Not news – dermatology is hot!

This trend started when I was in medical school. It has increased as the percentage of female medical students has increased. Young Doctors and Wish Lists: No Weekend Calls, No Beepers

For me the shame here is that the best and brightest no longer clamor for internal medicine slots. This rant comes from my heart as an academic internist. I apologize if I insult anyone.

Internal medicine is the cornerstone of adult medicine. We encompass a wide variety of complaints, and excel as diagnosticians. More recently, we have acquired the expertise to juggle the many medications that our sickest patients take.

Internal medicine is the common ground for all patients. We care for the complex with the aid of other specialists.

In medical schools, internal medicine generally represents the key rotation of the 3rd year. We win the teaching awards. We use physiology, pharmacology, biochemistry and anatomy daily.

In the old days, the best and brightest aspired to become internists. We all wanted to be Sir William Osler. But times have changed.

This notion of a “brain drain” to subspecialties from the bread and butter fields of medicine is not new. But in recent years it has come to be associated with a flight to more lucrative fields. What is new, say medical educators, is an emphasis on way of life. In some cases, it even means doctors are willing to take lower-paying jobs — say, in emergency room medicine — or work part time. In other fields, like dermatology and radiology, doctors can enjoy both more control over their time and a relatively hefty paycheck.

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What young doctors say they want is that “when they finish their shift, they don’t carry a beeper; they’re done,” said Dr. Gregory W. Rutecki, chairman of medical education at Evanston Northwestern Healthcare, a community hospital affiliated with the Feinberg School of Medicine at Northwestern University.

Lifestyle considerations accounted for 55 percent of a doctor’s choice of specialty in 2002, according to a paper in the Journal of the American Medical Association in September by Dr. Rutecki and two co-authors. That factor far outweighs income, which accounted for only 9 percent of the weight prospective residents gave in selecting a specialty.

For me internal medicine represents the pinnacle of science and human interactions. I see too many students who like internal medicine but elect other specialties for “lifestyle” reasons.

I guess we need to fix the internal medicine lifestyle. But then I rant about that incessantly. Our payment system influences lifestyle.

As usual follow the money if you want to know the real issues. Lifestyle is chic to blame. But it requires excellent reimbursement to adequately control lifestyle.

Clinical trials do change our behavior

Prescribing Patterns Respond to “Bad News” Findings of Clinical Trials

Physicians alter their prescribing patterns when clinical trial results suggest detrimental effects of the drug in question, two new reports in the Journal of the American Medical Association for January 7 suggest.

The intensity of media coverage appears to be a key feature in influencing physician and lay responses.

Now we just need to control the media!!!!! We can get our message out to all physicians if we just controlled the media. What a thought!

The above paragraph is meant to be sarcastic. I hope readers understand this meager attempt at humor.

More on malpractice – explication time

I was rightly chastised for not explicating my position on malpractice in last night’s post. When I found this link, I blogged in anger – a major mistake. This issue requires careful thought and a listing of all the problems. I made the mistake that a calculus professor might make, I went from equation A to equation F and skipped all the obvious steps in between.

The crux of Dwight Meredith’s argument:

When discussing tort reform, and particularly medical malpractice reform, it is helpful to know the size of the problem. How much money is paid out each year in medical malpractice judgments and settlements? That would seem to be a basic fact that needs to be established at the beginning of a public policy debate. After all, if we do not know the size of a problem, how can we ever decide on a solution?

The tort reform lobby and the scare tactic media almost never report that basic fact. If you do not believe me, go to Google News or Google and try to find the answer.

In my post, I noted that medical malpractice payments total a little over $4.2 billion per year. As I have previously noted, the total of all sums paid out in medical malpractice settlements and judgments is approximately the same as Estee Lauder?s sales of makeup. The total of payments in 2002 would have paid interest on the national debt for about eight days.

This argument assumes that we can quantitate the cost of malpractice simply by counting pay outs. If the malpractice problem was just lost court cases and settlement, then Dwight would have a good argument.

The figure he cites greatly underestimates the costs of malpractice. As most physicians know, the vast majority of malpractice suits are won by the defendant (the physician or physicians involved). However, these cases still require significant financial resources (which the insurer pays). Even more cases are filed and withdrawn – still with significant legal costs.

Now I do not know the cost of defending a malpractice case, but these costs are not insignifcant.

The threat of malpractice permeates medical practice. It clearly influences physicians to order more expensive tests than are necessarily indicated. It can hamper the doctor patient relationship. Many physicians now fear malpractice so much that it has influenced their care.

Another issue that Dwight overlooks is the inability of physicians to pass on costs. If Chrysler loses a lawsuit, they can raise the price of cars. Physicians work in an artificial market. Our income is controlled by third party payors. We cannot successfully increase fees.

Malpractice insurance costs are rising. No one can dispute that. If it were a lucrative field, we would see more companies offering this insurance. The decrease in malpractice insurers speaks much louder than the hyperbolic quote above.

I am still angry over this issue. I hope this explication has done a better job of making my arguments. Tort reform is a complex issue. One figure of approximately $4 billion does not describe the issue. It reminds my of having a blind man describe an elephant from one touch.