More Med Students Are Shunning Time-Demanding Specialties
September–October 2004
Alison DeLuca is busy. In addition to graduating from the University of Pittsburgh Medical School this spring, she is a competitive swimmer, co-vice president of her 2004 class, and enjoys pursuing interests in literature and creative non-fiction writing.
She also wants to be a mother some day, so when it came time to choose a medical specialty she picked psychiatry and hopes to work in a hospital emergency room. Like many medical students today, DeLuca chose a specialty that not only fits her interests, but one that fits her lifestyle.
“If you don’t assert some type of control over medicine, it will consume you,” DeLuca said. “I really enjoy taking care of people but I don’t think I can take care of people unless I take care of myself.”
Increasingly, medical students are seeking to balance their personal and professional lives. No beepers, no weekend call. When they leave work at the end of the day they don’t want to be called back.
As a result, interest is growing in specialties like psychiatry and dermatology. Hospital-based specialties such as emergency medicine, radiology and anesthesiology also offer stability.
On the flip side, fewer students are choosing primary care, general surgery and internal medicine and other medical professions associated with an uncontrollable lifestyle.
That worries some health experts, who warn about a critical shortage of primary care physicians.
“This trend has serious ramifications for our country’s health care,” said Dr. Lauren Oshman, national president of the American Medical Student Association. “The United States may soon not have enough primary care physicians to care for the underserved communities and society at large.”
Examining the Trend
Many factors have contributed to the trends, including changes in values among medical students, the structure of the health care system, an increase in the number of women in medical training and rising student loan debt.
In a study published in September in the Journal of the American Medical Association, medical students — worried that a busy, demanding profession might control their lives — rated hours and reducing on-call time more important than pay and prestige when choosing a specialty.
University of Pittsburgh School of Medicine enrollment figures for 2004 mirror national statistics that confirm these trends.
Dr. Joan Harvey, Pitt’s associate dean for student affairs, said students there, however, aren’t basing their decisions solely on lifestyle issues. Student debt increasingly is a factor.
More than 90 percent of Pitt’s medical school graduates in 2003 carried a mean debt load of $137,000 (the national mean was $109,457).
A growing number of graduating Pitt medical students who responded to a school questionnaire said debt played a role in their specialty choice.
Nationally, 11 percent of medical students 10 years ago had debt over $100,000. Today, about 21 percent have debt over $150,000, according to the medical student group. Oshman said it is working with Congress to lower the cost of borrowing and is urging medical schools and states to provide more scholarships for those seeking primary care. Similar efforts are under way at Pitt.
In the mid-1980s, the percentage of Pitt medical school graduates choosing primary care specialties — family practice, pediatrics and internal medicine — peaked at around 50 percentage points. This year, of Pitt’s 151 medical school graduates, about 36 percent chose a primary care specialty.
And of those who choose primary care, many are pursuing subspecialties such as cardiology, gastroenterology, oncology and rheumatology. These subspecialties further deplete the nation’s pool of general practitioners, Harvey said.
Some 8 percent of medical students graduating from Pitt this year chose general surgery. Although this is higher than the 3 percent seeking that specialty in the late 90s, it is down from 12 to 15 percent in the early 1990s.
Nationally, about 300 fewer general surgeons enter the field every year, according to a study in the September 2003 JAMA.
Like Harvey, Dr. Michael Fleming, president of the American Academy of Family Physicians, agreed that medical graduates also consider economic issues when choosing a specialty.
And with that, a health care network and payment system that is biased against specialtists works against attempts to increase participation in primary care, he said.
The payment system is set up for performing tests and procedures, a lot of which are done because they generate income, not because they are necessary.
“We have a very sick health system. The health care system values tests and procedures rather than taking care of people,” Fleming said. “The specialists do things, do procedures and therefore are more valued by the insurance companies and by the community. We value the wrong things.”
Family Medicine Loses
This emphasis devalues family medicine in the United States, he said.
“In Canada and Europe, a general practitioner makes 70 to 80 percent of the salary of a specialist. In the United States, primary care doctors make about half the salary of a specialist. That’s a significant devaluation and it’s because of the payment system.”
The growing number of women entering medical school also is influencing specialty choice, according to authors of the JAMA study.
Over the last 10 years, the percentage of first-year female medical students at Pitt has grown from 14 percent to 50 percent of the class.
However, Harvey and Fleming both agree that men are just as concerned with lifestyle issues as women.
“Traditionally, women have gone more into primary care areas than men, but I think that trend is changing here and nationally,” Harvey said. “Men are concerned with the same issues. They express a desire to have some control of their lives and family time in a way that is similar to women.”
Family considerations were a strong factor behind DeLuca’s decision to study psychiatry.
“Long-term I definitely had to consider what my life would be like if I had a family,” DeLuca said.
“Having seen some great mentors who were women and how they balanced their family life helped me to see it was doable in psychiatry, to be a mother and a physician.”
Source: www.post-gazette.com, May 11, 2004. The author, Joe Wilcox, is a freelance writer who occasionally reports on health issues.
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