The Lure of Specialties

Today's medical school students are attracted to specialty fields instead of primary care for a number of reasons. For starters, they are piling up tremendous debt in the pursuit of an MD or DO (doctor of osteopathic medicine) -- $200,000 in loans is not unheard of -- and then looking at the realities of a labor market that rewards high-tech, procedure-based medicine. Merritt Hawkins noted in the June report that the average salary offered to family physicians was $172,000 in 2007-2008, compared to $300,000 for an anesthesiologist and $360,000 for a hematologist/oncologist. Some other specialties commanded even more.

Medical students are also veering away from primary care practice for lifestyle reasons, including wanting more time for family and leisure. A radiologist, for instance, can work far fewer hours than a pediatrician or general internist and still make twice the salary. There's also a "wow factor" at work. Today's medical students were raised on gadgets, and they may understandably be attracted to fields that use computers, lasers, robotic tools and other technology, rather than embracing a future filled with patients with colds, high cholesterol and other everyday concerns.

Richard A. Cooper, a professor of medicine at the University of Pennsylvania and a senior fellow at the Leonard Davis Institute, says that some of the increased demand for physician services likely to be generated by an expansion of insurance coverage could be absorbed if doctors already in practice put in more hours, but that approach can only go so far. He suggests that the solution, from both an efficiency and economic standpoint, will have to involve "looking downstream" at the roles played by others in the health care system -- physician assistants, nurse practitioners, nurses, nursing aides and technicians.

"All you can do is try to get other people trained quickly, and you have to jettison as many tasks downstream as possible," he notes. "You don't pay a doctor for what a nurse can do, and you don't pay a nurse for what a nursing assistant can do."

Cooper, himself an internist, points out that while it may seem to make sense to encourage more students to go into primary care, there's a downside to that strategy because there will also be a need for more cardiologists, orthopedic surgeons and geriatricians as the population ages. "To make one kind of doctor, you have to give up making something else," he says. Primary care doctors will have to become more like specialists, he predicts, using their time to handle complex cases and allowing their staff to see to more routine patients.

"We have to train people for rural medicine. We have to have people who can do oncology and care for the aging population," Cooper says. Whether they're called primary care doctors or whatever, "we need more doctors to do what doctors do."