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.