Tuesday, March 18, 2008

Paging Dr. Welby

I used to wish I'd been good enough at math and science to go to medical school. Not any more. See, I'd have wanted to take care of whole families, the range of their problems, over a long time (until one of us died or moved away, I guess). Now I'm all grown up, and I know some primary-care docs who are willing to share something of what their professional lives are like ... and I am glad I didn't go that route. (Though I still resent Mr. Savinelli for saying that girls just aren't good at math, which has played a way bigger role in my life than it probably should.)

Anyway: what brings me here today is yet another report of how the best and brightest medical students are choosing specialties that are as far away from primary care -- and, not incidentally, from sick people -- as they can. This article in the NYT highlights the competition to get into dermatology and plastic surgery, which are apparently the current "it" specialties. Good hours, patients who can pay, and few patients dying on you. Pretty sweet.

Social justice issues? Well, we the taxpayers pay for the bulk of medical education in this country. Unfortunately, we're not turning out anywhere near the number of GPs we need ... especially as the population grays. Also, while most of us probably wouldn't begrudge the desire for a normal family life, isn't it in the nature of the professions to put your clients first? If a career in medicine is primarily about money and status, not caring for sick people, what does that mean for the profession? And what does it mean for the rest of us?


Kelly Hills said...

Yup - my sis is starting med school in the fall, and already knows quite a few students, most of whom are looking at what I've been calling boutique fields. For example, one of her friends knows he wants a family, and a healthy marriage - he's planning on going into pain mgmt/anesthesiology, so that he has "standard" 9-5 hours. He's genuinely concerned about chronic pain, so I'm very glad to have someone like him going into the field - but I admit I'm worried about the idea of people being motivated by hours and convenience, and not patients, illnesses, etc.

Bea said...

Perhaps the system needs to be restructured to meet doctors' demands? It's nice to think people might be choosing medicine as a vocation, and that they might be so grateful for their education that they're willing to sacrifice a lot to pay it back, but are we actually going to get doctors that way?

I have no concrete suggestions as to what this restructured system would look like. I simply suggest that doctors aren't any more (or less!) evil than anyone else, and perhaps we should try to work with what we've got.


Sue Trinidad said...

Agree a zillion percent, Bea! As I've posted here before, I think PCPs are truly stuck in a no-win situation in a lot of ways. It's simply unreasonable for us (society at large) to expect that smart, talented people who have other options will all choose a life of self-sacrifice. I spend a lot of time working with PCPs, and I have a huge amount of sympathy for how difficult their jobs are.

A study was published a while back (Yarnall et al, Am J Pub H 2003) that concluded that the average PCP would need 7.5 hours PER DAY just to deliver all the preventive care they're "supposed" to per applicable guidelines. So where are the sick people supposed to fit in that schedule? Clearly this is unworkable.

It's only made worse by the fact that our "system" (scare quotes for the fact that there's nothing systematic about it, imo) generally does not pay for patient education and counseling, but only for defined clinical interventions; that the whole behemoth is oriented toward acute illness response, rather than to health, etc. etc ....

Yeah. I'm with you!

Helen said...

Hey Kelly,

All I can say about your sister's friend is he obviously doesn't KNOW any anaethetists/pain specialists, because the route to get there involves LONG hours of late nights and on-call as you do the emergency anaesthesia roster while you get your clinical fellowship.

Pathology - that is the way to avoid oncall - unless you live in countries where the culture requires rapid burial or return to family.

Dad discouraged me from medicine (despite me having the marks) and it was the best gift he ever gave his daughter - much happier in an allied health role.


Helen said...

Sue, you make a terrific point about the orientation of the PCP payment being towards treatment rather than prevention.

I work in the NHS as a very rare creature - a public health dietitian - and I see daily that there is no way that time can be spent by family doctors delivering health promotion messages in ways that are going to faciliate change in the socially disadvantaged communities.

The Ottawa charter is still equally as valid as it was when written (rather a long time ago), where one of the central tenants is to "reorient health services".

Ah well, I guess I will have a job for life...


Kelly Hills said...

Helen - naaw, he's well into his residency, and knows that getting to his ideal won't be easy. But there's an end point, unlike other specialties.