• linkedin
  • Increase Font
  • Sharebar

    Are the best and brightest going into medicine?

    A loaded question, and everyone has an opinion. Among the intriguing thoughts: Maybe it's the wrong question.

    Are the brightest young people going into medicine today?
    When the Medical Economics Continuing Survey asked physicians earlier this year, "Do you think the brightest young people are going into medicine today?" 72 percent said, firmly, No!

    That rather depressing perception is shared not only by a hefty majority of the survey's 7,700 respondents but also by a number of high-profile physicians: "We all worry that American medicine may no longer be the magnet it has been for America's best and brightest," AMA Past President Yank D. Coble Jr. said last year in sizing up the profession.

    National Institutes of Health Director Elias A. Zerhouni has also fretted that many promising students may be shying away from careers in medicine and medical research.

    The litany of reasons is familiar to anyone practicing medicine today: Too much government red tape . . . and not enough reimbursement. An uphill battle to repay medical education debt . . . and a downhill slide into liability hell.

    Some of the more vocal among today's practicing physicians have lamented the transformation of their beloved profession into what they view as a trade. In short, maybe prospective doctors—if they're listening to those elders—are reluctant to come in for the same reasons doctors at midcareer are trying to get out. As one young doctor groused, "MBA graduates with six years of post-high school education may start for nearly the same compensation as physician residents with 12 years of post-high school education. This does not even begin to assess other factors such as lifestyle, indebtedness, and liability."

    The uneasiness is not exclusive to medicine. "Science as a profession isn't particularly honored," said Cornell University physicist and Nobel Laureate Robert C. Richardson in an interview with The New York Times in July. Richardson was talking primarily about PhD careers in the sciences and engineering.

    In 1975, the US ranked No. 3 in the world in the percentage of 18-24-year-olds who earned degrees in the natural sciences and engineering. Today our country has dropped to No. 17, and half of the engineers graduating from US schools were born in other countries. "The glamorous degree these days," Richardson concluded, "is the MBA."

    Putting the grumbles in perspective Just how legitimate is the "best and brightest" gripe? How much reality is in the perception? Any concerns about the Doctors of the Future must be put in context. Consider that average MCAT scores for both medical school applicants and matriculants have steadily increased over the past decade. Applicants' mean MCAT verbal reasoning score rose from 8.3 in 1992 to 8.8 in 2003. Mean scores in the physical sciences portion jumped from 8.1 to 9.0, and in biological sciences from 8.2 to 9.3. We're not sending schlubs to med school these days.

    True, medical school applications dropped by 28 percent from the mid-1990s into the early part of the new century, but after a six-year decline they rebounded in the 2003-04 academic year with a 3.4 percent uptick. Judging from the early tea leaves, the resurgence is likely to continue in 2004-2005.

    The Association of American Medical Colleges is quick to point out that for every student admitted to a US medical school today, another student is turned away. "We're not sacrificing quality," notes an AAMC spokesperson. One of our survey respondents shared this insight: "My older daughter, with a 3.7 GPA, could not gain admission to our state university medical school. I've told my younger daughter, 'Don't worry about medicine. Go to business or law school.' "

    Undoubtedly, many bright students who'd make perfectly wonderful doctors aren't getting into US medical schools. Yet we don't graduate nearly enough MDs and DOs to fill the slots in residency training programs—some 16,000 US grads compete with nearly 8,000 grads of foreign schools for roughly 21,000 slots. Some have argued that the capacity of homegrown medical education should be increased to stem the growing dependence on international grads, who this year filled nearly 60 percent of the first-year residency slots in family practice programs and 45 percent of those in internal medicine.

    Perception changes with the view How you feel about this issue may depend on your specialty, and whether you think it is attracting the cream of the available crop of graduating medical students. That's best and brightest, Residency Version. Charles J. Lockwood, head of ob/gyn at Yale University School of Medicine, feels that, nationwide, the quality of candidates "has fallen precipitously" and that his specialty "is in dire straits."

    Lockwood notes that applications and acceptances to ob/gyn training programs by US medical students have dropped to the lowest level in four years.

    "Many chairs and program directors tell me that average national board scores among applicants have dropped," Lockwood says. "Our current malpractice insurance crisis is rendering ob/gyn financially unsupportable and has broken the morale of most practitioners. That's just one cause of the particularly heavy hit we've taken in ob/gyn, along with rigorous work hours and the demands of night call."

    Ob/gyns who responded to the Medical Economics survey seem to agree with Lockwood. Only 18 percent feel that the best and brightest young folks are going into medicine, making ob/gyns one of the most pessimistic of the 24 specialties we surveyed. The only doctors less sanguine about the next generation of physicians were thoracic surgeons (just 11 percent think medicine is attracting the best and brightest) and plastic surgeons (16 percent).

    On the other hand, the most upbeat were dermatologists (40 percent), psychiatrists (40 percent), pediatricians (38 percent), and orthopedists (34 percent). The numbers in primary care were slightly less stellar—30 percent of FPs think the best and brightest are going into medicine, 28 percent of internists, and 28 percent of GPs.

    As you might expect, the more optimistic the specialty, the more likely its members were to encourage their own children to pursue a career in medicine.

    But is the question the right one? As much fun as it is to debate the "best and brightest" issue, these days leaders in medical education are focusing more on what to do with the students who do get into med school. They're trying to provide specific career guidance (check out www.aamc.org/students/cim) working to enrich and diversify the curriculum, and hoping to encourage more minority students to enter the profession.

    In July, the AAMC's Ad Hoc Committee of Deans published a report ambitiously titled, "Educating Doctors to Provide High Quality Medical Care: A Vision of Medical Education in the United States." The vision it articulates emphasizes a humanistic, patient-centered approach to care; attention to quality of life issues in clinical decision making; development of cultural competency; and effective use of scientific evidence, available resources, and technologies. Doctors, the report says, should also be trained to function effectively as members of an interdisciplinary care team, and they should know how to listen and communicate well with their patients.

    Indeed, interpersonal and communication skills are one of six new core competencies by which all physician training programs will be judged. The other competencies: compassionate and appropriate patient care, medical knowledge, practice-based learning and improvement, professionalism, and systems-based practice.

    Medical educators, in sum, appear more satisfied with who is getting into medical school than they are with what's being taught. The AAMC report and similar analyses by the Institute of Medicine and The Commonwealth Fund Task Force on Academic Health Centers worry aloud that teaching programs are not preparing doctors for the kinds of patients they'll see in their practices, and are not acquainting doctors with the world of healthcare that lies beyond the walls of the academic center.

    All of which leads us to reconsider the original question. As one of our survey respondents retorted: "Define 'brightest!' " Against the more expansive backdrop of what's going on in medical education, are the "best and brightest" really the best and brightest criteria for tomorrow's doctors?

    "I don't know that the brightest people necessarily make the best doctors," says Richard H. Streiffer, Chairman of the Department of Family and Community Medicine at Tulane University School of Medicine. "It is more than just smarts. And best? Best for what? Best should mean willing to serve, and excited and committed to do what the country needs."

    The "best," in Streiffer's view, should mean being "compassionate, effective at communicating and empathizing, willing to become part of a community and serve that community. Rural and inner city America are hurting for doctors, while the suburbs are teeming with docs. Minority and ethnic groups in particular need members of their communities to enter medicine."

    Medical school admissions policies "are wedded to numbers—high GPAs and MCATs," Streiffer adds. "Those numbers should be used as a threshold of academic ability and then largely discarded in deciding who gets in. We must use other factors—maturity, experience, service orientation, and work ethic.

    "Sure, we need physicians who are smart as hell," he says. "But most people need a doctor who is dedicated, kind, caring, there when needed, and knows enough to keep up and how to get answers."

    If your child wanted to become a physician, would you recommend it?
    Should your kid go into medicine? Although nearly three-fourths of doctors in the Medical Economics Continuing Survey don't believe that the best and brightest young people are going into medicine, a solid majority are still willing to encourage their sons and daughters to follow in their footsteps.

    When physicians were asked, "If your child expressed an interest in becoming a physician, would you recommend it?" 59 percent said Yes.

    Specialists who were more inclined to think that medicine is still luring the "best and brightest" were also the most likely to encourage their children to become doctors. For example, 70 percent of pediatricians said they'd give their kids a thumbs-up on a career in medicine, as did 71 percent of dermatologists, 71 percent of allergists and immunologists, and 70 percent of psychiatrists.

    The same was true in reverse: Doctors who think medicine is losing the best and brightest were the least likely to support their child's desire to join the profession. Just 48 percent of ob/gyns said they'd recommend medicine to their children; and thoracic surgeons, at 47 percent, were even gloomier. All other specialties at least broke the 50 percent barrier!

    Responses to the question, "Would you recommend medicine" ranged from "All my children are already physicians" to "No way!" Some were careful to qualify their answers; one doctor would be happy with a child's choice "unless it were pathology or anesthesia." Others appear content to let their children make up their own minds and hope that medicine, if chosen, will be the child's true passion. As one put it, "No sense in doing a job you're not suited for."

    Jeff Forster
    The author is a former Editor of Medical Economics

    Latest Tweets Follow