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New Orleans, LA
Dr. Kovitz is Director, Interventional Pulmonology and Medical Critical Care, Tulane University Health Sciences Center.
Correspondence to: Kevin L. Kovitz, MD, MBA, FCCP, Director, Interventional Pulmonology and Medical Critical Care, Tulane University Health Sciences Center, 1430 Tulane Ave SL9, New Orleans, LA 70112; e-mail: kkovitz{at}tulane.edu
The specialty of pulmonary and critical care medicine (PCCM) is in trouble. Not a meeting goes by without someone bemoaning the fact that we have too few people choosing the field. Couple this with a projected shortage of just such specialists for an aging population and the general public has a problem as well. How do we fix this problem that is of obvious import to both our specialty societies and society at large? Lorin and colleagues (February 2005)1 have made a good start. They begin to quantify the problem by looking to the source of trainees, internal medicine residents. It is they who must choose to enter our training programs, and if they are unwilling to do so, we must query them directly to understand the reasons. What are the key factors that influence decision making, and what can we do to not only keep from driving trainees away but also, more importantly, draw them to us?
A good place to start is the survey made by Lorin and colleagues1 of internal medicine residents (response rate, 61%) in university hospital training programs. Although 41% had "seriously considered" pulmonary and critical care, only 3.4% actually chose the field. There were attributes of the field that respondents perceived as attractive; however, lifestyle issues appeared to be significantly dissuading. Lack of free time, stress in potential role models, chronically ill patients, incompatible personality, and treating pulmonary diseases were most cited as reasons for avoiding PCCM as a specialty choice.
When people have a choice, lifestyle plays a major role in decision making. The scope of any given field will be attractive to some and not to others. The breadth of illnesses in PCCM, including many chronic disease processes, will interest residents in different ways. The attractiveness of the field will likely vary over time based on our capacity to manage the range of illnesses and the impact we can have on patients. As a field, we will attract more quality trainees as we broaden the range of clinical interventions available to improve the quality of life of our patients. The chronic cardiac or renal patient is not as debilitated as in times past thanks to new and expanded therapeutic options. We will also see the impact on the chronic pulmonary patient as our interventions for COPD, lung cancer, pulmonary fibrosis, and other entities improve.
The article posits that it is important to focus on the lifestyle issues of lack of free time and stress of the fellows and attending physicians who are the potential role models. Such is the choice we all face in the practice of medicine. The consequences of this choice become apparent comparing a field of daily life and death with long hours to a field of more leisurely scope and pace. However, I do not believe that the lifestyle issues above really play a definitive role in deciding against PCCM when one looks internally at the competing specialties within internal medicine. I do not know many cardiologists or oncologists with abundant free time or limited stress, yet these were among the preferred fields. A future iteration of this excellent study could compare these lifestyle barriers to entry among internal medicine subspecialties. However, is the problem really one of the lifestyle issues cited, or are these merely surrogates for something more fundamental?
One of the oldest clichés is that "you get what you pay for." Could financial considerations really be the root cause of the dearth of trainee interest? We like to think that people will choose the field they find most interesting and that they will be purely altruistic in making this choice. Ultimate income would therefore be secondary. This idealized paradigm may be true for some, but what about the more realistic scenario that most trainees find many different specialties interesting? Income potential likely plays a substantial role in decision making in this scenario, and a second look at the authors’ data supports this conclusion.
Recent data from the American Association of Medical Colleges2 once again notes the high cost of medical education and the subsequent $100,000 to $135,000 median debt burden held by 2003 medical school graduates. The first choice, general internal medicine (19.6%),1 is likely influenced by lifestyle and the need to get on with paying such a debt. But once someone chooses to subspecialize, it is important for us to apply income potential to this analysis of choice. Economic forces are real and, no matter how couched in other terms, have dominant impact. Table 1 . lists academic and private practice total compensation means based on 2003 data collected by the Medical Group Management Association (MGMA)3 alongside specialty choices, in decreasing order of preference, found by Lorin and colleagues.1
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What does all this mean? First, the authors have made an excellent start at looking for the root cause of the dearth of trainees choosing pulmonary and critical care as a subspecialty. Lifestyle, disease range, intervention potential, and role models will always have an impact on career choice. There will be always be a baseline of individuals who chose a field based purely on interest. We can also work at the edges and improve mentoring, role models, and subsequently our disease intervention options to make PCCM a more attractive option to trainees.
However, we cannot simply look internally to the field to solve the problem. Given a wide range of options, dedicated individuals who are willing to work hard will simply choose the better income potential between fields that are of similar interest to them. They will also be more likely to overlook shortcomings in a field if the income potential is sufficient. To solve the need for pulmonary and critical care specialists, we need to improve reimbursement. Critical care is reimbursed at a higher rate than a high-level evaluation and management visit. However, in reality, most critically ill patients and their care do not qualify as critical care by the Centers for Medicare and Medicaid Services guidelines. Critical care coding requires substantial time in the direct care of a critical and unstable patient. Airway stenting is reimbursed at a much lower rate than coronary stenting. These are not complaints, just facts, and there are many such examples. With reimbursement being a "zero sum game," it will be difficult to ameliorate the situation. We must advocate for our representative societies to advocate for us. If not, market forces will solve the increasing acuity of the shortage of pulmonary and critical care specialists. Either less-qualified practitioners will step in to fill the void, lowering quality and reimbursement for all, or patients will increasingly demand and pay for the qualified specialist. The laws of supply and demand will then kick in and trainees will gravitate toward an improved income potential. This can easily be subverted if our lobbying potential is less than others or if we work at cross-purposes. It is better to work among our overlapping societies and improve the "lifestyle" for all of us. We can no longer keep our heads buried in the sand. You get what you pay for...
References
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