Tuesday, October 19, 2004

Path of Least Resistance....
With a hat-tip to Graham (like the new look, BTW) for this link to a NPR story on the choices being made by fourth-year medical students across the country:Med Students Seeking Less-Demanding Specialties. Since it's pledge week at NPR I coughed up the $4.95 for the transcript so I can discuss it further.
Here goes:

This is MORNING EDITION from NPR News. I'm Steve Inskeep.

For most students, autumn is about buckling down to another year of studies. But fourth-year medical students have to think much further ahead. They have to make decisions about what kind of doctors they want to become. Today more and more medical students are opting to become specialists, raising predictions of a shortage of primary care doctors. To find out why, NPR's Julie Rovner traveled to Mt. Sinai Medical School in New York.....
JULIE ROVNER reporting:

It's been a long day for Bill Stebbins. He's a fourth-year medical student who's just started a new hospital rotation in internal medicine. During a brief break, Stebbins chugs the last of his umpteenth can of soda, delivering another dose of caffeine to his flagging system.

Mr. STEBBINS: And even though you know it has no calories, you know you're feeling good about yourself, that five years down the road you're probably going to die from whatever else is in here.

ROVNER: Stebbins' skin is about the same color as his green medical scrubs, thanks to a combination of a lack of sleep and the overhead fluorescent hospital lights. He looks older than his 26 years, but even with his deadpan delivery, he betrays his amateur status as he prepares to draw an arterial blood gas on a patient.

Mr. STEBBINS: Having blood drawn is not bad but when you dig for the radial artery and you have a moving target who's screaming, you're dealing with a needle as a med student, you know, the pressure's on.

ROVNER: The pressure's on in another part of Stebbins life, too. He has only a few weeks left to decide what kind of medical residency to apply for; in other words, how he wants to spend his medical career.

Mr. STEBBINS: It's a really tough decision to make and it's something that I think about every day and it's causing me mind-blowing amounts of stress, really. Like I've never felt more stressed in my life.

ROVNER: It's a big decision because switching specialties later is hard.

First off, it's the middle of October. If this guy has no idea of what he wants to do starting in July he is way behind in the ballgame. How many of Mr. Stebbins' classmates are still agonizing over this decision? How many have already filled out their online ERAS applications and how many have already scheduled interviews? Maybe NPR found out about him the same way they found their "swing voter". Mr. Stebbins needs to fish or cut bait or he may be disappointed come Match Day.
Mr. STEBBINS: My opinion wavers a lot on a day-to-day basis. If I had to get my obligation in tomorrow, I would specialize in dermatology. I would say that a lot of my decision is based on trying to find a field where I can have enough time to spend with patients and also spending time with my family and raising a family.

ROVNER: And he wants time for two of his other passions, music and tennis. Bill Stebbins thinks dermatology's nine-to-five schedule will offer him lifestyle heaven. Dr. Larry Smith says he's seeing more and more students like Bill Stebbins. Smith is dean of students at Mt. Sinai on Manhattan's Upper East Side.

Dr. LARRY SMITH (Dean, Mt. Sinai Medical School): I was really unaware of the almost Machiavellian thinking trying to scope out, you know, future incomes, future work hours, preservation of personal time. I realize that something had dramatically changed.
So serious research in to one's career choice, a career which is demanding regardless of specialty, is not wisely doing one's homework, it is instead "Machiavellian thinking". Especially when it goes against the desires of the academic medical establishment. I remember when I was in medical school there was an emphasis on choosing primary care as a career that bordered on demagogery.
Moving along:
ROVNER: So Smith set out to find out what. He read a series of studies by sociologists done for industry about intergenerational tensions in the workplace. And he discovered that what makes this generation of young doctors different is that they have very different priorities than their baby boomer parents.

Dr. SMITH: They are very much striving for balance. They saw the bad parts of open-ended commitment, which was what it did to their parents. I think the baby boomer generation had a lot of people who went for it 100 percent and became extraordinarily burnt out, were never home and if you just looked at, you know, the current 50-year-old physician, I mean, there's enormous discontent with their life.

ROVNER: Smith says, as a result, students are avoiding time-intensive generalist careers like internal medicine or pediatrics. They're gravitating instead towards specialties like dermatology, radiology and anesthesiology. Those offer more predictable working hours. But Smith says the unpopularity of primary care is about more than not wanting to be on call 24-7.

Dr. SMITH: I think the issue is, I'll be training a generation of doctors who are afraid to become people's doctor, as opposed to the specialist for a disease they may have or a procedure they may need. For a large number of the young physicians, they're fearful of that commitment. And this is really in stark contrast, I think, to a generation before, where, in fact, the concept of being someone's doctor was absolutely at the core of why most people went to medical school.

What about the fact that fifty percent of medical school applicants are women? Does not that play a role in the career mix of medical students? Or the desire to strive for "balance"? I'll have some more on the "doctors who are afraid to become people's doctor" in just a moment.
ROVNER: Back at the hospital, Bill Stebbins career conflict had intensified. He's just experienced for the first time the kind of excitement he's only ever seen on TV.

Mr. STEBBINS: That was a pretty wild scene. It was my first time ever being part of a code.
ROVNER: A code meaning the patient's heart had stopped. Bill and the rest of the team went to work.

Mr. STEBBINS: It was really exciting. You could feel your heart beating, sweaty, knowing that, you know, it's a time line of minutes.

ROVNER: The patient survived and was sent to recover in the intensive care unit. Bill knows he'd never be part of saving a life that way in dermatology and that's a hard thing to accept. On the other hand, he also knows that being a primary care physician has its own downside.

Mr. STEBBINS: The joys of being an internist when you were the--you know, that person's one doctor are now gone, because you are now the person standing in the way of them getting to the specialist. You know, when anything exciting comes up, your job is to send them to somebody else.
News flash for Mr. Stebbins: you don't always bring them back. Mr. Stebbins has a good point about what the internist has evolved into, a referral center. Why? Because for good or ill, that is what patients want and what the liability climate demands.
ROVNER: To some extent, today's medical students' desire to have a life outside of medicine is medical schools' own fault. Schools have recruited liberal arts majors like Bill Stebbins. The thinking was that a student with many interests makes a better doctor. Suzanne Rose is Mt. Sinai's associate dean.

Ms. SUZANNE ROSE (Associate Dean, Mt. Sinai Medical School): We have world-class musicians. We've had world-class athletes, somebody that went to the Olympics a few years ago. And some of them are reluctant to give up some of their passions and talents that they had prior to coming here.
I would disagree only to the point that I would have said to a "great extent' the schools are to blame. These bright young minds realized early that there was more to life than being a premed student. They see no need to change their hobbies to accommodate their career. The recruitment of more "academically diverse" students was supposed to create not only better physicians but more "humanistic" ones as well. Fewer technocratic biochemisty majors and more "balanced" liberal arts majors. This apparently has not worked as expected if today's students are "afraid to become people's doctor".
ROVNER: Baby boomer Rose is a gastroenterologist by training, one of the first women to pursue that demanding specialty. And she says she went after it with everything she had, sacrificing her other priorities.

Ms. ROSE: I have missed many events in my kid's life. I missed my son's first haircut, which is on video. He's now 19 years old and is doing well. And sometimes he jokes with me that I wasn't really his mother. It was some other nanny that took care of him.
Medical students are many things, but stupid usually isn't one of them. They can see the increased liability, diminished reimbursement, and other hassles of practicing medicine. They see no need to sacrifice their marriage, family life, or outside interests for what they see as less as a profession, and more of, well, just a job.
ROVNER: Rose says she's exactly the role model many of today's students don't want. But she's also afraid the balance may be shifting too far in the other direction; that today's students aren't willing to push themselves enough. She recalls one very bright student last year who was looking at some of the easiest programs available.

Ms. ROSE: And I said to him, `Why don't you go to the most academic program you can go to?' And he said, `I don't want to work that hard.' And to me that was shocking. And I said, `What do you mean by that? Don't you want to be the best doctor you can be?' He said, `I'll be great but I don't need to do that. I don't need to work as hard as you worked.'
And with the 80-hour workweek limits, he won't have to. The pooh-bahs mentioned above are wringing their hands because of what my landlord refers to as the "Beckham Rule". Medical school and residency have been altered to make them "easier" and "user friendly". And the powers-that-be are shocked, shocked! when students attempt to maximize the ease and user-friendliness of the system. What do they expect?
Cross-posted at Galen's Log
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