July 29, 2008
Specialties More Attractive to Younger Medical Students
By Vicky Eckenrode, Star-News, Wilmington, N.C.
Jul. 27--After Amanda Ruxton completes her medical residency, she hopes to work with underserved and indigent care patients.
"I've wanted to be a doctor since I was 7," said Ruxton, who started last month at New Hanover Regional Medical Center. "I was very excited to be done with medical school. This is the only job that comes naturally to me."
She will spend the next three years training in family medicine, one of the primary care specialties that some health experts worry draw too few new doctors.
This year, slightly more family medicine residency positions opened up nationwide, reversing a steady decline since 1998, according to the National Resident Matching Program, which pairs programs and graduating students using both sides' preferences.
Still, specialties like plastic surgery, orthopedic surgery, dermatology and diagnostic radiology stood out this year as the most popular and competitive programs among residency applicants.
For example, about two people applied for each slot available in family medicine or internal medicine in March during the national matching process.
By contrast, six people applied for each dermatology opening, and five people applied for each diagnostic radiology opening.
Some physician groups and health organizations worry that the draw toward those specialties instead of the ones responsible for families' routine health could have significant impact on access to doctors and depth of care in the years ahead, particularly as baby boomers age.
Part of the shift is a generational change being seen in a number of professions, said Mark Darrow, president of the South East Area Health Education Center, which administers New Hanover Regional's medical residency programs.
Going to his 30-year medical school reunion recently drove that point home.
"Well over half of us went into primary care, and that was just the thing," he said. "But nowadays, you look at the classes and there's a different interest now."
Darrow, a baby boomer himself, said long hours and night and weekend work used to be the norm. That's changing as younger generations of physicians bring different a different outlook to the profession.
"Then you got the Generation X'ers, who for the first time introduced this whole concept of self-preservation and family -- 'I need to get home at a certain hour, and I'm not going to throw myself in front of the moving train because I decided it's not worth it,' " he said.
The subspecialties often are still hard work, but their more predictable, daytime schedules help make them more attractive.
Money also plays into the trend, said Charles Schleupner, director of New Hanover Regional's internal medicine residency program.
Compared with payments and third-party reimbursements for areas like surgery, "the work of the internist, the pediatricians and the family medical person -- they're not recognized and rewarded in the same way," said Schleupner, who also serves as president of the New Hanover-Pender County Medical Society.
Then, there are the loans for medical school to be repaid -- amounts that typically can range from $100,000 to $250,000.
"If you're talking about starting out a life after a completion of residency -- you've got to consider paying off that debt and purchasing a home," Schleupner said. "If you can guarantee income that's twofold, you're going to pursue the subspecialty that's more remunerative."
Talk of debt forgiveness is emerging as a way to lure medical students into primary care, particularly in rural areas where physicians can be scarce. The idea is to exchange practice time in a needy area for loan help.
In terms of sheer numbers, most residency slots are reserved for internal and family medicine.
But health groups say the number of new doctors will not keep up with growth in the number of patients.
In North Carolina, there were 20.7 physicians per 10,000 people in 2005, according to a study published by the North Carolina Institute of Medicine, a nonprofit that studies state health issues.
The report predicts that without changes to provider supply levels, that ratio could drop by 8 percent by 2020 and 21 percent -- to fewer than 17 per 10,000 -- by 2030.
The study also showed that primary care providers were beginning to lag behind. Between 2001 and 2005, 30 counties in the state saw their primary care doctor-to-population ratios drop.
Though pockets of rural areas persistently have a hard time supplying enough doctors for the communities, physician levels statewide are holding steady right now with neighboring states.
A task force headed up by the North Carolina Institute of Medicine and including members from the various medical schools in the state, physicians groups and residency program officials, concluded that the problem could be addressed, in part, by expanding schools to increase the supply of medical students.
Expanding residency training programs, beefing up in-state retention efforts and adding workers like nurse practitioners or physician assistants in primary care services might be other ways to address the projected shortfall in doctor availability.
Because any of those options would take years to achieve, groups are sounding warning bells now, particularly as a large batch of existing doctors approaches retirement age.
About 13,000 active physicians reached the age of 63 last year, according to the American College of Physicians, and that figure is expected to soar to 24,000 in 2017.
"I'm six years away from retirement," said Darrow, who specializes in geriatric medicine. "There isn't going to be anybody left to take care of me except me."
With concerns about fewer doctors to treat baby boomers down the road, Darrow half jokes that he won't be able to retire unless the trend reverses and more physicians start entering the fields.
"We're going to run out of primary care for two reasons: We're not growing a lot of them, and the baby boomer generation isn't getting any younger," he said. "The private prayer of all us middle aged or passing middle age for primary care providers is that the market is going to demand it."
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