COMMENTARY
Negative Secular Trends in
Medicine: Summary
Six or seven years ago on CNBC, Barton Biggs noted that
when he started on Wall Street in the early 1960s, the best
doctors, lawyers, and investment bankers earned approximately the same amount, because the jobs required similar
intellectual capacity, hard work, and character. He then
noted that was no longer the case.
Why? What has changed over the last half-century,
causing medicine to lose its competitiveness for the smartest kids in the class?
In previous Commentaries I discussed some of these
negative trends: increasing student debt,1 high hospital chief
executive officer salaries,2 longer training periods,3 and
relentlessly encroaching bureaucracy, as exemplified by the
recent debacle involving the American Board of Internal
Medicine and the Maintenance of Certification requirements.4
The increasing number of applications and the attendant
expense for obtaining residency positions5 and restrictions on
resident’s work hours6 have also contributed, but have been
widely discussed elsewhere.
One negative trend that has not been adequately addressed and that I would like to mention before moving on is
the position of chief medical officer (CMO). I believe it is
important for physicians to appreciate that the CMO is a
hospital employee who answers directly to the chief executive officer. They do not represent the interests of the
physicians: that is the responsibility of the chief of staff—
and the individual physicians themselves. To the contrary—
the job of the CMO is to impose the wishes of the administration on the medical staff.
I divide what I believe are the negative secular trends into 2
broad categories: those outside and those within medicine. I
will not address the former, such as the increasing power of
hospitals and the insurance industry and the intrusion of
government. Rather, because I believe many of our problems
are self-inflicted, I will focus on what physicians can do to
make a career in medicine more attractive. As they say, “You
can’t change others, but you can change yourself.”
Funding: None.
Conflict of Interest: None.
Authorship: The author had access and participated in the writing.
Requests for reprints should be addressed to Robert M. Doroghazi, MD,
115 Bingham Road, Columbia, MO 65203-3577.
E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjmed.2015.08.045
I think doctors need to be more aggressive to protect their
interests. At least in some states, physicians have done a
reasonable job standing up to the plaintiff’s attorneys. Where
they often fail is in business situations, such as dealing with
hospital administrators and insurance company executives.
These people are talented, well-trained businessmen. Physicians are arguably the best trained professionals in the world,
yet they receive little or no instruction on how to run a business or how to negotiate. Physicians must be represented by
equally hard-nosed people, whether from within the physician
community or from the outside, who can go toe-to-toe with
businessmen to better represent the interests of physicians.
Should physicians unionize? Mentioning it does not
mean I recommend it. Having personally worked in heavily
unionized industries, the thought gives me considerable
hesitation. Note, however, that it has certainly done a great
deal for professional athletes. Whatever its final form, some
type of organized structure that represents physician’s interests and has clout is sorely needed.
Antonyms for aggressive include meek, submissive, and
docile. I would never suggest these terms apply to the latest
generation of physicians. However, I feel confident in
saying the rugged individualists graduated by medical
schools in bygone times are bye and gone.
I also believe physicians on the front line of patient care
need to be more forceful. Almost everyone that sits on the
regulation-setting and credentialing bodies, such as the
American Board of Internal Medicine, are from academia.
Most have little idea of medicine in the real world, such as
making rounds on 10 patients in the hospital, then performing
2 cardiac catheterizations, then seeing 20 to 40 patients in the
office, then seeing 2 or 3 consultations or admissions, then
taking call on nights, weekends, and holidays. I also believe
the trend of longer training periods and more subspecialty
credentialing is related to the same unrealistic bureaucratic/
academic mind-set: if one can create a pond, even a small one,
where none existed before, they can be a big fish.
I believe the professional societies and colleges could do a
much better job representing the practicing physician. After
all, they have their own bureaucracies to protect, and many of
the problems I discuss have occurred during their watch.
Good examples are the American College of Cardiology
Foundation/American Heart Association position papers,
which take an average of 920 days to write.7 For comparison,
460
the first atomic bomb and the St. Louis Arch were built in the
same amount of time. The guidelines often run 50-100 pages
and tens of thousands of words. It is probable that all of the
extant guidelines of the American College of Cardiology
Foundation/American Heart Association total more than
1,000,000 words, rivaling in length the IRS tax code. Such
guidelines are of little if any practical use.
Lifestyle seems to be an important driver of decision
making for young physicians. Many physicians sign on as
hospital employees because they want set hours, a steady
paycheck, and to avoid the business side of medicine, such
as making payroll. In my opinion, physicians becoming
hospital employees is the greatest negative secular trend in
medicine. They may have an MD behind their name, but
they give up all independence and leverage. They are simply
time clock-punching employees, serving at the will of the
hospital administrator, no different than a housekeeper, Xray technician, or floor secretary.
When I was in medical school in the mid-1970s, internal
medicine, general surgery, and pediatrics were the flagship
departments. They were considered the most prestigious
careers, and their residencies were the most competitive,
attracting the best students. Dermatology and the surgical
subspecialties, such as ophthalmology, were at the other end
of the list. This has undergone a 100% change. I cannot fault
anyone who wants to work less and earn more, but these
specialties also offered the best lifestyle in the 1970s, yet
lacked prestige and were rarely given strong consideration
by the top students. I do not believe it is in the best interests
of the future of medicine, or society, that the best students
choose these careers. I admit I do not have an easy solution,
other than to appeal to physicians’ altruism.
Likewise, I make 2 points in defense of those who choose
these subspecialties. First, modern American society places
an increasing premium on the services offered by these
physicians, so it is natural they would draw better talent.
These subspecialists also require little or no support from
the hospital to earn their livelihood, which I think will be a
very significant advantage going forward.
To summarize, I have the following recommendations to
make a career in medicine more attractive. (1) Student debt
must be brought under control. Students need to be thriftier,
and earn more money along the way. (2) Medical schools
must make a good faith effort to hold down tuition. The best
place to start is by cutting the bloated administration. (3) The
The American Journal of Medicine, Vol 129, No 5, May 2016
Federal Reserve reports that the biggest driver of increasing
tuition is the government subsidy of student loans.8 The
government needs to exit the student loan business. Sufficient
private money is available. (4) The high salaries paid hospital
administrators and the CMO increase the cost of patient care
and draw talented physicians away from the practice of
medicine. (5) I believe that tying the compensation of hospital
administrators to the hospital’s profits is a conflict of interests.
(6) The time required to train all physicians must be shortened
by at least 2 years, and hopefully 3 to 4 years for subspecialists. (7) Practicing physicians on the front lines of
patient care need to have much more influence over policy. (8)
Physicians need to be more aggressive in standing up for their
interests, supported by an organization with clout and universal physician support. (9) Physicians must retain their independence and not become hospital employees. (10) The
best way to make a career in medicine more attractive is for
physicians to work harder.
Robert M. Doroghazi, MD
The Physician Investor Newsletter
Columbia, Mo
ACKNOWLEDGMENT
The author thanks Judy Feintuch for assistance with the
literature search.
References
1. Doroghazi RM. Negative secular trends in medicine: student debt. Am J
Med. 2016;129(1):8-10.
2. Doroghazi RM. Negative secular trends in medicine: high CEO salaries.
Am J Med. 2016;129(2):e1-2.
3. Doroghazi RM. Negative secular trends in medicine: prolonged training
periods. Am J Med. In press.
4. Doroghazi RM. Negative secular trends in medicine: the American
Board of Internal Medicine, Maintenance of Certification, and overreaching bureaucracy. Am J Med. 2016;129(3):238-239.
5. Chang CWD, Erhardt BF. Rising residency applications: how high will
it go? Otolaryngol Head Neck Surg. 2015;142:1-4.
6. Popkin JH, Eissa KE, Mazor KM, Lemay CA. The ‘16-hour rule’: a
giant step, but in which direction? Am J Med. 2015;128(8):922-928.
7. Yancy C. Addressing the 2012 ACC/AHA Heart Failure Guidelines:
What’s New and Different. Presented at the Williamsburg (VA) Cardiology Conference, December 2-4, 2012.
8. Lucca DO, Nadauld T, Shen K. Credit supply and the rise in college
tuition: evidence from the expansion in federal student aid programs.
Available at: www.newyorkfed.org/research/staff_reports/sr733.html.
Accessed August 12, 2015.