Doctor incentives influence numbers, specialty choices and geographic distribution

Douglas W. Jackson

Compassion and altruistic motivations have been major incentives for students to make the required sacrifices to become physicians. In spite of the projected and current changes in medicine, it still remains a privilege to be a physician and practice medicine and it will continue to be in the future.

There are some cynics claiming the decreases in future income and reimbursement rates under health care reform will challenge the altruistic reasons students choose to become medical providers. Because of these changes, I have had several physicians tell me that they are not encouraging their sons and daughters to pursue a career in medicine.

Times have changed

Not knowing if the current thinking and motivation of students applying to medical school has changed, I assume it has not. I know that when I was training to become a physician, I was so motivated and involved with getting into medical school and completing each step along the way that I did not really have any insight into the business of medicine. At the time, I was pretty sure I would make a comfortable living after becoming a physician, but I was not sure what that income would be.

There is one major difference today for medical students. The years of education and expenses required to become a physician have seen many of them borrow significant amounts of money. Questions remain as to whether or not decreased future income and the debt they develop will influence students considering medical education.

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How much is too much?

According to the Association of American Medical Colleges, the average debt of a graduating medical student in 2009 was more than $157,000, and 85% of graduating medical students carry outstanding student loans. If current trends continue, future primary care physicians will make $100,000 to $150,000 per year and specialists $150,000 and $250,000 annually.

With the increased number of medical students in debt for their education, how will it affect the health care system? Students with high debt may be less likely to pursue family practice and other primary care specialties, and may seek specialties with higher income. This may be compounded by the fact that nurse practitioners and physician assistants provide assistance with most outpatient visits for common health problems, and do so at less cost than a physician.

How much debt will future physicians be willing to take on and repay following their education and training? A young physician with a large amount of debt needs to consider not only repayment of student loans, but also the income needed to buy a home, cars, life and medical insurance, as well as children’s educational expenses. Although most people in the United States earn less income than physicians, they usually do not start $150,000 in debt and at age 30 years or older. Will the current returns on their educational costs and years of training impact some of the applicants choosing medicine?

Changing landscape

According to the Association of American Medical College, the number of women entering U.S. medical schools has increased every year since 1982. For the class entering for the 1982-1983 year, the proportion of female medical school applicants was 32.7%. In 2009-2010, women received 48.3% of the MDs awarded. This was the largest number of women earning an MD of any national graduating class to date.

By the time students complete their postgraduate education, internships, residencies and fellowships, they are usually in their early 30s. Many students have delayed starting families during this time. Because many physicians often marry other well-paid professionals, full-time and long work-hours are not an economic necessity, but a career necessity. The demands of the medical profession are not conducive to being the primary care provider for a family because children need care around the clock. Therefore, many physicians elect to reduce their work hours, choose a specialty with more flexibility or even leave the profession altogether.

Certain specialties are more conducive to different schedules that are more compatible with the needs of income and caring for a family. According to a survey conducted in 2010 by the American Medical Group Association, 13% of male physicians practiced part-time and 36% of females practiced part-time, an increase from 7% and 29%, respectively, in 2005. Many physicians trying to be their family’s only income often choose the higher paying specialties.

A new trend is that more physicians are choosing salaried positions. Among the incentives to accept a salary are more fixed hours, a guaranteed income, and colleagues immediately available for referral and coverage. Salaried positions also offer physicians the use of existing electronic medical systems and no involvement in the business side of medicine. In addition to the desire to work reduced hours, each year some of our workforce leaves the medical profession altogether.

Potential physician shortage?

I question if the best candidates will chose careers other than medicine — careers that bring less debt into the equation. In general, physicians can be successful in many careers because of their ability to take tests and work hard academically. But we have to ask ourselves if the current return on educational investment will influence students considering medicine as a career.

Future projections predict physician shortage problems as well as geographical and specialty distribution patterns that do not completely meet societal needs. If 16,000 annual physician trainees are inadequate for what the United States needs, then does it necessarily follow that 22,000 to 24,000 are right? Central planning to address physician shortages or excesses is impacted by government distortion of the price-controlled health care markets. In addition, taxpayers may decide that the costs of subsidizing medical education can be eased by outsourcing for medical professionals. If this were to occur, then a method of assessing and ensuring the qualities of immigrating physicians must continue to be an integral part of the process.

It is my opinion that we will always have outstanding young people who are compassionate and want to be physicians. It is a satisfying career and so much of its reward is helping people. In addition, it is a stimulating and intellectually interesting profession. It is a privilege to be so involved in trying to solve and help with patients problems, caring for their needs and the ongoing relationships that develop. After 40 plus years in medicine, I still find it incredibly satisfying to enter the examining room and ask a patient what I may be able to do to help.

• Douglas W. Jackson, MD, is Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Road, Thorofare, NJ 08086; email OT@slackinc.com.