Why Primary Care is Sexier than Dermatology

In his book, Better, Atul Gawande recounts the moment he was offered his first job as a fully licensed physician after years of grueling preparation. The head of the department asked him what he wanted to be paid. Gawande didn’t know how much would be reasonable, let alone how much he wanted. It’s a problem we all face in medicine, though perhaps in a more subtle way, when we pick our specialty. We are not supposed to be "in this for the money," but let’s face it: most of us hope our dream specialty--the thing that gets us out of bed in the morning, ready to heal the sick and comfort the dying--also has a nice paycheck and doesn’t require excessive amounts of overtime to boot. Why not? We’ve worked hard for a long, long time (longer than any other professional degree course) and are burdened with excessive levels of debt that overshadow those of any other profession. William Weeks of Dartmouth has found that working hours for physicians are longer than for any other profession, and that the payoff in terms of educational investment is poorer in medicine than in law and business. It is largely the motivations of salary and working hours which have dramatically restructured the dynamics of specialty competition and thus the availability of healthcare across the spectrum of specialties.
This March the New York Times published an article examining the popularity of dermatology residency programs. It is undeniable that dermatology is currently among the most competitive specialty choices for young doctors. Only 61% of fourth years applying to dermatology residency in the US last year matched in that specialty, compared to 98% of internal medicine applicants. The numbers show another trend: the best and the brightest students, in terms of academic honors, board scores, and research experience, are heading towards dermatology. But, it wasn’t always that way. Several decades ago general surgery and internal medicine attracted the best and brightest medical students while dermatology drew few.
Dr. Eric C. Parlette, a dermatologist in Chestnut Hill, MA, attempts to explain this trend in the article: “It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time.” Certainly the procedure-based emphasis of our current reimbursement scheme is a major factor in the rising popularity of dermatology and other specialties like plastic surgery, which are low on preventative care and big on procedural therapy. Moreover, an additional factor heightens the appeal of these specialties: cosmetic procedures, paid in full without insurance middlemen. The 40-hour average workweek for dermatologists also adds to the appeal of the specialty, making it the crown jewel in the young doctor’s ROAD to success--an acronym for the well-known lifestyle specialties of radiology, otolaryngology, anesthesiology, and dermatology. The acronym is passed along like a mantra for success in the hallways of American medical schools, and it is very clear to students where the payoff lies. Less work and more pay is an obvious choice for many students when faced with the reality that in 2000 the average family practitioner saw 122.9 patients per week and made $144,700 before taxes, while the average procedure-performing cardiologist saw 92.4 patients per week and took home $315,500 before taxes, according to the American Medical Association Physician Socioeconomic Statistics (2003).
Certainly we need dermatologists. Many of them are passionate about unappealing but important diseases like skin cancer and contact dermatitis. However, the problem with the inordinate popularity of specialties like dermatology and plastic surgery is that it comes at the expense of other specialties, those relied upon for the treatment of widespread, life-threatening diseases. Primary care specialties are the neglected siblings of those that line the procedure-based ROAD. The skewed specialty distribution has ramifications for the health of our patients, who may find it difficult in the coming years to gain access to life-saving but un-flashy preventative care for diseases like heart disease and diabetes.
Beyond the effects on healthcare delivery to individuals, there are major systemic reasons why a healthcare system based on primary care is best. In February of this year an American Journal of Medicine study showed that as the proportion of physicians in primary care practice increases, healthcare costs decrease. Last year we spent $2.3 trillion on healthcare, according to the National Coalition on Healthcare. The money was used to sustain a decidedly inefficient and wasteful system. If increasing access to primary care could help make our ailing system significantly more efficient, it’s certainly worth a try. Furthermore, according to a 2001 study in the Journal of American Family Practice, we could have better detection of breast cancer and reduced incidence and mortality caused by colon and cervical cancer, as well as improved health outcomes for a list of a dozen other major killers of Americans. A 1992 study in JAMA found that we could have to fewer tests, higher patient satisfaction, less medication use and lower care-related costs. Finally, in 2001 a study in the American Journal of Public Health found that strong primary care would lead to reduced health care disparities, particularly for areas with higher economic inequality. This list of benefits reads like a laundry list for a utopian health care system. In the mangled words of John Lennon, imagine a world with less use of emergency rooms and hospitals, and better preventative care.

We have no choice but to look for solutions to the systemic issue of physician supply and demand in order to provide both individual patients and society with the best possible care. The most obvious solution is to find a better way to reimburse doctors so that pay for educating patients about disease processes would be at least on par with providing liposuction and Botox. A prototype exists in New York State, where the infamous Eliot Spitzer proposed a program called Doctors across New York that would compensate general practitioners with an aggressive loan repayment program and increased salaries. We need to change the incentives for careers in primary care so that all doctors can afford to make career decisions based on patients rather than profits.

"For Top Medical Students, An Attractive Field" was published on March 19, 2008 Fashion & Style Section of the New York Times.