare beneficiary.

The Baby Boomers are about to hit 65 and retire. Then there will be two or less people in the workforce per each beneficiary. Boomers will be demanding, entitled people for the most part.

Medicare will not survivie. It's already one of the lowest payors in the country and many physicians have opted out of the program. For those that remain in it, we are subject to raids (audits) where our charting and billing is scrutinized and we stand the risk of being asked to repay thousands that were supposedly overpaid to physcians, and paying fines. What sane doctor would continue to want to participate in Medicare?

Thank you, Independent, for a terrific forum for discussion of an excellent article!
Let's not forget that many people do NOT have a job and, therefore, do not have access to job-based HSA nor other employer-based medical coverage. Average folks, jobless or not, cannot afford the concierge model.
Paperwork for a multitude of health plans--both private and government--costs doctors money and time.
Everything started to go downhill in the 1980s when Managed Health Care came between doctors and their patients. More and more third parties, including drug companies, have continued to complicate this relationship.
I'd like to see a brand new system that is based on a doctor/patient relationship rather than one run by corporations. Tax payers (especially those obscenely overpaid corporate managers) need to support a government system that provides services for citizens in need: veterans of our ongoing wars who are returning home with multiple physical and mental injuries, persons who have chronic illnesses such as multiple sclerosis, and those who have lost their jobs.

Another good article on how government UNDER reimbursement affects family medicine doctors (and ultimately US):

http://www.venturacountystar.com/news/20...

For the physicians in this thread, a few side questions ...

What does it take to become part of a provider network (as in my Blue Cross PPO)? Can any physician join or is membership limited based on some criteria? Once a physician joins a network, are they agreeing to accept a payment schedule set by the PPO organization? If so, do PPO's pay considerably better for services than others (e.g. Medicare)? Do insurance companies ever try to put the squeeze on PPO payments?

"Another good article on how government UNDER reimbursement affects family medicine doctors (and ultimately US) ..."
--- maximum

Nowhere in that article are there *any* references to government reimbursement!

The article is entitled "Local doctors are opting out of insurance-based medicine". It refers to underpayments and dictation of treatment by *insurance* companies - not the government.

It appears that the biggest obstacle we continue to face in the health care reform debate is how to respectfully discuss the issues without necessarily agreeing. It seems that most people agree that the current health care system is broken and unsustainable. It therefore seems reasonable to suggest that the debate should be about the terms of reform. There are, however, several contributors to this site (and others) who seem to consistently struggle with the principles of respectful discourse which, in my opinion, detracts from the debate. It will be difficult to achieve health care reform on the national level if we cannot have a civil discussion in this small community based forum.

Eastbeach asks:

"Once a physician joins a network, are they agreeing to accept a payment schedule set by the PPO organization?"

Yes, once physicians have signed a contract with an insurance agency and joined a network, physicians will only be paid per the "fee schedule" of the PPO insurance company. And the "reimbursement" comes 3 to 5 months later too. There is no negotiation.

" If so, do PPO's pay considerably better for services than others (e.g. Medicare)?"

No. Insurance companies all seem to use Medicare reimbursement amounts as guidelines.

What other business or service people are "reimbursed" by a third party, months later for services or goods already delivered? If I call the plumber, I pay him the agreed upon price at the time of service. If I need a lawyer, I pay him/her the fees directly.

Thanks Dr. Brott. I've heard of "Net 30" terms, but that's usually in units of "days"!

A friend of mine just got out of Cottage after emergency surgery for a broken neck (two places!). The surgeons did a great job and saved his life. I'm told the insurance representative who later visited him was a "green" low-level employee who walked him through a simple Q&A checklist. At the end, she checked the "outpatient" box. This, after his doctors had recommended in-patient rehab at the Rehabilitation Institute.

One can debate whether in or out patient would have been more effective, but the insurance rep seemed to quickly make a decision benefiting the insurance company.

For over two decades we have had whom we believe to be the best primary care M.D. in town. If he left I would seriously consider the route of alternative medicine. His book "Evolution RX " explains the simple common sense of how we can keep fit and stay that way.

It is sad to see so many primary-care docs cannot make a go of it in Santa Barbara County. But.....

$150,000+ for a self-employed professional isn't starvation; it is on a par with firefighters,nurses with overtime, and other public employees (taking into consideration pensions, medical insurance, and other fringe benefits). One can wonder why a nurse can earn 6 figures with minimal call and overtime (including benefits) after 2 years of community college, but I digress.

Yes, the PCP spent an extra 7 years (4 years med school + 3 years residency) in training, but the residency years do provide a living income ($35000).

As the article indicated, the major problem is that PCP's get so much less than their interventionist colleagues. A radiologist makes 3-4 times that of a poor pediatrician. Yep - a radiologist - who works set hours 8-5 (if that) and never has primary care for a patient, earns $400,000+ with 12 weeks vacation.

With numbers likie that, only the bottom-of-the-heap med students would go into primary care. Basically, PCP (and PCP-like specialties such as Psych or OB/GYN) are non-competitive residency matches. Last year, the toughest residencies to get into were Ortho, Radiology, and Dermatology. Even General Surgery, which used to be a glamorous, competitive spot, is now a "gimme"match.

Vast amounts of medical literature indicate that much of specialist intervention is useless or harmful - spinal fusions for chronic back pain, coronary stents for stable angina, prostate cancer screening, breast cancer screening - yet patients and physicians march ahead. We (as a society) insist on it, because by and large we don't pay for it directly, and we can't stand the thought of waiting and watching. Oh, and the interventionalist gets pay big bucks for it.

One easy example: Medicare pays a cardiologist to put in a stent 20 times what it pays a PCP to put the same patient on medical therapy - with no difference in results for stable angina. The patient often thinks that the cardiologist saved his life. He may have (doubtful), but the medical therapy would have been just as efficacious at a fraction of the price. However, Americans will never accept this, and so we doomed to spiral of increasing costs and zero marginal benefit until we go completely bankrupt.

A few thoughts from a classmate of Anne White, one of the docs featured in the excellent article by Isabelle Walker, about some issues faced by many physicians, especially those starting out.
BillT mentions that $150,000 for a self-employed professional isn’t starvation (not sure where that amt comes from; salaries noted in the article are <$90K, except the doc who took out a bank loan to pay herself $140K gross). In any case, drs are faced with a lot expenses that other occupations don’t have, including recurring fees for med malpractice (in my case, $6,000/yr; more for other specialties), med licensing, hospital credentialing, DEA certification, continuing med education (all required to practice medicine) and maintenance of board certification, repayment of student loans, and prof society memberships. This does not include any of the expenses involved in running the business, and are in addition to basic living expenses and health ins, income taxes, and (hah!) saving for retirement. Firefighters and most nurses have their profession-related fees, health ins, and some kind of retirement fund covered, and no overhead. BillT is correct in saying it is “only” for the 4 years of med school that there is no salary, and that residency pays a living income. – But only enough to cover basic living expenses, and not to repay the loans, which continue to accrue interest unless they are one of the few with interest subsidies.
To put a face on this, I (like many other non-procedure practicing docs) am in a specialty that pays about the same as primary care, and has had repeated significant cuts in reimbursement over the past few years. So I had 3 more years of training, during which despite a frugal lifestyle, I could afford to make only occasional interest pmts on my student loans, with unpd interest adding to the principal of the loans. I was in training with foreign med graduates from India, Canada, and Europe, among other places, none of whom owe a cent for their medical education – it was free. Upon finishing my training, the cost for repayment of my loans is over $2,000/month. I am driving a 14 year-old car with 150,000 miles on it. Last year, I had to take out a “loan” (special time-limited low interest cash advance from a credit card co.) to pay my income taxes. The income tax deduction for student loans is laughable, with a max deductible amt of $2500 for those with incomes <$65,000. The rest is paid with after-tax $, which makes those loans very expensive, indeed.
Not to belabor the point, but only to put into perspective and real terms the plight of many physicians who are trying to make a living in their chosen profession. My desire to study medicine was to do something interesting and useful with my life, which I am doing. But from a financial standpoint things are very rocky, for myself and many of my colleague-friends, with many of us on the verge of bankruptcy or barely getting by on our own personal ponzi schemes.

I really sympathize with the financial situation of primary-care docs. Let me clarify:

The $150,000 figure is a national average, and some of you will make less. Allowing for professional expenses of malpractice insurance (<10K for a PCP), DEA licence, CME's, that is still $130,000. Allow a student loan of $200,000 amortized over ten years. That still ends up $100,000 a year for a self-employed income.

Yes, after insurance, pension, and what-nots ,you will make less than a nurse or a prison guard, but it is not starvation wages.

Currently, the best of both worlds is to get a job as California prison psychiatrist.