Med students shun family care

By Lisa Greene, Times Staff Writer
In print: Saturday, March 22, 2008

USF medical student Alexis Lipton, third from right, and her classmates cheer Thursday at Skipper’s Smokehouse as they learn where they will do their residencies.
	[KATHLEEN FLYNN | Times]

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TAMPA — Jammie Ferrara wants to be an anesthesiologist in part because she wants to do "lots of hands-on procedures."

But Ferrara, who is now finishing her final year of medical school at the University of South Florida, has an even more important reason for picking her specialty: It's family-friendly.

"It's demanding mentally, but I'll still be able to have a life," she said.

Ferrara, 27, is among a growing number of medical students choosing "lifestyle" specialties — areas of medicine that offer more controllable hours and better pay.

The flip side: Fewer doctors are interested in primary care.

"It's an absolutely huge problem," said Dr. Stephen Klasko, dean of the USF medical school and vice president of USF Health. "Nationally, it's a crisis. It's hard to find the best physicians to go into some of the most important residencies."

Leaders at the American College of Physicians, which represents internal medicine doctors, are so worried that the group issued a report on the "impending collapse" of primary care.

"When I graduated from medical school, back in 1973, the people at the top of the class all wanted to go into internal medicine," said Dr. Steven E. Weinberger, senior vice president for medical education and publishing. "There's been a tremendous shift."

That shift has made spots in the popular specialties fiercely competitive. About 500 medical students applied for four slots at USF offering graduate training in dermatology. An additional 540 students applied for the four USF slots in orthopedics.

The specialties are so popular that medical schools have coined an acronym. It's called taking the E-ROAD: emergency, radiology, opthalmology, anesthesiology and dermatology. Other popular specialties include plastic surgery, orthopedics and pathology.

Ferrara is one of the lucky ones. She learned Thursday that she won a spot to do her graduate medical training, or residency, in anesthesiology at Yale University.

• • •

Nationally, there are three U.S. medical students who want to do plastic surgery for every two slots available, according to the National Resident Matching Program. But for every U.S. medical student who says internal medicine is the top pick, there are two slots available.

And the move from primary care is probably even more pronounced than the numbers show, Weinberger said. These days, more of the students going into internal medicine make that a stepping-stone to advanced training in a sub-specialty, he said.

It also means that more primary care spots are going to students of foreign medical schools. In this week's match for residency slots, 86 percent of diagnostic radiology slots were filled by U.S. students; only 44 percent of family medicine slots went to U.S. students.

The move is gradual because the number of training slots don't change overnight. But increasingly, top students are vying for "lifestyle" spots. The specialty with the highest percentage of medical honor society members, the top-achieving students, in 2007? Dermatology, with 47 percent.

Family medicine ranked near the bottom, at 6 percent.

• • •

Follow the money, and the shift isn't surprising. Average pay for an anesthesiologist is $344,691, while a pediatrician makes $185,913, according to a 2007 survey by the American Medical Group Association. An orthopedic surgeon pulls down $436,481, while an internist makes $193,162.

Those salaries make a difference to today's medical students, Weinberger said.

"People are graduating with a lot more debt now than in the past, and are concerned about the debt once they go into practice," he said.

But he and several USF students said lifestyle is a bigger pull. The popular specialties have more predictable hours. Ferrara, for example, doesn't have children now, but picked her field with the future in mind.

"Most importantly, it's an excellent field for women to be in," she said.

A balanced life is better for patients as well as young doctors, said Jason Wilson, president of his class. Wilson doesn't want to see a return to the days when residents worked 120 hours a week.

"Marriages fall apart, people aren't healthy," said Wilson, 29. "I think that's not good for your patients. You have to have a better sense of how the world works" to be a good doctor.

Only in the surreal world of medicine, where new rules passed a few years ago restrict residents to working "only" 80 hours a week, would Wilson's chosen specialty be considered the easy way out.

He's one of 15 classmates going into emergency medicine. Despite the intense, demanding work, emergency duty is scheduled in regular shifts that makes it more predictable for doctors with children or other professional interests. During his residency, Wilson plans to pursue a Ph.D. in anthropology.

Others say their personalities drew them to their specialties. Peaches Marie Raval Orallo likes the quick decisions that anesthesiology requires, while fiance Peter Fiester was drawn to radiology because "it's so cerebral."

Raval Orallo says she and Fiester would have picked their fields whether they were popular or not. Still, she was shocked when she talked to a family practice doctor and he warned her of long hours and falling reimbursements.

What he told her: "Primary care is dead."

• • •

But Weinberger still loves his field. To him, nothing else offers the range of diagnostic puzzles, the direct connection of the medical school science to the living patient.

"Internal medicine is a tremendously gratifying specialty from an intellectual point of view, as well as taking care of patients," he said wistfully. "Things like the high debt ends up trumping the gratification they would get."

For all the talk, he's not alone. It may lack cachet, but internal medicine is still a big field. In Thursday's match of med students with residency programs, it was the top choice at USF, drawing 23 students.

Among them is Waldo Guerrero, 26, who will head to Shands at the University of Florida. Internal medicine means you get a chance to see everything, he said.

"I am doing the unpopular thing," he said. "But it's something that's needed. If you get to people with preventive medicine, they're not going to need surgery."

Guerrero wants to be like his father, and treat the same patients for years, to know their hopes and help their troubles.

"You are going to make less money, but ultimately you've got to do what you love," he said. "Do what's going to make you happy."

Times staff researcher John Martin contributed to this report. Lisa Greene can be reached at greene@sptimes.com or (813) 226-3322.

About this series

In coming months, the Times will look at changing forces affecting doctors, medical students and the practice of medicine, and how the decisions doctors make about their careers will affect patients' care.