“Always Do Right. Gratify Some People, and Astonish the Rest.”

Below, an excerpt from an article in the most recent (December 23 ) New England Journal of Medicine titled  “Medicine’s Ethical Responsibility for Health Care Reform — The Top Five List, by Howard Brody, M.D., Ph.D. ”    (At the end of the excerpt, I offer my commentary. )

“Early in 2009, members of major health care–related industries such as insurance companies, pharmaceutical manufacturers, medical device makers, and hospitals all agreed to forgo some future profits to show support for the Obama administration’s health care reform efforts. Skeptics have questioned the value of these promises, regarding at least some of them as more cosmetic than substantive. Nonetheless, these industries made a gesture and scored some public-relations points.

“The medical profession’s reaction has been quite different. Although major professional organizations have endorsed various reform measures, no promises have been made in terms of cutting any future medical costs. Indeed, in some cases, physician support has been made contingent on promises that physicians’ income would not be negatively affected by reform.

“It is appropriate to question the ethics of organized medicine’s public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the “special interests” affected by health care reform, justify demanding protection from revenue losses?   . . .

“the myth that physicians are innocent bystanders merely watching health care costs zoom out of control cannot be sustained. What we now know about regional variation in costs within the United States suggests that nearly one third of health care costs could be saved without depriving any patient of beneficial care, if physicians in higher-cost regions ordered tests and treatments in a pattern similar to that followed by physicians in lower-cost regions.. . .

“ Physicians should recognize that the high cost of future medical care is one of the main stumbling blocks to the passage of health care reform legislation that would extend insurance coverage to most Americans who now lack it . . .

“In my view, organized medicine must reverse its current approach to the political negotiations over health care reform. I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty’s “Top Five” list. The panels should include members with special expertise in clinical epidemiology, biostatistics, health policy, and evidence-based appraisal. The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit. Examples of items that could easily end up on such lists include arthroscopic surgery for knee osteoarthritis and many common uses of computed tomographic scans, which not only add to costs but also expose patients to the risks of radiation.^4,5 

“Having once agreed on the Top Five list, each specialty society should come up with an implementation plan for educating its members as quickly as possible to discourage the use of the listed tests or treatments for specified categories of patients.  . . .

“Some societies will be tempted to bluff their way through the Top Five exercise, deliberately omitting cost-cutting measures that would particularly affect members’ revenue streams. Societies could display their professional seriousness by submitting their lists for review and comment to several societies in other specialties.

“Some would object that considerably more comparative-effectiveness research is needed before such lists can be compiled and implementation strategies developed. And indeed, today we have no idea how to implement a practical plan that would recapture the roughly 30% of health care expenditures estimated to be wasted on nonbeneficial measures. I would guess, however, that if we were trying to save that entire sum of money, we would be proposing “Top Twenty” or “Top Fifty” lists for many specialties, not just the Top Five. I suggest that no matter how desirable more research is, we know enough today to make at least a down payment on medicine’s cost-cutting effort. As good citizens and patients’ advocates, we should begin where we can.

“A Top Five list also has the advantage that if we restrict ourselves to the most egregious causes of waste, we can demonstrate to a skeptical public that we are genuinely protecting patients’ interests and not simply “rationing” health care, regardless of the benefit, for cost-cutting purposes. As we inched closer to the entire 30% savings, we would inevitably face increasingly controversial treatment cutbacks — cases in which a substantial minority of experts believed a treatment provided real benefits for many populations. Such controversies should be postponed until the evidence is clearer and a more acceptable national structure for adjudicating such debates is in place.

“Another objection might come from primary care specialties. Given the serious shortage of primary care physicians in the United States, due partly to the income gap between that field and others, shouldn’t societies of primary care physicians get a pass on the Top Five list? Although I’m sensitive to the urgent need for increasing the primary care workforce, I would argue that all physicians have ethical responsibilities. Showing that we are ready to stand alongside all other specialties in examining our own practices in light of the best scientific evidence is an important aspect of professional integrity and should not be avoided by any specialty.

“Finally, the best rebuttal to the antireform argument that all efforts to control medical costs amount to the “government getting between you and your doctor” is to have physicians, not “government,” take the lead in identifying the waste to be eliminated. Mark Twain said, “Always do right. This will gratify some people and astonish the rest.”  

  ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

My take:  First, let me say that I consider the sums that Pharma, device-makers and hospitals have agreed to give up are relatively small when compared to what needs to be done. Many drugs and devices are hugely over-priced; many hospitals are extraordinarily wasteful. In the past ten years, private insurers have done little to rein in costs.

That said, Brody makes a good point: “Where are the doctors?”

If we are going to make our bloated health care system affordable, virtually everyone will have to give up something.  There is no one villain in our dysfunctional system.  All of us (including patients) are complicit.  Just like members of a dysfunctional family, we are accustomed to things being done in a certain, counter-productive way.

I do agree that primary care physicians, geriatricians, palliative care specialists, pediatricians, psychologists, and others who practice “cognitive medicine” (listening to and talking to patients) are underpaid. But in order to stay afloat, many find themselves becoming more entrepreneurial in ways that may be hurting patients—and probably aren’t helping them.

For example, sometimes it’s more economical for a primary care physician to simply refer the patient to a specialist, and move on to the next customer, spending no more than 8 to 10 minutes with each.  In some of these cases, the family practitioner gives up the chance to use what he knows about a patient he has been seeing for a numbers of years. If he asked questions, really listened, and explored the problem , perhaps he would arrive at a better diagnosis. He might be able to detect and treat the illness himself. At the very least, he could make a better referral.  Too often, a primary care physician recommends a patient to a specialist who runs some tests—and refers her to another specialist.  The patient may wind up seeing three or four specialists before ever getting a diagnosis that leads to effective treatment.

 So I agree that primary care doctors and others in this group should come up with their own list of the 5 most wasteful practices.

 At the same time, I think we should boost the incomes of doctors who practice cognitive care by paying them significantly more for the time they spend explaining risks and benefits to patients, answering phone calls and e-mails, advising families on how to care for patients at home, talking to patients about how to participate in their own care, and most importantly, counseling, consoling and caring for their patients.  Net, net, these physicians should see their incomes climb so that they don’t feel the need to find other ways to boost the bottom line.

What I like most about Brody’s idea is that it asks specialties to begin to put their own houses in order.

There is a limit to what we can accomplish through legislation. Physicians know, better than anyone else (except, perhaps, nurses), where the waste is in their own specialty.  I think of how anesthesiologists reduced patient risk by examining their own practices, and figuring out how to make their patients far  safer. (The number of lawsuits fell dramatically.)

 While we wait for health care reform to become a reality, three or four years from  now,  physicians should seize the opportunity to lead reform.

Comments

[Maggie Mahar]

Concernred FP--

Thanks. Test-taking is a particular skill and if you're good at taking one test, you're probably good at taking all tests.

I was always extremely good at taking tests, as is my son. My daughter isn't. They're both extremely bright, bright enough to make very good doctors if that was what they wanted to do.

And as a teacher, I saw kids who could ace a test, and those who couldn't.

On GPAs--I understand what you're saying about GPA's showing determination, commitment, persistence, etc. over the long haul.

But pre-meds typically take many math and science courses, and much, if not all of their grade depends on tests . So we're back to favoring the good test-takers.

Also, as someone else on the thread noted, many pre-meds don't dare taking courses in the humanities because they don't have as much practice writing papeprs, know that other students in a really good seminar will be majors, and are afraida "B"will hurt their GPA.

I did have med students in my English seminars, and they tended to be better in class discussion than in the papers.

But they didnt' get discouraged becaue I didn't put grades on any of hte papers-- I wanted students to just keep improving, competing with themselves.

So instead of giving a grade, I would type up a cover sheet of comments. Often fairly long (you can imagine!)

I kept a carbon of the comments, and at the end of the term, re-read the comments when assigning a grade.

In order to figure out how I felt about hte paper, the students had to read the comments. (Too often, students just look at the grade.)

And at the beginning of the year, I explained that their final grade would be based partly on progress. Throughout the term, I I would look at my comments on their last paper before reading their next paper to see if they were responding to the comments.

As long as the pre-meds did the reading and thought about it (I could tell in class discusssion--I called on people who didn't have their hand up) I often gave them As instead of Bs just because I wanted to encourage them--and I didn't want to hurt their chances of getting into med school.

I agree; humanities courses should be required for pre-meds. And rather than focusing so much on the GPA, med school admissions panels should look at the transcript. If the students is getting As in very difficult science and math courses and Bs in what look like serious humanities courses, that should be fine.

The problem with the emphaiss on the GPA is that it makes pre-meds too cautious when picking courses. . (Also if a student is coming from a small college that is not at all well known, it's hard to know what to make of the GPA. )

At the Mayo Conference, the speaker was suggesting two or three interviews for med school admissions while putting less emphasis on scores.

And let me be clear, he was suggesting including students with a GPA of 3.6 instead of 4 in the pool--still dedicated students and hard workers.

Jenga-

Maybe very competitive people are very good team players in football, but in life that's not the case.

And while people don't fit into neat pigeonholes, people at the extremes can be categorized as "very competitive" and "excellent at collaborating."

We won't agree on this. Let me just say that very compeitive docotors often don't
collaborate well with nurses and others.

They tend to become annoyed if a nurse speaks up and says, "Doctor, you forgot number 3 on the checklist."

And I don't want someone operating on me because he's competing with another surgeon to to see who can take on the most difficult cases.

Please just tell me: "You're not a good candidate for surgery--the risks are too high.

[Concerned.FP]

Maggie,

I agree with your assessment of the MCATs and testing in general. Good test-takers are trained to take tests. High scores on tests are a result of excellent training in taking tests and not a reflection on clinical aptitude or clinical decision making. Also, folks who take standardized tests well, tend to take all standardized tests well whether it’s the MCATs, USMLE, Boards, or SATs. I agree there's too much emphasis on the MCATs and standardized testing for its own sake. I think these tests give administrators a contrived, arbitrary, but "objective looking" score by which to judge a candidate for admission... It also comes with the built in CYA, because if the medical student turns out to be a dud, you can't blame the administrator because "so and so's MCATs were off the charts."

I disagree when it comes to GPA. Unlike the MCATs, GPA is a measure of effort, drive, dedication, and, to a degree, intelligence over an extended period of time. I have found that the folks who have high GPA's tend to carry these qualities which I think are necessary to becoming a good physician. Note these qualities are necessary, but not sufficient. They still need excellent critical thinking, good communication skills, and compassion. I think taking your literature class at Yale (or one's like it) should be mandatory for all pre-meds. After your class, I'm certain their critical thinking and communication skills will have bumped up a notch or two.

A few years back, undergraduate admissions directors in California and Texas were moving away from the SAT and instead emphasizing GPA and high school graduation rank for the reasons described above. They had found that GPA was a better indicator of success than the SAT. For all his faults, I think even Larry Summers while president of Harvard made a similar statement.

[jenga]

First, people don't fit into nice categories "team player" or "competitive". It is not an either or proposition and is a false choice. I would say you want both qualities. Any will tell you he best team players are often the most competitive, because they care how the team does more than other members. They desire to improve. Pushing yourself to get better is a good thing not a negative.

MCAT- We don't know if MCAT scores correlate with
clinical ability because we really don't know how to measure clinical ability. Other than opinion, Resident and Intern performance is entirely dependant on an attending's opinion. There is no metric. The Mayo statement is a tagline every school will say or try and demonstrate the same. We don't who will have the best clinical ability, heck we're not even quite sure who the best physicians out in practice are. We have ideas but results can easily vary due to patient demographics, practice arrangements, etc.

And you didn't answer the question if you admit more people that are "poor test takers", what are you going to do if they end up being poor test takers on their board examinations? Will they get a pass there as well? Would you want a non board certified physician operating on you and yours? Because the metric we do know, MCAT correlates to USMLE which correlates to Board Exams.

I've been teaching med students, interns and residents for about a decade as well. I've known all kinds but the handfull I know that were absolutely truly talented, most, not all crushed such tests. The handfull that were truly knuckleheads and I would tend to look elsewhere if sick usually didn't.

[Maggie Mahar]

Jenga-

MCAT scores do not correlate with clinical ability. In fact, the more years that pass after residency, the less correlation there is.

One of the things I like about Mayo is that it puts clinical ability first.

Docs who scored well on their MCATS may be great researchers, but if they are going to choose clinical pracice, I'm more interested in how they are with patients.

Wealthier students who go to private schools are taught to take tests. Much of private education in this country is about preparing to take SATs adn getting into a "top" school.

The fact that lower-income students are not as good at test-taking simply means that they have not been trained to take tests. (And in their world, "how did you do on the test" is not what their peers or their parents focus on.)

Teaching studnets at Yale for 11 years (including 4 years as a grad student) I knew many students who tested well and many who didn't. When it comes to ability to think critically, imagination, empathy, intuition, etc. etc. test-taking skills just aren't that important.

Finally, good test-takers tend to be very competitive.

Increasingly medical schools are realizing that very competitive students are not good team-players, and today, medicine is a team sport.

[jenga]

One thing I left out is "service". If I have one bias for, it is military service. Medical training is very regimented and people with military experience have proven their commitment and often do extremely well. They have not just have written their "service" on a piece of paper, they've lived it.

[jenga]

Maggie,
I agree on one point and disagree on two points.

I agree, I think GPA is overvalued. It's too subjective. You are dealing with bias and perceptions of schools and in no way are comparing apples to apples. There can even be bias in the same school due to different teachers. I know personally for me, I never made a 4.0 until I was in medical school. I think you could relax that and not effect graduates.

I disagree about the MCAT. MCAT scores do correlate to the USMLE. The USMLE correlates to the national board exam. The MOST important aspect of a physician's job is medical decision making. Remember First Do No Harm. We all want less mistakes and relaxing the only metric that has a window into decision making is a mistake. It is the only objective apples to apples comparision we have. Some can better prepare true, but it's the same test for everyone. Everyone knows that. If you lower the standards for Socioeconomic Class. Do you lower the USMLE when they get there? Do lower their standards for the national board exam when they get there? Which gets to my final disagreement.

At somepoint you have to buck up and do it yourself and stop using your background as a crutch or a stepping stone, a patient's life doesn't grade on a curve. Eventually you have to overcome any perceived disadvantages, and privilege can be a distandvantage as well, and make it on your own. It is insulting to those in the low socioeconomic class, myself included, to think you constantly have to make excuses for them or to think they can't compete with those that are more well off.

You should sit in on an interview. Nobody knows who is interested in primary care. THEY ALL want to be rural family physicians, which gets back to my main point. Just train more PCPs and less specialists if thats what you want to do. These complex algorithms, carrots and sticks, cajoling are weak and unneeded when the direct mechanism is already in place.

You don't need to verify family income until after someone gets in. Most students get loans. Unless you are saying in addition to lowering standards, adding gold stars to their chart for their financial status we must also pay for most of their school. Again when do you let them stand on their own and stop making excuses.

[doubleaseven]

I completely agree with the Author. In fact I wrote a note on AMA's unethical behavior on this topic and another one on responsibility of all the stake holders. Both fell on deaf ears.

http://wp.me/PzWG3-1j
http://wp.me/PzWG3-3A

[Maggie Mahar]

Jenga--

First, this is not my idea.
It came from a Mayo Clinic conference on how we should reorganize medical educatoin.

We need mroe students who want to be primary care docs in inner cities and in rural areas.

Surveys of what students actually do after med school shows that African Americans are much more likely to become family docs in inner city ghettos.

Kids from poor rural areas are much more likely to practice in poor rural areas.

The majority of kids from famlies in the top quintile have little interest in primary care or in practicing in poor areas.

Meanwhile, each year, the % of students admitted to med school from the top quintile rises, while the % admitted from the lower 4 quintiles drops.

Thus, the AMA recently urged that: ". Admission criteria should focus on recruiting those students who are most likely to care for the neediest patients, despite the obstacles."

(This issue brief explains that this means admitting more low-income students.)

Low-income students who apply to med school have somewhat lower GPAs and test scores. The Mayo Clinic conference (and others) argue that med schools should lower the bar for admission--perhpas a 3.5 GPA rather than a 3.8 (out of 4).

Reserach shows that after med school the low-income students with lower scores is just as good a clnician.

Unfortunately, too many people interviewing students for med school tend to feel that the candidate who would make a good doctor is someone who reminds them of themselves.

Family income is very relevant. Students from low-income homes are much more interested in "service" -- and are willing to practice where they are needed--in poorer areas.

Finally, yes of course verification of family income is needed, just as it is for medical school scholarships and loans based on need.

Funding for those need-based scholarhips has been doubled in the Senate bill.

[jenga]

Why wouldn't they jsmith?

I'm an idealist I think the best candidate should get the position. I certainly don't think of someone as boorish, self absorbed or sophmoric based on their political leanings, which I guess happens in the undergraduate world. But it shouldn't in medicine, and that is the natural progession where this conversation is going. I think most Americans including myself, don't care what humanities my physician took in college, the last nonmedical book they read is, if they own a Che Guevera Tshirt, if they've ever seen CATS or what they think of Mike "the Situation". . Yes, I like everyone want to see caring and compassion in a Doc, but you know what I want more than anything, the right diagnosis and treatment in the most efficient manner possible. Invoking Occum's Razor, less specialists, train less. More PCPs, train more.

[jsmith]

Maggie, I think you mis-read my unclear post. I was trying to state that med schools probably won't enroll a lot of low-income students. I was not saying that low-income students would not choose primary care.

[jenga]

Maggie,
I've been in probably 50 med school interviews and I can tell you probably 49 of those stated they wanted to be rural family practice physicians and they want to help people and their community. Are you suggesting we add their parent's 1040s to their file and if so why stop there? Should we ask who they voted for in the presidential election and and what party they belong to and only admit Democrats that are pro abortion that voted for Obama? That's the road you are heading down unless you simply look for the candidate you feel will make the best physician based on interview and objective data. A family's financial status is irrelevant to how good a physician they will be. Private schools really don't matter as much as you think they do. They have no bearing in selection. I went to a very small state school and in my group of 10, I beat out 8, 1 from Yale, 1 from Columbia and two from other private schools. And after seeing it from the inside, private schools and certainly income do not matter nor should they.

I'll say again if you want less specialists, don't train them. It's far simpler.

[Maggie Mahar]

jsmith, Jenga, Legacy,

jsmith-- I think that admitting low-income students is LIKELY (not "unlikely" as you suggest in your correction) to happen at our med schools for a couple of reasons:

1) the Senate bill doubles the amount of money available for studens in terms of scholarships

2) many med schools are realizing that the students they are admitting are not the doctors we need for a new health care system.

Most people agree that medicine has become a "team sport." We need doctors who know how to collaborate with other docs, nurses, etc.

The bright, very competitive, type A personalities coming from a private schools who have been in teh majority in med schools classes doesn't work as well in that collaborative situation. They don't want to be Indians. They want ot be the chief.

Med schools also recognize that we need more doctors who are committed to "service" to the community. Experience shows that low-income students are more likely to embrace this idea.

Not all med schools will be in the vanguard of the change. But many will be.

Finally, in terms of whether "more money" is the best way to build our supply of primary care docs.. .

We don't need doctors who go into primary care because the money is better than it once was.

We want people going into primary care becuase they Want primary care-- long-term relationship with patients,
service to a community, etc.

Family practice requires much work and dedication. You can't bribe people into doing it.

Jenga-- yes, medicare does have control over specialty slots.

And I think they will use it.

They may or may not cut specialty slots (though they could, without harming the system).

But I think Medicare will fight the pressure to increase specialty slots (coming from certain lobbies)--and reduce them at least in some specialties where we have a surplus of docs, and too much overtreatment. .

And I think they will increase the slots for primary care, etc.

Bottom line: you are right. Supply is key. And this can be done.

Legacy--

I agree that nurse practioners and phsycians' assitants will be key to solving the primary care shortage.

Right now, we have a nursing shortage in large part because nursing school teachers are paid poorly.

This makes it difficult to recruit teachers.

I'm told that there ia long line of qualified candidates trying to get into nursing school (especially today--it's a stable profession), but not enough space in the schools for these students because not enough teachers.

I know that the House bill hiked pay for nursing school teachers. I'm not sure if that provision is in the Senate bill.

If it's not, it could be added as they merge the bills. (It's hard to imagine that there is a great deal of opposition in Congress to the idea of paying nursing school teachers more.)

[jsmith]

My last post should have read "not very likely...". Apologies.
Legacy Flyer, Absolutely. I have an NP that I supervise now. She's great. I don't know if the feds have a plan for more NPs and PAs (I don't know that they don't either), but I think we're headed that way in any case because of med students' choices.
jenga, Well, that might work. The problem is political, as I am sure you know.

[jenga]

jsmith,
Actually the simplest way to train more primary care residents is to do just that. HHS has the pursestrings for residencies. Medicare currently funds the vast majority of residency slots now. If you want less specialists, simply stop funding and cut say 20% of specialty residency slots, close those and give them to primary care residencies. It closes the gap and is guaranteed to work. If you want fewer specialists, train fewer specialists.

[Legacy Flyer]

jsmith,

I think the feds do have a plan and that plan is to make a lot more nurse practitioners and physician's assistants to fill the gap.

Question for you: Do you (or would you consider) use(ing) PAs or NPs in your practice to "extend" your ability to take of patients?

[jsmith]

Maggie,You are correct that demographics predict specialty choice. But notice that I said "enough" primary care docs, not "more" primary care docs. It is estimated we will down down over 100000 of us in the next decade or so. Admitting enough students of the correct demographic 1) is very likely to happen given the realities of the admission process in the US and 2) would probably not close the gap even if it did happen. The best, simplest, most effective solution is more money, which will attract those students, who, for good or for for ill, will likely make up the bulk of med students for the foreseeable future. Unfortunately, it is probably not going to happen to the extent it needs to. Prediction: worsening shortage.

[Maggie Mahar]

Keith, Fred, Richard, Legacy, Concerned FP, Dr. Rick, Sharon

Keith--- What you say about avoiding humanities courses that might bring down your GPA underlines the fact that, in admitting students, we put too much emphasis on GPA and tests scores--too little on maturity, character and the knowledge that can lead to wisdom..

Fred--
Yes, we cannot afford to add to the total amount that we are spending on doctors. We need to cut what we pay for less effective treatments to raise the money to pay primary care docs more.

jsmith- You write: "If we want enough primary care docs, the only way to get them is more money."

No the evidence shows that one way to do it is to admit more low-income students. (See my long reply to everyone.)

This also means finding bright kids interested in medicine in inner-city and poor rural schools in high school, mentoring them through high school, college and the med school admisssions process.

With much more generous scholarships and loans available, more low-income kids will be going to med school.

Richard--
Certainly, some specialties won't come up with honest "top five" lists. But some will.
Much depends on the leadership in the specialty society . .
If 1/3 of the specialties took the challenge seriously, this would be enormously helpful.
On college education:
First, I'm afriad I have met quite a few doctors who don't continue reading adn learning after college, except it their specialty (and some dont' do that.
What percentage of doctors read history, good novels, serious political writing while practicing medicine?
I enjoy talking to doctors, interviewing them, etc., because on the whole they are bright.

But we have all met insensitive, boorish doctrors-- people who seem incapable of imagining what another person (i.e. the patient) is thinking or feeling. As a result, they're not very good doctors. (Unless they have no patient contact.)

Based on my experience teaching undergraduates, I would say that a great many college sophomores fit the "boorish, insenstiive and self-absorbed" profile. Hence the word "sophmoric."

But somehow, by the end of senior year, their minds and imaginations have opened.

You can see this in many ways. Poll college sophomores and seniors on a question like

"Do you think we should quarantine people with AIDS on an island?"

or "Do you think George Bush is one of our greatest presidents"

and you'll find that four years of college makes an enormous difference.

Legacy-
I agree that many students choose a specialty because, like you, they find it intellectually fascinating.
This is one of the best reasons to pick an area of expertise.
I also think that your generation of med students was less money-conscious than med students a decade later. The whole society was more money-driven a decade later.
I too don't think people should be forced into primary care--or bribed into primary care.
But I do think that broadening the pool of applicants will bring in more students who want to go into primary care. (See my long comment addressed "To Everyone."
As you say, in medical school, as in life, there are "types"-- the guy who is going to be an ortho-pod, the one who will pick plastic surgery . . .
People don't always conform to "type-casting" but to some degree we do.
And kids coming from poorer families just seem more interested in family care, maybe because, in their own famlies, they became caregivers at a young age, maybe because as children, they saw people in their families not getting the basic care they need.
For whatever reason, they seem more service-oriented. And we need them in the profession.

Dr. Rick-- very good questions. And I do think that much of what ails us is stress-related.

Concerned FP--
I agree about externalities.

Antoher way to put it is this: today we pay doctors according to how much it costs them in: time, physical effort, mental effort, years of educatoin needed etc. to perform a procedure.

What we don't factor in (anywhere in the equation) is how much the patient (Or society) benefits.

So a doctor could spend hours counseling a patient and getting him off tobacco, and be paid far less than a doctor performing one of those procedures that Jenga describes as "sexy."

Sharon MD-
I think your generation of young doctors are less money-driven than many med students were back in the 1980s. (By the time you went to med school, it was clear that medicine wasn't a clear path to easy money.)

And I agree about restructuring loans.

Finally , the fact that you compare your disposable income to your parents-- and feel lucky-- relates to what I was saying in the long comment to "everyone."

Money is relative.

[Maggie Mahar]

Everyone-- Since many of you are discussing the same issue, let me respond to all of you at once. (Later, I'll add some individual responses.)

First, let me address the argument that med students ultimately pick a specialty based on how much they will make-- that money is the primary consideration.

Reserach shows that this is not true of everyone. Students coming from low-income families are much more likely to choose primary care or family practice. And, they are very likely to want to practice in an area like the area where they grew up- a poor rural area or an inner city.

As this recent article from JAMA points out:

"Money is not the only consideration, . . . Medical career choice involves many factors. For example, students who grew up in rural areas and those with a demonstrated interest in caring for underserved groups are more likely than others to practice primary care.
" And students at public medical schools are more likely to choose primary care careers than those at private schools, as are students in rural as opposed to urban schools."

Why are students from low-income famlies more like to choose famly practice?

Perhaps they don't feel that they need as much money to live well--and their definition of "living well" may be different.

As we all know, wealth is always relative, and beauty in the eye of the beholder. Someone growing up in a household where her parents have a joint income of $45,000 is likely to feel satisifed with a smaller home, less expensive car, clothing, etc. than something who grew up in a home where the parents have joint income of $200,000.

In the case of the low-income student, their parents (and their parents' friends)may be less likely to measure their success in terms of how much they make. (Or parents and friends will feel they the young primary care doctor is very successful, even if he is making only $125,000.)

Perhaps those from low-income homes don't feel as much of a need to compete with others in terms of where they go on vacation, whether they send children to private schools, etc.

Service-- "giving back" to their community seems to be important to low-income students (which is why they typically go back to the poor communities where they grew up) and the satisfaction that they get may be more important than money.

Meanwhile, if we want more primary care docs, we're admitting the wrong kids to medical school. The quotes below are from an article by Dr Robert Bowman on medical school admissions http://www.unmc.edu/Community/ruralmeded/admissions_income_quintile.htm.

"Those most likely to gain admission [to medical schools today] have the highest income levels, and are children of professionals. . .

In 2003, "60% to 65% of students admitted to med school" came from famliies who are among the wealthiest 20% in the nation. And "the percentage of med students coming from these wealthiest homes was rising by 2% a year."
In 2003 dollars, these were households reporting mean income of $140,309. . "About 1 out of 60 kids in this income group who was medical school age are admitted to medical school, about 1 out of 20 if they were Asian or Indian.

"Basically those that want medical school can get medical school in this income group. The students in this group grew up in high income and professional families and private schools in greatest percentages."

When Bowman writes "Those who want medical school can get it" he is referring to the fact that the pool of affluent children of professionals who went to private schools competing for the slots is relatively small, making the odds of getting in relatively high.

(It is much harder to get into med school in Canada because med school is subsidized, and students from a much wider demographic apply.)

There are few older or rural-born students in this high-income group.

"This group is likely to include the youngest students, those who are potentially less mature, and are the ones who are more easily influenced by surroundings such as charismatic faculty, medical school environment, peers, . . . "

They are least likely to choose "family medicine, rural locations, and primary care poverty. "

By contrast, when you drop down to the second step from the top on a 5 step income ladder, you find that students are coming from homes with "a . mean income of $65,812
18 - 22% of medical students come from this group." They have a harder time getting in (just 1 out of 209 are admitted.") When it comes to picking a specialty, you find " a balanced choice of family medicine, rural, and poverty careers."

Money just doesn't seem to be as important.

Drop down to the 3rd step on a 5 step income ladder: $42,930 family income; 9-13% of med students coming from this group; there chances of being admitted are just 1 in 403.

In this group, more and more students are choosing primary care, rural care primary care in very poor areas. Many African Americans in this group.

Move down to the bottom two steps on the income ladder, the number choosing primary care, and"proverty primary care" increases. Here you find more black males, rural males and Mexican-American males.

Then there is this article on who chooses to practice primary care in rural areas:
" Rural born medical . students are more likely to be found in rural practice, primary care, family medicine, and rural underserved locations. .

" Rural interested students were more likely to be older, married, and white. They were more likely to choose rotations away from major medical centers and they did volunteer work at twice the level of other students. About 68% chose family medicine, and 60% were interest in working with socioeconomically deprived populations in practice, the highest of any medical student group. Stability, service orientation, and maturity characterize those most interested in rural practice."

That last sentence is I think very important: "service orientation and maturity."

These students are somewhat older --which argues against cutting out those four years of college.

19 year-olds and even 21-year-olds are notoriously self-absorbed.

Four years of college education with a firm grounding in the humanities may begin to open them up to becoming aware of a world beyond themselves--- history couses, literature courses, economics courses focusing on developing natoins, philsophy couress that raise questions about ethics, justice etc . .
all can help.

(I taught English lit-undergradutes at Yale for 11 years--including many pre-meds in my classes-so I know this demographic pretty well. During four years of college, those who take advantage of the education change enormously, psychologically, emotionally and intelletually. Their minds open up. They begin to grow up.)

Finally, some months ago I attended a conference at the Mayo clinid focused on how we should change med school education.

There was much discussion of trying to recruit more low-income students (beause they choose primary care and are willing to work in under-served areas.)

And the suggestion was made that we should sliglhtly lower GPA thresholds and test scores required for admission in order to broaden the pool, and draw in the kids most likely to want to choose priamry care and be willing to work where they are needed.

The research shows that low-income kids who go to low-income schools have lower GPA and test scores in college.

But, at the end of med school they are equally good clinical practioners (whether in primary care or in another specialty.)

The feeling is that we're putting too much emphasis on scores.

Finally, the Senate bill includes much additional funding for scholarsips and loans for low-income kids, so I think we are going to move toward broadening the pool of applicants.

[Fred Moolten]

"If we want enough primary care docs, the only way to get them is more money." -jsmith

That additional income may be welcome and deserved, but a complementary approach requires a reduction in specialist income through the variety of mechanisms that have been discussed in these blogs and incorporated into reform proposals.

The combined effect should be a reduction in average physician income, which in my view is something the higher paid specialties can afford, and the nation can't afford to omit from the reform process.

[jsmith]

Sharon, I was not referring to the decisions and motivations of individual doctors. Of course these vary. I was referring to the aggregate supply of generalists. In that analysis, what are important are the statistical factors that predict specialty choice. This analysis trumps what people say, what they say they believe, and even what they believe that they believe. Remember that people don't really know why they do the things they do and will often come up with a convenient reason even if it wrong. There is a considerable psychological literature on this.
The cold hard facts are that starting salary predicts residency fill rates. Google Ebell JAMA. If we want enough primary care docs, the only way to get them is more money. Lifestyle factors are much less important --not in individual cases of course, but in the aggregate. Loan repayment, as far as I know, hasn't been adequately studied. I'd be interested if someone else knows about this.

[Dr. Rick Lippin]

The reason that I posted my "two simple mandatoty questions" below is that it has been known for decades that up to 80% of visits to primary care doctors are stress related.

But the consensual denial between patients and their doctors continues. And the unnecessary tests are ordered and the unnecessary (and often unsafe) pills are pushed.

Dr. Rick Lippin
Southampton,Pa

[Green Tea]

Nice post, thanks for sharing this wonderful and useful information with us.

Green Tea Diet

[Richard Kasbeer MD]

Regarding the main point of this thread, I think the “top five” concept is great, yet I agree with the comment that some groups will submit helpful lists, and others probably will not. My specialty society is the result of the now-decades-old merger of two groups. The first was an educationally-oriented society and the other was a political organization. As a result of this merger of academic and economic concerns, the list from my field might be self-serving. It is still worth trying for the reasons given.
On another subject not originally part of this thread, I agree with the physicians who believe four years of college before medical school is an unnecessary luxury. I must admit that the extra two years of electives were extremely enjoyable for me many years ago, and I did indeed take many classes outside my areas of strength, but it is hard to make a case that they made me a better doctor. A humanities professor might not agree, if he fails to consider what each of us reads and learns after our formal education is finished.
One must assume future physicians have already taken the most rigorous curriculum available in their high schools. All the medical school requirements can be taken by such talented students in two years of college (potentially less for those whose high schools offered advanced placement courses). I assume those requirements still include a year of college English. Also keep in mind that the first year and most of the second year of medical school traditionally involve intensive science courses. After that second year, the typical student would be 22 years old, and mature enough to proceed to study clinical medicine. Consider that fully-educated nurses are already in the work force at this age, having begun exposure to patient care several years earlier.
Of course, it is unlikely that decreasing the college requirement to two years would prevent medical schools from accepting, or even preferring, applicants with four or more years of college, but it would give the qualified and motivated younger student the opportunity to avoid amassing two more years of college debt.
And yes, K-12 education needs improvement for the many, but it is currently adequately preparing the few future physicians to make an on-time entry to the track described.

[Legacy Flyer]

Sharon,

Reasons why people become primary care docs vs. specialists and which specialty they choose are complex. When I was going through this process, financial considerations didn’t play role for me and I don’t think played a major role for most of my classmates. But I am sure you are more familiar with what med students are thinking now.

I went to Med School in 1975 wanting to be a Family Practitioner or Pediatrician. At that time my Med School was committed to turning out primary care docs who would practice in the state. I did a summer rotation in Family Practice during the summer of ’76 with a wonderful older GP. He did everything (surgery, OB, etc.) and I remember staying up at night with him to deliver babies. But working with him convinced me that I wouldn’t be comfortable practicing as he did - too much uncertainty. I was also part of the “Pediatrics Track” for those who were interested in going into Pediatrics and I spent the summer of ‘77 doing research with an excellent Pediatric Endocrinologist, treating diabetes, growth disorders, etc.

But entering the clinical rotations, I soon became disillusioned. Rotating through the VA Hospital and the renal service on Medicine turned me against Internal Medicine. I spend many months working in the Pediatric ER at the U., which basically functioned as a walk in Pediatric Clinic. I liked Peds (although my wife was not happy with all the “creeping crud” I brought home) but after a while, it also developed a certain monotony: earache, rash, vomiting/diarrhea – then repeat. Then on a whim, in my senior year, I took a rotation in Radiology, loved it and never looked back. At that time Radiology was undergoing a renaissance with developments in CT, Ultrasound, Angiography and Invasive Procedures. I was fascinated to be able to look into a body, deduce what was going on and sometimes even treat it. I immediately decided to sign up for Radiology and “the rest is history”.

I say this because some people assume that the reason docs become “specialists” is for the money. That was not true in my case - like you I did not come from a wealthy family and would have been happy (and made more money than my father) with the salary of a Pediatrician and/or Family Practitioner. My observation of my med school classmates was that their decisions also did not seem to be determined primarily by financial considerations. The jocks went into Orthopedics, the aggressive guys (rarely women in those days) went into surgery, those that were interested in the psyche went into psych, etc. Women tended to go into Peds, Psyche, Family Practice, Internal Medicine but not surgery. The best looking guy in our class with the perfect hair cut went into Plastic Surgery. OB/GYN was making the change from a primarily/exclusively male specialty to one in which women are in the majority. In other words, specialty choice seemed to me to be highly correlated with personality, interests, etc. Recently, I went to my 30 year Med School reunion and nothing I heard there made me change my mind.

Of course having gone to a state med school in the 70s, I came out of med school owing less than $10,000 (considering the quality of teaching we received, the number of people in my class and the amount of “scut work” we did in the hospital, I don’t think my education was subsidized – but that’s another story)

The only realistic talk I ever heard about choice of specialty and its financial implications/working conditions was given by the head of OB/GYN at one of our Univ. affiliated hospitals. He basically laid out the working conditions and salaries of all the various fields including primary care and the various specialties. He said: “I am not trying to tell you what specialty to choose, I just want to make you aware of financial and life style issues that they don’t teach you about in Med School so that later on you can’t say: ‘nobody told me’”

I think it is a shame that people would choose a specialty that they don’t like just because of money. I also think it would be a shame if people that truly enjoyed a particular aspect of medicine were forced into primary care – although I believe our country needs more primary care docs and fewer specialists in the future.

[Dr. Rick Lippin]

Here are two simple mandatory questions that need to be asked by your primary doctor during every patient visit. If your doctor does NOT ask these - find another doctor.These questions will change US medical practive and save a lot of money

TWO SIMPLE MANDATORY MEDICAL HISTORY QUESTIONS

Proposed by Dr. Rick Lippin, June, 2002

Propose that all health care providers (especially primary care providers) ask adult * patients two simple questions when taking the medical history during every patient visit. Using the JCAHO model for pain (JCAHO’s so called 5th vital sign) patents would report levels from 1 to 10. The questions are simply:

“ How are things at work?”*
“ How are things at home?”

1= “couldn’t be better”
10= “couldn’t be worse” (in crisis stage)

The answers to these questions could then lead to referrals and standardized tests for further diagnostic workup for stress and depression and they would not “burden” the primary care providers with a requirement to do a full exploration of the problems very likely to be elicited

* for students substitute word “school” for “work”

Dr. Rick Lippin
Southampton,Pa