Only a generation ago, in the 1980s, medical students thought about what specialty to choose simply in terms of what interested them most. All doctors made a comfortable income; money wasn’t a primary motivator. There was a sense that cardiac surgeons or neurosurgeons could make more than most other physicians, but in fairness their training was much harder and longer. Internal medicine was held up to us as the most prestigious and intellectually rigorous of the specialties, and was highly attractive to medical students who are a competitive lot at baseline.
For kids growing up in the 1960s and 70s, there was also a strong impetus toward doing work that benefited society. We remembered the civil rights era, the rise of feminism, and the start of the Peace Corps. The women who made up the first major wave of female physicians in the United States were determined to prove themselves as deserving of medical school admission as any of the men, by working as hard and achieving as much or more.
As a medical student in the 1980s, I considered a number of specialty options. Pulmonary internal medicine and critical care were my favorite rotations. On the other hand, anesthesiology involved critical decision-making in real time, and a great deal of pulmonary physiology (all those ventilators to manage). Besides, anesthesiologists work in the operating room. This can be a good or bad thing, depending on how much you like operating rooms and the company of surgeons. From my point of view it was fine.
At the time there was a shortage of American-trained anesthesiologists, urgent enough that the American Society of Anesthesiologists paid me a generous stipend to do an eight-week clerkship in anesthesiology one summer in hopes of recruiting me into the specialty. So when I chose anesthesiology, I had the fun of entering a specialty I enjoyed, and the gratification of working in an underserved field.
How times have changed. Today the most competitive residency positions are in dermatology and radiology.
Though we clearly need excellent radiologists and dermatologists, I have to wonder if part of the motivation for many of the medical students who choose these fields could be something other than a passion for the specialty—perhaps the controllable schedules, or lack of emergencies. Meanwhile, big-city residency positions in general surgery and neurosurgery, which in the past would have been highly sought after, go unfilled.
Everyone hears about the shortage of primary care physicians, who by all accounts are financially undervalued, but how many Americans realize that a critical shortage of specialists is looming ahead in just a few years? The 77 million babies born in the boom years between 1946 and 1964 are reaching the age of 65 at the rate of 10,000 per day. They need primary care physicians to manage their overall health care. But they’ll also need orthopedic surgeons to fix their hip fractures, cardiac and vascular surgeons to open their blocked arteries, and cardiologists to treat their faltering heart rhythms. They’ll need surgeons to remove their lung cancers, breast cancers, and colon cancers, and medical oncologists to manage the cancers that aren’t amenable to surgery.
By 2015, the Association of American Medical Colleges estimates that the shortage of specialists will match or exceed the shortage of primary care physicians. Cardiothoracic surgeons aren’t being trained fast enough to keep up with retirements. Critical shortages of general surgeons are forcing rural hospitals to close, since every emergency room needs a general surgeon on call. While we have enough general pediatricians—since U.S. birth rates have been flat since the 1970s—there’s a serious lack of pediatric pulmonologists and endocrinologists.
Physicians are working less than they used to—evidence shows that as compensation declines, the motivation to work harder declines too. A decrease of just four hours a week in the average physician work week amounts to a loss of 36,000 physician FTEs per year. Today, a recent survey shows that 44% of female physicians in large groups now work part time. In today’s economy, universities can’t afford to increase their medical school class sizes substantially. And Congress is unwilling to increase Medicare funding to expand the number of residency spaces. We may face a shortage of 130,000 physicians by 2025, or even more if young physicians continue the trend to work less. We can import physicians from abroad, but third-world countries can ill afford to lose them.
It will be interesting to see if the next generation of medical students will step up to the plate. Will they continue to flock to the specialties that offer the most controllable schedules and the best “work-life balance”—a concept that doesn’t deserve the reverence it gets? Or will they elect to work in the specialties where they’re really needed? We’ll see. In the meantime, my advice to the baby boomers is to stay healthy—there’s no telling who’ll be practicing medicine, or what kind of medicine they’ll choose to practice, a few years down the road.
excellent! totally true that med students follow the $$ in terms of choosing specialties—to a shocking extent.
It all comes back to $$. I went to a private med school (wash u. st. louis) for ~6k a year (room, board, tuition); my internship salary was ~14k. End of residency: zero debt.
now, to go to a private med school costs >100k/year and internship salaries are 40k. most med students are 250k in debt when they graduate.
it is no surprise that they follow the $$. they have no real choice.
so any change in the system must start by correcting this problem.
I agree with your conclusion: stay healthy!!
I agree; although knowing some of these young doctors-I understand their choices. It was not do much about the money-it was about having a family and wanting to be there for them and their partners.
Dr. Sibert, I tried to post my comment on KevinMD, but the thread on this topic had already been closed, so I came here.
Can you comment on this youtube video that shows a patient being instructed to push his own propofol in the operating room. Is this reckless or just no big deal. I’m on the patient end, so don’t know. Thanks
Good afternoon, Emily–
The short answer is that I don’t approve at all. In fact, I just posted a blog on this very topic, so check apennedpoint.com to see what I really think!
Thanks for reading.
I’m 40. I’ve been out of general surgery residency for 7 years. I just quit a job for Texas tech trauma where they start you of out at 160K per year but with 6 nights of in house call you can boost that all the way up to 220K. That sounds horrible but it’s about what I’ve averaged the last 7 years. The guys I know from residency that went into general surgery are all doing the same or worse so I don’t feel so embaressed.
My first job was an income guarantee in an underserved town of 20,000. The patients that had insurance there wanted to go to a bigger center. The ones without insurance were sent to me. The town needed and probable needs a general surgeon but can’t afford one. I GROSSED 150k that first year. After that I bought out of my contract for 100k. There is a reason some areas are underserved.
There is also a reason some SPECIALTIES are underserved. My second job was employment for a major hospital chain. 330K a year. I covered 3 different hospitals (12 calls a month) including county where 40 percent was gratis, free. The thing about indigent care is that it’s mostly nights and weekends and when you call in anesthesia they act like YOU owe them something. After 2 years I still wasn’t making my expenses so the CEO insisted I cover a fourth hospital. I told him to find somebody else so he did for 250k and 20 hospital calls a month. (I thought I was desperate). Atleast the hospital is learning you dont make money by taking call. Next I went to Texas tech for a few years and as of today I’m looking for my next pot of gold. That’s one good thing about general surgery, you can always get another job that is just as shitty as the last one. Great job security. Who else is going to do it? I wouldn’t do it again. Would you?
I encourage all the residents to specialize. I’ve never councilled any med student to go into general surgery. You should be ashamed of yourself if you are talking medical students into general surgery. Thankfully most aren’t as gullible and dumb as I was and go into optho or derm or radiology or neuro or ortho or ENT or interventional or etc…