Real Life Is Full of Choices
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* Richard D. Iliff

*To the Editor:* The latest in the string of hand-wringing articles to land in my email was “The Impact of Debt on Young Family Physicians,”1 accompanying an article documenting that 58% of graduating family physicians reported having >$150,000 in educational debt and 26% reported having >$250,000.2

The same week there appeared a TEDMED talk entitled “Why Doctors Kill Themselves.” The week before it was “ABFM to Study Need for Resources to Combat Physician Burnout.” At the Denver FMX last fall the General Session was by the author of *The Upside of Stress*. I was randomly invited to an American Academy of Family Physicians (AAFP) feedback panel during the last national convention in Philadelphia, and the other participants (all younger than I) were so universally angry or depressed at their practices that I left angry and depressed, too. The keynote speech for the next Kansas Academy annual meeting is on the urgency of work-life balance.

Last week the AAFP News sent out its usual cheery headline: “2016 Match Sets Record for Family Medicine Choice.” Then I got to the comments, which dumped all over the Academy: only 48% of the family physician (FP) slots were filled by American students, only 5% of whom chose FP slots; the AAFP is just a propaganda organ whistling in the graveyard, having ruined the private practice of medicine by its blind leap into the arms of corporations, accountable care organizations, and the National Committee for Quality Assurance/patient-centered medical home/TransforMed experiment.

I am a 66-year-old family physician, residency and fellowship trained, with 5 years of military service, 6 years of work in a hospital emergency department, and 30 years of solo private practice. My income is twice the specialty average, I have a great life, and the doom and gloom is a real downer for me. So here goes.

The debt issue, from the perspective of age, is a problem of perspective. A student with $150,000 of debt and a starting salary of $170,000—pitiful though that may be compared with other specialties—will have no trouble paying off that debt over a lifetime of practice while still living a comfortable life, putting kids through college, and buying a house. So relax. If you went into family medicine to get rich, you should have chosen orthopedics. But you knew that already.

The real problem is that FPs feel like they are on a hamster wheel. They take a job with a hospital because that seems more secure than private practice. They spend a lot of time managing extenders rather than practicing medicine. A certain level of productivity is required, and their electronic medical record is so clunky that they finish charts after dinner. Even so, time with patients is spent on point-and-click; eye contact is rationed by all those inapplicable boxes. I know, because I get 8-page reports from the emergency department on ear infections, which inform me that the patient is not depressed and does not fear domestic violence. Thank you very much.

Then there are the committee meetings, the huddle groups, the lack of control over staffing and operational decisions—all those things I decide in the privacy of my own mind, or at the nurse's station 5 feet from the stand-up desk where I do my electronic prescribing and, mercifully, paper records.3

There are 2 ways for an individual to walk away from this scenario. One is direct primary care,4 which, remarkably, the AAFP is promoting. Productivity drops by 70%, however. The other is to enter traditional private practice, opting out of Medicare. That is what I've done, and it enables me to give great care to 3500 patients, generate a cardiology income, support a great team of nurses, and experience the joys of freedom and personal choice. Life is full of choices.

## Notes

*   The above letter was referred to the authors of the articles in question, who declined to comment.

## References

1.  1.Philips J. The impact of debt on young family physicians: unanswered questions with critical implications. J Am Board Fam Med 2016;29:177–9.
    
    [FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjkvMi8xNzciO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzI5LzUvNjM2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  2.Bazemore A, Peterson L, Jetty A, Wingrove P, Petterson S, Philips R. Over half of graduating family medicine residents report more than $150,000 in educational debt. J Am Board Fam Med 2016;29:180–1.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjkvMi8xODAiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzI5LzUvNjM2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  3.Iliff D. Solo practice: the way of the future. Fam Pract Manag 2003;10:23–6.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=14577266&link_type=MED&atom=%2Fjabfp%2F29%2F5%2F636.atom) 

4.  4.Eskew PM, Klink K. Direct primary care: practice distribution across the nation. J Am Board Fam Med 2015;28:793–801.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjgvNi83OTMiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzI5LzUvNjM2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)