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The New Physician September 2000
Psychiatry, general surgery, emergency medicine--they all sound good, but which one would you choose? Let The New Physician’s second look at medical specialties guide you to the right career.

In the May–June 2000 issue of The New Physician (TNP), we brought you the first in a two-part series about choosing the right medical specialty to suit your professional and personal needs. We covered what it takes to be a family practitioner, internist, obstetrician–gynecologist or pediatrician. Now, let’s turn our attention to psychiatry, general surgery and emergency medicine and meet specialists in these fields from across the country.

You’ll notice that no two specialists’ stories are the same, yet there are several common factors affecting the nature of all of these careers. For one, there’s location—an emergency room physician in an inner-city hospital will treat far more traumas from violent crime than one in a small, rural community. And then there’s gender—progress has been made, but women specialists still earn only 72 percent of what men make, and most of those financial gains are in nonsurgical fields. Don’t forget to consider administrative realities as a factor—the amount of paperwork physicians must attend to in a private practice far exceeds that in most group practices in which office managers or other staff oversee it. And lastly, there’s managed care—in all specialties, grasping the regulations imposed by managed care requires time, and for many, generates distracting frustrations. This begs the question of whether or not accepting patients covered by HMOs is worth the hassle—a question that each physician must answer.

The following profiles may answer other questions you have about specific demands and rewards unique to each specialty. As you weigh what’s important and how these professions relate to what you want, don’t forget that medical practice is a business as well as a healing art. Although medical schools don’t address many of the business matters you must handle, you will have to be prepared for them nonetheless.

So, as you explore the options of which specialty to pursue, consider finding a mentor with a successful practice and observe what steps she takes to ensure her business’ survival. The majority of specialists TNP interviewed agree: Get some help with the business of your practice. It will pay off handsomely and leave you free to do what you do best—caring for patients.

“Psychiatry is the frontier of medicine,” says Dr. Maria Caserta, director of residency training at the University of Chicago. “The science behind psychology is finally catching up with the rest of medicine. It’s a very exciting time.”

Caserta started her career with a Ph.D. in neurobiology. She transferred those skills to psychiatry 12 years ago because she considered the field’s breakthroughs to be cutting edge. Back in 1988, the genes for such psychological diseases as bipolar disorder were just being detected. Now, the field is exploding with discoveries, and Caserta believes that within months, science will target the mutation of genes associated with many more psychological imbalances, thus enabling the development of pharmaceuticals to treat specific disorders. Physicians now prescribe a handful of general drugs to treat a wide range of psychological disturbances.

Caserta divides her time between teaching, research and seeing about 10 individual patients per week. Typical symptoms she and most psychiatrists treat include depression, difficulty concentrating, not doing well at work or school, behavioral changes, constant crying or anxiety, withdrawal or lack of joy in life, sexual dysfunction, or menstrual problems—or a combination of any of these. Issues commonly examined in a psychiatrist’s office can range from sexuality to financial and career to child abuse and schizophrenia.

Dr. Barry Lieberman of Beverly Hills has been in private practice for 29 years. He schedules about 10 appointments per day, treating individuals, couples and families. Lieberman concurs with Caserta that most patients have a biological underpinning for their problems, and consequently, most are on medication. “Psychiatry is interesting because of the human mind,” he says. “The mind is the function of the brain in the same way that vision is the function of the eye. [Normally] functioning brains lead to normal attitudes. Abnormal thoughts, feelings and behaviors are often neurologically or metabolically based and can be chemically altered in the brain.”

Unlike other therapists, psychiatrists can treat patients physically as well as psychologically through the use of drugs. Even so, Caserta and Lieberman advocate one-on-one psychotherapy with patients as well as prescribing necessary medications. This can be the most fulfilling part of a psychiatrist’s practice.

“You can make the greatest contribution in this field because it allows you to talk to the patient and see the whole person,” Caserta says. “The time I get to spend with my patients is gratifying. People really do improve. It’s very rewarding.”

Lieberman attributes the one-on-one contact to why he doesn’t become weary in this often high-stress profession. “Avoiding burnout and being a good psychiatrist means you have to care about people, be interested in what goes on within them and enjoy helping them change,” he says. “I’m an active cognitive behavioral psychotherapist employing medications when necessary and, through conversations, helping them identify destructive behaviors and attitudes.”

Dr. Julian Pichel of Palo Alto, California, practiced psychiatry for 34 years and is now retired. He believes the mind–body connection to be a legitimate one and a combination of medication and therapy to be the most effective treatment. He cautions young psychiatrists, however, that there is a danger in relying too heavily on drugs. And there’s a lot of pressure to do this—stemming from patients’ demands or pharmaceutical companies’ advertising.

“Doctors have to be discerning,” Pichel warns. “Some patients want to avoid the psychological issues and just want the drugs. Then again, other patients want only to talk and absolutely won’t take medications. I encourage a multifaceted approach.”

Changes that medications have brought to the field are reflected in the public’s perception of psychiatry. “It’s gone from one extreme to another,” Lieberman says. “People used to think psychiatry was just a Freudian thing where the patient would lay on a couch and the doctor would do nothing but listen. Now, people think you are a drug pusher. [But,] it’s neither extreme. Most psychiatrists are in the middle of the spectrum.”

According to the American Medical Association (AMA), approximately 84 percent of psychiatrists occupy an office in either a private or group practice, while 16 percent hold positions at hospitals. In either place, psychiatrists will come upon clients who require long-term pharmaceutical and therapeutic treatment. Most managed-care guidelines, however, restrict the number of patient visits allowed to psychiatrists.

“It doesn’t work to only allow six visits for a patient who really requires 25,” Pichel says. “Serious chronic disorders need more attention and time. HMOs are preventing some lifesaving procedures.”

Lieberman disregards the restrictions. “I’d rather see people for nothing than deal with an HMO. Sometimes that means I don’t get paid anything because I don’t want to have to fight for it.”

Parity legislation has been introduced that would define psychiatry as equally important as primary medical care and allow more reimbursable visits. Some states have already passed such legislation. Pichel encourages new physicians to help change the system by becoming involved in the process. He points out that today’s managed-care gatekeepers include medical experts and not just business people. “If patients and doctors demand change, it will happen,” he says.

Besides managed care, Pichel, Lieberman and Caserta voice only one other significant downside to the profession: patient suicide. Although it rarely happens—Lieberman has lost two patients during his nearly three decades of practice, and Caserta only one—it poses difficult issues. “I felt awful when it happened,” Lieberman says, “but then I was reminded of the limitations of what anyone can do. If I was a cancer specialist, I would lose about half of my patients.”

In terms of salary, Medical Economics reports that psychiatrists begin making about $60,000 per year, but the average annual income ranges between $118,600 and $200,000. Most psychiatrists will say their quality of life takes precedence over financial gains; and autonomy plays a big role in their happiness.

Both Lieberman and Pichel emphasize the value of being their own boss. “But mostly,” Lieberman says, “I love having an influence in people’s lives whom I wind up liking and respecting.”

Maintaining one’s own personal life while helping others with theirs is an important rule to follow in order to succeed in psychiatry. Pichel advises that “the more you tie up your self-esteem with what you do professionally, the more you are setting yourself up for trouble.” He avoided much of the stress that comes with the job by giving his time to a community children’s clinic, the local school district, and participating in recreational activities.

Caserta finds her personal rewards through working in an academic environment. She says it allows her to stay in touch with colleagues and keeps her apprised of new discoveries.

Of the nearly 40,000 licensed psychiatrists currently practicing, approximately one-third of them are women. Although Caserta admits that finding a balance in her life depended on the help of her husband’s flexible work schedule, she urges other woment to seriously consider entering the field. “It’s very rewarding,” she says. “Some of the advances occurring in this century will reveal how the mind and brain work. Because of that, it’s the most exciting field in medicine.”

The more than 4,000 students currently pursuing psychiatry must complete four years of residency. Psychiatric specialties include focusing on children and adolescents, geriatrics, forensics, psychopharmacology and psychoanalysis.

R. Russell Hewlett Lee, now retired, practiced general surgery at the Palo Alto Medical Foundation for 40 years. He says he initially entered the field because he liked working with his hands. But, he cautions that it’s not a relaxed environment. This profession requires surgeons to work on their feet for long—often excruciating—hours at a time. “It’s hard work,” he says. “You’re always on call, and when you get the call, you can’t just have a conversation on the phone. You have to go back to work.”

For the 40,448 surgeons practicing today, work means consulting with people diagnosed with a range of conditions. The vast majority of surgeries—approximately 70 percent—have to do with breast cancer. Surgeons also perform appendectomies, cesarean sections, thyroidectomies, hysterectomies, prostatectomies, as well as procedures for colon and rectal diseases, lower back pain, tonsillitis, gall bladder or other abdominal problems, hernias and hemorrhoids. Laparoscopic surgery has simplified the field and enabled faster recovery for patients, but due to the emotional trauma that often accompanies surgery—especially breast cancer procedures—Dr. Marshall Ravden of San Diego says it’s important to remember you’re dealing with people when they’re at their worst.

“[So,] you need to be compassionate; show them you’re concerned for their problem,” he says. “Even if you’re rushed, all that matters is to show that you’re interested in them.”

As a staff surgeon at Kaiser Permanente, being rushed is a problem Ravden has to deal with on a daily basis. Even so, he prefers that pressure to the stress he endured for 11 years in private practice in Connecticut. Although he enjoyed his autonomy and a thriving client base, the countless hours of having to explain himself to insurance companies became too burdensome. He tried merging his practice with another business to consolidate overhead and share the tedium, but he still wasn’t happy. When told about a job at Kaiser in San Diego, his first thought was, “Over my dead body.” Now, nine years after signing up, Ravden is one of 3,200 surgeons around the country on staff at a hospital or with an HMO, and he says he wouldn’t go back. He makes as much money as his friends do in private practice, but he says he doesn’t have the headaches.

Location is important when considering general surgery. Lee urges new physicians to carefully research where they want to work. “Make sure the group you’re joining has quality surgeons who are smart, honest, capable with their hands and personable. Get to know them before you join up. Otherwise you [may] end up with either 100 percent workaholics or goof-offs.”

Another reason to connect with a good group is to give yourself a personal life. According to Ravden, being on call never ends for a general surgeon, and a 60-hour workweek is typical. That time is spent conducting about 50 inpatient visits and performing up to 20 procedures in the operating room per week. On average, he finds himself in the operating room close to 500 times per year. Teaming up with other surgeons promises intellectual stimulation and the ability to participate in family vacations, conferences and educational seminars, he says.

For the 10 percent of surgeons who are women, job sharing is a common way to find time for their own families. For Ravden and Lee, holding faculty positions within California’s state university system contributes to a high level of personal satisfaction. And, with time, they say, everyone finds a unique recipe for success.

“You need a sense of humor and high tolerance for stress,” Lee says. “If you’re operating and a major blood vessel goes crazy, and you don’t have the right instrument to deal with it, you have to be adaptable.”

He says the greatest anxiety develops when someone—especially a child—dies on your table. “It’s devastating to doctors to have to tell people whom [they’ve] never met that [they] did everything they could to save [the family’s] loved one but couldn’t.”

Even with the long hours and stressful situations, Lee and Ravden recommend a general surgery specialty. New surgeons start earning about $150,000 per year, while more seasoned doctors average $190,000. Higher paid surgeons earn up to $300,000. But Ravden, a native of South Africa, sternly advises choosing this specialty for the right reasons—and these don’t include your salary.

“It’s sick to do this for the money,” he says. “You must go into it because you have a feel for the work, find it interesting and know you’ll be comfortable with it. Choosing medicine for the money is what is backfiring now in this country, and one of the reasons there are so many lawsuits.”

General surgery residency lasts five years for the 8,000 students who annually choose this field. Specialties include general, vascular, pediatric, trauma/critical care and hand surgery.

If you can gracefully handle chaos, alcoholics, sleepless nights, a lack of routine and short-term relationships with patients, then consider going into emergency medicine.

“I really like the variety,” says Dr. Kenneth Scissors of Grand Junction, Colorado. “You’ll have a newborn in one room and a 99-year-old in the next. You have to be equally comfortable with both.”

Traditionally, most physicians who choose emergency medicine are trained in family practice, but Scissors began as an internist. After 12 years, he grew tired of constantly being on call, having few days off, and getting aggravated at managed-care issues. Plus, he wasn’t enjoying his patient population. So, he switched to emergency medicine.

“When you’re a primary care doctor,” he says, “you don’t get to pick and choose whom you work with, and that can be difficult. You’re bound professionally to love your patients dearly, but a lot of them are highly dysfunctional. It’s tempting to cave in to their neurotic demands. One of the things I like about being an [emergency room] doctor is that you don’t get trapped.”

He says he thrives on the emergency room’s erratic and intense atmosphere and the short-lived relationship with patients. But there is a downside to being unfamiliar with patients. Scissors thinks patients who don’t know you are often uncomfortable revealing the gravity of their situation.

“Most of the time you think chest pains are just heartburn,” he says. “But when the work-up comes back, and you realize [the patient] had a mild heart attack, you understand that you have one shot with these people, and if you blow it, you’re dead meat. And so are they.”

During his typical 12-hour shift, Scissors cares for patients with broken bones, chest pains and strokes, kids with high fevers, and a colorful array of middle-of-the-night patients who either have had too much to drink or reveal a not-so-hidden agenda for their visit.

“You get a mix of people—[those] with real injuries, those with psychological disturbances who get scared from bodily sensations, and those who fabricate stories to get drugs or [as] an excuse to get off work. You have to be on your toes to sort it all out and treat everyone fairly, but make sure you’re also being appropriate,” he says.

Dr. Bob Pitts, who practices in Middlebury, Vermont, agrees that the work is gratifying and prefers the schedule in emergency medicine to other specialties. Like Scissors, he works three 12-hour shifts per week, starting at either 7 a.m. or 7 p.m. That leaves plenty of time for family, vacations and even solitude. The only hard part is losing sleep, or having to make it up on days off.

“You have to be able to fall asleep any time, day or night,” Pitts says. “If you can lay down and sleep anytime and anywhere, then you can do this job.”

During a typical shift, Pitts treats about 30 patients. He, too, favors the short-term relationships of the ER, but is also attracted to how critical and exciting the interactions can be. “Even though you don’t get to know patients well, you can still have a big impact on how they tolerate what’s happening to them.”

There are two types of emergency medicine physicians: those certified by the American Board of Emergency Medicine and most likely to work in trauma units, and those mainly oriented to primary care issues. Trauma care emergency medicine physicians deal with such life-threatening conditions as head injuries, gunshot or stab wounds, organ damage and other multiple injuries, often leading to emergency surgery. Only large hospitals in bigger cities tend to house trauma units in their facilities.

Dr. Rick Steinmark practices at New Britain General Hospital about 30 minutes from Hartford, Connecticut. Although he is board certified in critical care, many of the emergency medicine doctors he works with are not. He says that doesn’t matter to him, because they generally treat the same conditions and are capable of performing whatever is necessary. Some of his more complex and rare procedures include emergency surgeries on the chest area to stop bleeding or release pressure around the heart, inserting a tube into the chest to drain out blood, or inserting tubes into the neck to enable breathing. But like most emergency medicine physicians, he usually attends to simpler, less urgent needs.

Pitts and Steinmark are salaried by the hospital regardless of how many patients they see. As such, Steinmark works a 40-hour week and spends just under half of his time on paperwork, although not entirely answering to HMOs. What irks him most about his job, however, is the message that managed care sends to people about when they can and cannot visit the ER.

“If [patients] have chest pains, managed care tells them to call their doctor,” Steinmark says. “That goes against all recommendations. They should go immediately to the ER. Emergency rooms are the safety net for society. We’re here 24/7, and when they come in, they’re ours.”

At times, that means the hospital won’t be reimbursed for the visit, but ER physicians don’t have to worry about this—that’s up to hospital administration to resolve. Scissors has even less contact than Steinmark does with managed care because he’s contracted with the hospital as part of a fee-for-service group of ER doctors. It’s a break-even deal for the hospital, but he says hospital administrators recognize the ER as an entrance point to hospital stays, so their relationship is mutually beneficial.

A survey published in Academic Emergency Medicine cites that starting salaries for this profession begin around $110,000, average at $140,000 and peak at $160,000. “It’s not like you get rich,” Scissors says, “but I make about the same as an internist now and work half the time.”

Women make up less than one-fifth of the 21,233 practicing emergency medicine physicians, but that number is growing as approximately one-third of the emergency medicine doctors under the age of 35 are female. The 3,125 residents now in training will remain in their emergency medicine programs for three to four years.
Colorado-based freelance writer Leigh Fortson specializes in covering health care and alternative medicine. Part I of TNP’s look at medical specialties can be found in our May–June 2000 issue.