Wednesday, September 17, 2008

Not everyone can be Cliff Lee

I read with interest the recent, and highly blogged about/commented-on, article from JAMA about the career leanings of fourth year medical students. The stunning finding from the paper is that only 2% of graduating students plan to become primary care internists after completion of residency. Another 5% are ticketed for a family practice career, while another 12% plan to pursue primary care pediatrics. Add it up and it means that 82% of graduating medical students are looking to stay far, far away from the very field of medicine where there is the most need. Moreover, 70% of general surgery chief residents are doing super-specialty fellowships rather than taking jobs as bread and butter community general surgeons

Very interesting. And with the possible ascension of Obama to the presidency, and his promise to bring health care to all the uninsured in some vaguely defined fashion, the problem of physician access becomes even more pronounced. So why are our talented, bright students from this generation opting out of primary care?

The reasons have been reviewed ad nauseam: poor pay (relative to the subspecialties), increased paperwork, hassle from insurance companies/Medicare, lack of perceived autonomy, overall sense of dissatisfaction. I get that. And I applaud those who do choose primary care. Primary care represents in its purest form what the concept of "doctoring" is all about. Patients are followed over the course of a lifetime and an astute clinician can diagnose and treat illnesses of acute and chronic nature. Long term relationships are established. Ideally, it can be one of the most rewarding careers available to a motivated and intelligent prospective young doctor.

I don't necessarily buy the premise that all we have to do is pay primary care docs a little more and the problem will be solved. The article in JAMA suggests this to be the case as well. Certainly the debt load that a young doctor has to shoulder is a factor but I think the reasons for the primary care shortage are deeper. I think there is a generational component involved that doesn't get addressed as much as maybe it should.

We live in the era of "work hour reform". Surgical residents are forced to go home following a night on call, irrespective of work to be done. In a few years, new restrictions may limit residents to 57 hours in the hospital per week. And the only uproar and dissent you hear is from the old guard of established attendings. Residents and medical students almost universally support the new measures.

Anticipated lifestyle has become a major factor in determining career choice of younger medical students. I'm not going to stand in judgement of anyone who decides that spending time with family and being able to go to the opera and symphony on weekends is more important than slaving away in a grungy hospital late into the evening or going into the OR to do an emergency colectomy at 3AM. But this is medicine. You are a doctor. Disturbingly, medicine has become a default pathway career choice for high achiever types who don't want to become lawyers or financiers. Magna Cum Laude? Oh, you ought to go to medical school. You'll make six figures and earn the respect of your community.

There is this sense of entitlement that comes with such thinking. A sense that "I've earned the right to do what I want and enjoy my life" just like those guys from college who weren't as smart but have been bringing home solid coin for ten years as "consultants" while you scrimped and deferred gratification on your resident salary. Younger doctors expect, even demand, both financial compensation and the ability to work the same hours as the CPA guy down the street.

As an analogy, think of an All-Star Little League team. The first day of practice, everybody tells the coach they want to play shortstop or pitcher. That's what they did on their regular teams. But not everyone can be the shortstop. You can't have 9 starting pitchers. Somebody has to be the catcher. Somebody has to trudge out to the lonely post in right field. Otherwise, your team will get crushed. Similarly, we have all these medical students who want to be dermatologists and radiologists and plastic surgeons. Well guess what? We need more right fielders in medicine. We need more motivated medical students who want to throw themselves into primary care and general surgery. Frankly, I'm not sure why students are allowed to choose whatever they like. If we need more primary care docs, them we ought to mandate that a certain percentage of graduating seniors have to go into IM or family practice. Mandate that only a select few can obtain fellowships in GI or plastic surgery or pulmonology.

Like most problems, the solution involves some sort of compromise between rival factions. Something needs to be done about the ridiculous debt burden that students must assume. And the pay discrepancy needn't be so extreme. But younger doctors need to do their part as well. This job, being a doctor, isn't like any other job. It's a privilege and certain obligations come with the privilege of wearing the white coat. You're going to have to do some scut work. You're going to have to work more weekends and evenings than you thought. You're simply going to have to give more of yourselves to your patients if you want to earn the entitlements you want.


Bongi said...

wize words. it has to do with meeting a need. and i don't mean the need of the doctor.

rlbates said...

Good post, Buckeye. Good comment Bongi.

walt dandy said...

Our generation really gets a bum rap. The thing about it that really sucks is that to say anything contrary to "we consistently work 80 hours or less" is to expose your program to a shutdown faster than you can say 81 hours. Some of us deserve a break from these "no one knows how to work hard anymore" diatribes.

Jeffrey Parks MD FACS said...

I realized I was going to get hammered a bit by younger docs who might interpret my post as a generalized indictment of all residents coming through the 80 hour work week era.

Obviously there are going to be the exceptions. When i was a chief I could tell right away which interns had "the stuff", the ones who would be excellent physicians in any era of training.

But the statistics are ceratinly curious, you have to admit. Why the rush to get out of general surgery and primary care? Why are dermatology and radiology the hardest residency slots to obtain? Why are there three separate GI groups covering a hospital with 200 beds? Do a literature search; lifestyle has become a major factor determining choice of career.

All I'm saying is that it's dangerous to simply trumpet the assumed position that the problem of physician shortage lies solely with our crumbling, broken health care infrastructure. We're all accountable to some degree. The more adamant one is that one's position is absolutely just, the less likely the opposition will be to compromise....Just an alternative point of view. KevinMD will give you a different stance....

walt dandy said...

My last post probably came across a little more whiny than I intended. My apologies. I know what you mean about knowing who's got the stuff. We get medical students who do "audition" rotations on our service. One group (the ones we want) won't leave the hospital for days on end if you don't threaten their lives to get them to go home. Another group is eyeballing the door at 1630, and you wonder why they are NOT picking a lifestyle specialty.
I agree with you wholeheartedly that tons of people are choosing lifestyle specialties. I honestly don't know the data about our generation's career choices as compared to previous generations, but it would be interesting to find out.
I hate to say it, but I also agree that money is an important factor in people's choice of career. It seems that there are cycles of specialty shortages, and the more desperate hospitals/communities become the more money they are willing to put up. Word gets out, and next thing you know people are all over that specialty. I guess I'm arguing that market forces will steer people in the right directions. I've been told that in the mid 90's you couldn't find an anesthesia job anywhere in this country. All of a sudden residency programs couldn't fill their spots, but when it became clear that anesthesia wasn't going to be taken over by CRNA's the spots started filling again relatively quickly.
Also, based on my observations in the communities in which I've been a medical student and resident it seems that the problem isn't so much a shortage of primary care docs and general surgeons as much as it is that they all want to work in reasonably sized metro areas. That leaves the smaller communities wanting, while in the larger cities they are fighting tooth and nail for patients/cases. I could be completely wrong because, as I pointed out, that is just my observation.
I'll finish this somewhat disjointed diatribe of my own by talking about money. None of my friends in the business world or law who are successful work much less than I do. That being said, I'm willing to bust my hump for fair pay. The problem is that I don't know exactly what fair pay is. I don't need a BMW or a mansion on the hill. I do, however, need to pay back a shitload of student debt and would like to provide a reasonably comfortable life for my family. Again, I don't know exactly what comfortable means. The kids don't need to go to the brand name private school, but I would like to be able to afford a good education for them. This is all very hard to pin down, but I assure you that I'm not in neurosurgery for the money. There are easier ways to make money. Selling mortgage loans to people who can't afford them, for example.

MedZag said...

The big turn off to me, as a medical student, to primary care isn't necessarily the reimbursement/hours issue. PCPs still make a decent salary, enough to make a life on if invested/saved intelligently, so if I found myself really loving the field that would not deter me. Indeed a majority of the best physicians (as a true embodiment of the sense of the word) I have met are PCPs. Most likely entering gen surg residency, so obviously the hours isn't an issue.

What has really turned me off to the field is that it is the field the insurance companies have been able to sink their teeth furthest into. The loss of autonomy is huge. I know all fields have fallen victim, but the gross majority of family practice docs I talk to are frustrated beyond words that they are not able to manage their patients in the best manner possible. The best medication for a patient isn't covered by their insurance. They can't get covered for large numbers of tests and procedures, even visits that are for anything other than a "general checkup." And its tangibly hurting their ability to care for their patients. Also, besides psych, family practice is the area of medicine most in need of time to talk to the patient. Patient counseling, education, and collaboration is arguably more important as a PCP in managing patients than the PE. But with reimbursements cut and PCPs hustling to hit in 20-30 patients a day, they aren't able to take the time to do those things.

In all, though, I agree with your post. The dire need of primary care goes much further beyond the issue of reimbursement.

Florida Derm (from CLE) said...

I don't know if I'll have any credibility here, but suffice it to say I made a decision to train in a "lifestyle specialty" when my primary focus in life shifted from medicine first to a medical career as part of my life with my family. At least I think that's what happened. The choice happened fast. Now I still feel a little guilty, especially when responding to posts by old school general surgeons who are "in the trenches". I will always have a lot of respect you guys. There's no badge of honor for dermatologists among surgeons, and I get it.

On a large scale, I'm convinced that these trends away from primary care and general surgery are largely because the American health care system does not incentivize generalists. Even the most principled medical students have to at least subconsciously consider an opportunity to work half as hard for twice the money. Nobody is going to put it in their personal statement on their application, but honestly, it matters. I'm not saying it's the main reason I trained in derm, but it was in the equation. No one has even mentioned the crisis in academic medicine, where teaching physicians make insulting salaries.

The studies are clear, as you mentioned. There has been a trend toward "lifestyle specialties" for at least fifteen years. I'd argue that it's no coincidence that most of these are well compensated, too. More women (i.e. mothers) are entering these fields as well. I can tell you that in dermatology, there are more women in training than men, and most of them plan to work less than 40 hours a week. That's not a criticism, but it's true. I can't prove that there is a generational difference, but there sure seems to be. (Individuals who work hard and working mothers shouldn't be insulted by these ideas.)

I agree with most of the points that have been made about the health care system's contribution to the trend away from general medicine and surgery. Buckeye, you bring up a good point about accountability, though. We all have a role to play. Unfortunately, we need to admit that we are not all selfless and that physicians and physician organizations get greedy. In dermatology, wait times for new patients are often two to six months, while the society leaders don't think we need more residents, practices are trending more towards cosmetics and away from medical derm, and Mohs surgeons are lobbying on Capitol Hill against reimbursement cuts for BCC removals paying $2000. It's a two way street. We're all involved in the inequitable distribution of limited resources. I'm sure there are similar issues in every specialty.

I've been enjoying your blog, buckeye. It's nice to read posts about stimulating topics every now and then instead of regurgitating 10 year old jokes on a fantasy football message board...

Anonymous said...

I think that there is something not mentioned in all of these posts: that subspecialists tend to address limited medical problems, and there is a higher chance that as a subspecialist that you will achieve a "cure" to those problems, rather than having to "manage" uncurable diseases (as an internist is often called upon to do).

It does take a certain personality to be able to see many patients in a day, manage their chronic problems, but not cure any one of them. In that respect, internists are stronger people. Year after year of this must having a wearing effect.

As a surgical subspecialist, I took on the extra burden on the front end--a longer more arduous residency, but I have the reward of being able to "cure" my patients often. If there is a cholesteatoma, for example (I'm an ENT) , I remove it. (OK, bad example--cholesteatomas often are the gift that keeps on giving too). But often, such removal does effect a cure. There is immediate gratification, and reaffirmation for the doctor--"I did the right thing". I imagine that such reaffirmation for the internist is harder to come by.

Toni Brayer, MD said...

Wishing our young doctors would be more altruistic and choose a life career that has the worst pay, the least autonomy, the most hassles with regulators, the least respect, the most dumping and disdain from other specialties, the most overhead and hassles is quite a fantasy, isn't it?

Pay them more. That's it. There hasn't been a rush to radiology because doctors like working in the dark. There hasn't been a rush to anesthesia because doctors like turning dials. Anything else is just wishing and our health care crisis worsens. Primary care is the cornerstone of health in every other Western nation. That means it has tremendous value for society and patients. Value=Reimbursement in a capitalistic society.

Anonymous said...

Whats wrong with Right Field?? Babe Ruth was a Right Fielder, Roberto Clemente too.

Bongi said...

there is another side to the lifestyle debate. in my country we have a growing shortage of general surgeons. our country needs to train 50 a year to strike even (retirements, emigration and death) but we only train 25 a year. each year we get deeper into trouble. when i started studying surgery it was already considered a tough career. but these days, because of the growing shortage, the general surgeon is working harder and longer hours to handle the work that needs to be handled.

this means that the job becomes tougher each year. we are also in a career where you can't go home if you are tired when there is a gunshot abdomen. you have no choice. this scenario discourages people from joining surgery programs, thereby compounding the problem. the longer things stay this way the worse will become the working hours and the less likely people will be willing to study surgery if lifestyle is a factor.

in the end we need people who go into it for completely different reasons. soppy sentimental things like making a difference and filling the void etc do somehow come to mind.

Anonymous said...

"Frankly, I'm not sure why students are allowed to choose whatever they like."

You cannot be serious about this. You're not sure? You can't even think of the slightest reason why?

Myself, and most of my friends who matched into competitive specialties, would never in a million years gone to medical school if we were going to be assigned a specialty by some third party. I mean, the very idea is absurd. Hey, there's all these fields in medicine and you're probably going to like a couple a lot. We know that you were at the top of your class and have a lot of career options. But we're going to force you to do the field we want for the next forty years. Need a pen?

Anonymous said...

How about working to change the culture in medical schools, too? In my institution, back when, there was no lack of a culture of self-sacrifice. We heard all our first-year lectures under a huge portrait of Howard Taylor Ricketts, for example. But we were told that we were too smart and too talented to waste ourselves in primary care. Now the first is gone and the second remains. Bah.

Anonymous said...

The previous commenter illustrates how deeply American med students would resent being told what to specialize in. A carrot is much better than a stick, here. Loan forgiveness for primary care, perhaps general surgery, in underserved areas--and not a measly $20K. And what if fellowship programs looked favorably on docs coming out of such a service? You might have some of the specialty-bound willing to put in a stint. Some might stay (am I dreaming?)
While I'm dreaming, then, let's have no insurance payments for primary care at all. HSA's for everyone! and vouchers for the poor, with public health funds for vaccines, TB and HIV treatment. This may seem a little off topic but it's about making primary care more attractive. I'm doing it, but I am realistic--if only the people who love it as much as I do go into primary care, we'll get oh, maybe 2% of med school grads...

Jeffrey Parks MD FACS said...

Frank- Right field at Yankee stadium = cool gig. Right field in little league = siberian Gulag.

Toni- What ought to be the standard pay for a family practice doc? Should we bump starting salaries up 30 grand? Will that reverse the trend? The job is still going to be frustrating and you're still going to have to work longer than you would to earn the same amount as a specialist.

Anon- I'm quite serious. You think Harvard MBA's dictate to Morgan Stanley what branch of finance they end up in? They get shunted into wherever there is a need and whichever specialty they show a superior aptitude. Same thing with law school grads who score jobs with the elite firms. They do what they're told. Only in medicine can a graduating class of eight general surgeons all decide to go into plastics and no one bats an eye.....

Now again: I wholeheartedly support some form of loan forgiveness for those inclined to accept a fam practice residency..... It is a two way street

Dr bean- Well put, and great ideas.

The Happy Hospitalist said...

You get what you pay for. Plain and simple.

Anonymous said...

i don't know how surgical subspecialties are, but the highly sought after medical subspecialties have way more applicants than spots. so in a way, they do dictate where people go. moreover, if anything, most studies suggest we need more subspecialists going forward, not less. it's just that we need even more primary care docs going forward.

the hospitalist trend released some built up steam by allowing those who couldn't get into fellowship and didn't want to do primary care an intermediate solution. it fed into young doc's egos that they could be a lifestyle doctor, make more money, and become a'senior administrator' of a group well before they were ready to do it. we'll see how they treat their young once the numbers stabilize and the hospitals reduce their support of the groups. right now all they care about is their workload and number of shifts. once they have to take pay cuts to add people or start outpatient clinics to follow up on discharge issues, we'll see how good they are at administration.
and i agree with you buckeye-paying more isn't going to solve the problem that the job involves many hours of unappealing work. unless you pay a lot more. and where this money would come from is not at all clear.

Michael Rack, MD said...

"You think Harvard MBA's dictate to Morgan Stanley what branch of finance they end up in?"

Not right away, but after putting in several years (the equivalent amount of time as a residency), there is a choice.

MiamiMed said...

First of all, I'm a long time lurker on your blog. I'm also going into surgery next year with an eye towards possibly staying in general surgery.

I'm going to explain what pushes me away. No one trains true general surgeons any more. General surgeons continue to lose progressively more procedures, and the malpractice environment in many states makes being a general surgeon trying to do anything a big liability. Are you a liver specialist? When you did that A-V fistuala, did you have specific training as a vascular surgeon?

On top of it, 120 hours a week was nuts, and 58 (or 48 as it is in much of Europe now) is also nuts. The only thing true about training hours, is that optimal number of hours for training is the only thing not taken into the equation when setting them. I'm scared that I'll work a lot as an intern, and then get kicked out after 58 hours as a chief resident. The worst of both worlds so to speak. When I come out, I sometimes wonder whether I'll ever get credentiald to do anything beyond a PGY-1 or 2 level procedure anyway in the current environment.

I really love medicine, and I enjoy the broad specialties. That is why in the face of a wife, some kids, and a quarter million dollars in debts, I'm still considering one of them. However, I'd be crazy to not think elsewhere.

If we want to put more people into generalist specialties, fix the problem. I'm already a debt slave, and I refuse to become a work slave as well based on some government or organizations sense of "need" of a certain specialty.

Anonymous said...

Perhaps a MMPI to add another dimension to consider when evaluating prospective residency matches. Losing a resident because they find that they don't like the work/demands/hours/patients is a terrible waste of a slot.

Attended a C Everett Koop lecture several years ago in which he described his activities as a Dean at Dartmouth. Required premed course was service to home bound, long term care or otherwise Non-doctor 90210 type patients to expose would be doctors to a side of the profession not usualy seen! Not sure if this still in force

Gary M. Levin said...

Well, like Sid Schwab I am a bit of an old fart, but not a dinosaur.
I could say that 'back in my day' it was this way or that way. I remember 100-120 hour weeks and unfortunately was sertonin deprived much of the time. Different strokes for different folks. I really wanted to be an Ob/Gyn....was great at endocrinology, won a prize for a paper on complications of oral contracetives, but when it came down to night up delivering babies destroyed me to the point where I would fall asleep in clinc. I eventually wound up as an Ophthalmologist, and a pretty good one at that. My days varied from 11 hours to 16 or 18 hour days counting all the administrative stuff, committee work, and my share of medical politics.
Following a rotating internship (I don't think they exist anymore) I served in the Navy during

Vietnam.There I really learned general to treat rashes, sore throats,meningitis, depression, personality disorders, venereal disease, now called STDs, and sharpened my surgical skill doing circumcisions on a rolling ship.
Following that I did a year of general practice and three years running an E.R. You can't do any of that anymore without a paper trail and certification from some board or another. We would have a lot more primary care docs if the system had not been so buggered up by academia, and insurance companies.
When we are young and idealistic we have no idea what mortgaging our life really means to get a medical degree. In the past the discretionary income allowed for significant debt. Today that discretionary income has gone the way of the World Trade Center..blown out of existence.
Family physicians are discriminated against not only by insurance companies, but by other docs, and hospitals. They have restricted hospital priveleges and sometimes even if they have had training in procedures are limited from performing them.
From the time we enter medical school and are taught by academicians who are experts in their relatively small area, students quickly figure out the 'food chain'. It's a lot more than economics, although rewarding primary care doctors much more would shift the balance.
I could easily go back and do primary care, but now I can't even go on an Indian reservation as a GP.

HMS said...

Projected 35,000-44,000 PCP shortage in US by 2025; this can post as a serious problem in our [health care] baseball team's future.

Anonymous said...

I am husband, father, senior surgery resident, and officer in the US Navy. I have worked (much) greater then 80 hrs a week throughout my residency. It has put my marriage under great duress to the point of pending divorce as well as financial hardship. I would like to reinforce my colleague Dr. Dandy in stating that the new generation of general surgeons are considered "soft" due to the training requirements implemented (but often not obeyed). I have the privilege of training at a "premier" institution and can say without hesitation that my fellow residents and I offer the same level of high quality of care that those who currently practice general surgery did in their residency training. I do not know if as an intern I would have "the stuff" but I do believe I (and my peers) would be someone you would be proud to have as a junior partner.

Anonymous said...

Your hatred of subspecialists is really sad, esp. many of your surgical subspecialist colleagues. Just a newsflash to you - General Surgery is not a primary care specialty either. One could very well say a general surgeon is a specialist (i.e. not being primary care) as well, so be careful. Just bc others don't wish to be martyrs, doesn't make them beneath you. It makes them smart.