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So You Want to be a...

The New Physician May-June 2000
It’s a fundamental quest--selecting a specialty. Let these physicians’ tales help you find your way in Part 1 of The New Physician’s look at medical specialties.


Tome things never change, like the reason why most students choose medicine as a career. Certain types of people just like helping other people. Couple this enthusiasm with intellectual prowess, indefatigable commitment, plus a few student loans, and welcome to medical school. For most folks, it’s that easy.


Committing to a specialty, however, can be more daunting. Is knowing a little about a lot of things more appealing than knowing a lot about a few things? Do you want to work with women or children or the entire family? Does surgery seem like the most exciting career path to take? Or do you thrive on more personal, long-lasting relationships that come with treating common, everyday maladies?


These are just a few of the things to think about when delving into what kind of physician you want to become. In an effort to help answer some of your questions, The New Physician (TNP) presents the first of a two-part series that takes an in-depth look at medical specialties. In Part I, we’ll focus on family practice, internal medicine, obstetrics–gynecology and pediatrics. In our September 2000 issue, Part II will cover emergency medicine, general surgery and psychiatry.


While interviewing physicians for this piece, it became immediately clear that the story of each specialty could not be told without addressing the business and politics of medicine involved in each field. In 1984 when TNP last looked at “Seven Specialties Up Close,” HMOs and managed-care systems were considered reasonable and inevitable solutions to the high cost of medical care. The physicians TNP spoke with this time around, however, revealed attitudes are tolerant at best and, in most cases, downright bitter toward managed care.


Like it or not, the business of medicine has changed dramatically in 16 years. Doctors must hire staff to weed through complex and tedious paperwork. Capitation rates reduce income potential and discourage lengthy visits with patients. Physicians who have 40 years’ experience are required to obtain approval for tests and referrals, often from administrators lacking medical backgrounds. These and other facts are enough to drive some would-be physicians down a completely different career path.


On the other hand, some doctors find the new system appealing since it offers a more balanced lifestyle. To them, going to the office from 8 to 5, never having to enter a hospital (since hospitalists are growing in numbers), and relying on a consistent salary is just fine. To most physicians TNP spoke with, however, the paradigm of managed care defeats the very nature of what it takes to become a great physician.


The cautionary tale seasoned doctors are telling is this: Think very carefully not only about which specialty suits your personality and goals, but be aware of the impact other choices will have on your business—income, time and ability to provide quality care. Research the medical climate of where you will practice (regionally as well as private or group practice vs. within an HMO); how you will practice (whether or not you will work with HMOs—understanding there is a choice); and what you can do to make the system work for you and the well-being of your patients.


Regardless of your specialty, most of these physicians insist that, now more than ever, if you choose a small private practice, you must know how to run a small business. That means firing and hiring, writing employee handbooks, handling systems management, overseeing the books, maintaining effective and polite phone manners, and more. So far, business courses aren’t required to become a doctor. So, like many other things, it’s up to you to work out the details that will ensure the survival of your practice.


These overviews should offer the latest information today’s new physicians will need to succeed in making the right specialty choice for their careers.“When patients call my office, they encourage my assistant to put the call through because they’re a ‘friend’ of mine. My assistant once asked me if all of my patients are friends of mine, and I said yes.”


Dr. George Blatti’s relationship with his patients is typical and almost necessary for a thriving family practice. Based in Nassau County on Long Island, Blatti says that after practicing for 26 years, one becomes invested in the physician–patient relationships, and this develops into a powerful bond. Being a family practice physician, Blatti says, is not so much a job as it is a calling.


It’s a good thing so many residents are answering that call since more patients see a family practice physician than any other specialist. In 1999, a little more than 9,300 residents were in family practice, and 45 percent were women. Of those already in practice, 17,207 are women. In 1998, single family physicians saw an average of 4,318 patients. These numbers come as no surprise, though, considering that family physicians do everything from performing circumcisions to managing patients with Alzheimer’s—not to mention the many things in between.


Dr. David Leonard of Fairfax, Virginia, thinks there’s a misconception about this specialty. “There aren’t enough people who choose this field as their first choice. There’s a perception that it’s not that challenging, and that all you treat are colds and flu,” Leonard says. “Or, they think we assume to know everything. We don’t. We are specialists in common diseases. If something more complex shows up, we refer patients to someone else.”


A typical day for Leonard is to rise early and make his hospital rounds at 6:30 a.m. when his older patients are most alert. That way, he can also release them right after breakfast. Since he rarely has more than five patients in the hospital at one time, the schedule works smoothly. He then heads to the office so he’s seeing patients by 7:45 a.m., and makes it home by 7 p.m. to spend time with his wife and children. He’s on call two nights a week and every fourth weekend. He keeps up-to-date by reading medical journals during his free time and listening to informative audiotapes while on his commute. Believe it or not, he also finds time to exercise—it’s his way of practicing what he preaches.


Nearly 95 percent of what family physicians do takes place in their offices. That means conducting a lot of physicals, treating upper respiratory infections, diabetes, hypertension, obesity, chest pain and a host of behavioral or emotional stresses such as attention deficit hyperactivity disorder, anxiety and depression. In fact, family physicians are often the first counselor sought by a person experiencing anxiety and depression. Emotional upsets require doctors to embody empathy, patience, understanding and good listening skills. Prevention also comprises a significant part of family practice, Leonard says. So does trust.


“You can’t prove that your patient has good health because of your influence, but you have to believe it,” he says. Even so, Leonard basks in the glory of what happens after trust has been established. “Once a patient trusts you, her compliance goes up. Plus, she doesn’t want to disappoint you. A personal bond breeds a desire in the doctor to help the patient, but the patient also doesn’t want to let the doctor down. It’s a mutually beneficial relationship where we both want the other to win.”


Blatti elaborates by saying that no matter where you practice, this specialty is conducive to highly personal, long-term, multigenerational relationships. Blatti, for instance, now cares for young mothers who were once his child patients. But cultural influences and demographics should be considered when thinking about where to hang out a sign. He should know. He has practiced in rural Minnesota, New York City and now the suburbs.


“You need to get a feel for the economic, moral and medical sociology of where you want to work and live,” he says. “Look at the impact of HMOs, colleagues, hospitals and politics.” He explains that in rural settings, you may have to treat everything imaginable since specialists are far away. At the same time, people in rural areas often can’t afford health insurance, creating economic difficulties. When practicing in the inner city, Blatti says, family physicians have the influence of nearby hospitals and universities, but neighborhood health centers are considered the defined caregiver for designated areas. That leaves room to design programs unique to those demographics. In the suburbs, Blatti claims there are so many doctors fighting for turf that there’s very little elbowroom. The economic benefit, however, is that you deal with a more affluent and educated population who is usually covered by health insurance.


Both Blatti and Leonard acknowledge, however, that regardless of the region in which you practice, the moral fabric of any community comes into play. For the 65,343 practicing family physicians, there’s no choice but to address teen pregnancy, drug use and youth violence. “The times determine what we need to discuss with kids, and that can influence what you focus on and how you practice,” Blatti says.


On average across the entire country, most family practitioners start earning about $110,000 per year and peak at around $135,000. Capitation rates and payment methods vary from place to place and should be investigated before committing to a practice, hospital or HMO.


Leonard vigorously denounces the capitation system saying that the $6 to $11 per patient it pays isn’t enough to employ the staff necessary to keep up with insurance paperwork. Plus, he says, “HMOs position doctors to work for them instead of the patient.” In his mind, this can result in the HMO actually jeopardizing the health of patients. He urges students to stay true to their initial drive to become a physician by developing a good bedside manner, spending time with patients and remembering that patients are the priority.


For Blatti, it’s not the managed-care systems that are hard to absorb. He handles the work by committing about half of each workday to administrative tasks. His bigger concern is that scientific knowledge and technology are advancing so quickly that today’s family practitioners have a higher learning curve than ever before. “How we treat things now will change dramatically in another 10 years. Even the diseases of tomorrow will be different. It’s exciting, but a little frightening, to have to keep up with all that,” he says.


Family practice residency programs run three years and graduate about 3,500 students each year. Every state in the country offers at least one program. Most of them are community based and affiliated with a medical school.


Internal medicine is the perfect field for sleuths as diagnostic expertise requires a passion for solving puzzles. “Things are constantly evolving and because of that, we’re in a chronic state of future shock. You have to be a perpetual student to put it all together,” says Dr. Bill Waters III of Atlanta. “If you like that idea, there’s nothing as challenging and wonderful as internal medicine.”


Waters, in his 38 years as an internist, has never been bored. Not only does he find the science fascinating, but working with people aged between 16 and 96 compels him. “The real fun is being part of thousands of families. You’re invited into the innermost recesses of the patients’ lives. You see how their health affects other members of the family, what the emotional climate is, and you always have an opportunity to help. I call that giving courage transfusions,” he says.


The 113,066 practicing internists in the United States can be broken down into 12 subspecialties. But even the typical internist treats such serious problems as hypertension, diabetes, ulcers, pneumonia, menopause, kidney failure, lung and heart disease, and congestive heart failure—all warranting the need for those courage transfusions. Even though one-third of Waters’ patients is elderly, he still treats such minor problems as respiratory infections, sexually transmitted diseases, urinary tract infections and broken bones. There’s more, but what it adds up to is between 60 to 80 hours of work per week.


Romanian-born Dr. Alexander Perrian, who lives and practices in Tucson, starts his 12-hour day visiting patients at the hospital. “It’s the highlight of their hospital day,” he says. “Even if I don’t do anything, I just take a few minutes to hold their hand and talk.” After that, it’s back to the office to one of his 4,000 patients (the average load for internists is around 3,300). He chooses to be on call 24 hours a day. When the phone isn’t ringing, Perrian spends time with his children and reading journals. But in terms of late-breaking medical information, frequently it’s his patients who alert him to news they read in a daily newspaper. That, along with attending conferences, pursuing continuing education courses, and researching things on the Web, keeps him apprised of what’s new in his field. Perrian also finds time to participate as a preceptor for students at the University of Arizona.


An equally impressive curriculum vitae reflects Dr. Toni Brayer’s list of accomplishments. Based in San Francisco, Brayer, one of the nearly 32,000 female internists, is the first woman chief of staff at California Pacific Medical Center and past president of the San Francisco Medical Society. Her position is a result of her drive and mirrors her advice to young doctors: “Do something you’re passionate about. Get involved with the community, and if you don’t like something, get politically active and pursue public policy.”


Brayer’s passion for the past 14 years has been her practice. And since women often choose a doctor of the same gender, she finds herself spending much of her time on women’s health issues. But to her, there really isn’t a difference between men and women physicians. It’s uncertain how many of the 22,150 internal medicine residents are women, but it doesn’t matter. To her, good doctors are nurturing and demonstrate excellent listening skills. She does think, however, that most patients feel more comfortable talking to a woman, which may explain why studies show that female doctors spend slightly more time with patients.


According to Brayer, there’s a downside to that extra time spent. She claims managed care is penalizing women physicians—and anyone else who spends quality time with their patients—for this attribute. To her, that’s just the beginning of “the misery factor” that the current medical system imposes on the profession. In fact, she believes the detriments of managed care outweigh what’s enjoyable about medicine. “Internists have it worse than anyone,” she says, “because we do so many different procedures, and we have to get approval for all of them. That adds up to hundreds of hassles a day.”


Another weighty concern of hers is that new doctors who haven’t experienced anything other than a managed-care system will become comfortable with it. “[This] drives doctors to mediocrity by eliminating competition and choice,” she says. What’s more, she says, the advent of hospitalists keeps her from interacting with and learning from colleagues, which narrows the scope of her profession and limits her pool of knowledge.


Waters agrees. So much so that he penned The Grand Disguise (Eklektik Press, 1998), a book about what he thinks went wrong with managed care, and how we might create better alternatives. “We have three doctors in my practice,” Waters says, “and to operate as a viable business, we’ve had to hire 11 employees. They tend to the paperwork and answer 700 calls a day from insurance companies for referrals, precertifications, medications, procedures….”


His advice to students? “Learn how to deal with the system. Team up with other doctors, hire a business manager who knows about medicine. But you, the doctors, have to be the CEOs of the company. Otherwise you won’t make it.”


Perrian’s experience with managed care is less formidable. “They’re a necessary evil,” he says. “You can play their game and still make lots of money. Plus, finding a good doctor is far more important than finding a good car mechanic or hair stylist. Lots of people will stay with you even if they have to pay out of pocket.”


Furthermore, Perrian doesn’t think managed care drives people away from internal medicine. It’s the long hours and lifestyle. He especially cautions female medical students who want children to be mindful of that. “I’ve seen several brilliant women internists retire at 35 to have their own children.”


Most internists are between the ages of 35 and 44. Perrian believes the choice to retire that those female doctors make is a very painful sacrifice. Brayer is a living and working witness to that. “In this profession—maybe any profession that demands a lot of time—you’re constantly torn between work and parenting,” she says. With a 4-year-old son of her own, Brayer’s solution, and what she suggests to other women, is to have a marriage where each spouse fully participates in raising the kids. Perrian advises future internists to wait until after residency to marry. Then, there won’t be any surprises about how exacting the profession can be, he says.


Even so, all three doctors encourage students to consider becoming internists—regardless of political or personal difficulties. Brayer urges being flexible and open-minded about it all.


New internists typically start their practice with an average income of $110,000 and work up to an average of between $150,000 and $200,000. Physicians in the Northeast earn the most, followed by Western states, and finally, the South.


People who enter pediatric medicine say they do it primarily for the love of children. It certainly isn’t for the money, since other medical specialties pay more. The average starting income for pediatricians is about $105,000 and peaks at around $136,000. The rewards, then, in working with children are substantial in a different way—watching them grow and witnessing the great impact you have on their lives. The physicians TNP spoke with say this is what motivates them and keeps them content. According to the American Academy of Pediatrics (AAP), more than 81 percent of those surveyed say they’re satisfied with their work.


A 50-hour workweek is the average for full-time pediatricians. A few of those hours are spent in the hospital visiting newborns, but 78 percent of their work is in an ambulatory setting. With the exception of circumcisions, pediatricians generally don’t perform surgery. Their patients range from newborns to teens (up to 18–21 years old, depending on insurance policies). And their average day includes providing preventive care, counseling mothers on breastfeeding, conducting well-baby checkups and physicals, managing upper respiratory infections and treating diarrhea, sprains, broken bones, burns and acne.


Dr. Nancy Hoffman of Grand Junction, Colorado, worked two years as a full-time pediatrician and then became pregnant with her first son. Since her husband is a cardiologist and works upwards of 80 hours per week, Hoffman knew she would be the one to cut back her hours to care for the baby. Now, three children later and another on the way, Hoffman’s 15-hour workweek affords the perfect balance for both her personal and professional needs.


“The parents of my patients don’t mind that I’m only in the office two days a week,” Hoffman says, explaining how to keep the confidence of those she serves. “If the nature of the problem is complicated and needs special attention, or if it’s urgent, they go to one of the other eight doctors in our practice.”


Of those eight doctors, six are women, all of whom work part time. The flexible work hours may be part of the reason why the number of women pediatricians is quickly on the rise. Of the 56,159 pediatricians now practicing in the United States, nearly 50 percent are women. Of pediatricians under the age of 35, 6,600 are women and 5,200 are men.
According to Hoffman, reading journals and interacting and exchanging information with other physicians in the office keeps her up-to-date. And since immunology is probably the only aspect of pediatric medicine that’s constantly changing, that’s not hard to do.


This specialty is bestowed with many rewards, but pediatricians also have to respond to a bevy of urgent problems including: poison ingestion, sudden infant death syndrome, dog bites, AIDS, child abuse, teen pregnancy, diabetes, obesity, eating disorders and other physical problems related to behavioral difficulties.


These critical situations aren’t easy. “It’s very traumatic to deal with the families of children who will die,” says Dr. Rona Stein of Baltimore, referring to a young patient who died of cancer. “When the parents bring in one of their other children, you never know whether to ask how the chronically ill child is. She could have died without you knowing. Then, the other kids are less of a priority, and it’s all very hard. You just have to separate emotional involvement from clinical judgment.”


Counseling parents takes up a significant portion of a pediatrician’s day. And since doctors don’t get paid for that, a pediatrician-to-be needs to enjoy the act of listening and advising and accept that it’s part of the job. “Parents usually think what they’re doing for their child is right,” Stein says. “Even if you know it’s not, even if you think it’s stupid, you still have to figure out why they think it’s right. Then offer alternatives. That’s what persuades them to change.”


Because of the wide range of emotional and physical challenges today’s children face, many pediatricians act not only as the primary parent educators, but also as society’s premier child advocates. In fact, the AAP encourages its members to become involved in such community efforts as advocating healthy eating and behavioral habits, car safety seats, health coverage for the underserved, homelessness and pregnancy prevention measures.


With such a serious list of issues to be concerned about, Hoffman stresses that a sense of humor is essential to the trade. Stein agrees but finds nothing funny about the impact of managed care on her three-person private practice. “It can’t get much worse,” she says, citing universal frustration among doctors and patients alike. She strongly suggests that new doctors “treat your practice as a small business and pay attention to the things you never learned in med school. Hire support staff to do the paperwork. Don’t cut overhead. Defy the cultural norm that doctors’ offices have to be chaotic.”


Hoffman’s group practice is doing exactly that. Administrative staff handles the paperwork, and Hoffman takes home a percentage of the practice’s profits. “I love what I do,” she says with a laugh.


While some physicians become active in child advocacy work, one in three pediatricians participate in such subspecialties as neonatology, critical care pediatrics, infectious disease or rheumatology. Subspecialties usually require another two or three years of education after the typical three-year pediatric residency (of which 7,684 people now undertake).


If you’re a woman, you already have an intimate knowledge of the role gynecologists play. Because that role is so intimate, those who pursue obstetrics–gynecology (ob–gyn) may need even more compassion, sensitivity, good bedside manner, and empathy for women than what is required by other medical fields.


Ob–gyns are responsible for caring for the preventive health of women and tending to all aspects of the female reproductive system. Duties include performing annual exams and Pap smears, treating infertility, ensuring healthy pregnancies, delivering babies, and managing ovarian and breast cancer, menopause, osteoporosis, sexually transmitted diseases, nutrition and weight control. Furthermore, ob–gyns must be comfortable addressing socially controversial issues—teen pregnancy, contraception, pregnancy termination, domestic violence, postpartum depression—that directly impact patients. Because these physicians cover such broad territory, many women choose their ob–gyns to be their primary caregiver.


Although most women who comply with preventive measures are relatively healthy, sometimes it’s necessary for an ob–gyn to perform surgeries. The most common are cesarean sections for difficult deliveries, hysterectomies, removal of fibroid tumors, laparoscopies and breast biopsies. About 10 percent of patients’ conditions get referred to specialists, such as infertility experts. Subspecialties in the field cover reproductive endocrinology, urogynecology, maternal–fetal medicine and oncology.


The nature of this business is feminine, so Dr. Stephen Rabin of Beverly Hills, who has been practicing for 20 years, cautions men about what it takes to work effectively with ob–gyn patients. “Men and women are different animals. You need to understand where they’re coming from, their emotions and their needs,” he says. “You can’t approach things from a male’s point of view. You have to be open-minded about their individual needs, then figure out how best to help them.”


This difference between the sexes surely explains why 36 percent of the nearly 40,000 practicing ob–gyns, and more than 65 percent of ob–gyn residents are women. It’s also no surprise that there are three times more women ob–gyns than men under the age of 35. Indeed, this field is virtually exploding with women.


Even so, both Rabin and Dr. Allyson Gonzalez, of Santa Monica, agree that you have to choose this field for the right reasons. “You need to really, really want to do this,” Gonzalez says. “It requires an enormous commitment since it takes so much time and energy.”


What she means is that the average 60-hour workweek can easily grow with long days and late nights. Although both physicians are in private practice and have designed some personal time into their schedules, babies simply don’t wait until you’re on call or you’ve had a good night’s rest. The schedule can be relentless with as many as 15 deliveries in one week. In other weeks, there may just be one. Regardless of numbers, the ob–gyns TNP spoke with don’t like to pawn off a woman in labor to someone else—even if it means losing sleep and forfeiting vacations and being on call 24/7.


Rabin attributes these demands to the number of physicians who ultimately choose not to practice obstetrics. “It bothers me a lot to see obs giving up that part of their practice after only eight or 10 years. It can be very, very rewarding, and good obstetricians are sorely needed,” he says.


Gonzalez believes there are different ways to handle what’s required of the profession. She started her career in 1997 at a managed-care facility. Although it didn’t suit her personality, she said working within an HMO provides a more flexible schedule for those who want to raise a family of their own. “It’s not like a private practice where you can develop relationships with your patients,” she says. “But, you have to look at the advantages and disadvantages of each choice and find the balance that suits your needs.”


In the past decade, Rabin’s needs were so deeply affected by managed care that he chose not to work with HMOs at all. “Politics have taken over medicine. I would rather give up medicine than have to appeal to a button pusher to tell me that I can’t perform a certain test,” he says. As a measure of his own commitment, Rabin still consults with former patients forced to see other doctors because of his refusal to deal with HMOs. Ironically, Gonzales doesn’t accept HMO patients either, claiming she can’t afford it since she would have to hire too many people to cover the paperwork.


Dr. Wendy Hobart, an ob–gyn in Kansas City, Missouri, has only been practicing since August of 1999. The biggest surprise she’s encountered touches upon a slightly different issue. “You don’t learn anything about the business of medicine in school,” she says. “Even if someone else does the paperwork, you still have to know about billing and coding, which procedures you can and can’t perform according to insurance criteria, which hospitals you can work with, and so on.”


Rabin’s answer to these politics, and his advice to the students he teaches at the University of Southern California, is literally to head for the hills. “Rural areas may not be the ideal place to practice, but in reality, that’s where people in our field are needed. Plus, you can still make a decent living and not have to compromise your ideals as much as you have to in big cities,” he says.


Like Rabin, about 10 percent of ob–gyns enhance their profession in the fields of research and academics. Those who only practice medicine make more money in the Northeast than those who live in the southern or western states, according to Medical Economics magazine. After a four-year residency, a new ob–gyn makes about $165,000, while veterans typically take home around $225,000. According to the American College of Obstetricians and Gynecologists (ACOG), more than 54 percent of gross revenues in private practices go to paying for staff, office equipment, employee pensions, benefits, supplies and malpractice insurance. This can run as high as $70,000 per year.


That figure may seem startling, but as of 1996, more than 76 percent of the ob–gyns surveyed by ACOG had been sued. Most claims were based on allegations having to do with a neurologically impaired infant, followed by a failure to diagnose some type of cancer. Although more than half of the cases were dropped, the average claim paid almost $460,000. Doctors won 65 percent of the cases, but still, as a result, 9 percent of the physicians went out of business.


All things considered, the satisfaction ratio in ob–gyns is high, based on long-term patient relationships. Once a woman finds an ob–gyn she likes, chances are she won’t go seeking another as long as she lives within close proximity to her caregiver.
Colorado-based freelance writer Leigh Fortson specializes in covering health care and alternative medicine.
Watch for part II of TNP’s look at medical specialties in the September 2000 issue.