For the second panel of the resident and medical student student (RaMS) track at this past DPC Summit, I featured two physicians hired straight out of residency and titled the panel “You’re hired”. During this session, actually all the sessions, but especially this one, there were plenty of established DPC docs in the comment section pitching their practices in the hopes of attracting someone looking to work at their practice. As the interest amongst RaMS has increased, so has the growing need for more DPC docs. Practices ranging from 3 or more years have been expanding rapidly and many have found difficulty recruiting young physicians. So with the increase in learner interest in DPC, why has it been so hard to hire newly minted physicians?
The first, most prominent, and most obvious reason is purely financial. Medical students are graduating with six figures of debt, going upwards of half a million for some. By the end of residency, they have barely made a dent if any to the principal. One of the more common arrangements for those hiring is an “eat what you kill” model, meaning pay goes up with the number of patients. Most practices have patients on waiting lists, but even so, to onboard and see all the new patients takes time and no one can get to 300-400 patients in a month. In this model, new hires are encouraged to do what many of the owners and founders did, which is to work some side hustle like in the emergency room or urgent care. New docs looking to be hired generally just want one job, and they want that job to pay well. Neither of those criteria are met in the “eat what you kill” model. For the few practices with the ability to offer full pay and benefits, the reasoning becomes a little more unclear. It may just be the locale is not attractive enough or the hospital systems still pay better. Currently, the hospital systems still pay very well with full benefits and loan repayment plans compared to most DPC offerings. We all know about golden handcuffs, but sometimes in the abyss of debt, the shine of the golden handcuffs seems like the only light of salvation.
Problem number two is risk. DPC, though gaining in interest and popularity, still remains a “new” model and as a whole still remains at the chasm between early adopters and the early majority. This means the people who actively pursue DPC tend to be more entrepreneurial types, choosing to build their practice from scratch rather than joining an existing practice. Even this category has two sub-types: the risk taker and the late start. Risk takers will just go for it with all their debt, working long hours at a second job to survive, while building their DPC. Late starts slap on the golden handcuffs with their eyes set on their dream DPC once they’ve saved up enough from working FFS. Outside of the entrepreneur types are the employee types who really just want a good job with good pay after working so many years to finally make attending money. They are wired to go with the “safe” option i.e. the mainstream option i.e. FFS. Even if the pay and benefits come close, the employee type is still likely going to lean towards FFS. In summary, those most passionate about DPC are unlikely to be hired by a DPC, and those not as familiar or passionate are not going to be as interested or motivated to join one.
Hiring docs fresh out of residency will likely remain an issue for at least the next 5-10 years unless DPC goes into the early majority category sooner. Several things need to happen before more residents pick a DPC job out of residency. 1. More openings need to offer full salary and benefits. Generally only the entrepreneur types can tolerate “eat what you kill” and they are building their own practices. 2. Established DPC education within residency programs. Many faculty around the country are still outright antagonistic towards the model and further discourage employee types to join a DPC. In this same vein, partnerships of DPC docs with their local residencies so residents can get to know the model more personally and are more likely to join that or a similar practice after graduation. 3. Continued growth and success of not just the 3+ year practices but also the new practices. More and more RaMS have friends or mentors or friends of friends doing DPC and everyone is watching. If everyone sees nothing but success, the path becomes safer and therefore easier to choose. Luckily, as a whole, the trend seems to be moving in the right direction for all three criteria. Time now is the only uncontrollable variable.
Excellent post/discussion, but you left out one important thing that all DPC docs can do now, and costs practically nothing- take medical students. Yes, it will continue to be a struggle to hire Family Medicine and Internal Medicine residents out of residency, but they won’t get to those residencies if they are not attracted to primary care. Having previously worked for 20 years at a urban medical school (including 10 years as Primary Care Clerkship director and 4 years as curricular dean), most students are not interested in primary care because during medical school, they are mostly exposed to the insurance based primary care system, and don’t realize there are other options. Salary and student debt are certainly factors in student career choices, but lifestyle and job satisfaction is critically important. Students see Emed and hospital medicine as valuable because shift work allows them to control lifestyle. They love their primary care faculty, but also see how miserable they are in clinic. By exposing medical students during their 3rd year clerkships, students will see primary care as a viable career option. I would encourage every DPC doc to contact their closest medical school and see if they can take students on their rotation.
Thank you for writing this! I am scheduled to give a lecture on DPC to my local residency program in a few weeks, and am happy to have the opportunity to share my love of DPC with them. I appreciate your other points as well!