Career Choices in Medicine: Will Dermatology Still be King?

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It is that time of the year when fourth year medical students are gearing up to send in their applications for internships. I confess, for the first time in years, I sense that the choices are not clear.

It used to be you could look into the crystal ball and paint a picture for them of what their life would look like when they were done:  it used to be that if they chose primary care, they would probably over a lifetime make perhaps 3 to 5 million dollars less than a colleague in a procedural specialty, be harassed with a lot more forms, longer hours, and unless they retreated to a concierge practice where they set a high dollar bar for admission to their practice, they would be very busy. 

On the other hand, if they picked dermatology (and I love dermatology, and find it an intriguing discipline), they could count on a good lifestyle (very few dermatological emergencies), they would do lots of procedures, and make a healthy living. The same was true for ophthalmology,  radiology--all very competitive disciplines for students to enter. 

But what if:

  • You get paid only for managing disease, for caring for a stable of patients--in other words, what if there is no fee for service? (By the way, Massachusetts is bravely going this route.)  Doing more procedures then will cost you money, not mint money. Suddenly, many procedure based specialties don't look so hot.
  • What if Medicare or insurers stopped paying for MRIs, CAT scans and PET scans on an individual basis, but rather only reimbursed for disease management ? The owners of such facilities (who in many cases are doctors) have counted on business continuing as usual and may fold like Chrysler dealerships. Radiology as a career choice might be less attractive.
  • What if the physician who cared for the patient, who had formed a steady relationship with the patient over the years, who knew the family, and who was the one who admitted them to the hospital (and then acted as quarterback and kept a close eye on the consultants called in and ensured communication)--what if that individual got paid top dollar?  Yes, what if primary care became the plum? Look at who President Obama picked to be Surgeon General: a primary care physician par excellence. There is a message there.

My advice to my students is that there is too much afoot to read the crystal ball--too many swirling snow flakes. Just look what is happening this week:

  • the House releases its health care bill
  • Center for Medicare and Medical Services (CMS) releases a revised physician  pay schedule
  • The FDA is about to finally get to rule over tobacco companies

So my advice to my students is this: Follow your heart. Remember why you entered this field.  Do what you really love to be doing, and don't worry about lifestyle, reimbursement and the like. The secret of the care of the patient is caring for the patient (Peabody's famous quote) and so if you care, and that's what brought you to medicine, any choice you make will be the right choice. It is a wonderful time to be a physician.

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Abraham Verghese is an author, physician and med school professor. He is the author of Cutting for Stone and his writing has appeared in many major publications. More

Abraham Verghese is a physician and writer. His third book and first novel, Cutting for Stone, was published by Knopf in 2009. He is also known for two acclaimed non-fiction works, My Own Country, which was based on his experiences working with persons living with HIV in Johnson City, Tennessee; that book was a finalist for the National Book Critics Circle award and was made into a movie. He followed that with The Tennis Partner, also a New York Times notable book and a national bestseller. His writing has appeared in The Atlantic, The New Yorker, The New York Times , The New York Times Magazine, Sports Illustrated, and The Wall Street Journal as well as many medical journals. Verghese is board-certified in internal medicine, pulmonary medicine and infectious diseases. He attended the Iowa Writers Workshop at the University of Iowa where he earned his MFA. He currently practices and teaches at Stanford University School of Medicine where he is a tenured Professor and Senior Associate Chair for the Theory and Practice of Medicine in the Department of Internal Medicine.
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