duh – money matters in specialty selection


Category : Medical Rants


Primary Care Physician Shortage Linked to Lower Income

In primary care, salaries were lower than in other specialties and residency slots were less likely to be filled, Mark Ebell, M.D., of the University of Georgia, reported in the Sept. 9 issue of the Journal of the American Medical Association.


And the average debt for a medical school graduate has quadrupled — going from $35,000 to $140,000 — in the nearly 20 years since Dr. Ebell first studied salary disparities. In a 1989 study, Dr. Ebell described a linear correlation between the median income of physicians in a specialty and the percentage of residency positions for that specialty filled by U.S. medical school graduates.


Since that time, decreasing numbers of U.S. graduates are choosing primary care (family medicine, pediatrics, and general internal medicine), and the income disparity between primary care and other specialties has grown.


The number of U.S. graduates entering family practice residencies, for instance, has dropped by 50%.


Meanwhile, student debt has risen to a median of $140,000 for the class of 2007.


Dr. Ebell’s current study examined whether there is an association between specialty selection and anticipated incomes using current data.


Residency information came from the National Residency Match Program; mean annual salary in 2007 came from the annual American Medical Group Association survey of physician salaries.


The analysis was limited to specialties offering at least 100 postgraduate year-one positions.


There was a strong correlation between higher overall salary and higher fill rates with U.S. graduates (r=0.82, P=0.001).

Boys and girls, this is not rocket surgery or brain science.  Fourth year medical students make career decisions based on many factors, and money may be the most important factor.  I hate that money is that important, but it really is.

Our health care payment mess induces students to make career decisions using the wrong parameters. 

Back in the 1970s, when I was a medical student and resident, internal medicine was the most competitive field, and fields like dermatology, radiology, anesthesiology and orthopedics [the ROAD] were easy to enter.  What happened to change this – Medicare and especially the RUC.  Our payment structure has no rationale.  CMS pays for episodes in a rather arbitrary manner.  They have not thought through the implications of how physicians are paid.

"Democracy is a device that insures we shall be governed no better than we deserve." – George Bernard Shaw

I do not think that quote applies to the payment problems, but maybe it does.  We need a radical change in physician payment, one that we upset many specialists and subspecialists.  We need that change for the health of our patients.  Who will have the courage to make such changes?  Do you see any bravery in the political arena?  Do you imagine any bravery at CMS?

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Comments (5)

While I completely agree that income is a strong factor leading students away from primary care, it is not the most important. As our study just published in JAMA showed, few students (2%) chose general internal medicine. However, the main factors were teaching, nature of patient care, and lifestyle. Salary was not associated. Students observe primary care physicians struggling to see complex patients in short visits and catch up on phone calls after hours and decide that this type of practice is not for them. That it pays substantially less while their debt is growing simply makes the decision more clear. Now, one of the main reasons primary care delivery is so unsatisfactory is low reimbursement for cognitive services. However the subtle difference is that just raising primary care salaries and/or relieving debt burden is not enough. We need to change the nature of practice entirely. I say more about this and our study on my blog at http://www.drmintz.com

I agree with Dr. Mintz. Nobody wants to practice hamster wheel medicine. That’s what the current system wants us to do. Until it pays for something different, I don’t see the tide changing. Maybe $300k a year would be enough to make you practice hamster wheel medicine, but not if there are other alternatives. A lot of med students rotating through like what we do, they just don’t like the pace at which our medical system wants us to perform.

Payment and lifestyle are hopelessly conflated. It is artificial to try to separate them. The major reason primary care lifestyles are so challenging is that primary care doctors who want to fulfill their salary expectations have to schedule high numbers of patients per unit time. That, and the ridiculous documentation requirements (again, a hoop to jump through to get paid).

Also, what medical student is going to admit that money matters? Please. Since day one of applying to medical school, the notion that medicine is more like a priesthood than a job is drummed into us. Even our language of “reimbursement” rather than “payment” perpetuates this myth.

A medical student survey is therefore meaningless. Revealed preferences–not stated preferences–are the way to get at this problem. If money doesn’t matter, then please explain the phenomenon among UK medical students after a sudden jump in primary care payments.

No question money matters and you are correct that separating reimbursement from money is difficult since low reimbursement leads to squeezing in more patients with leads to “hamster wheel medicine” that Dr. Bob points out. My point is that it is not simply the money but the entire system. If for example, primary care physicians had to deal with no paper work and could see far fewer patients in much longer visits, but not make one penny more, I beleive you would attract many more students to primary care. Conversely, if the only thing we did to solve this crisis is to forgive all loan debt for students going into and practing primary care, it is likely that some students will take the offer, but many may not because they would rather have $140K in student loans then practice primary care medicine as it is practiced now.

[…] think that DB’s Medical Rants spells it out correct in this assesment: Boys and girls, this is not rocket surgery or brain […]

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