<p>I’ve mentioned it a couple of times, but as an MD/JD candidate, I’ve been considering the practice of law over the practice of medicine for the past year or so. Shouldn’t I be a doctor? I’ve often thought. The job doesn’t seem fun, and it’s awfully subject to the whims of the government, and the turmoil it imposes on my twenties and thirties is a nightmare… but… don’t I owe it to somebody? Of course, some lawyers do a tremendous amount of good in the world, too. But somehow it just doesn’t feel the same… I think.</p>
<p>But a funny thing happened when I attended my school’s Match Day today. The applause largely followed predictable patterns: when somebody popular went to the front, the cheers were loudest. New folks got polite applause, but they simple didn’t know the folks in the audience as well. Big-name hospitals similarly got applause – Stanford, Brigham & Women’s, Beth Israel. Sometimes, with an unknown hospital, the audience waited to see how the candidate reacted. UMDNJ? Is he happy? When a student wilted, even for a moment, the audience gave a milder, polite, supportive clap. When a student exulted, the audience followed his lead.</p>
<p>And a funny thing struck me: Is it just me, or is the audience clapping louder for “lifestyle specialties”? It seemed that the applause was a lot louder – not a little, a lot – when they knew that one of their classmates wasn’t going to have to kill themselves for the next few years. Surgery and medicine seemed more muted; dermatology and radiology received overwhelming enthusiasm.</p>
<p>And a quick check revealed that huge numbers of “lifestyle specialty” candidates – far more than I was used to. Rumor has it that this is why my classmates had a higher-than-usual number of “scrambles” – for one of the premiere medical schools in the country, scrambling is usually pretty rare. And yet this year and last year, we had pretty substantial numbers. Why? Because my class is, increasingly, shunting into those competitive specialties. They aren’t competitive because the medicine is glamorous or sophisticated; they’re competitive because… well, because you get to keep your humanity a little while longer.</p>
<p>This is the trend I see taking hold in medical schools today. More and more HMS students are accepting positions not at Beth Israel and San Francisco General, but at McKinsey. More and more, my classmates speak of our Boston Consulting-entering counterparts not with disdain (as practicing physicians tend to) but with envy. And, overwhelmingly, they are shunting into dermatology, radiology, ophthalmology… anything that will pay well while allowing them to retain some semblance of their lives.</p>
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<p>On an economic note, this is an impossible-to-avoid foolishness. Radiology pays well only because Medicare, back in the early days, decided it would. Medicare could, at any moment’s notice, radically slash radiology compensation – and everybody would follow. It could, with a single stroke of the pen, destroy an entire specialty. In fact, President Obama has hinted that an ideal system would do exactly that: radically slash reimbursement rates (as much as 25%) for fields like cardiology, radiology, anesthesia, and dermatology.</p>
<p>Medicare, under his and Congress’s direction, is seeking to promote some specialties at the expense of others; make it easier to replace physicians with NP’s and PA’s; to continue to impose new regulations on physician practices.</p>
<p>And the most frightening thing is that they might be right. There is an imbalance of physician distribution. Physicians do need to be held accountable to external authority. And NP’s and PA’s are valuable and underutilized members of health care teams.</p>
<p>But that is little consolation to my classmates, who as of today are locked into their fields for the rest of their lives. If the President wishes (perhaps even correctly) to slash their pay, they will have no recourse. With a single stroke of the pen their expectations can be entirely wiped out.</p>
<p>And yet they have ended relationships for these programs; studied for years for these programs; given up everything else they might ever do with their lives for the chance to be a radiologist. Twenty years or five years or six months down the line, Medicare might decide to change all of that, and they’ll have no ability to respond. They have to place their bets when they’re twenty-six or twenty-seven, and they don’t get to change their minds ever again.</p>
<p>These people have spent their entire twenties on the move. Physicians don’t get laid off because layoffs are built into their lives. You go to college, often away from home. Most folks don’t get into medical school directly; they have to find a job or a master’s program in the meanwhile. They enter medical school, usually in a different location entirely. You do residency, maybe a transition year, maybe a fellowship – again, all in different places. By the time you’re 35, you’ve held five different jobs, usually in five different places – and this was all automatic. There is no way to avoid the “turnover” which any other sector would call a forced layoff.</p>
<p>You do this, ostensibly, as an investment. Into yourself, into your family, into society. But all of this can change – by a new technology, by a new labor staff, by a single lawsuit, by a change in insurance law. Or, above all, by a change in what the government feels like paying you tomorrow.</p>
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<p>“I might not want to be a doctor,” I observed this afternoon to my friend, a third year medical student at another top-tier school.</p>
<p>“Well, me neither,” he answered. “But it’s too late, I’m committed now.” And, after spending $180,000 on his first three years, he’s correct. “Which is why I’m going to radiology.”</p>
<p>See, my friend doesn’t want to be a doctor, but enrolling in medical school destroyed any other options he might ever have had. So he’s looking at the specialty list and trying to figure out: which specialty can be least “doctor”-like? Which ones will let me spend time with my children? Provide for my family? Allow me time to breathe and grow and enjoy the other pieces of my life?</p>
<p>Apparently, my friend has decided that radiology will move him the farthest away from he thinks it means to be a physician. And precisely because of that, he is choosing it.</p>
<p>Every student I know – every single one – chose medicine because they thought they would enjoy the feeling of being a doctor. Once they’d spent a couple of years immersed in it, many of them changed their minds. When the world of medicine has degenerated to the point where medical students are intentionally seeking the specialties that feel the least like medicine, something is profoundly wrong with the career.</p>