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.