Friday, May 09, 2008

So you want to be a doctor?

In Reasons Not to Become a Doctor Tara Weiss writes that physicians’ professional rewards are shrinking, and that is contributing to a growing shortage of doctors. She quotes three authors from the recruiting firm of Merritt and Hawkins:

This is not just a question of career choice---consumers will be affected greatly by this shortage. If you think there’s a long wait for an appointment now, it could be nothing compared with 15 years down the road. The three co-authors of Will the Last Physician in America Please Turn Off the Lights, all from the physician staffing firm of Merritt, Hawkins and Associates, say the wait will jump to three to four months to see a doctor for a non-emergency, and a routine doctor’s visit will cost two to three times what it does now—whether you are insured or not, they say.

I have a lot of respect for Merritt and Hawkins. They are uniquely in touch with physicians’ attitudes and working conditions. But you don’t need data from Merritt and Hawkins to know that what Weiss says is true. The shortage of doctors, particularly primary care, touches all of us.

Although all doctors realize the increasing frustrations of the profession, medical blog reactions have been somewhat more optimistic:

Kevin M.D.

DB’s Med Rants

JaneMarie MD

The Blog that Ate Manhattan

My take? I can’t see myself doing anything else. I love medicine. It is said that one of my medical school mentors was quite wealthy and worked for the university, at his own insistence, for a dollar a year. He’d say to his students “You should love medicine so much that if you were independently wealthy you would be willing to pay for the privilege of being a doctor.” I sometimes feel that way!

Nobody goes into medicine primarily to get rich. Perhaps a few consider it just a job. Most appreciate the professional rewards. For me the issue is not the profession of medicine; it’s the baggage. I love medicine but I hate the baggage. The baggage is growing and choking off the professional rewards. For many doctors, even the ones in the profession for the “right” reasons, the baggage has become unbearable.

Wanna be a doctor? Think long and hard, and count the emotional cost.


janemariemd said...

Thanks for stopping by, and the link, Dr RW! I don't know about the goals of current medical school enrollees 'cause I'm more than 20 years out, but I do think I had some classmates who weren't going into medicine primarily to help people. I distinctly remembering feeling that we had a cross-section of humanity--equal parts good, bad, and ugly in our class. But, maybe that's the way it should be--just like the humans who are our patients.

blacktag said...

With the proviso that I haven't read the book, and that there well might be certain paragraphs relevant to foreign medical graduates, I think that a 'future shortage' is unlikely.

Today, American science and engineering depends on the best from foreign countries, particularly China and India. Why not medicine?

The short answer is that medicine is far more protectionistic than science. If the barriers to entry were reduced, the USA would have an ample number of physicians who are very good at what they do. Having worked with physicians from the USA, UK, Europe, Singapore and Hong Kong, physician standards do not differ much in my opinion. (Of course, research output differs, but this is frankly more infrastructural than related to doctoring/technical ability).

Sure, doctoring isn't just about technical ability; a certain cultural and linguistic similarity does help with patient interaction. While it is true that many would prefer to speak with a doctor with the right accent, the looming 'shortage' is likely to be in areas where US medical graduates gravitate away from.

Certain non-clinical specialties in the United States are already staffed by a predominance of foreigners of certain nationalities, who eventually take up US citizenship. Rather than create a strawman argument, the authors should also take a good look at the American medical establishment's policies.

In a note from abroad, Australia is having some success currently obtaining excellent English speaking physicians from abroad to staff its rural areas.

Anonymous said...

So, You Want To Be A Doctor…..

Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason stated and speculated for this decline of this health care profession that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training.

Yet considering the additional attention of shortages of students in some medical schools as well, one may ask the question as to whether or not people want to be any type of doctor in the first place in the United States. About one third of their lives are spent achieving the requirements of this profession. Reasons for not choosing to enter this profession are several and valid and include the following:

There is the issue of long hours- with primary care in particular because of the apparent lack of doctors of this specialty. Such doctors may be over-worked without an expected pay reflecting the work they do. Furthermore, those doctors employed by health care systems are required to see a certain number of patients a day, and receive a monetary bonus if this expectation is exceeded. It seems that most doctors are members of such health care systems. So burnout never anticipated certainly may occur. And I consider such a requirement mandated by health care systems demeaning to this profession, and leave the doctor without the control that the doctor is entitled to due to their training and experience, and this competes with the other adversary of doctors, which is managed care. In fact, even government healthcare programs provide financial incentives in relation to the pay-for-performance system to improve the quality of care.
However, the recent increase in hospitalists, who are those doctors that are usually Internal Medicine doctors who care for patients presently under hospital care, and they have lessened the load for all doctor specialties for the work they do that the admitting doctors would have to do without their presence. This in itself makes a doctor possibly more effective and efficient in their practice outside of the medical institution.

All doctors, I presume, face a high degree of emotional and physical stress associated with their profession, as stated in the previous paragraph, for example. And this is not to mention the incredible stress associated with patient care in the first place, with some patient cases causing more stress than others. Patient care duty is a noble and great responsibility.

Doctors, due to the changes that have occurred recently in the U.S. health care system, not only have the issue of money to deal with, but also a loss of autonomy regarding patient care combined with loss of respect that may be due in large part to the others previously mentioned who dictate how they practice medicine.

Ironically and often, these others who direct these doctors are not as qualified as the doctor in the first place. This is complicated by the perception that the public, with some who view doctors as having the easy life with their pay and profession, which does not seem to be the case presently. Another frequent occurrence is the doctor’s patient directing their care with their doctor from either DTC ads or researching medical disorders on the internet themselves.

There are also reasons of malpractice insurance, which is why doctors choose to join health care systems, it is believed, to pick up the tab for this necessity, along with eliminating the concerns of running a practice in a private manner, which historically has been the case, as their offices are owned by the health care system as well. Yet having another pay their malpractice premium does not eliminate their concern about being sued for error perceived by one of their patients. To protect against this, defensive medicine is implemented by doctors, which basically involves copious amounts of documentation and ancillary diagnostic testing regarding the doctor’s adherence to recommendations and guidelines.
It has been said that up to 90 percent of malpractice cases against a doctor are baseless and without merit, so they are unsuccessful for the plaintiff, yet this still affects the rate the doctor or another system has to pay for malpractice insurance of a wrongfully accused doctor. This is combined with the amount the doctor has to spend to defend themselves in such cases, which separates them from their focus on the restoration of the health of their patients completely.

Furthermore, malpractice lawsuits cost about 100,000 dollars over the course of about 4 years for such cases. A tort reform in Texas in 2004 resulted in annual malpractice premiums reduced by about a third of what they were. Soon afterwards, claims against doctors remarkably dropped by about 50 percent. Some specialties of doctors pay more premiums for malpractice than others. For example, OB/GYN doctors have been known to pay around 300 thousand dollars a year for this insurance. Certain types of surgeons experience a similar high rate of malpractice premiums. Malpractice flaws are catalysts for doctors to practice the inappropriate defensive medicine mentioned earlier to avoid potential litigation, which is a waste of health care resources with ordering unneeded patient methods or procedures to cover themselves against such lawsuits.

Also, about a third of the U.S. is insured by Medicare, which progressively has lowered what they will reimburse a doctor for regarding the care doctors give a patient they treat. This fact is recognized by other insurance companies who will eventually follow the recommendations of Medicare, usually, regarding the reimbursement issue, so it seems. This will lead to a doctor having to see even more patients in order to make it financially with their profession, as this has resulted in the overall income of a doctor experiencing a decline of about 10 percent over the last decade or so.
Further complicating the financial state of a primary care doctors is that doctors normally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed. About 20 years ago, that debt was only about a fifth of what it is today. Paying this debt off is typically about 2 thousand dollars a month that doctors on average is what the doctors choose to pay in order to eliminate this debt in a timely fashion.

Conversely, there are some who believe that doctors in the U.S. are over-paid. This may be true, but they are not absent of financial concerns as with any other profession. And as mentioned earlier, clearly doctors accept more responsibility involved with human health than other vocations, so this should be kept in mind perhaps more by others.

Most doctors do not recommend their profession to others for such reasons stated in this article so far presently, and perhaps other reasons not mentioned. This is somewhat understandable, yet extremely unfortunate for the health of the public in the future. There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state of mind that occurs as a doctor in today’s health care system, which is expressed by them at times in apathy, cynicism, and vexation regarding their limitations coerced by others.

Conversely, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession. Personally, I believe that the intentions of most physicians are bonafide. Yet in time, due to the nature of the current health care system, doctors frequently and really do become cynical, demoralized and apathetic. This may be considered a significant concern to the well-being of those in need of restoration of their health, understandably.

Not long ago, the medical profession that has been discussed had overt honor and a clear element of nobility. Such traits are not as visible or recognized anymore, which saddens many intimate with the profession and importance of public health that is needed by many.

“In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero

Dan Abshear

Author’s note: What has been written has been based upon information and belief.