Insufficient evidence

A friend brought this opinion piece in the New York Times to my attention yesterday.  Dr. Karen Sibert, a stridently proud full-time anesthesiologist, argues that women who choose to work as part-time physicians are short-changing their patients and the country.  I’ve been meaning to write something about the changing relationship between physicians and their careers for some time, and so this may as well serve as my first post on the subject.

Suffice it to say at the outset that the column makes all kinds of claims that it does not support, and that its author seems to me to be the kind of doctor who views her own experience as illustrative of how things ought to be for everyone.  These are cut from the same cloth as doctors who had the tar ground out of them during residency, and so think that every new doctor should have a similarly grueling experience because that’s just what doctors go through in their training.  This tendency to romanticize a negative runs strong in my profession.  There’s usually some kind of bluster about how it instills a sense of commitment, an immersive dedication to the practice of medicine, which I happen to think is so much hooey.

Begins Dr. Sibert:

I’M a doctor and a mother of four, and I’ve always practiced medicine full time. When I took my board exams in 1987, female doctors were still uncommon, and we were determined to work as hard as any of the men.

Today, however, increasing numbers of doctors — mostly women — decide to work part time or leave the profession. Since 2005 the part-time physician workforce has expanded by 62 percent, according to recent survey data from the American Medical Group Association, with nearly 4 in 10 female doctors between the ages of 35 and 44 reporting in 2010 that they worked part time.

This may seem like a personal decision, but it has serious consequences for patients and the public.

Medical education is supported by federal and state tax money both at the university level — student tuition doesn’t come close to covering the schools’ costs — and at the teaching hospitals where residents are trained. So if doctors aren’t making full use of their training, taxpayers are losing their investment. With a growing shortage of doctors in America, we can no longer afford to continue training doctors who don’t spend their careers in the full-time practice of medicine.

Dr. Sibert does not actually support these assertions with any numbers.  I don’t know many practice hours per provider per year are necessary for taxpayers to recoup their investment, and she doesn’t tell us.  Who knows if a part-time career gives back enough to make the investment in the doctor’s career worthwhile.  I suspect its hard to quantify, but am skeptical that part-time physicians are providing insufficient benefit to make their educations not worth the money.

It isn’t fashionable (and certainly isn’t politically correct) to criticize “work-life balance” or part-time employment options. How can anyone deny people the right to change their minds about a career path and choose to spend more time with their families? I have great respect for stay-at-home parents, and I think it’s fine if journalists or chefs or lawyers choose to work part time or quit their jobs altogether. But it’s different for doctors. Someone needs to take care of the patients.

The Association of American Medical Colleges estimates that, 15 years from now, with the ranks of insured patients expanding, we will face a shortage of up to 150,000 doctors. As many doctors near retirement and aging baby boomers need more and more medical care, the shortage gets worse each year.

I don’t dispute that there is a shortage of doctors.  I just don’t think this shortage is due to a plethora of part-time providers.  Rather, I think that few doctors want to work where the need is greatest.  Want to really make a difference in delivering care to those who really need it?  Convince doctors to move to South Dakota to practice.  I suspect patients in medically underserved areas would be thrilled to have whatever providers they can get, part-time or otherwise.  If practices are hiring physicians for part-time positions, one can safely assume that part-time positions will cover whatever needs those particular practices have.  Or is that not the way a market works anymore?

The decline in doctors’ pay is part of the problem. As we look at Medicare and Medicaid spending cuts, we need to be careful not to drive the best of the next generation away from medicine and into, say, investment banking.

This paragraph makes no sense in the context of the larger article.  Presumably female doctors who choose to make less in part-time positions are motivated by something other than money, so higher salaries may not provide much motivation to change their minds.  I can understand why Dr. Sibert doesn’t want to make less money (me neither!), but her newer colleagues may have different priorities.  Further, if recruitment is such an issue, why stymie that effort by demanding that new doctors adhere to an austere standard of what “real” doctors are expected to provide?

But the productivity of the doctors currently practicing is also an important factor. About 30 percent of doctors in the United States are female, and women received 48 percent of the medical degrees awarded in 2010. But their productivity doesn’t match that of men. In a 2006 survey by the American Medical Association and the Association of American Medical Colleges, even full-time female doctors reported working on average 4.5 fewer hours each week and seeing fewer patients than their male colleagues. The American Academy of Pediatrics estimates that 71 percent of female pediatricians take extended leave at some point — five times higher than the percentage for male pediatricians.

This gap is especially problematic because women are more likely to go into primary care fields — where the doctor shortage is most pronounced — than men are. Today 53 percent of family practice residents, 63 percent of pediatric residents and nearly 80 percent of obstetrics and gynecology residents are female. In the low-income areas that lack primary and prenatal care, there are more emergency room visits, more preventable hospitalizations and more patients who die of treatable conditions. Foreign doctors emigrate to the United States to help fill these positions, but this drains their native countries of desperately needed medical care.

Dr. Sibert seems to want to have her cake and eat it, too.  She wants women to enter the medical profession to provide primary care, but she only wants them to do it as full-time providers.  It makes sense that female doctors take more extended (read “maternity”) leave than their male counterparts.  If we want women to become doctors in significant numbers, then it’s apparent that we’ll have to accept this.  Pace Dr. Sibert, it’s obviously what those women want.

I’ll also wager that a couple of part-time doctors in a low-income area running a primary care clinic would make a big difference in that area’s ED visit rates.  Again, medically underserved areas need doctors, full stop.  It’s hard enough to recruit in those areas without making the jobs even less appealing to providers who might otherwise consider them.  And I’ll just be honest and tell you that foreign doctors who emigrate to the US often take the jobs that domestic medical graduates don’t want.  If they’re willing to practice here, it means that even the unappealing positions in the US are better than what they’d get back home.  They will probably still be more willing to take those jobs (for less money) than graduates of US schools even if there are more of the latter.

If medical training were available in infinite supply, it wouldn’t matter how many doctors worked part time or quit, because there would always be new graduates to fill their spots. But medical schools can only afford to accept a fraction of the students who apply.

An even tighter bottleneck exists at the level of residency training. Residents don’t pay tuition; they are paid to work at teaching hospitals. Their salaries are supported by Medicare, which pays teaching hospitals about $9 billion a year for resident salaries and teaching costs as well as patient care.

In 1997, Congress imposed a cap on how many medical residencies the government could subsidize as part of the Balanced Budget Act. Last year, the Senate failed to pass an amendment to the health care bill that would have created thousands of new residency positions. Even if American medical schools could double their graduating classes, there wouldn’t be additional residency positions for the new doctors. Federal and state financing to expand medical education will be hard to find in today’s economic and political climate.

All the more reason to make medicine as attractive a profession as possible.  Yes, there are limited slots available in American medical schools and residencies.  So we want those slots to go to the very best applicants.  Wouldn’t you want the best doctors at the end of the process?  I’d rather have a stellar part-time doctor on my staff than a full-time mediocrity.

Also, while it’s true that residents are paid for their time, they’re essentially indentured servants.  Residents put in 70+ hour work-weeks and get paid a fraction of what attending physicians make.  They provide the round-the-clock staffing that hospitals need to stay open.  The $9 billion Medicare shells out is worth it for that alone.  The program isn’t short-changed if afterward the residents choose somewhat less stifling lives for themselves.

We often hear the argument that nurse practitioners, nurse anesthetists and physician assistants can stand in for doctors and provide cheaper care. But when critical decisions must be made, patients want a fully qualified doctor to lead the health care team.

Yeah, well, you can’t always get what you want.  Dr. Sibert goes on about how desperately we need providers for primary care, but then poo-poos the professionals who might provide a cost-effective solution.  And I’ll say this again — nurse practitioners (and PAs and nurse anesthetists [who, I suspect, really stick in Dr. Sibert’s craw]) can provide many of the same services that doctors do with the same level of competence and compassion.  Dr. Sibert implies that NPs are supplanting doctors in critical decision-making roles, and I disagree.  MDs are still at the head of the medical hierarchy, and when an MD’s expertise is necessary that’s who usually calls the shots.  But (sing along with me!) for patients who lack care because of poverty or geography, an NP is a hell of a lot better than nobody.  Perhaps needy patients would be willing to defer care because they don’t want to see a PA (though I doubt it), and they’re free to do so.  I suspect most of them would get over this foolish prejudice were a PA-staffed clinic to open in their neighborhood.

Policy makers could encourage more doctors to stay in the profession by reforming the malpractice system to protect them from frivolous lawsuits, safeguarding their pay from further Medicare cuts and lightening the burden of bureaucratic regulations and paperwork. And in a perfect world, hospitals and clinics could keep more female doctors working full time by setting up child care centers — with long operating hours — on site.

Here we go with malpractice reform.  The reason I kind of side-stepped Burt’s question about malpractice reform is that I don’t really know how “frivolous” lawsuits can be prevented.  Yes, it sucks to enter a profession where one in three get sued (to quote the numbers for pediatricians).  But patently frivolous lawsuits lose, and the bar for winning a med mal case is actually pretty high.  I don’t know how one can weed out “frivolous” suits without thus prejudicing the subsequent cases by implying that they are sufficiently meritorious to proceed.  (Dr. Sibert doesn’t say.)

With regard to bureaucratic regulations and paperwork, I am mostly in agreement with Dr. Sibert.  These aspects of contemporary medical practice are onerous and tedious and often seem arbitrary and poorly-conceived.  (One of these days I’ll write a post about what a pain in the ass re-certification with the American Board of Pediatrics has become, accepting in advance that none of you give a damn.)  But part-time providers face them just the same as full-time providers, so Dr. Sibert’s preference for change doesn’t really speak to her point.  I doubt that the paperwork is the big reason a doctor would leave the profession outright.  (Anyone who”s gone through the residency match process or applied for a medical license [as most of us are expected to do in residency] is well-acquainted with tedious paperwork and arbitrary regulations at the entry level.)  And yes, it would be nice if there were more affordable child care for everyone, but maybe female doctors can already afford good child care and simply prefer to raise their kids themselves to a great degree?

In the meantime, we can only depend on doctors’ own commitment to the profession.

Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It’s fair to ask them — women especially — to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency. They must understand that medical education is a privilege, not an entitlement, and it confers a real moral obligation to serve.

I recently spoke with a college student who asked me if anesthesiology is a good field for women. She didn’t want to hear that my days are unpredictable because serious operations can take a long time and emergency surgery often needs to be done at night. What she really wanted to know was if my working life was consistent with her rosy vision of limited work hours and raising children. I doubt that she welcomed my parting advice: If you want to be a doctor, be a doctor.

I’m going to try to keep my disdain for this attitude out of my response.  Suffice it to say I find Dr. Sibert’s statements unappealingly self-congratulatory.  Her implication that doctors who work part-time or take time off to raise kids aren’t “real” doctors rankles.  I work full-time, so perhaps I pass her muster, but I have also structured my work week to allow me plenty of daytime with my husband and son, and to have time during the week to pursue those things that make my life more enjoyable.  This makes me a much happier doctor than I would otherwise be.  I happen to think happier doctors are better doctors.  There is ample time in my schedule and the schedules of my part-time colleagues for every patient who wants to be seen to be seen.  Our patients in the hospitals are managed by us, with no gaps.  We have three excellent NPs who provide primary care, with nobody worse off because of it.  How is this arrangement an indication of a lacking commitment?

I also question Dr. Sibert’s authority to set the moral standards.  We can pick apart each other’s professional choices until the cows come home.  I don’t know where she practices, but if she really wants to prove her moral worth I invite her to go practice on a native American reservation or hang out a shingle in the Aroostook County.  Whose service sets the bar?  Who benefits if talented young women are told that the medical profession is only really theirs to consider if they are willing to make their desire to be mothers secondary?  If a young woman becomes a part-time doctor in Harlem providing primary care to poor patients, is she less of a “real doctor” than a full-time physician who joins the staff at Lenox Hill Hospital?  If a doctor works part-time doing overnight shifts to Dr. Sibert can get some sleep and maybe be less error-prone the next day, is she not providing a valuable service that deserves acknowledgment as such?

Fine, so I didn’t try all that hard to keep my disdain out of my response.

You can’t have it all. I never took cupcakes to my children’s homerooms or drove carpool, but I read a lot of bedtime stories and made it to soccer games and school plays. I’ve ridden roller coasters with my son, danced at my oldest daughter’s wedding and rocked my first grandson to sleep. Along the way, I’ve worked full days and many nights, and brought a lot of very sick patients through long, difficult operations.

Patients need doctors to take care of them. Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient; it deserves to be a life’s work.

And, it seems, it can only be a life’s work if it consumes a sufficient amount of said life.  Women who become doctors who take time off are doing so out of convenience, rather than as a reflection of values that differ from Dr. Sibert’s.  Talented women who want to take an active part in raising their children must be told to find another profession.  Part-time doctors are little more than hobbyists.

I’ll write another post on this topic soon, but for now let me conclude by saying that we need good doctors.  Doctors are well-respected and well-compensated, but it is nevertheless a difficult and demanding job.  We need to make the field more appealing, not less.  We need to find ways of attracting more providers to primary care, not fewer.  We need to accept that medical providers need not always be physicians.  And we need to accept that doctors who subsume their lives within their careers are increasingly rare, and that this model is outmoded at best and reactionary at worst.  Treating physicians who value their family or private time and who wish to consider this time when making professional decisions as somehow failing a professional (or, heaven help us, moral) test is unlikely to correct any shortfall of providers in the years to come, so a more helpful attitude would behoove those who purport to value patient care above all else.

[Cross-posted at Blinded Trials.]