It is that time of the year when fourth year medical students are gearing up to send in their applications for internships. I confess, for the first time in years, I sense that the choices are not clear.
It used to be you could look into the crystal ball and paint a picture for them of what their life would look like when they were done: it used to be that if they chose primary care, they would probably over a lifetime make perhaps 3 to 5 million dollars less than a colleague in a procedural specialty, be harassed with a lot more forms, longer hours, and unless they retreated to a concierge practice where they set a high dollar bar for admission to their practice, they would be very busy.
On the other hand, if they picked dermatology (and I love dermatology, and find it an intriguing discipline), they could count on a good lifestyle (very few dermatological emergencies), they would do lots of procedures, and make a healthy living. The same was true for ophthalmology, radiology--all very competitive disciplines for students to enter.
But what if:
- You get paid only for managing disease, for caring for a stable of patients--in other words, what if there is no fee for service? (By the way, Massachusetts is bravely going this route.) Doing more procedures then will cost you money, not mint money. Suddenly, many procedure based specialties don't look so hot.
- What if Medicare or insurers stopped paying for MRIs, CAT scans and PET scans on an individual basis, but rather only reimbursed for disease management ? The owners of such facilities (who in many cases are doctors) have counted on business continuing as usual and may fold like Chrysler dealerships. Radiology as a career choice might be less attractive.
- What if the physician who cared for the patient, who had formed a steady relationship with the patient over the years, who knew the family, and who was the one who admitted them to the hospital (and then acted as quarterback and kept a close eye on the consultants called in and ensured communication)--what if that individual got paid top dollar? Yes, what if primary care became the plum? Look at who President Obama picked to be Surgeon General: a primary care physician par excellence. There is a message there.
- the House releases its health care bill
- Center for Medicare and Medical Services (CMS) releases a revised physician pay schedule
- The FDA is about to finally get to rule over tobacco companies
Comments (13)
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Abraham Verghese
I like your conclusion : students should always follow their heart when they have to make that choice... otherwise, how can they be good doctors ?
Saternius, from Fashion Trends
Hate to sound pessimistic but haven't we seen this movie before?
Genuine health care reform will need much more than the current short term fixes that are being debated. The lopsided workforce ( 55% specialists), tertiary care and hospital centric training, powerful interest groups and lack of financial and infrastructural support for public health will ensure the status quo for the foreseeable future. And of course, there is the question of personal responsibility (no policymaker will touch this with a barge pole).
The way doctors are trained today encourages a siloed culture and makes them resistant to dialogue with other stakeholders in the health care workplace (administrators, therapists, policymakers). Enhanced collaboration between physicians and other stakeholders is critical to health care reform.
Your advice to "follow your heart" is right on, and applies more broadly than just to medical students. Finding your calling is more important than finding a job.
No need for a crystal ball. Money doesn't buy happiness. Follow your heart.
Similar conversation is taking place here and here . I appreciate the advice you are giving individuals, but as a profession and an industry, physicians and specialists are much more concerned about the economics. Note not the content of the posts, but the comments and follow-ups. Nobility of a profession and following one's heart will only go so far when you read those comments.
I entered medical school with the hope that we would build a national health system such as those in Britain, France or Canada. Many of my classmates also supported such a system as we see that the present system is unsustainable. Perhaps older doctors are locked into mortgages and lifestyles that require larger incomes, but most medical students and recent grads knew that we were not taking a sure path to riches.
Also, I wonder how many people are aware how much of the present cost of healthcare goes toward administrative expenses and profits for insurance companies?
"Follow your heart"? An interesting idea for sure, but the medical school environment is so virulently hostile to primary care that this simply perpetuates the current massive bias in favor of technical subspecialties. It's difficult to explain to laypersons who reside outside of the hot-house environment of medical school, but the degree of casual contempt and even derision aimed at primary care has to be experienced to be believed. And until this toxic environment is actively and effectively addressed, our primary care crisis will continue to worsen. What passes for a primary care 'system' in America is collapsing before our eyes.
As a clinical instructor in family medicine, I have given lectures at local medical schools and residencies, and hosted medical students in my practice. Over the past decade medical student interest in primary care has evaporated like snow in a blast furnace. When I offered to give a talk on rural family medicine last year, the professor I contacted turned me down because no one in her class of residents had the slightest interest.
Mull that over when you suggest that students "follow their hearts". It's a hell of a lot easier to follow your heart when it promises three times the pay for less than half the work; this accurately summarizes the current primary care versus specialty imbalance.
I need to agree with Geoff Witting.
As a US medical student about to enter my third year rotations I can attest to the fact that primary care does not receive as much respect as it should. In fact I often get the impression that except for a few exceptions it seems that primary care is the field slated for those who are in the lower portion of their class rankings. However, that is not to say that these students aren't hardworking or intelligent, it just speaks more to the fact that modern medicine is so competitive that as soon as you begin medical school students begin to jostle and compete for class rank with an eye toward their residencies.
As Geoff Wittig pointed out, it is a lot easier to follow your heart when it promises three times the pay (often more!) for less than half the work. In order to truly get an understanding of how hectic and frustrating primary care is today you need to spend some time in a primary care office and follow the physician as he struggles to meet with an ever growing stable of patients in an ever dwindling amount of time and then you need to keep in mind the amount of time he/she will need to spend haggling with insurance companies so that they can get their patients the best care. All of this in the backdrop of dwindling reimbursement and you begin to get an idea of primary care medicine today.
The vast majority of medical students came into this field to care for patients and to do what they love. If the government is truly serious about improving healthcare they need to level the playing field for us. They need to begin imposing caps on medical malpractice (I remember during my first week of medical school one of professors told us that half of us would be sued for medical malpractice and that of those half the likelihood was high that they would get sued again) so that doctors can practice medicine without constant fear of malpractice litigation.
Obama's plan has failed to address this issue and that's unfortunate since studies have shown that the single most significant factor in malpractice litigation is not whether the physician is competent or not, but rather whether the patient likes them.
In closing, raise salaries for primary care physicians in relation to the high salaries of specialists and you'll see a growing migration of medical students to primary care. With increased compensation primary care will be able to regain the respect it deserves.
(disclosure: I'm thinking of going into EM not primary care, like Dr. Verghese said, do what you love).
Coming from a family that has a few doctors, I understand that they all take an oath to make the right decision but with all this talk about following your heart, isn't that something that truly goes without saying or mention. Whether we like to admit it or not that emotional component helps us make some of the most difficult decisions that we have to make in our lives.. I'd say the same holds true for doctors that are basically in charge of life and death at any given moment. xo Hairstyles
I think the promise of big money can often cancel out the emotional component.
What a lovely, inspiring post -- as a fourth-year medical student, I couldn't agree more with the message of 'following your heart'. Thank you for writing this post.
PS: Thanks also for the shout-out to future Surgeon General Dr. Regina Benjamin -- she has a very impressive resume, and I'm excited what she'll accomplish in the upcoming years. However, and I understand that this is very ungenerous of me, I can't shake the itch that Dr. Sanjay Gupta would be a more worthy contender.
When I heard Dr. Gupta was up, I too was very excited. However, he chose not to become our SG, for now.
My question to you is what positive purpose does your ungenerous statement serve? Do we always have to scratch an itch? Some thoughts are best left unsaid. Please, reset your thinking and speaking. Thank you.
I am a senior physician in a university practice at a state school. Following your heart is easier if you don't owe ~$130,000 in student loans. Loan forgiveness is often used to encourage people to go into primary care. Until the education costs become less oppressive there will be the tempation to go into highly paid specialties.
The changing demographics of the student body also encourages female students to go into "life style" fields i.e. Radiology, E.R., Hospital Medicine, etc. These are fields that enable them to combine a family and career.
Medicine is still the most rewarding career a caring person to enter. My father told me when I was a student to do something I liked and that satisfaction would outweigh the compensation in the long run. Forty some years of experience has proved that he was right.
(By the way my three sons are M.D.'s as are two of their spouses.)
I am certainly hopeful that a new CMS reimbursement schedule will be fairer. The current system is completely irrational. In critical care medicine, doctors are compensated on the basis of (claimed) time spent. A doctor who spends 60 minutes and accomplishes nothing gets more than a doctor who spends 30 minutes and accomplishes a great deal with the same disease state. I have also noticed that it is not necessary to be board certified to claim critical care time. You can be in primary care, psychiatry, or even dermatology to do it. I have been witness to such frauds for years.
--A Concerned Physician