More medical school grads select specialty practices

Robertha Cherry felt fine Tuesday at the Ghent Family Medicine clinic at Eastern Virginia Medical School. She was just in for her check up.

The 73-year-old great-grandmother of 13 has her diabetes and blood pressure monitored every three months with a doctor she has known for years.

Her blood sugar seemed fine, but the doctor ordered a lab test and had her blood pressure taken - twice. The first time it was high; the second time "it was down, but not like they like it," she said.

So, Cherry went home with a new blood pressure medicine and advice to call back if she had any problems.

Experiences like Cherry's may become rare as more medical school graduates, including those who will take the stage at EVMS' commencement on Saturday, choose to become specialists instead of primary care doctors. The trend has led to an out-of-whack ratio that contributes to higher medical costs and poorer health outcomes, said Dr. Christine Matson, chairwoman of the family and community medicine department at EVMS.

Ideally 40 to 50 percent of physicians should be primary care providers, studies by various health care groups have shown. Currently, about 30 percent are primary care doctors and about 17 percent of medical school grads are choosing primary care.

The result has been more aggressive medical treatment at a higher price often with worse outcomes, studies of Medicare beneficiaries done by the Dartmouth Center for Evaluative Clinical Science have shown.

"Some diseases you can't diagnose if you're standing too close," Matson said.

Say you've been troubled by headaches.

One of the most common causes of headaches is muscle tension, Matson said. A primary care doctor is trained to think about the most common causes first and treat for them.

If those common causes are eliminated, doctors start to look for the less common causes. That's where specialists are supposed to come in.

But if you're just tense, an expensive MRI is not going to help and could even hurt as medical tests and treatment carry their own risks.

Now, say you're tense because things are unusually tough at home. You're more likely to tell a family doctor you've known for years. And, knowing you, your doctor is more likely to have a better treatment plan.

EVMS will graduate 105 M D s this year. Eight will enter a family medicine residency, 17 will go into pediatrics, and 23 will do an internal medicine residency.

Although all three disciplines can be gateways to primary care work, pediatrics and internal medicine also are paths to specialties.

Matson said that 15 years ago, about 80 percent of EVMS internal medicine residents went on to become primary care doctors; now it's 10 to 20 percent. For pediatrics residents, it's split about half and half. It used to be dominated by generalists.

"The specialities start out paying more than primary care ever does, even with experience," said Erin Kate Dooley, an EVMS graduate who will add Dr. to her name Saturday.

Add to that - or rather subtract - the debt medical students incur. Medical school graduates in 2007 reported an average of about $140,000 in educational debt. As the debt load increases, the number of doctors choosing primary care decreases, according to the American Medical Association.

"I've watched some of my classmates struggle with that," said Paul Scanlan, who also is graduating Saturday.

Scanlan's not sure whether he will be a primary care doctor or specialize in emergency medicine. He did rotations in some of the higher-paid specialties, such as anesthesiology and radiology, but he said the patient interaction he likes was missing.

"It's good money, I guess," Scanlan said. "But I was chafing."

Scanlan said he has the freedom to follow his heart because the Navy has picked up the tab for his medical education and provided a stipend to live on. In return, he'll work as a Navy doctor.

The former Navy pilot today will receive his military commission and will start an internal medicine residency at Portsmouth Naval Medical Center in July.

Scanlan has a 4-year-old son. Many of his classmates have children as well. He doesn't see how they can pay off their debt - some as high as $300,000 - and support their families on a primary care doctor's salary, which typically starts at about $125,000.

"You have to think about the money," Scanlan said. "It's got to be a consideration."

One of the solutions is to provide loan forgiveness programs for civilian primary care doctors who agree to work in areas of need. Some exist now, Scanlan said, but too often they require that students commit before their medical training and before they know what they want to do. If the programs could allow students to join later, you "might get more people interested," he said.

Though she has a "mortgage's worth of debt with no equity," Dooley will start her EVMS family medicine residency in Portsmouth in July. For her, the opportunities for service both here and abroad outweigh the money.

"I really love the whole spectrum of human life," Dooley said. "You see the huge need, even in our own country. It's really motivational."

Nancy Young, (757) 446-2947, nancy.young@pilotonline.com