Influence of controllable lifestyle on specialty choice

[Guest Ian Wong]

Here's a recent article in JAMA regarding the current trend of lifestyle becoming a more significant factor in residency choice by senior US medical students. One conclusion of this study was that 55% of the change in specialty preferences between 1996-2002 could be explained purely by lifestyle considerations (after controlling/accounting for other confounding variables.)

 

This paper also includes some demographic information as far as hours-worked, and annual income for many specialties. Of note is that from 1996-2002:

 

Anesthesia applicants increased from 172 to 944

Family Med applicants decreased from 2415 to 1404

Radiology applicants increased from 499 to 903

Gen Surg applicants decreased from 1559 to 1123

 

Here's the link to the JAMA website for this particular issue:

 

jama.ama-assn.org/content/vol290/issue9/index.dtl

 

The article itself can be found here:

 

Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students. Dorsey et al. JAMA 2003;290:1173-1178.

 

jama.ama-assn.org/cgi/content/full/290/9/1173

 

Definitely worth looking at, and there are additional related links to other articles scattered in this issue.

 

Ian

[Guest cracked30]

I find it interesting that family dropped, I kinda refutes the proposition, Family is a VERY controllable lifestyle.

[Guest dakar]

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[Guest moo]

Family med has taken a huge hit in the US in the last few years and this is largely due to public perception of the specialty. In the US the majority of children see pediatricians, while the majority of adults see internists as their PCP. The role of the family physician is ill-defined. My friend went to a family medicine residency fair last week, and afterward he came back more convinced than ever that he was not going to do family med (cited several factors: low pay, desperation of programs, inability to find a job afterwards). The majority of family medicine residencies (even the very good ones) are being filled by IMGs and US DOs (osteopathic physicians). In fact, I think last year less than 50% of family medicine residencies were actual US grads.

[Guest UWOMED2005]

It's true that in family you are your own boss and can control how you practice. But there are two other things to consider, sort of inter-related. . .

 

1) What you consider the standards of family practice to be.

 

As a family physician you are in complete control of your practice hours. . . as long as you and your conscience are happy with your decisions. Some family physicians still feel an obligation visit all their in hospital patients - which necessitates visiting the hospital before clinic, often at 6 or 7 am. Likewise, where for some FPs 'call' consists of an answering machine message directing their patients to the ER, some FPs still do phone call or will even do a house call if the situation is urgent. Finally, some FPs (I worked with one in London) feel an obligation in a time of FP shortages to take on extra patients.

 

Combine these three phenomenon and you're looking at hours not unlike a general surgeon.

 

2) What you expect to make in Family Practice combined with the overhead you pay.

 

It is 100% true that a family physician, as an independent business owner, is free to set their own hours - even limit their hours to 3 mornings a week. It is also 100% true that they will make less money if they work those kind of hours.

 

A lot also depends on overhead. The idea that family medicine is a poor paying specialty is not entirely true. If you are working in small town Ontario, bought your office for $45,000 straight up, got your equipment on sale from a retiring FP and know how to tailor your practice, $250k after overhead on 9 to 5 is not unrealistic (or so I'm told by a doc in this situation). But if you want to practice (and pay for an office) in Downtown Toronto and don't have good business skills. . . expect a totally different situation. In such a situation, if you are the primary bread-winner for your family and expect a student-debt-adjusted-post-overhead salary of $100k. . . expect to work A LOT more hours. If you're trying to pay off that $100k debt, it would be a LOT more hours indeed. . .

[Guest cracked30]

I think that those stats really show that people are less interested in patient care specialties.

 

Rads and anesthesia, NO PATIENT care, ie. you are not responsible for inpatients. It's kinda sad, I thought people went into medicine to help people.

[Guest phantom8]

While Family Med is dropping in popularity (here in Canada too), with the way CaRMS and residency positions are looking, it's either hope for the best in the specialty of your choice, going to the States, Family Med, or the highway.

 

Quite frankly, I'm nervous about the recent news that that are an equal number of residency positions as there are med students graduating for this coming year, meaning less and less choices for residency. And of course, the surplus of unfilled residency spots in previous years have been in Family Med. Not too hard to do the math, unfortunately.

[Guest moo]

There's nothing wrong with wanting to go into radiology or anasthesiology. They are a vital part of the health care team. Just because you have no patient contact doesn't mean you don't work hard. Pathology is another one of those specialties where there's no patient contact but who are you going to ask to get lab results when you do a tissue biopsy. Underneath the microscope is a patient... not the kind of patient contact you expect but still a vital part of the health care system.

[Guest cracked30]

Yeah, but a slide doesn't make the nurses wake you up at 3am for a Tylenol order.

[Guest UWOMED2005]

Neither do the patients, if you write the following order* in all of your charts.

 

Tylenol 325-1000 mg PO q4-6h prn

 

I also like:

 

Gravol 25-50mg PO/IM/IV/SC q4-6h prn

 

Some residents automatically stick ativan orders in. I'm not a big fan of that at all. Instead, I prefer:

 

Warm milk 250mL PO qhs

 

I'd have added in a "Bed Time Story qhs" order as well but I'm not sure if that which of PO/PR/IM/IV/SC/OD/AU. . . probably AU. Definitely not PR. Of course the nurses would have killed me for actually writing in the cart. But I'd rather try those two options first before immediately jumping on the benzo bandwagon.** I find it rather humorous the number of times I've been asked to order a benzo, only to find out the patient is already asleep by the time it was given.

 

Now of course, you're assuming in writing these orders that your nurses will use some common sense in administering these orders. Fortunately, I've found almost all of the nurses to be better than me at deciding when to give non-prescription meds to non-patients, considering many of them having been doing it for upwards of 20 years day in day out and I've only been a clerk 8 and a half weeks.

 

*Of course - make sure to R/O liver pathology, or especially, admission for tylenol overdose. Even more key for benzos - why I don't like them.

** note, I'm not saying benzos don't have their place. I just don't like handing them out like they're candy. Some patients really do need a benzo to sleep in a hospital setting.

[Guest peachy]

Uwomed, how long before I have a clue what the joke in your post is?

[Guest Ian Wong]

You will see two minds regarding the PRN Benzo order at night-time, depending on a number of different factors such as:

 

- how conscientious are the nurses.

- how conscientious is the resident.

- institutional/specialty/personal preferences

- how pager-phobic the resident happens to be

 

and probably a bunch of other things. Some people treat PRN Benzo's just like prophylactic rounds on the wards prior to turning in to bed (in other words, going up to the wards and talking to the nurses to get any orders written up at midnight before you've started sleeping, in an attempt to minimize the number of 3 am pages), and therefore write the PRN order so the nurse won't page them at 3 am asking "Can I give Mr. Smith some Ativan to help with his sleep?"

 

Other residents won't write that PRN order, on the grounds that they'd like to be the one to decide whether a patient should be getting some kind of night-time sedation instead of the nurse (no medication is completely benign, after all). You wouldn't want to sedate an agitated patient who happened to be agitated because there was some kind of treatable organic cause for this erratic behaviour. I fall into this second category. If your patients are elderly, zopiclone also can be a good sleep aid, and wears off sooner than Ativan, so patients are less likely to be snowed in the morning.

 

peachy, you too will learn the medicalese above. Inasmuch as writing out prescriptions is a huge part of being a physician, it's pretty amusing that you can be proficient in writing out all the above abbreviations with only an hour's worth of teaching!

 

Ian

[Guest aneliz]

Save the "bed-time story" PR for really *special* patients :lol

[Guest UWOMED2005]

Peachy, here are some of the translations. You'll have to learn them anyways. . .

 

PO - by mouth

q4-6h - every four to six hours

prn - as needed

IM - Intramuscularly

IV - Intravenous

SC - Subcutaneous (that one might be wrong, but the University Hospital Nurses knew what I meant)

qhs - at bedtime

PR - by rectum (ie suppository)

OU - in each eye (ie eyedrops)

AU - in each ear (ie eardrops)

 

So. . .

 

Tylenol 325-1000mg PO q4-6h prn

 

becomes. . .

 

Tylenol one normal strength to 2 extra-strength tabs taken by mouth every 4 to 6 hours when needed.

 

Basically the directions on the box, or what a patient would take at home.

 

I was actually dead serious about the Tylenol and Gravol orders on every chart. It saves a lot of hassle. But it is kind of funny to write PO/IM/IV/SC because it leaves a whole lot of options and overall the order is extremely vague.

 

The joke is the Warm milk and bedtime story orders (Warm milk by mouth at bedtime.) Nobody orders that - well, except for me. I asked the nurses about warm milk one night on call I was sick of all the benzo trick-or-treating that was going on with patients who I'm not sure needed it. I find it amazing they filled the "scotch, a cigarette and a sandwich"* order I wrote the previous week but wouldn't get someone who was having trouble sleeping some warm milk.

 

Next time I'll try to order tryptophan.** That's the amino acid in turkeys that makes everyone conk out in the middle of the CFL thanksgiving monday night football games. And I know a few people it has worked for.

 

* Yes, I did order a patient "scotch, a cigarette and a sandwich." It was for patient who was palliative, in her last few days and when asked that's all she wanted. As it turns out, the pharmacy keeps alcohol on hand for such situations. And yes, I definitely cleared that one with my consultant.

* Once again, I think benzos have their place in treating insomnia. Just not as candy and/or when other options haven't even been tried.

[Guest Ian Wong]

I've seen "Beer 1 can NG q8h" before in treating a guy with delirium tremens from alcohol withdrawal. Not sure why they didn't use a fat dose of Ativan instead, but hey, fight fire with fire!?!

 

Ian

[Guest UWOMED2005]

Yeah, we had a dialysis patient we ordered "Beer PO bid" for. He was an alcoholic, was a risk for the DTs and would have refused admission without the beer.

 

But I agree. . . there's somewhere where I'd rather use Ativan, Valium or Librium.

[Guest cracked30]

All things considered, lifestyle should be high on your criteria for including a specialty. The pay, across all specialties is about the same when you look at hours worked, with extreme exceptions. But we all can't be dermatologists and opthamologists.

 

My friend is a family doc in a nearby county, took a two year residency, and now does about three shifts of emerg per week, one half day of family clinic, and assists in the OR one half day. He earns 20-25K per month, before taxes. Thats not much less that an orthopod or general surgeon expects to make per month, before expenses and taxes.

 

The hard surgical specialties are not really worth the hassle.

[Guest driedcaribou]

I know you just had a typo UWOMED2005 but isn't OD right eye and OU in each eye?

 

Also, your comments on Family Practice are very helpful to me in thinking about what I would want to do a specialty in.

 

Thanks!

[Guest UWOMED2005]

Yep, I think you're right.

 

I haven't been through Ophtho yet so I haven't actually used those abbreviations yet.

[Guest therealcrackers]

You have obviously BLOCKED last year's neuro exam out completely... good for you (shudder) :x :\ .

[Guest UWOMED2005]

That thing never happened. If it had, it would be a story told by evil grandparents to scare grandchildren around the world.

[Guest strider2004]

My classmate once ordered 'TLC daily please'. The nurses didn't like him after that.