Tuesday, April 21, 2009

It's Hard to Stop a Moving Train: A Primer on Inertia in Modern Medicine

As a senior medical student, I recently went through the match. The match is the process within which senior medical students (or anyone else seeking a residency) are accepted to residency positions. Most schools release a match list after the process is over. This allows everyone to see who is going where and which specialties are being pursued. A match list is more than just a list. It is largely a reflection of the interests, philosophies, priorities, and successes of a medical school class. It is also interesting to see how these things change over time. Specialties come in and out of vogue, priorities change, and what was once the pinnacle of achievement becomes a dumping ground for those that couldn't get in to some specialty that was itself a dumping ground not too many years before.

While these things wax and wane, it is clear within my own institution (and really amongst medical school graduates at large) that the last decade has ushered in a paradigm shift. The traditional medical school class is full of extreme type-A overachievers who have been at the top of everything forever. The traditional rank order list of the years of yore reflected a desire amongst the top applicants to continue this type of function. Once upon a time, and this was before any work hour restrictions or attention to resident health, students fought over the right to work 120 hour weeks in surgery pyramid programs or gruelling schedules at large academic medical centers as internists. Those days are clearly gone. In those same years of yore there were a cadre of specialties which brought a more friendly lifestyle, sometimes without a significant pay cut. Specialties like Dermatology or Radiology were a way out for those who were done with the intense pace that categorizes life in the hospital. From the medical community at large, these jobs have often been considered secondary. I know an old internist who referred to essentially all radiology as "scut." No one speaks like that anymore. In fact, the current shift has made these specialties the most attractive to the creme de la creme.

The classic lifestyle specialties are known as the ROAD specialties (Radiology, Opthamlmology, Anesthesiology, and Dermatology). My class, which is graduating around 170 people, had over 20 people apply to radiology in the match. 5 More matched (with several not matching) into Dermatology. We had 15 match into anesthesia (which is also become more attractive to the lifestyle conscious). We had 9 match into Opthalmology, with atleast 2 more taking time off for research to apply more competitively next year. If you add it up, this puts 49 people (or nearly 30% of the class) in the four most most lifestyle friendly specialties. We have more people in all but one of the ROAD specialties than in General Surgery. We have more people going into these specialties than internal medicine.

The other divergence of members of the top of the class is to direct surgical specialties. It seems like in many cases, the broad training of general surgery is no longer required or desired. It really does make some sense. You can cut a year or more off of your training or enter a field which requires the same number of years it takes to train to be a generalist to be a specialist. Applications to Neurosurgery, Orthopedics, ENT, and Urology are stable to way up. Direct Plastic Surgery and Direct Vascular Surgery are insanely competitive, with the former being the most difficult to attain residency in all of medicine.

So why the paradigm shift? We could blame it all on our lazy generation, but I think that there's much more to it. This is still the extreme Type-A hardworking group at the top of the academic curve that it was in generations past, and I'm not sure that the true underlying ethic is extraordinarily different in this group.

I've heard different explanations:

1.There are more women in medical school today, which tend towards more lifestyle friendly specialties. This is however nowhere remotely true in a universal sense (In fact, the fields with the fastest growing percentages of women residents are the difficult surgical fields, and the field with the highest percentage of women is OB/GYN, which is hardly lifestyle friendly). This also doesn't explain why a higher percentage of men are going after lifestyle friendly or direct specialty fields.

2. Medical School isn't as hard as it once was. This is probably true in the sense that the total number of hours required of a student is probably less than it once was. On the flip side, the amount of standardized testing and the overall knowledge requirement has probably increased. This is certainly not a slam dunk.

3. Medical Students aren't socially conscious anymore. This one is almost hilarious. Students today flippantly bounce from one cause to the next, with what has to be record enrollment in every social justice group in existance. Medical missions and the "underserved" are the thing du jour. Students are so busy being socially conscious, that it is sometimes hard to figure out when they have time to study medicine. Students in the 70s were probably far less likely to intentionally pursue something in order to fall on the grenade.

So you've probably guessed that I've got a theory. You're right. You may have also guessed that it boils down to simple economics. You're also right. Atleast, it boils down to a combination of respect and simple economics.

Physicians (nearly all physicians) used to tower above their communities in a financial sense. From the ushering in off Medicare until the HMOs of the 90s, physicians were usually amongst the wealthiest in town. This was true of all specialties. Student loans were relatively low, and training time was MUCH less in many specialties than it is today. Money, while important, was really much less of an issue. Everyone could do well. Today, through a combination of declining physician reimbursement and everyone else getting richer, the relative wealth of medicine is much less. It makes the financial factor more important in specialty selection. Students are often sitting on a student loan mortgage or two. My personal student loan payments will be approximately 5 times my mortgage payment, and still 3 times my mortgage payment if paid off over the same 30 years.

Additionally, specialty physicians (while often of questionable added value compared to their generalist counterparts) are virtually always better compensated. Lifestyle specialties are usually much better compensated on an hour to hour basis.

Today, there is an inverse relationship between pay and value. The most critical jobs, or atleast the most logistically complicated important jobs (middle of the night emergencies and such) pay much less than most of their elective outpatient counterparts and come with the added sucker punches of higher rates of being sued and an inability to select your patients.

In the past, the difficult specialties like primary care or general medicine were respected. They are clearly not in the same way today, and they are clearly not respected above their counterparts in more friendly specialties at all. To be a generalist today is to be hit with a mountain of paperwork (no reimbursement for completion), lower reimbursement, higher rates of lawsuits, and generally poor public opinion. No wonder people are running from it. Reading CT scans from home at 10:00 AM is a heck of a lot less demanding than poring through dead bowel at 2:00 AM, and you get paid a lot more to read the scans.

There will always be people who find some sort of inherint satisfaction outside of direct specialization or lifestyle friendly specialties. I for one chose general surgery because the I am personally satisfied with the idea of being able to handle everything, having a broad scope, and being the last line of defense. There is a growing number who agree with me, but that number is dwarfed by those running for the hills away from all that really matters.

Here's the problem. You can't run a medical system in which everyone is a Radiologist. You cannot operate a system in which everyone wants to perform cool new endovascular or robotic surgical procedures, but no one is willing to do the midnight appy. People really need a PCP to be the first line of evaluation in many cases. I am in no way denigrating specialists or radiologists, but we need all types. The problem is that the train has left the station and is moving. The medical system will continue to move people away from where they are needed most. Our skewed payment system in concert with a confused legal system and laws limiting physician's ability to be compensated in a relatively appropriate manner have taken the medical train on a one way track towards a cliff, and we all know its hard to stop a moving train.

46 Comments:

Anonymous poormedicalstudent said...

As a PGY3 general surgery resident, I would agree with what you've stated here. Why put up with the hours, horrible patients, lack of payment when it's easier to pop a few zits and play a daily 18 at the local country club. The question is, how do we change it? The answer is strikingly easy: let the laws of economics take over.

Insurance companies and the government can continue to change reimbursements at their leisure, but the day of reckoning is upon them. As rural/non-urban/non-academic hospitals continue to close for lack of a general surgeon to take call, things will change. When academic centers start folding due to lack of funding for the basic necessities of good internists and trauma call, things will change.

Pretty soon the public will realize it's not their right to force me to take our their perforated appy at 2am. Rather, it's a privilege/service I provide in return for a fee. Due to the social good it provides, something most physicians still take seriously, we don't command the proper price (infinite, as saving a life is priceless), but rather settle for a more reasonable amount. However, that reasonable fee is not $50.

When patients realize the care they seek is not available on demand, they'll start calling their insurance providers and congressman. They'll demand better, and if it's not provided, they'll wise up and take it upon themselves to pay for the care they so desperately want. Instead of saving for a botox injection or tummy tuck, individuals will save for a possible Hartmann's following perforated diverticulitis or that 3-vessel CABG.

By 'saving' I mean purchasing private insurance, which private insurers will be happy to provide due to market principles of profit potential. Those same insurers will also be required to reimburse according to what physicians want, lest those same physicians refuse to accept said insurance, making it a less competitive product.

Long and short, unless the US government becomes socialist/communist (a goal of the current adminstration with regards to HealthCare) and strikes down the sale of healthcare to individuals willing to pay, the invisible hand will return balance where currently it is lacking (due to government meddling)).

10:19 PM  
Blogger MiamiMed said...

I hope so. Unfortunately, the current market is so horridly meddled with, that it is hard to call it a free market. Insurance companies may be private, but they are beholden to such a ridiculous littany of laws governing what insurance has to cover. Wide price variations between states are atleast in part a result of requirements to cover a variety of things from fertility treatment to therapy for autistic children. People should be able to do exactly what you describe now, but we have already moved so far down the road of economic fascism that it is already illegal in many places.

3:32 PM  
Blogger MiamiMed said...

I hope so. Unfortunately, the current market is so horridly meddled with, that it is hard to call it a free market. Insurance companies may be private, but they are beholden to such a ridiculous littany of laws governing what insurance has to cover. Wide price variations between states are atleast in part a result of requirements to cover a variety of things from fertility treatment to therapy for autistic children. People should be able to do exactly what you describe now, but we have already moved so far down the road of economic fascism that it is already illegal in many places.

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Blogger MiamiMed said...

This comment has been removed by the author.

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