Tuesday, September 9, 2008

Factors Associated with Medical Students' Career Choice Regarding Internal Medicine: Pay is Not Really One of Them!

I am very pleased that our work on Factors Associated with Medical Students' Career Choice Regarding Internal Medicine was just published in JAMA. This was a survey of 1,177 medical students who were just about to graduate from our institution and 10 other US medical schools. We were interested in the factors affecting career choice, both for those choosing internal medicine (IM) and those who chose to do something else. About 23% percent chose IM careers, but only 2% of students (24/1177) stated they were choosing general internal medicine. This means that most of those choosing IM had decided already to go into subspecialties such as gastroeterology and oncology. We found that three factors influenced career choice in internal medicine: educational experience, nature of patient care and lifestyle. For those students choosing IM, these factors pushed them toward IM. For those not choosing IM, these factors generally pushed them away from IM.

There are a few things that may not be obvious from what was in the paper or what will be reported in the media.

This is a crisis!

The survey did not ask specifically about primary care. Of the 2% of students stating they were interested in general IM, many of them could (and will likely) do hospital medicine which is becoming a popular choice for generalist IM physicians. Also, only 4.9% of students selected family medicine, which it the other group that practices general, outpatient primary care. Therefore, not including pediatrics or OB, only about 6% of graduating medical students want to go into general primary care. To me this is clearly a crisis. If almost all of our future physicians don't want to go into primary care, who is going to take care of our aging population with multiple medical problems?

Changing the curriculum is unlikely the answer

As a medical educator, I am happy in the sense that most students (78%) were satisfied with their IM experience during medical school and felt they had adequate exposure to what an internist does. However, I am frustrated that few students (20%) felt that their education experience made a career in IM more appealing. In other words, they feel that they have seen and learned alot, and appreciate the teaching on their IM rotations, but say "no thank you" when it comes to IM as a career choice. In the past, educators have suggested that adding more outpatient experiences might help enhance student interest in IM, but the study showed that for students who trained in an outpatient IM setting, about 1/3 said this made an IM career more attractive, but about 1/3 also said it made an IM career less attractive.

Paying primary docs more is not the (only) answer

One factor that did not significantly influence career decision was reimbursement, and this was irrespective of student debt (an average of over $100,000). According to the survey, compared with other specialties that they were considering, students saw IM as requiring a greater breadth of knowledge, but requiring more paper work and having a lower income potential; paperwork being the biggest detractor from an IM career. This should not be a big surprise, since student are knowledgeable about the problems of the health care system and generally don't go into medical school to get that big pay check. Most do initially go into medicine for altruistic reasons.

Lifestyle was clearly an important factor, and this generation of students values a balance of work and personal/family life. However, outpatient primary care is about at close to 9 to 5 as you can get (I certainly couldn't wake up as early as my surgical colleagues). In addition, many primary care docs no longer do inpatient medicine, so going to the hospital in the middle of the night no longer necessarily applies. In addition, though shift work allows for more time off, it also causes more time on.

We are currently analyzing some of the open response questions, and hope to have this out soon. However, my impression regarding lifestyle has more to do with the nature of practice and patient care (which was the other influencing factor). Though we primary care physicians work closer to "normal people" hours, we end up bringing a lot of work home, much of it paper work. Students see primary care physicians trying to see complex patients in short time slots, filling out endless paper work (not just notes in the chart, but referral forms, prior authorizations, medical billing, etc.) and spending a lot of time doing extra "busy" work such a phone calls back to patients about results or to an insurance company to approve a drug (which students quickly realize in uncompensated care). This is not why they went to medical school. They went to medical school to take care of patients and spend time with them, not to rush them through a visit and help them through a bureaucratic system. The fact that primary care pays less than the other specialties is very likely the icing on the cake of why students are not choosing primary care.

Thus, loan repayment (for students choosing primary care careers) and increased compensation for primary care is a step in the right direction and should occur. However, in order to prevent the eventual lack of US trained primary care physicians in this country, the system has to change. The nature of practice and patient care that turns students away from primary care is due to a system that does not properly compensate cognitive services while heavily reimbursing tests and procedures. I have previously written about how this has radically changed how mental health services are delivered in this country, and the same is about to happen in primary care if something is not done quickly.

Though each of the Presidential candidates have different approaches to health care reform, both leave the private insurance and government funded systems relatively intact, thus not addressing the problems of reimbursement for cognitive services and mounds of paperwork to deliver care. The medical home has been mentioned as one possible solution. If this indeed changes the nature of practice of primary care, then students may become more interested in the IM and other primary care fields. However, if the medical home becomes extra paperwork to complete to eek a few extra dollars out of the system, then we are indeed in trouble.

P.S. Thanks to Dr. Karen Hauer for her leadership on this project, as well as all the hard work by my colleauges from the Clerkship Directors in Internal Medicine.


Anonymous said...

Payment for services really is the primary issue here, I'm not sure why you're trying hard to say it isn't.

why do you think "hamster wheel" medicine is the norm? Because that's the only way to maintain incomes in primary care.

Pay more for primary care visits and physicians can start doing more coordination, backing off on volume, etc.

It's why concierge/retainer practices work so well. Pay more for services rendered, deliver the services adequately and rationally. It's fairly simple, really.

The "volume problem" is almost completely derived from the payment problem.

pod said...

Internal Medicine and primary care used to be where the thinkers went, imitating their "Chief of Medicine", hoping to diagnose and treat.
That is no longer true because the beaurocrtic regulations enforced by the payors have reduced all internists to clerical workers. The EMR deepens the insult, being in effect a way to prove that you did what you billed for. The generic templates and mindless query boxes ("what is the lot number of the vaccine?") insult my sense of pride in my work and waste much of my time with things I have no interest in whatever.

Money is a consideration. I never made near $100K in my 35 years as an Internist, having no procedures or tests to pump up my income. Clearly my thoughtful interactions with patients are not valued nearly as much as a "sleep study" or an MRI. In the end I was frustrated and turning bitter so I left. I conceptually miss the joy of patient care and diagnosis but it was a mirage for the last twenty years. In the future as my generation become elderly and designer drugs become more costly there is a terrible reckoning to occur. I am not optimistic for the profession but there is a lot more to life than a job and I intend to savor what is left of these small joys. I did devote 35 years to medicine and in retrospect it was a charitable contribution to my patients and to the science of medicine. Now the Chief of Medicine is a Jiffy Lube salesman. By the way your air filter looks a little dirty, it may be prudent to replace it before trouble occurs.