Medical Education Feature -- August 2003
By Ken Ortolon
If you knew what you know now when you enrolled in medical school, would you do it again? A growing number of America's newly trained physicians say no. They apparently are so disillusioned with medicine they would pick another career if they had the decision to make again. So says a recent survey of resident physicians.
Some of those responsible for training the next generation of physicians say that could have dire consequences for the nation's physician workforce -- and the patients who depend on physicians for care -- in future years.
According to the 2003 Survey of Final Year Medical Residents conducted in February and March by Merritt, Hawkins & Associates, 24 percent of residents say they would select a field other than medicine if they could begin their education again. That's almost five times the number of residents who were having second thoughts just two years ago. In 2001, only 5 percent said they would do something else. The number was 11 percent in 1999.
"I think it caught everybody off guard this year," said Mark Smith, executive vice president of the Dallas-based physician search and consulting firm. "I'm not surprised that it increased, but I am surprised it increased that much."
The survey, conducted by the company every other year, was mailed to 4,870 residents selected randomly. Three hundred and twenty-five completed surveys were returned. The survey polled residents in specialties Merritt, Hawkins considered to be in high demand, including anesthesiology, cardiology, dermatology, gastroenterology, neurology, oncology, orthopedic surgery, otolaryngology, and radiology. Unlike previous surveys, Merritt, Hawkins did not include primary care physicians because they were deemed to be in less demand than other specialists.
"Even before they enter the world of professional practice, many newly trained physicians wonder why they didn't chart a different course," said Merritt, Hawkins Chief Executive Officer Joseph Hawkins. "This should be an exciting time for doctors 'coming out.' Instead, many of them are already disillusioned with medicine."
Scott Holliday, MD, a third-year anesthesiology resident at The University of Texas Health Science Center at San Antonio, says a few of his colleagues have discussed alternative careers, such as going back to school after their residency to get a master's degree in business administration and entering a medically related business field. "I've heard people actually mention going to law school, finishing up, and maybe entering into another profession post-residency."
Both Dr. Holliday and Ned Snyder, MD, a plastic surgery resident at The University of Texas Medical Branch at Galveston, say much of the frustration comes from the uncertainty about medicine's future.
"The climate of medicine is very frustrating," Dr. Holliday said. "A lot of that frustration comes from uncertainty. What does the future of medicine hold? How is Medicare-Medicaid reimbursement going to affect our careers?"
Dr. Snyder says he thinks a lot of frustration also may come from the training process itself rather than dissatisfaction with medicine. "For the most part, the people I know, even the people who are disgruntled with their training process, feel like there's an end point, and they don't think they would choose to do something different in the end," he said.
"Medicine is a long haul," Dr. Holliday added. "It requires a lot of perseverance and dedication. But the rewards in the end greatly outweigh the time and dedication you've had to put forth."
Lois L. Bready, MD, associate dean for graduate medical education at UT San Antonio, says it's natural for residents to have some discontent after years of hard work and few rewards.
"If you're asking people at the end of their training, many of them are pretty well ready to go on to the next step in their career," Dr. Bready said. "They're a little bit disillusioned with what they've been through."
Mr. Smith says the survey indicates that several factors contribute to residents' dissatisfaction, including school loan debt, managed care and reimbursement problems, increased government intervention in medical practice, and lifestyle issues. But foremost on the list is the medical liability climate. Sixty-two percent of residents who answered the survey say they have significant concerns about professional liability. Insufficient practice management knowledge and availability of free time also ranked high.
"The publicity [about rising liability premiums] has been significant, much more than it has been in the past," Mr. Smith said. "It's something that's made every publication nationally at some time or another. That's really struck a chord with these physicians."
Older physicians' dissatisfaction also is a factor rubbing off on the new generation, Mr. Smith believes. "Much of the discontent of these newly graduating physicians, if you will, is based around the lack of satisfaction among their older mentors and peers. You have physicians in the 50-plus crowd who are disenchanted with medicine. They've lived through the managed care days. There's a pretty high frustration level among physicians about lack of control, about income, about malpractice. I wouldn't want to understate those individuals' influence on these residents."
Roland Goertz, MD, chief executive officer of the McLennan County Medical Education and Research Foundation in Waco, which trains primary care residents, agrees. "All of this has added up," he said. "Liability issues, older doctors in the prime of their careers lamenting about the fact that medicine is not what it used to be. Young learners, residents, are not immune to hearing all of those issues and reading about all of those issues."
Where's the Reward?
Do most young physicians still perceive that the rewards are adequate? Dr. Goertz has some doubts.
"Our system has worked so well because it has attracted the brightest and the best into medicine," he said. "It has worked that well because there have been rewards out there that have been perceived by those pursuing those careers as being congruent with what's expected of them. That's where the disconnect begins to happen. Those rewards do not appear to be satisfactory to a significant number of the best and the brightest to overcome what's expected of them."
Dr. Goertz says medical schools already are seeing a shrinking pool of applicants. If a significant number of disillusioned residents were to choose another career, that could have a dramatic impact on the physician workforce, he says.
"That is a huge concern, if you pair it with the results of other polls showing that more than half of physicians over age 50 or 55 would retire tomorrow if they could," Dr. Goertz said. "Those are all indications that you have a loss of desire to fulfill the physician role the way most of use who were trained more than 10 or 15 years ago intended to fulfill it. That has some dire ramifications on society, whether we want to admit it or not."
All of this occurs while there is added pressure to turn out more physicians. "It's no mystery that the generation going through [medical school] now is a little bit different as a group than some of the prior generations have been," Dr. Bready said. "There is a much broader mixture of folks going through now than there was maybe a generation and a half ago. It's not all white men anymore. So you have individuals who are balancing more than just their careers."
Dr. Bready says that has caused a progressive decline in the number of hours worked by the average physician. "If you're going to have to deliver the same amount of care with fewer hours worked per week by provider, clearly you need more providers," she said.
Mr. Smith says much of the current dissatisfaction among residents may dissipate as they move into practice and reap the financial rewards that come with being a physician.
"They've been seeing all the downsides without experiencing any of the benefit," he said. "There's a big change going from being a fellow or resident making $30,000 to having a base salary of $300,000 or $350,000. That can overcome a lot of woes."
But income is only part of the equation for today's young physician, he adds. The marketplace is going to have to show the flexibility to provide the type of practice environment these physicians want, he says.
"Part of it will come from allowing them to create an opportunity that meets their needs or meets their desires, whether that is a certain amount of time off, a minimal amount of call, a certain amount of flexibility in their schedule, control and input into their practice," Mr. Smith said.
"It isn't as if these physicians are going to leave medicine, but they're going to demand more from it than did their fathers and mothers and the people that recruited them into the field. The marketplace now has to respond to these physicians to say, 'What is it you want? What would make you happy? What can we do to offset this dissatisfaction that exists?' That's one thing about a free-market economy, it does respond. And it's amazing the impact it can have."
Ken Ortolon can be reached at (880) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.
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