One of the groups most affected by the changes in the new health law are medical school students. When they graduate and complete the hospital residencies that follow they will begin practice under a system that will be significantly different than when they began college. With millions more people expected to have health insurance, demand for primary care physicians is expected to go way up.
Allison Fero, of Kaiser Health News, recently sat down individually with four medical students to discuss their career expectations, their concerns about the changing environment for doctors and their assessments of how the new law will affect the practice of medicine.
The students are in their third or fourth years of medical school, so they are all in the process of rotating through assignments in each of the major specialties as they consider what type of medicine they want to practice.
Marco Ferrera from Florida State University, who entered medical school right after college.
Nancy Bello from Philadelphia College of Osteopathic Medicine’s Georgia campus.
Myfanwy Callahan from Case Western University. Before going to medical school, she received her master’s degree in public health.
Kerry-Ann Kelly from Morehouse School of Medicine in Atlanta. She, too, has an MPH.
Q. Why did you decide to pursue medicine?
Nancy: It’s so cliché, but as long as I can remember I wanted [to be a doctor]. Then I became a patient and it made me want to pursue it more. I encountered good physicians and bad physicians and the good ones inspired me to be like them and the bad ones [made me want] to get to medical school to change that.
Myfanwy: I always loved science, but I also liked that borderline between science and communicating science to other people. When I first got out of college I did public health policy, so that is where I thought I’d communicate between scientific journals and policy makers. But I realized I was missing the people, I was missing the science. I didn’t have any patient contact, so I really felt that going back into medicine was a chance to get at the root of communicating with people.
Marco: I always wanted to go into something where I could use my skills to help people, and I started shadowing doctors in college. My dad was a doctor so I got to see that aspect early on. But I didn’t know I wanted to be a doctor until I entered college. I guess it was from volunteering, I just really enjoyed it. The more I got involved in volunteering the more I wanted to do something like that with my life.
Q. Do you plan to enter into primary care or to specialize?
Myfanwy: Right now the plan is primary care. I’m thinking internal medicine, but I haven’t actually done my rotation in internal medicine yet so we’ll see where that goes.
Nancy: I’ve narrowed it down. I have not made my final choice yet, but [it’s] between internal medicine and neurology; if I do internal medicine it won’t be general. I’ll end up specializing in something. [I’ll decide after] rotations. I’m leaning a lot toward neurology and if for some reason I end up not liking it, then I’ll do internal medicine just because it’s a field that has a lot of opportunity to specialize later on.
Kerry-Ann: I plan on going into ob-gyn, which is considered primary care for women.
Marco: There’s nothing I’m completely certain on. Right now I’m doing my first rotation with is psychiatry, next is family medicine, then surgery. This year is where I find out what it’s actually like, because we work whenever the doctor works, so you really see how their lives are. Something might sound good on paper, but maybe it’s not what you thought it was.
Q. The shortage in primary care physicians has been a concern in recent years. Will this have an effect on your decision to enter your chosen field?
Myfanwy: Not really. Just saying that we need more primary care physicians isn’t going to make people suddenly jump for it. It still has so many pressures of getting people shorter and shorter appointment times, and not getting paid for education even though education and preventive care are some of the most important services you can do as a primary care person. So there are a lot of poor incentives in medicine, and that really needs to be solved before we get at the root of the problem.
Nancy: No, not personally. I feel like if I specialize in an area I can think better and I can become an expert in that area versus doing something general and knowing a little bit about everything. I don’t function well [that way].
Kerry-Ann: Yes, I always thought about primary care, I thought about family medicine. I chose Morehouse School of Medicine because they have a focus on primary care and serving the underserved, which paralleled with my mission. I think ob-gyn, although it is a specialty, is very much primary care for women.
Marco: [Yes], I like the idea of primary care and I know how much of an issue it is with the shortage of primary care doctors. The mission of the medical school I’m at is kind of geared toward creating more primary care doctors. I’d have to see, it all depends on what I end up enjoying the most, but I could see myself doing primary care.
Q. One component of health reform that is sure to affect doctors is the implementation of comparative effectiveness research. Are you learning about this? Also, if you are being trained to factor cost into treatment decision, how would you do that?
Myfanwy: Yes and no. My med school actually does have a five-week program at the beginning where we talk about public health issues. We have maybe four lectures on health care finance and knowing the basics of Medicare versus Medicaid and things like that. On the other hand, legally we’re focused on the individual. We’re required to do whatever we need to do to help that one individual, and often times that goes against what, from a larger society standpoint, is the right decision. So it’s not taught very well in medicine right now, but it’s an issue we’re going to run across as soon as we’re under residency.
Nancy: It comes up on an individual basis. Attending [doctors] will talk to you about it if they want to, but it’s not a formal education. It’s more like if they decide to share with you the frustrations they encounter.
Kerry-Ann: Absolutely. That’s something we consider in the treatment of our patients. They force us to be conscious when treating patients about why you choose a particular drug, outside of efficacy. Our patients are mostly impoverished and if we want to get them to take their medication we have to find a way in which they will be compliant, and finances is the number one reason why patients are non-compliant with medications.
Marco: Yes, definitely we are. One of the big things about the way FSU is set up is that there is no teaching hospital. Really a lot of our training is working at doctors’ offices. So we have to find out about [the patient’s] insurance and what they can afford, and a lot of my doctors have commented on how different that is from their medical school. In a hospital you just sort of order whatever test you want, but we are very aware of the costs of things.
Q. Do you think that the current system is broken? How would you like to see it changed?
Nancy: It’s definitely broken. The how part is very difficult. There needs to be change to the system obviously but some of the changes they want to implement might be too ambitious for the short term, but at least it’s a movement toward some change. One of the [aspects] of the new reform that I think is great is having everyone have health insurance. That’s essential, having health care available for everyone, and not having preexisting conditions affecting people’s ability to get insurance.
Kerry-Ann: Broken in so many ways. It just doesn’t work. Do I have a solution? Not really because I don’t know enough about our system to have a solution. But everybody needs health care coverage, the unemployed, the employed, the people who are underemployed because a lot of times working people still can’t afford health insurance. The second step is quality of care. Now that they are covered, are they going to get the same quality of care as someone who could pay fee for service out of pocket? I hope that what’s going on in the legislation and in the current administration.
Marco: Yes, it’s absolutely broken. I guess this has a lot to do with your view on how money should be allocated and what a right versus a privilege is, but the way I see it is that medicine shouldn’t be treated like a business. It’s just gotten more expensive and that’s a result from increasing costs due to better medical technology, which on one hand is a great thing because it’s increasing life expectancy for chronic illnesses but the downside to that is it’s making everything more expensive. For a lot of people it keeps them from seeing the doctor.