Robert C. Bowman, M.D.
Common Sense Flaws and Questions to Ponder
How can medical students today be so different than those of a few years ago, or decades ago?
1. Medicine is not a "controllable lifestyle" by its very nature. Those applying to medical school could choose virtually any career, have similar status, and make similar if not better income. Why medicine and how is this different that past generations of physicians?
2. Students choosing medicine now have to focus earlier and resist a number of distractions that many of their elders find most challenging. Why would medical leadership imply that today's students are "lifestyle oriented," implying that they are less work-oriented and perhaps even a bit on the "lazy" side? These arguments sound like the paternalistic "Well when I was an intern" comparisons of my generation with previous and so on. This sounds less like any Generation A,B,C comparison. Clearly college students as a whole have changed in studies and there are differences in other young professionals. It remains to be seen whether medical students are similar to college students and others in their generation or whether they are more like "us."
3. Those in medicine and medical education realize, teach, and counsel repeatedly that the individual decisions of physicians within their specialty determine "controllable lifestyle" and balance issues. Students have at least enough exposure to see the variation that exists within a few specialties and individuals in those specialties.
Flaws in Definitions - Variability in Certain Specialties
1. Family medicine is a prime example of a specialty that is "different." Family medicine is more impacted by admissions of various types of students (older, instate, rural). There is also a wider variation in types of family medicine careers. Perhaps the most common student exposure is to FP faculty who have little call and lots of control over what they do. Also studies clearly show that family physicians that can choose to do so, do practice outside of major medical centers at 70% levels. The practices often seen and the comparative studies done use the least representative family physicians. Studies also demonstrate that FP docs choose FP even with high debt (although some studies list some limits to this). Considering FP in this study in the same way as other specialties is problematic.
2. Other specialties in the study involve residencies with very limited access, making "choice" variable and invalidating the approach. A specialty by specialty review of Changes in Specialty Choice 1987 - 1999 reveals other reasons for career choice change such as new specialties with increased demand (ER), expansions in specialty positions, changes with health policy such as Reimbursement Changes, category changes, losses due to subspecialization, and other factors.
3. This "lifestyle" study should also avoid including emergency medicine. New specialties take a few years to become "steady state" and emergency medicine has yet to reach this point. Until this time, any time delay comparison will show improvement. The major factor complicating ER workforce is just how much physician assistants and nurse practitioners will fill ER positions. Primary Care Retention PA and NP contributions are increasing across hospital, ER, and subspecialty positions as directed by health policy and major medical center sponsored expansion of PA and NP programs.
4. Family medicine had a great 6 year "honeymoon" period with a 30 year decline interrupted by a great 5 year run of increase by health policy efforts.
Studies that are not careful to control for various types of bias such as health policy, honeymoon, limited numbers of positions, or other types of changes are a problem.
Methodological Flaws
The greatest area of concern for this career decision research is the timing of the study.
Assumptions were made regarding the application of medical student survey data to define controllable and uncontrollable career choices. The rationale for such application is not entirely understood. There are assumptions that medical students are like college students. There are also assumptions that family practitioners are all alike, when the 43% who are inside major medical centers are very different than the 57% outside. These studies did not allow a variety of different career types within a specialty.
Studies involving career choice of the students graduating 1994 - 2000 are subject to significant error, since career choice was forced by the managed care "panic." This resulted in more choosing primary care and family medicine and dramatic changes in many of the specialty choices involved in the "controllable lifestyle" studies during this time. For example, instate urban born students and those born in counties with medical schools were the ones most likely to choose family medicine and primary care in greater numbers during this time. see graph
Some specialties had a "rebound" effect after the 2000 graduating class.
The combination of the two above areas means a greatly distorted frame of reference in beginning and end point, not based on "controllable lifestyle" but on changes due to the managed care panic. Other studies are also likely to be impacted that begin or end during this time period. Such studies include the Title VII studies (ending in the period), the controllable lifestyle studies (begin and rebound after), and studies of declines in family medicine or primary care. Surgery and family medicine have actually been in 30 year declines, long before controllable lifestyle studies became popular.
Mixing Data Types
The study uses medical student perceptions regarding lifestyle, but does not use medical student perceptions regarding income (either higher or increasing income potential) or work hours. The assumption is made that students are impacted by income and work hour data that is reduced to a single number at a certain point in time. The truth is closer to a range of numbers in each area with a wide degree of interpretation. Also student perceptions of the changing status of the career or work hours or income should be considered. Changing status may actually be more important than lifestyle. As with perceptions regarding controllable lifestyle, the student impressions are likely varied in these areas.
Changes in Admissions
There have been subtle changes year to year for decades regarding admissions, including origins, performance on the MCAT, ethnicity, social status and more. These changes in the medical students admitted are also a concern regarding studies of career choice. There have been increases in admissions of those student from higher social status (Asian, higher income) and decreases in admissions of those of lower status/rural origin (birth, background). There has also been a slight increase in older students, which tends to favor family medicine and moves students away from surgery, cardiology, and ophthalmology. Overall these changes would tend to move the medical student group toward less service orientation as noted by Madison. Service orientation analysis can allow 70% of the primary care group to be predicted. Changes in those oriented toward service would be a factor to consider. Service orientation would be very likely to have a negative correlation with "controllable lifestyle." The changes have occurred for decades, but the managed care compressed the impact, in a similar fashion as the choice of family medicine was impacted. This could have impacted the study greatly.
The greatest changes in admissions have been increases in urban born and foreign born, generally those who are Asian. Asian students are younger, have more concentrated urban origins, have the most professional and educated parents, and have the highest income levels in the US. With increases from a few hundred to 3500, this is a massive change with great decreases in lower income, rural, white, male categories. This is also a group that has highly urban practice preferences for just a few US cities.
Flaws in Perspective
One of the most disturbing assumptions by the medical profession involves a heightened sense of cause and effect, of claiming credit when it is not relevant. This is particularly difficult with and research based on surveys and particularly recall studies (Pathman DE, Konrad TR, Agnew CR. Studying the retention of rural physicians. J Rural Health. Summer 1994;10(3):183-192.). It is entirely possible that medical school actually has very little influence on career choice. Perhaps medical school may re-awaken previous influences. Why the concentration on career decisions focused on a few months of rotations in the third year, as compared to the lifetime of experiences and influences that have shaped a young adult long before medical school? These career influences extend far beyond birth and in many other dimensions such as role models, personal health experiences, family and parents, social status, community and school influences, role models, obstacles, and peers before and during medical school. Social status, age, education, and parents are just a few that change the distribution of specialty choice. Temporary influences can also have great impact, as seen in the managed care "panic."
It is also very difficult to word, distribute, collect, and interpret medical student surveys, interviews, and statements. One example is the number of students rating primary care training as less important, but then noting many of the topics addressed by primary care training as being inadequately addressed. Simple statements or interventions often have complex interpretations.
1. A popular one now is the use of co-pays for Medicaid prescriptions by some 40 states. States think that they are saving money by directly intervening in the prescription category that is rising the fastest among health care categories. However, the lack of access to prescriptions drives a number of other costs in office, emergency room, mental health, and other areas. It pushes more costs over to patients, who are on Medicaid because they have very little resources. This may also have negative impacts on the "safety net" providers that have less volume resulting from such policies. Studies demonstrated extreme increased costs for restrictions in prescriptions to mentally ill patients. Few studies have been done in this area beyond this one.
2. Another example of complexity is interfaces between medical care and education. Which is better, increasing interventions and technology involving high risk prenatal care or more investment in education, mental health, anti-tobacco and other lifestyle changes, the factors at conception and before most related to prenatal outcomes?
An increasing concern that should be raised by all in the medical profession is that medical education may be avoiding responsibility by deflecting attention and "blame" on others, such as students. This has long been a problem with solutions for maldistribution, where models have existed for years and yet have not been replicated by medical education and often rural and inner city communities are blamed (Why Doctor's Don't Go Where They Are Needed). Other medical leaders have embraced rural medical education and magnet health high schools and have attempted to rally medical education (Academic Medicine's Season of Accountability and Social Responsibility Butler). Education involvement is particularly critical for family medicine choice as it depends upon admissions of inner city, rural, older, and lower socioeconomic status students. Schools in such areas have higher costs, are behind in technology and teacher qualifications, and have lower property values blocking revenue generation. Medical education can provide valuable stimulation to such schools, teachers, and students. Efforts to recruit lower social status students in the latter years of college may not be as effective, may not attract the "broader" types that are more likely to serve, and may not result in long term placement of such practitioners. Existing programs in states with better education allow admission to select for rural, family medicine, and academic. In states with less stellar education, there are compromises in one or two of these categories that impact choice of specialty, location, or attrition rates.
A major consideration should be given to a growing problem in medical education - the intensity of the medical education experience. There is an alternative hypothesis rather than controllable lifestyle:
Students who did not have enough length, breadth, and depth of certain medical school experiences would not feel comfortable choosing the more demanding (less lifestyle-oriented) medical specialties. Without more specific questioning, and perhaps even qualitative work, this would be difficult to discern.
Enough Length, Breadth, Depth, and Orientation
A simple example would be delivering enough babies to survive the common complications and build confidence and competence enough to consider obstetrics. Surgery has had declining portions of medical school curricula. Studies note that primary care may be overwhelming to medical students without at least 6 months of experience. These studies involved students doing long term preceptorships who tended to have rural backgrounds and interest in rural family medicine. As such they were likely to have a greater exposure to continuity medical homes, primary care, and generalist orientation. Other students may need even more time for a fair consideration of a primary care career (Verby Articles). Older students tend to choose family medicine, psychiatry, and emergency medicine. It may be that the lack of previous experiences hampers student choice much more than perception of lifestyle. Age and Physician Specialty
Contrasts with past medical training in the US
Conferences, studies, and meetings increasingly address the quality of medical education. The evidence is mounting regarding the increasingly passive nature of medical school training. Teaching contact time is decreasing. Numbers of procedures are declining. Indigent training volumes and facilities are less. Managed care changes with faculty having even less continuity with patients. Federal audits and regulations impair training opportunities. Liability continues to disrupt the potential of learning by doing. Perhaps one of the most challenging areas to address is declining revenues with increasing demands to make up the difference in clinical activities, leaving students and residents further and further behind.
Contrasts with other countries
Predoctoral directors and medical students in Canada report concerns regarding the lack of intensity in US training. Graduates of medical school now doing residency in the US also not the lack of "hands-on" decision-making in US medical education.
Contrasts with newer models
Combined medical school/graduate training, such as accelerated family medicine residency programs, have stellar outcomes regarding perhaps the career least lifestyle and salary-oriented of all, rural family medicine. The two intensive medical education learning experiences, the M-3 year and the PGY-1 year, are stacked back to back in this model with progressive intensity throughout. Studies note that accelerated graduates are twice as likely to choose rural practice and even the medium and small rural locations, as compared to the usual FP graduate. This outcome is even more significant because there is no selection bias toward rural practice and the training involves 6 years in some of the most urban parts of the nation. Even the gender impact is notable, with female accelerated graduates going rural and even small rural locations in the same distribution as males, again contrary to published research. (accelerated) The failure of medical education to replicate such programs and instead, terminating such programs, is a major concern regarding workforce leadership in the nation.
Discussion
The key areas of concern involve the timing of the study in regards to the managed care period and the variations in the specialties themselves.
The quality of medical education needs to be a major consideration for medical education and must be addressed before consideration of any sort of expansion.
Additional studies need to address the alternative hypotheses of length, breadth, and depth.
Physician Distribution in the US
Flawed Physician Workforce Studies
Changes in Specialty Choice 1987 - 1999
Distributional Medical Schools