The Doctor is Out

Sickened by the shift to managed care, more physicians are claiming disability, moving into administration or leaving medicine altogether

What he means, according to disability consultant Arthur L. Fries, is that physicians' policies used to be worded broadly and priced generously. Insurers considered them "prime prospects, because they had big needs, big lifestyles and big earnings, and they had an attitude of, 'You work until you drop.'"

Fries used to sell disability insurance himself; now he consults with physicians across the nation who are trying to go on disability. He cites recurring factors: "Increased paperwork, disrespect, unhappiness and managed care telling them when to go to the bathroom." Not to mention salary reductions that provided "quite an encouragement to lean into a disability claim."

The New Generation
Physicians have long been ill-distributed, clambering over each other in metropolitan areas and leaving tiny towns unserved. Now, rumors are flying that we'll soon have a surplus of physicians. So maybe this slight hemorrhage of practicing physicians is just Darwinian necessity?

Medical-school applications are down nationwide, so markedly that the Association of American Medical Colleges is polling its participants to learn why. Applications to St. Louis University School of Medicine dropped from 7,215 in 1997 to 6,206 in 1998. Applications to Washington University School of Medicine dropped from 5,823 to 5,143, and the dean expects them to decrease again in 1999.

Applicants still wildly outnumber the small pool that's chosen, though, and deans insist that the caliber of those students hasn't dropped. Outsiders wonder whether they know what they're getting into. Med students gain their clinical experience at teaching hospitals that see the most serious and complex cases; in that world, managed care has far less say. As for classroom experience, academic medicine's pretty sheltered. Some faculty members do maintain clinical practices, and do moan about the higher patient loads and paperwork rigamarole of managed care, but their malpractice insurance and salaries are paid by the school and their managed-care contracts are negotiated collectively.

Still, even med students absorb a bit of the real world by osmosis. And they do read. "Physicians Enter the Job Market," a recent article in the Medical Student Journal of the American Medical Association, opens with the warning, "The model of the past, when medicine was a reliable field in which hard work was rewarded by a stable and comfortable lifestyle, no longer holds true."

Asked whether students are prepared for the new paradigm, Dr. Alberto Galofre, associate dean for curriculum at St. Louis University School of Medicine, scrawls three rectangles on a yellow pad. He labels the first "medical school," the next "graduate medical education" (residency) and the third "real life." "I deal with here," he explains, pointing to the first rectangle. "When they graduate med school, they go into hospitals for three more years of education. Then real life. And that is where you have the problems.

"We've had these discussions: How much should we do for real life?" he continues. "They should know what managed care is. But shouldn't we prepare them in such a way that it doesn't matter what system is in place tomorrow?"

Students aren't sure. Nationwide, almost 61 percent of graduating medical students say they received inadequate instruction about managed care, according to the 1998 Medical School Graduation Questionnaire just released by the Association of American Medical Colleges. In a 1995 survey, SLU med students complained they'd received insufficient information about managed care and insufficient experience with its offshoots, family medicine and outpatient care. (Now SLU includes a section on managed care in one of its required courses, although it hasn't gone as far as, say, the University of British Columbia, which rewrote its goals for medical students to include the ability to "consider the cost and societal implications of their approach to providing health care.")

"Have we had a huge change in the amount of time we spend teaching managed care? No," says Dr. Alison Whelan, associate dean of Washington University School of Medicine. "But we have begun to increase the amount of teaching about the practice of management. Students receive at least a couple hours of lectures about the business aspects, and we've started a biannual managed-care symposium.

"Students see the way the practice of medicine is altered by the way health care is managed," remarks Whelan, "the amount of time physicians spend on paperwork, the office personnel required to submit it all. They see that as part and parcel of the care of the patient." They also spend more time learning to plan for discharge, she adds, because patients go home less well.

Whelan doesn't see students fretting about the increased business aspects of clinical practice, but Navarro has seen just how unprepared some of her clients are for those challenges. In her opinion, "it's not bad for them to get a couple courses in accounting, marketing, strategic thinking. And they have to have the capacity for teamwork, the capacity to manage bureaucratic politics."

Ask Galofre whether students are taught teamwork, and he shrugs genially. "Teamwork -- that is a tough one. It deals with being socialized to the profession, which happens gradually. We can teach our students how certain things should be done, but what really changes them is when they go into a clinical situation and see it done differently. What I hear from our students is that some areas are better for teamwork; in others, people say, 'Look, I am the one who is responsible, so I will say how it should be done."

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