Medical School Dean Reflects on Changes in Students

By Gardner, Dave

The face of American medicine is changing, bringing with it a mixture of challenges and blessings.

According to reports in the national media, simply finding a doctor in the years ahead may become difficult. BusinessWeek magazine is predicting a shortfall of 50,000 to 100,000 physicians relative to national demand by 2020.

A federal advisory board known as the Institute of Medicine is predicting that within three years senior citizens may have to cope with a smaller than needed healthcare workforce.

Gender issues and some associated fallout are also coming into play. In the 1970s, 10 percent of American physicians were women, while females now make up one-third of the physician workforce.

Since 1996, there has been a 40 percent jump in the number of women choosing primary care versus a 16 percent decline for men. Women physicians are also favoring other areas of care where the financial prospects are not as enticing as other specialties – areas such as pediatrics and obstetrics.

BusinessWeek comments that workforce issues with child care may cause some of these female physicians to have limited availability for on-call situations. Younger physicians, as a whole, trying to balance work and family, may favor working within in a team or practice medicine only as a “hospitalist,” a physician who only sees hospitalized patients and has no office hours. The magazine questioned whether the growth in female involvement was a negative for the profession.

Robert D’Alessandri, M.D., president and dean of the proposed Commonwealth Medical College, comments that he has personally witnessed broad physician changes since the 1970s, when he was a medical student. At that time, his class included only six females among 150 students.

According to Dr. D’Alessandri, a modern medical class will be tilted only slightly towards male enrollment. Rather than criticizing women in medicine, Dr. D’Alessandri notes that many female medical students possess powerful listening and inclusion skills.

He says enrollment will also feature more mature and highly- focused non-traditional medical students who have had alternate careers and subsequently return to college highly seasoned.

Specialty decisions

The “old days” of medical school generated great student desire for the study of internal medicine, and strong competition developed for the available residency slots. General surgery was also popular, as was pediatrics.

Today, many medical students choose surgical sub-specialties. Those students at the top of their classes often pick orthopedics, neurology or radiology, for practical reasons.

“When I attended medical school, the tuition was $3,000 and my total debt was $10,000″ says Dr. D’Alessandri.” My father worked as a laborer, and put in extra hours to help me. I also worked and, as a result, I had almost no debt when I graduated. Today, however, the average medical student runs up $200,000 in debt, and this creates a desire to enter the higher-paying sub-specialties?”

The financial realities of malpractice insurance are also being recognized by today’s medical students. When Dr. D’Alessandri started out as a practicing physician in the 1970s, this insurance usually required a short approval process and a $600 annual premium. Today, application procedures are complex and annual premiums range from $15,000 to $200,000.

Billing issues are also changing substantially, according to Dr. D’Alessandri. He comments that, in the past, physicians didn’t expect payment for all of the services they delivered, and patients trading goods in lieu of payment was common.

“Medicare heavily changed this,” says Dr. D’Alessandri. “Medicare is a very good program and has helped a lot of people, but physicians now expect to bill and then be paid for everything. This has changed the business aspects of billing and collection, and it is not medicine.”

The biggest change in physician practice identified by Dr. D’Alessandri involves modern technology.

These advances are saving lives and advancing patient quality of life, but Dr. D’Alessandri warns that technology is not a substitute for old-fashioned human interaction.

“I tell students to be wary about the over-use of technology,” says Dr. D’Alessandri. “A physician can rely too heavily on technology and forget the basic skills of carefully examining the patient.”

Gender differences Concerning the “male versus female” physician issues that have been identified by the national media, Dr. D’Alessandri flatly rejects gender as a reason for young physicians preferring the saner hours of large-group practices. He explains that the true issue is that young medical professionals want their work hours limited to allow them to be better parents.

“Many of our young people have a healthier outlook than their predecessors did, and want more leisure and family time,” says Dr. D’Alessandri. I have always worked 80 to 100 hours a week, and love what I do. But younger physicians, both male and female, want more family time. These are inevitable changes, and accommodations will have to be made, not for trivial things, but for family time and relaxation.”

Concerning the role of the hospitalist and a teamwork approach versus solo medical practices, Dr. D’Alessandri points to intensive care unit (ICU) case studies that took place 20 years ago.

He says that specialists practicing only in an ICU achieved better patient outcomes and higher efficiencies than admitting physicians who managed ICU cases.

Additionally, hospitalists deliver acute care with more efficiency, a better focus and achieve quicker patient discharges. The only potential problem with the hospitalist approach is that good communication must take place between the admitting physician and the hospital medical team.

“In medical practices, a team approach is also reasonable because no doctor can be on-call all of the time,” adds Dr. D’Alessandri. “This is actually not a new approach, because in small practices someone had to cover for a physician when they were off. Medical groups can alert their on-call physicians to any potential problems that might come up, and the necessary patient records are readily available in the practice’s office.

Reimbursement problems Concerning dollars and treatments, many physicians are now finding themselves with reimbursements that have been greatly reduced. Insurers can reduce payments to influence physicians, but Dr. D’Alessandri says that most doctors try to resist the pressure. Unfortunately, the cognitive aspects of care by a physician are often not properly reimbursed. A 30-minute technical procedure may receive a higher reimbursement than 90 minutes of counseling.

“Medical policies and decisions must be driven by care, and not by reimbursement dollars,” says Dr. D’Alessandri.”

The number of physicians who will be available to care for America’s numerous and aging boomers is a great concern for Dr. D’Alessandri. Demand for pediatric services and other sub- specialties may also exceed the capabilities of the available physicians in the future.

Dr. D’Alessandri believes that a federal or Blue Ribbon group of experts should be appointed to study and address these future supply- and-demand issues.

“I tell my medical students that when they walk into an examining room and close the door, there should be only pure medicine, just you and your patient,” he says. “This must be how a doctor derives satisfaction, and not from billing and collections.”

Copyright Northeast Pennsylvania Business Journal Jul 2008

(c) 2008 Northeast Pennsylvania Business Journal. Provided by ProQuest Information and Learning. All rights Reserved.