Medical Journalism and Public Awareness

ULSE PTHE MEDICAL STUDENT SECTION OF JAMA

MAKING A LIVING: ALTERNATIVE CAREERS FOR PHYSICIANS

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PPUULSELSE Alternative Careers for Physicians Editors in Chief Jason A. Konner, Stanford University School of Medicine Jonathan H. Lin, MA Last year, a consensus statement medical journalism. John Timpane Columbia University College of Physicians and Surgeons from the American Medical Associa- writes on the 2 fields that are likely to Ivan Oransky tion, Association of American Medi- be the most abundant and lucrative New York University cal Colleges, and 4 other groups de- source of employment for physicians: School of Medicine clared that there is “compelling evi- pharmaceuticals and biotechnology. dence” that the United States is on The United States is not the only Senior Editor the verge of a physician oversupply country where physicians are over- Li-Yu Huang, MHS crisis.1 One widely cited author esti- abundant. Japan, France, and Ger- Texas A&M University mated that by the year 2000 there many all face physician surpluses of Health Science Center may be as many as 165 000 physicians their own8; and in recent years the College of Medicine more than required by a managed Czech Republic has also faced a severe 2 9 Associate Editors care–based system. Already, the physician oversupply. The destiny of United States is burdened with a sig- excess physicians in the Czech Repub- Bryan K. Chan Stanford University nificant excess of physicians. The cur- lic, argues Bohdan Pomahac and coau- School of Medicine rent supply of about 200 physicians thors, may serve as a predictor of how Scott Gottlieb per 100 000 population outstrips the successful their Western counterparts Mount Sinai School of Medicine 145 to 185 ratio that is generally will be in finding desirable employ- of the City University of New York agreed to be appropriate for a man- ment. Jason A. Konner aged care–dominated system.3 Karie Praszek notes that the per- Stanford University In an effort to forestall this crisis, ceived surpluses are mostly categorical School of Medicine many leaders are calling for the fed- and geographical. While the national Heather R. Schroeder-Mullen eral government to limit residency supply of physicians is 200 per 100 000 Case Western Reserve University 4 School of Medicine positions. In 1997, a demonstration population, there is a dearth of practi- Ronald J. Willy program was implemented in New tioners in rural and inner-city regions, Brown University York State that coordinated the ex- where the supply averages 30 per School of Medicine change of Medicare benefits for volun- 100 000 population. It is estimated that Sue Sun Yom, MA tary decreases in residency positions, 11 000 physicians are needed to bring University of Pennsylvania resulting in a decrease of 2228 resi- this figure up to 50 per 100 000 popula- School of Medicine dency positions.5,6 Encouraged by the tion, which is thought to be the accept- success of this program, the Balanced able minimum for any region.2 JAMA Staff Budget and Taxpayer Relief Acts of The future for US physicians is full Charlene Breedlove 1997 allocated $7 billion per year to of uncertainty—but also full of oppor- Managing Editor extend this opportunity to hospitals tunities. Tomorrow’s doctors should Juliana M. Walker throughout the country.5,6 not be unemployed; rather, they Assistant Editor While many authors remain pessi- should be redefined. AMA-MSS Governing Council mistic about the future for thousands References Michael W. Bigelow, PhD, Chairperson of unemployed US physicians over the Cesar Aristeiguieta, Vice Chairperson next 1 to 2 decades, some maintain that 1. http://www.aamc.org/newsroom/aamcstat/ Francine Wiest, Delegate 030397.htm#med. Accessed March 30, 1998. such concern is unnecessary. Market 2. Weiner JP. Forecasting the effects of health re- Natalie Groce, Alternate Delegate forces will prevail, according to health form on US physician workforce requirements. Kristin Cooper, At-Large Officer economist Uwe Reinhardt, and trained JAMA. 1994;272:222-230. Steven Stack, Speaker 3. CooperRA.Seekingabalancedphysicianworkforce Jeffrey Towson, Vice Speaker physicians will seek out and mold alter- forthetwenty-firstcentury.JAMA.1994;272:680-687. native career paths.7 This issue of Pulse 4. Rivo ML, Kindig DA. A report card on the physi- Christopher R. Cogle, MD, Past Chairperson cian workforce in the United States. N Engl J Med. focuses on alternative career options 1996;334:892-896. Pulse is prepared by the Pulse editors and JAMA that today’s physicians can anticipate in 5. Culliton BJ. US government pays hospitals not to staff and is published monthly from September train doctors. Nat Med. 1997;3:1057. through May. It provides a forum for the ideas, the near future. Suzanne Fraker dis- 6. Cohen JJ. From the president: a little help for opinions, and news that affect medical students cusses some of the options for which an rightsizing residencies. Acad Med. 1997;72:984. and showcases student writing, research, and art- 7. Reinhardt U. The impending physician surplus: is work. The articles and viewpoints in Pulse are not MD degree may be particularly suited. it time to quit? JAMA. 1997;277:69. necessarily the policy of the AMA or JAMA. All Two articles address some specific 8. Nathan R. Japan proposes physician cutbacks. Nat submissions must be the original unpublished Med. 1997;3:1057. work of the author. Work submitted to Pulse is areas in which physicians will likely be 9. Ministry of Health Care. Czech Health Statistics Year- subject to review and editing. employed. Scott Eggener describes a book 1995. Prague, Czech Republic: Ustav Zdravot- nickych informaci a statistiky Ceske Republiky [In- Address submissions and inquiries to profession that has gained increased stitute for Health Care Information and Statistics of Pulse Coeditor in Chief Jonathan H. Lin, public attention in recent years— the Czech Republic]. 1996; 91:118-123. 630 W 168th St, Box 673, New York, NY 10032; phone (212) 568-1084; Cover: Morning in Simla, photo taken in Simla, Himachal Pradesh, India, during the monsoon e-mail: [email protected] season by Sarita Shah, a medical student at Johns Hopkins University School of Medicine.

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Physicians Enter the Job Market Suzanne Fraker, Director, Career Management and Development Products, American Medical Association

The model of the past, when medicine was a reliable field The question of exactly how 200 000 surplus MDs will be in which hard work was rewarded by a stable and comfort- employed remains to be determined. A look at past prac- able lifestyle, no longer holds true. There is more opportu- tices and current trends may prove useful. In 1990, Rucker nity, however, away from the bedside than ever before. Phy- and Keller10 assessed the breadth of involvement in alterna- sicians are among the most capable individuals in the work- tive careers of the then 11.8% of physicians outside clinical force, and their particular training in the biomedical and practice. They identified more than 900 employment op- clinical sciences makes them a valuable asset to law firms, portunities in 12 broad categories. While physicians have businesses, consulting firms, and other corporations. entered professions as varied as politics and entertainment, The worsening job market and changes in the practice of the careers that will hold the most opportunity for them are medicine motivated physicians to leave patient care and those for which a medical education is particularly suited. seek alternative careers.1 The experience of physicians in Three fields that are full of opportunities for MDs are bioin- California, where the health care market is already deeply formatics, patent law,11 and governmental legislation and penetrated by managed care, illustrates the frustrations policy. with which many physicians are dealing.2 In a 1995 survey of The newest surge of employment for MDs may come office-based MDs and DOs, 21% of physicians over age 50 from the young field of bioengineering. Several chemical said they wanted to retire or sell their practices within a giants have recently shown a keen interest in developing year.3 A San Francisco survey of 173 practitioners of mental genetically engineered food sources. These massive under- health found that 43% were considering leaving the field.4 takings will undoubtedly require medical doctors to care- There are also indications that specialists in certain fields fully evaluate the safety of these products, as well as to ad- have found it necessary to relocate to other states just to dress skeptical consumer groups. maintain a sufficient patient population.5 The key to taking advantage of these options is the real- In 1997, physician focus groups conducted by the Ameri- ization that a medical career needs to be developed and can Medical Association met to discuss physician career managed for an entire career life cycle. The idea of actively management in an era of increased demand for efficiency, managing a career is a new and unwelcome concept for productivity, and cost-cutting.6 As a group, they identified most physicians, but is a reality that must be addressed to work pressures and job insecurity as leading causes of dissat- ensure employment in today’s complex marketplace. Nu- isfaction in clinical careers. In addition to these compelling merous resources are available commercially to guide the dissuasions from patient care, MDs may soon find that clini- physician in the process of self-assessment.12-16 New niches cal practice may not be an option, as the job market for abound, and the creativity and resourcefulness of physi- clinical positions is already more than saturated and will cians will help them find a variety of alternate ways to em- soon be forced to absorb a surplus of trained physicians.7 ploy their skills. This problem was forecasted early in this decade, by the Council on Graduate Medical Education.8 Preventive mea- References sures such as limiting the number of graduate medical resi- 1. Donelan K, Blendon RJ, Lundberg GD, et al. The new medical marketplace: physicians’ views. Health Aff. 1997;16:139-148. dency positions to 110% of the national graduating class 2. Pascual P. California doctors say managed care erodes income, quality of care. size and eliminating up to 25% of US medical school pro- The Business Press (via Knight-Ridder/Tribune). May 1, 1996:42-44. 3. Terry K. Forecast for doctors: stronger winds of change. Med Econ. 1995;72:161. grams in the next 5 to 10 years have been widely iterated 4. Hymowitz C, Pollack EJ. Psychobattle. Wall Street Journal. July 13, 1995:A1. suggestions but have yet to be fully implemented. 5. Ginzberg E. The future supply of physicians. Acad Med. 1996;71:1147-1153. 6. American Medical Association. Physician Focus Groups: Career Management. While reasons to leave the field of patient care may be- Chicago, Ill: American Medical Association; 1997. come more pressing, fortunately, inducements for MDs to 7. Weiner JP. Forecasting the effects of health reform on US physician workforce requirements. JAMA. 1994;272:222-230. enter other fields are rapidly growing. No longer does the 8. Council on Graduate Medical Education. Improving Access to Health Care acquisition of medical training imply a lifetime of work lim- Through Physician Workforce Reform: Directions for the 21st Century: Third Report to ited to the clinical setting. Today, physicians are finding Congress and the Health and Human Services Secretary. Rockville, Md: Health Re- sources and Service Administration; 1992. that a medical degree opens the door to an increasing 9. American Medical Association. Physician Characteristics and Distribution, 1995- number of opportunities in a variety of settings. 96 Edition. Chicago, Ill: Department of Data Survey and Planning, Division of Survey and Data Resources, American Medical Association; 1995. There has long been a sizable portion of physicians in- 10. Rucker TD, Keller MD, eds. Careers in Medicine: Traditional and Alternative Op- volved in occupations outside patient care. In 1980, of portunities. Garrett Park, Md: Garrett Park Press; 1990. 11. Timpane J. Six hot careers: biotechnology, pharmaceuticals, and beyond. 373 503 MDs in the United States, at least 59 000 (15.8%) Science. 1996;273(suppl):1898-1913. were not involved in patient care. In 1994, the number was 12. American Medical Association. Assessing Your Career Options: A Workbook for Taking Charge of Change. Chicago, Ill: American Medical Association; 1998. nearly unchanged (57 000), although the proportion of 13. American Medical Association. Leaving the Bedside: The Search for a Nonclinical these MDs sank to 10%, likely as a result of the lucrative Medical Career, Revised Edition. Chicago, Ill: American Medical Association; 1996. 9 14. American Medical Association. Managing the Job Interview. Chicago, Ill: Ameri- return for providing patient care in the 1980s. With an can Medical Association; 1997. anticipated physician surplus as high as 200 000, this abso- 15. American Medical Association. Evaluating and Negotiating Your Compensation Arrangements. Chicago, Ill: American Medical Association; 1998. lute number can be expected to increase dramatically over 16. Rosen S. Career well-being. http://www.harbornet.com/biz/office/ the next decade. sct001.html. Accessed April 2, 1998.

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The Power of the Pen: Medical Journalism and Public Awareness

Scott Eggener, Stanford University School of Medicine

With approximately 4000 journals indexed on MEDLINE, number of physician-writers without ties to professional containing more than 9 million abstracts, the sheer mass organizations. of emerging biomedical knowledge is overwhelming.1 Un- Defining the job of a medical journalist is difficult. fortunately, there is a gap between the wealth of expand- They specialize in fields as varied as marketing, public ing information and the quality of public health, partly relations, policy planning, advertising, speechwriting, pro- because of the difficulty of dispensing this information to ducing, and computer programming. They work in news- the lay public. The editors of the New England Journal of rooms, corporations, hospitals, nonprofit organizations, Medicine noted recently that “the problem of [communi- entertainment industries, schools, government agencies, cating health] is not in the research itself but in the way it health maintenance organizations, and pharmaceutical is interpreted for the public.”2 To facilitate the flow of per- firms. tinent medical research to the public at large, we rely on While the range of occupational opportunities for a the skills of medical journalists. medical journalist is extensive, it is difficult to gauge em- Reflecting the public’s voracious appetite for medical ployment supply and demand. Compensation for medical news, health stories are now regularly found as page 1 news- journalists varies widely. Freelance writers are paid per paper stories and as daily segments on prime-time televi- word or per project, while a full-time metropolitan news- sion newscasts. In addition, the need for reliable sources of paper reporter earns about $80 000 per year. Some writ- medical news has produced the Journal of Health Communica- ers’ incomes are dependent on subscriptions or syndica- tion, a Division of Health Communication at the Centers for tion. Becoming a medical writer can be as easy as Disease Control and Prevention, health communication distributing a newsletter. However, landing a full-time po- graduate programs offered at 6 universities, and other re- sition in a major media market typically requires consider- sources. Thus, medical journalists are facing expanding job able experience. opportunities, greater visibility, and the potential to have a “If physicians have the same attributes as a really good more powerful impact. journalist, they help reflect a better rendition of reality,” Among the media available to reach American health says Stephen J. Bloom, associate professor of journalism at information consumers are newspapers, magazines, medi- the University of Iowa. The model doctor and journalist cal journals, billboards, radio, pamphlets, and mailings. share similar qualities: the ability to conduct a focused and Two of the most influential and extensive are television and fact-oriented interview, perform a relevant (physical) ex- the Internet. The potency of television can be illustrated by amination, assemble reliable and reproducible data, ana- a recent survey of regular viewers of the NBC medical lyze quickly and accurately, and describe results in a clear, drama “ER”3; 32% indicated that information they receive concise, and unbiased manner. from the show helps them make choices about their fami- While physicians offer the advantages of understanding ly’s health care. Remarkably, 12% of viewers have contacted medical terminology and having had clinical experience to their physicians because of something they saw on the guide them in fairly relaying health information, they gen- show. Another widely used system, the Internet, provides erally lack the benefits of a formal education in journalism. around-the-clock access and, unlike many other resources, “Don’t think you can waltz into a newsroom and suddenly is capable of accommodating personal health inquiries. become a star,” warns Mr Bloom. “The MD degree won’t do This ever-growing collection of information continues to anything for you, unless you’ve already proven yourself a influence the “wired” groups of society—the educated, first-rate journalist with a track record of superbly written wealthy, Generation X, and Baby Boomers—and has great and well-researched medical stories.” potential for countless others. As long as a discrepancy exists between medical wisdom While every practicing physician is a health communica- and the health of the population, there will be a valued role tor, some choose to make it a career. When the American for the medical journalist. According to David Satcher, MD, Medical Writers Association (AMWA) was founded in recently confirmed as US Surgeon General, “We’ve come to 1940, its membership consisted almost entirely of those a point where, unless we can communicate to people out- with MD degrees. Over the next 50 years, however, physi- side of medicine, we can’t achieve a lot of our goals.”5 cian membership in AMWA steadily declined. In 1955, 76% of members possessed an MD degree, yet in 1991 References 4 this figure dropped to only 9%. Betty Cohen, former 1. http://www.apconline.org/journals/news/oct97/medline/htm. Accessed April president of AMWA, explains that “As AMWA evolved, 2, 1998. 2. Angell M, Kassirer J. Clinical research: what should the public believe? N Engl other [nonphysician] writers entered, bringing different J Med. 1994;331:189-190. expertise. Physicians may have felt it was no longer their 3. Kaiser Family Foundation. http://www.kff.org/archive/repro/media/ers/ ers.html. Accessed February 2, 1998. organization.” Since 1991 this trend has begun to reverse 4. Good B, Endriss S. Membership committee embarks on physician recruit- itself and as AMWA membership has increased by 20% to ment. Am Med Writers Assoc J. 1992;7:30-32. 5. Rubin R, Rogers H. Under the Microscope: The Relationship Between Physicians and 4000 members, physicians now comprise 12.5% of all the News Media. Nashville, Tenn: The Freedom Forum, Vanderbilt University; members. There are few data available to assess the total 1993.

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Everywhere and Then Some: Physicians Making Careers in Biopharmaceuticals

John Timpane, PhD, The Philadelphia Inquirer

Physicians from disparate fields are found throughout con- nies learn to deal with and interact in the changing world temporary pharmaceutical companies, as well as throughout of managed care, subspecialist internists are the population many biotechnology companies. from which most physicians are hired.3 For example, sev- The opportunities for physicians are tremendously var- eral of the largest drug companies, including Novartis, ied and often form-fitted. Depending on their interests Merck, Bristol-Myers Squibb, and SmithKline Beecham, and abilities, physicians may work in a variety of positions, have significant research efforts under way in several areas including that of bench scientist, medical support pro- relevant to the aging segment of the population and will vider, and administrator. Many devote the majority of need gerontologists as part of that effort. Tremendous ad- their time to clinical and scientific responsibilities, ie, de- vances in the development of novel neurotherapeutic signing new studies, writing protocols, initiating and agents, largely derived from biotechnologic advances in monitoring studies, interpreting data, preparing medical molecular biology and genetics, have expanded the phar- reports, extrapolating results, and developing a clinical maceutical need for clinician-scientists with experience in strategy to bring a new drug or new indication for an ex- neurology.4 Similar scenarios exist for specialists in oncol- isting drug forward.1 ogy, virology, pain, epidemiology, respiratory disease, and These responsibilities reflect many of the factors that infectious disease. attract physicians to the industry in the first place—a re- Experience with patient care may be the most unique search career with ample resources, the use of special skills, and indispensable skill that MDs have to offer. This is an a desire for change and challenge, an interest in pharma- element most research scientists lack: actual experience ceuticals, and a desire to contribute to development of new with the kinds of people who might be administering or drugs.2 Naturally, there are lifestyle issues that motivate in- taking the drug in question. In business parlance, MDs dustry physicians as well, the most important of which are speak the language of the clients—in this case, of both pa- regular hours, remuneration, and career flexibility.2 A phy- tients and other MDs. Still other MDs have had experience sician entering the pharmaceutical company at an entry managing an office or a medical department or a clinical level position can expect to earn $110 000 to $120 000 plus study. bonuses and benefits during the first year.3 Salaries advance Finally, MDs generally have extensive backgrounds in proportionally. For example, pharmaceutical neurologists anatomy and physiology, and often are a part of the inter- receive on average 20% more than those in equivalent aca- disciplinary teams that prepare a compound for clinical demic positions, in addition to stock options and bonuses.4 trials. They know enough science to understand the goals Careers in the biopharmaceutical sector also have the ad- and procedures of the project, and their understanding of vantage of opportunities to travel, to attend medical and the relationship between medicines and organ systems scientific meetings, and to be involved in a variety of career helps bridge a crucial divide between the creation of the settings. compound and its testing in humans. Classical physiology There are, however, several factors that may deter a phy- may become much more important to biopharmaceutical sician from entering the field. A survey in 1991 of pharma- companies in the next 10 years as the Human Genome ceutical employees with MD degrees revealed several rea- Project advances. This will require a shift from modern mo- sons for job dissatisfaction; these included bureaucracy, lecular biology back to classical physiology, employing ge- ethics being subverted for profit, autocracy, favoritism, and netic as well as surgical and chemical variables. restrictions on initiative and responsibility.2 Subtle cultural Physicians possess many attributes that cannot be pro- issues are also involved. While the concept of MDs working vided by nonphysicians. At the same time, the opportunities within the pharmaceutical industry is gaining acceptance that biopharmaceutical companies offer can be attractive. among physicians, there has long been a sense of mistrust As physicians struggle with the economically driven vagaries of the industry that has kept some from making the transi- of a modern medical career, they may find a comfortable tion.3 and productive alternative in drug development. Another limiting aspect is the level of competition for References highly coveted positions in the biopharmaceutical sector. 1. Spilker B. Career opportunities for physicians in the pharmaceutical industry. Greater numbers of physicians are applying for these posi- J Clin Pharmacol. 1989;29:1069-1076. tions. Because the cost of discovery and development of a 2. Shaw L. A misunderstood specialty: a survey of physicians in the pharmaceutical industry. J Clin Pharmacol. 1991;31:419-422. new pharmaceutical drug can total $100 million to $200 3. American Medical Association. Leaving the Bedside: The Search for a Nonclinical million or more,5 pharmaceutical and biotechnology com- Medical Career, Revised Edition. Chicago, Ill: American Medical Association; 1996. panies are careful to hire only the most qualified applicants. 4. Peroutka SJ. Role of neurologists in the pharmaceutical industry. West J Med. These industries seek in their physician employees varied 1994;161:328-330. 5. DiMasi J, Hansen RW, Grabowski HG, Lasagna L. Research and development and demanding qualities. Specialized knowledge is one. costs for new drugs by therapeutic category; a study of the US pharmaceutical While generalists usually fill the niche of helping compa- industry. Pharmacoeconomics. 1995;7:152-169.

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Physician Surplus: The Czech Story Bohdan Pomahac, MD, Brigham and Women’s Hospital, Augustinova Hana, MD, Prostejov Hospital, Prostejov, Czech Republic, Richter Libor, MD, Bata Hospital, Zlin, Czech Republic

Not long ago physicians in the Czech Republic could be though the majority of them still obtained jobs, more than found working in factories at manufacturing occupations. 25% had to accept a specialty that was not their first choice. After being forced out of health care by the communist A small percentage of graduates set their sights on practic- regime, these doctors accepted practically any paying job. ing abroad. Although the communists are no longer in power, a simi- Although the percentage of graduates who do not practice lar situation may arise for a different reason: the Czech medicine remains undetermined, it seems that those who Republic has an excess of physicians. leave the field can usually find work in pharmaceutical com- In the 1970s, elementary school students in the Czech panies or others in the medical field. Many graduates choose Republic were taught that the health care systems of their this option intentionally, lured by higher salaries and a more country and of the Soviet Union were the most developed attractive lifestyle. For example, in 1996 the average monthly in the world. While statistics showed a high number of phy- income of a medical graduate was approximately Kc 6310 sicians, this did not always translate into a high level of de- (US $185),3 while the national average was Kc 9676 (US velopment. Probably the major factor that contributed to $285).4 Starting salaries in pharmaceutical companies are the current situation was the organization of health care. As generally well above the national average. In an effort to con- with similar other branches of the national economy, the tinue postgraduate education and to become eligible for work productivity in health care grew extensively, not as the national board examinations, some medical graduates work result of increased efficiency but of a greater number of for a much lower monthly salary (Kc 3000, or US $88), or physicians and staff being hired. even for free.3 While pharmaceutical and biotechnology This surplus was not apparent in the communist system, companies offer more than satisfactory salaries and benefits, but became clear in the new Czech market economy after there are still other attractive options including a combina- the so-called Velvet Revolution. In 1995, there was 1 physi- tion of research and clinical work. Career tracks of this type cian per 295 citizens. This was much higher than other have traditionally not been supported in the Czech Republic, countries, such as Great Britain where there was 1 physician but several universities have recently opened programs offer- per 715 citizens, or Italy which had 1 physician for every 667 ing positions for those interested in research. inhabitants.1 Insufficient control over expenses and ineffi- The process of Czech health care transformation contin- cient management caused waste of labor and supplies. The ues. In the meantime, the Czech model of downsizing and widespread shortage of health care resources motivated a redeployment will continue to serve as a valuable teacher, group of physicians to call a strike in the fall of 1995. This and its successes and failures may guide other countries in turn led the health care minister to convene a group of that face similar problems. experts to analyze the efficiency of hospitals, with the inten- References tion of closing the least productive health care facilities. 1. Ministry of Health Care. Czech Health Statistics Yearbook 1995. Prague, Czech The theory is that the management of the remaining hospi- Republic: Ustav Zdravotnickych informaci a statistiky Ceske Republiky [Insti- tals will have to improve so as to handle a greater workload. tute for Health Care Information and Statistics of the Czech Republic]. 1996; 91:118-123. Because a rapid downsizing of the health care system 2. Ministry of Health Care. Lekari evidovani na uradech prace v Ceske republice would likely cause a high rate of unemployment, officials jako uchazeci o zamestnani ke konic letosniho dubna. [Physicians registered decided to reduce the number of students accepted to at unemployment offices by the end of April of this year]. Zdravotnicke Noviny (Health Care Newspaper). 1997;35:11. medical schools. This has already been reflected in the total 3. Casopis lekarske komory. [ Journal of the Health Care Chamber]. 1997;6:11. number of medical graduates. In 1994 and again in 1995 4. Tyden. [The Week]. 1997;12:24. more than 1500 students graduated from all Czech medical 2 schools; in 1996, the number dropped to 1293. MURMURS Even with these changes, however, unemployment is expected to grow. There were 289 registered unemployed • Watch for the debut this fall of a new Web resource: The Medical Student physicians by December 31, 1995.2 This number repre- JAMA. sented less than 1% of the total 36 348 physicians at that • Plan now to attend the 1998 AMA-MSS Annual Meeting, June 11 through time. Significantly, however, 202 of these unemployed phy- 14, at the Hyatt Regency Hotel in Chicago, Ill. This year’s program will include a presentation, “Miracle on Everest,” by Beck Weathers, MD, a sicians were 1995 medical graduates, representing almost a Texas pathologist who nearly lost his life climbing Mt Everest in May 14% unemployment rate for that class. 1996. For more information, visit the AMA-MSS Web site at http:// Medical graduates are clearly in a difficult situation. Hos- www.ama-assn.org/mss. pitals are hesitant to sign contracts for longer than 1 year • Apply now for positions during 1998-1999 on the following AMA-MSS because even the near future is unstable. The general view- committees: Legislative Awareness, Minority Issues, Computer Projects, point of the medical graduates was reflected in a recent and Long-Range Planning. The National Board of Medical Examiners 3 also has 2 positions for MSS members on its Medical Student Liaison questionnaire released by Chamber of Physicians. Approxi- Committee. Applications for all these positions must be postmarked by mately 40% of the medical school graduates questioned July 24, 1998. For more information, call (800) AMA-3211 ext 4746 or would not have applied to medical school again. Even e-mail: [email protected].

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Family Medicine: A Call to the Front Line

Karie Praszek, Anita Taylor, MEd, Kathryn Chappelle, MA, Oregon Health Sciences University

Between 1965 and 1992 the proportion of physicians in gen- in the United States have a greater potential to alter demo- eral practice declined from 51% to 35%.1 Despite repeated graphics. Though the demand for this option has thus far expressions of concern by government agencies and health been underwhelming, the retraining of subspecialists for care experts,1-3 an imbalance in physician career preference primary care careers remains a viable potential means of has persisted, favoring oversaturated specialty fields. The redistributing the physician workforce.18 1992 report of the Council on Graduate Medical Education Job satisfaction may explain why relatively few physicians (COGME) set a national goal for at least half of graduates to have chosen to retrain. A recent large study showed that begin careers in family practice, general internal medicine, even in this turbulent period of health care transformation or general pediatrics by the year 2000.4 80% of physicians surveyed were satisfied with their jobs Analysis of data from the National Residency Matching and overall satisfaction was equivalent for primary care and Program (NRMP) from the time since the COGME report non–primary care physicians.19 suggests that this goal is being approached. Following a 4- It appears that the precautions against overspecialization year decline between 1988 and 1991, the number of family urged by health care leaders at the beginning of this de- medicine residency positions filled in the NRMP jumped cade are now being heeded by its end. The changes are far from 1658 in 1992 to 2002 in 1993, an increase of more than from complete, however, and opportunities for young phy- 20%. By 1997, the number of filled positions was 2905, an sicians to practice medicine, even in the midst of a physi- increase of 75%.5-8 Historically, approximately 95% of those cian surplus, will continue to exist in the unsaturated pri- entering family medicine have proceeded to enter primary mary care fields. care practice.9 Additionally, 60% of those entering pediatrics and 35% of those entering internal medicine have also References 9 entered primary care practice. Taking these figures to- 1. Council on Graduate Medical Education. First Report of the Council. Vol 1. gether, it can be expected that 37.5% of the 1997 graduates Washington, DC: US Dept of Health and Human Services; 1988. 5,8 2. Association of American Medical Colleges. Supplying Physicians for Future will have a generalist career, up from 27% in 1992. Needs: The Report of the Task Force on Physician Supply. Washington, DC: Associa- There is evidence to indicate that financial incentives tion of American Medical Colleges; 1990. 10 3. Politzer RM, Harris DL, Gaston MH, Mullan F. Primary care physician supply influence specialty choice, and managed care is providing and the medically underserved. JAMA. 1991;266:104-109. new economic incentives for young physicians. Between 4. Council on Graduate Medical Education. Improving Access to Health Care 1985 and 1993, states with the highest penetration by man- Through Physician Workforce Reform: Directions for the 21st Century: Third Report to Congress and the Health and Human Services Secretary. Rockville, Md: Health Re- aged care also had the highest rate of growth in primary sources and Services Administration; 1992. care physicians’ income.11 5. Kahn NB, Jackson SJ, Schmittling G, Ostergaard DJ, Graham R. Results of the 1993 National Resident Matching Program. Fam Med. 1993;25:511-516. This attraction paradoxically may put underserved rural 6. Kahn NB, Garner JG, Schmittling GT, Ostergaard DJ, Graham R. Results of populations in some peril, as HMOs may be luring some gen- the 1995 National Resident Matching Program: family practice. Fam Med. 12 1995:27:501-505. eralists into prosperous urban areas. Recently, young physi- 7. Kahn NB Jr, Garner JG, Schmittling GT, Ostergaard DJ, Graham R. Results of cians have begun to respond in earnest. In 1997, the Associa- the 1996 National Resident Matching Program: family practice. Fam Med. 1996;28:548-552. tion of American Medical Colleges Medical School Gradua- 8. Kahn NB Jr, Garner JG, Schmittling GT, Ostergaard DJ, Graham R. Results of tion Questionnaire demonstrated a significant rise in the 1997 National Resident Matching Program: family practice. Fam Med. 13,14 1997;29:553-558. graduates planning to practice in an underserved area. 9. Martini CJM, Veloski J, Barzansky B, Xu G, Fields SK. Medical school and stu- Many educators believe that recent changes—including al- dent characteristics that influence choosing a generalist career. JAMA. 1994; 272:661-668. lowing medical students to rotate through rural and inner- 10. McKay N. The economic determinants of specialty choice by medical resi- city clinical settings and providing required clerkships in dents. J Health Econ. 1990;9:335-357. 15 11. Rosenthal M, Diamond J, Rabinowitz H, et al. Influence of income, hours community-based practices—are having a positive effect. worked, and loan repayment on medical students’ decision to pursue a pri- A less apparent influence on specialty choice may come mary care career. JAMA. 1994;271:914-917. from distinctive cultural influences engendered in aca- 12. Rivo ML, Kindig DA. A report card on the physician workforce in the United States. N Engl J Med. 1996;334:892-896. demic medical centers. Students and residents may en- 13. Simon CJ, Dranove D, White WD. The impact of managed care on the phy- counter an unwelcoming attitude toward primary health sician marketplace. Pub Health Rep. 1997;112:222-230. 14. Association of American Medical Colleges. 1996 AAMC Medical School Gradu- careers and expressions of these sentiments can have sig- ation Questionnaire. Washington, DC: Association of American Medical Col- nificant effects on specialty choice.16 leges; 1996. 15. Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG. Which Alternatively, the trends in specialty choice might be ex- medical schools produce rural physicians? JAMA. 1992;268:1559-1565. plained by the increasing tendency of medical schools to 16. Hunt DD, Scott C, Zhong S, Goldstein E. Frequency and effect of negative comments (‘badmouthing’) on medical students’ career choices. Acad Med. recruit students with a particular interest in primary care. A 1996;71:665-669. program initiated in 1974 at Jefferson Medical College that 17. Rabinowitz HK. Recruitment, retention, and follow-up of graduates of a program to increase the number of family physicians in rural and underserved combines a selective admissions policy with a special educa- areas. N Engl J Med. 1993;328:934-939. tional curriculum has proved effective.17 18. Wall EM, Saultz JW. Retraining the subspecialist for a primary care career: four possible pathways. Acad Med. 1994;69:261-266. While medical student choice has an important effect on 19. Chuck JM, Nesbitt TS, Kwan J, Kam SM. Is being a doctor still fun? West J Med. physician supply, the 650 000 physicians already in practice 1993;159:665-669.

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