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Shoes
American Journal
of Obstetrics
and Gynecology F o u n d e d in 1920
volume 172
number 6
JUNE 1995
T R A N S A C T I O N S OF T H E S I X T Y - S E C O N D A N N U A L M E E T I N G OF T H E C E N T R A L A S S O C I A T I O N OF OBSTETRICIANS AND GYNECOLOGISTS Shoes Presidential address Bruce H. Drukker, MD East Lansing, Michigan First, permit me some allegory. Slowly they walked, Just two of them. The hill was steep and the upper path had been misty with rough, gnarled roots and sharp stones protruding into the path. The lower part had been flat and pleasant. The smooth, level areas had a pleasant feel about them, and there was sun and warmth. As they looked back over their shoulders down into the mist, no one was following them along the steep part of the path. Slowly they crested the hill. Ahead, the meadow unfolded, filled with flowers shimmering brightly and moving gently in the breeze. The remaining short, winding path ahead would be easy. Then they would be able to sit and relax. The older one stopped to catch a breath. He looked down at his shoes, scratched and scuffed from walking among the sharp rock outcroppings. The soles and heels had become worn, yet there was enough of both to finish the path. He looked at his friend and asked, "Who will fill our shoes? Who will walk the path? Why should they even think about it? Why expend the effort to do this?" Have you looked at your shoes lately? They might be new or perhaps worn, scratched, scuffed, and even resoled. Who Will fill them in the years to come? To not answer this question is thoughtless. We have an obligation and an opportunity to consider those who will follow. What are we doing or what can we do to From the Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University. Presented at the Sixty-secondAnnual Meeting of The CentralAssociation of Obstetricians and Gynecologists, Memphis, Tennessee, October 13-15, 1994. Reprint requests: Bruce H. Drukker, MD, Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University, B-316, Clinical Center, East Lansing, MI 48824. Copyright © 1995 by Mosby-Year Book, Inc. 0002-9378/94 $3.00 + 0 6/6/63659
encourage new people in new shoes with new goals and ideas to walk the path of medicine, in particular, obstetrics and gynecology? Plato said, "The direction in which education starts a man will determine his life." Most physicians are comfortable sharing their expertise with residents in obstetrics and gynecology. This can be either informally in the clinical setting or formally in didactic classes or seminars, but we most look farther back down the academic road for those who will make the career choice to follow in our shoes in obstetrics and gynecology. The decision to enter medicine is affected by multiple factors, including personal, demographic, and environmental conditions.' I would like to consider each area: three points of view. Individual interests and attitudes are basic and formative, whereas demographic factors include attributes such as age, sex, community of origin, marital status, and social opportunities. We can have some influence on demographics, particularly as it relates to opportunities afforded to selected underrepresented minority students, for example, at Michigan State University the advanced baccalaureate experience program. Environmental factors are also rapidly changing, including physician supply and demand, burgeoning cutrate managed care, cost of education, medical school accessibility, and, importantly, medical school curriculum. Is the educational curriculum motivational, enabling, and molded toward lifelong learning? Who are the role models? Those in traditional academic settings are mandated to transfer the curricular content, make it relevant and motivational. Our day-to-day lives must demonstrate caring, consistency, and concern. Clinical teaching faculty in medical schools, our partners in the educational process, are an extremely important influ1661
1662
Drukker
ence on career choice; thus the influence of these physicians in obstetrics and gynecology is paramount. You are a critical part of the team. Day-to-day positive attitudes are crucial. These include positive reinforcement, fostering inquiry, personal evidence of true compassion, empathy in patient interactions, and living a life with an attitude of helpfulness. Just as positive attitudes are paramount, negative attitudes expressed by any faculty m e m b e r can be destructive. Consider the bickering physician, the uncaring physician, the economically centered physician, the u n h a p p y physician, and the carping physician. These attitudes will create immense feelings of dissatisfaction, negativity, and disillusion toward our specialty in young medical students. This type of physician is easily identified as an annoyance, a p o o r example of a true caregiver, and certainly not an appropriate role model for those who will follow. When considering an example, let me recall for you the words of Abraham Lincoln, "Character is like a tree and reputation like its shadow. The shadow is what we think of it, the tree is the real thing." Let's look carefully! How and when does the choice of medicine begin? Career choice in medicine is a twostage p r o c e s s - t h e first is tentative, occurring during years of high school. 2 This venue provides an environment for a student to begin to translate his or her own concepts of self into a career. Most often this stage is related to personal observations. T h e students compare themselves to one or more physicians they have known. Later, usually in the early years of college, a second transitional stage occurs. Here occupational preferences become molded through course choices. With some degree of frequency, however, the transitional phase may be delayed. At Michigan State University's College of H u m a n Medicine, for example, 40% of the 1994 matriculants have not followed the traditional path. Often a hiatus occurs beween college and medical school, with an alternative work opportunity before matriculation begins the study of medicine. These intervals can be from 1 to 5 to 6 years and occasionally even longer. In these interval situations underlying desires and yearnings toward medicine surface. Motivational factors can include j o b dissatisfaction or lack of fulfillment with an initial career choice, a changing economic status, availability of new financial aid, or possibly a personal life change. A converse action can also occur. During the transitional period science curriculum can a p p e a r to be too difficult, or critical nonacademic factors occurring in an individual's life can play a part in the change. A student may be influenced by a physician's unfavorable image, or there can be a change to natural sciences if physicians in general are seen as inferior scientists? Others may change to social sciences or even law if they perceive physicians as just businessmen and not humanitarians. Many evaluations have been completed attempting to evaluate the type of
June 1995 Am J Obstet Gynecol
person entering selected fields of medicine. Is the individual an extrovert or an introvert? Is the person j u d g m e n t a l (that is, structured and systematic) or perceptive (that is, flexible and reactive)? 4 Generally, those eventually choosing obstetrics and gynecology a p p e a r to be a hybrid with strong traits of assertiveness and adventureousness. We tend to have outgoing personalities and be action oriented. Yet we also demonstrate flexibility and empathy. Whatever affects personal choice, it must also include the individual's personal qualities, such as need, values, attitudes, and interests. Moral, religious, philosophic, and ethical feelings form a crucial component in the decision. How do demographics affect those who will fill our shoes? Certainly age must be considered. The mean age of students matriculating who are > 32 years old increased from 489 in 1982 to 1983 to 795 in 1992 to 1993. The overall age of matriculants from 1982 to 1983 was 24.4 years c o m p a r e d with 24.7 years in 1992 to 1993. 5 The sex of matriculants is also changing. In 1982 to 1983, 31.4% of matriculants were women, c o m p a r e d with 41.6% in 1992 to 1993. 5 This change is also mirrored in the number of women entering residencies in obstetrics and gynecology. For example, in 1975 16.2% of entering residents were women, c o m p a r e d with 58.9% in 1993. 6 In the past women tended to enter pediatrics, internal medicine, family medicine, and psychiatry. These choices were based on the observations that women tended to be more nurturant, dependent, feeling-oriented, empathetic, and social and perhaps less aggressive, less autonomous, and less action-oriented than their male counterparts. You may disagree, and, yes, there are changes. As long ago as 1977 McGrath and Zimet v found female medical students more aggressive and autonomous and less nurturant and affiliative. Today these changes are evident and even more distinct. Women are motivated toward obstetrics and gynecology because it provides identity satisfaction, a true sense of serving, and a clear opportunity for professional bonding. Will males be a minority in the next century in our specialty? It is potentially if not highly probable. Diversity in medical schools is also changing. There is a marked increase in Asian matriculants, a moderate increase in black matriculants, and a decrease in white applicants. Other minority and underrepresented minorities are also increasing, including Native Americans and Hispanics. In all racial ethnic groups, other than u n d e r r e p r e s e n t e d minorities, men predominate. However, among blacks 61% of matriculants are women. In other underrepresented minorities there are 45% women, whereas among Asians and whites 40% of medical school applicants are women. ~ These demographic observations are also affected by
Volume 172, Number 6 Am J Obstet Gynecol
reversal of declining numbers of medical school applicants from a peak of 42,000 in 1974 to a trough of approximately 27,000 in 1988. Since 1988 there has been a dramatic increase in applicants, to almost 38,000 in 1992 and 42,800 in 1993. 5 Along with this increase in the medical school applicant pool, there have been changes in overall and science grade point averages. Over the past 10 years those <3.0 have increased, whereas those > 3.5 have decreased. 5 However, because of the large applicant pool, schools still have the opportunity, should they elect to do so, to select a substantial number of applicants with grade point averages > 3.5. Multiple environmental factors influence the choice of medicine as a career. With respect to medical school, the type of curriculum is crucial, particularly as implemented in the third year. Yet the first 2 years of medical school form an important base for critical analysis and eventual empathetic behavior. The learning experience must be positive. Delivery of curriculum by faculty in a professional, friendly environment with a sense of advocacy is crucial. Clincial teaching faculty appear to be a paramount influence on career selection. The sequence of curriculum delivery may be important. Students who have made a tentative career choice even before entering the third year of medicine are infrequently led to change on the basis of the clerkship sequence, whereas undecided students are more likely to pick a specialty during the first half of the third year clerkship experience. Other important factors influence choice of specialty. These include society at large, the economic environment, and the perceived effect of other factors, such as medical liability and personal resources. There is no question that economic and educational factors are critical in guiding students to practice career choices where shortages are perceived as being present and the potential for successful practice more favorable. However, the altruism of being a physician continues as an overarching influence. I would like to further analyze this thesis regarding choice, particularly in a select a r e a - t h e environmental factors. How does today's practice and economic environment affect a student's interest in obstetrics and gynecology? Often these two influences are subtle and understated during the career selection process. During pesonal counseling Sessions with students who are considering obstetrics and gynecology economic potential is infrequently discussed. Perhaps students feel the topic is too crass and would leave a poor impression with the counselor. From the students' perspective any economic advantage at that point in their lives would seem luxurious. Economic incentives become more apparent and of greater concern for the young physician during residency. Here they can be powerful persuasive instruments. The ring of dollars may override long term
Orukker 1663
goals, personal satisfaction, and a reasonable practice. Mistakes are made. Consider the number of young physicians entering obstetrics and gynecology who change their professional arrangements within 2 years of completing residency. I doubt it is an inconsequential number, yet I am not aware of statistics and facts. Thus the observation may be purely speculative. Residents also become aware that the practice style has changed. Groups are "in," defined hours, both office and call, are "in." An individual's life can have some organization. There can be time for personal and family life, if they are carefully fostered and guarded. These are positive enhancing attributes for our specialty. This can be supported by the fact that only a small percentage of physicians still practice in a traditional solo arrangement without some type of coverage arrangement. Yet in rural areas it is this inability to obtain coverage and the lack of intellectual cross-fertilization that leads to an environment that makes recruiting difficult. Usually recruiting to rural areas is achieved by offering high dollars with short-term guarantees, often exceeding $200,000 annually. Although the money seems good, burnout is also high: Does frequent change in rural areas really produce a long-term benefit? Not really. The solution to this problem is still nebulous. There are other factors that critically affect the environment. Consider economic naivet6 or "the head-inthe-sand ostrich syndrome." This refers to failure to recognize the changes in medicine and the influence of managed care on obstetrics and gynecology. If it is not already a component of your life, I can assure you it will shortly become a key factor in your business and patient care activities. Students considering obstetrics and gynecology are perceptive. They will learn of these changes. Will our current state of having ample wellqualified residents change to a dearth of applicants in 5 to 10 years? I am beginning to wonder: can you really make a silk purse out of a sow's ear or perhaps lemonade from bad lemons? As we listen, we hear some physician leaders state that there is an opportunity for all in managed care. Yet what a difference from the poignant presidential address of a departed colleague. Dr. Thomas McElin ~ in 1972 in his presidential address strongly supported the excellence of classic medicine and argued logically against some of the criticisms made against the specialty at that time. Yet he indicated willingness to change if change was necessary. His presentation was a brave apology for quality personalized medicine, yet it was predictive; change did occur, but did we believe that things would go as far as they have? Look at your own life. I venture it is fair to speculate that, for the majority, today you are working harder for less. Your earning power is dropping. Your expenses are increasing. Your autonomy, even reasonable au-
1664 Drukker
tonomy, is decreasing. If you are in managed care or attempting to carry your share of care of the underserved, the integrity of your business is threatened. Your charges are heavily discounted, and you may be coerced into other discounted arrangements. Our colleagues in Kentucky are currently in the thick of such a situation. In some rural areas, where Medicare and Medicaid patients make up 75% of a practice, Dr. Robert Goodin, the Kentucky Medical Association's president elect, said, "Physicians couldn't keep their offices open on the kind of reimbursment rate cuts being proposed and then you talk about expanding that to cover maybe 90% of their practices." Yes, there may be counterarguments, but the principle is clear: if you cannot pay your costs, you are out of practice and out of business. Recall clearly, however, that everyone of us has an expected, justifiable entitlement. We are entitled to a fair economic return on an expensive, 8 year-long educational investment. If loss of that entitlement isn't enough and causing you some degree of distress, recall that with increasing frequency your practice will be guided by practice guidelines. Your medical liability is probably still a problem. You are probably spending more time on less effective committees. You can be disenrolled or deselected from a managed care contract for no cause. Check the wording in a recent contract you may have signed. Your future is clouded. Do you really know where you will be in 5 years? Who will fill your shoes? Can we identify the driving forces that control obstetrics and gynecology? Who listens to us, or perhaps we should ask, do we speak with a clear, articulate voice? I submit to you not really, not consistently, not always authoritatively, not with strong passion, not with clear vision, certainly not with a uniform, single voice. I call to your attention the words of Abraham Lincoln who reminds us that "The dogmas of the quiet past are inadequate for the stormy present." Currently we as a nation, and our Congress in particular, are consumed with health care reform. The goals are meritorious, providing all Americans affordable basic health care and reining in the burgeoning costs of health care. Can it be done and what are the sacrifices? Importantly, I ask you where is individual and personal responsibility in this complex cost-benefit equation? I submit to you that every man and woman in this country can do something of importance to reduce their use of the resources in the health care system. But do they or will they? To date, evidence for an affirmative answer is scant. Life-style carelessness still runs amok on many areas of the l a n d - drugs, alcohol, guns, smoking, overeating, and plain laziness. Do we have the fortitude to take hold and evoke change? It requires personal commitment, conscience, and involvement. What is happening right now? The debates in Con-
June 1995 Am J Obstet Gynecol
gress continue, albeit somewhat abated, but in this nation health maintenance organizations and preferred provider organizations are moving over the landscape conquering locale after locade. Health maintenance organization enrollment is burgeoning, with a 10% increase in enrollment in traditional health maintenance organizations alone from approximaely 39 million in 1993 to 43 million in 1994. As these health care alternatives grow, in their wake there is change. Medical markets are restructuring, and classic cost shifting used in the past to provide service for the underserved is being eliminated. Price, competition, market share, and survival are all part of the lexicon of medical managers. There is no more fat in the system, but without a small margin of latitude the educational efforts of hospitals and medical schools will begin to wither. When the driving force for cost reduction is barreling toward more and more capitation and discounting and carveouts and price is the only basis for choosing physicians, hospitals, and others providing care, the educational system will falter. There are suggestions that this is already beginning to happen. What does this medical education system look like in 19947 There are 141 medical schools, including 15 osteopathic medical schools. A total of 72,347 students enrolled in classes for the years 1994 through 1997, including 6888 in osteopathic medical schools. There are 998 teaching hospitals training medical graduates for at least 3 years among 5100 short-term, nonfederated hospitals in the United States. There were 101,420 residents in graduate medical education programs in the United States in 1992 and 447 registered nurse baccalaureate programs in 1993 to 1994 and 58 physician assistant accredited programs in 1994. Do you really think the system can continue at that pace and magnitude? If you take a hard, conscientious look at a medical schools funding sources, you can begin to see the problems for those following in our shoes. Approximately one third of the revenue supporting medical schools' academic missions comes from revenues generated by faculty providing clinical service. In 1993 this was almost 8.3 billion. 9 The success of the managed care machines and their insatiable appetite for clients, client control, and profit forces medical schools into the bargaining arena, scrambling and competing with others for managed care contracts. Without contracts there won't be patients, causing therefore a reduction in revenues. Medical schools need dollars for survival. They cannot be successful if they rely only on tuition or state budgets. Because medical schools now enter the bargaining pit for contracts and clients, they also enter the shady world of competitive pricing and discount medicine. Unfortunately, the faculty practices cannot afford not to bargain about the cost of physician ser
Volume 172, Number 6 Am J Obstet Gynecol
vices. In doing this, we alienate ourselves from our erstwhile staunchest a l l i e s - c l i n i c a l faculty, community physicians, and alumni. Is it a slide down a slippery slope? Your opinion about outcome as an observer is as astute and perhaps even more pragmatic than mine. Are their solutions found in the following quotation from Jules Henri Poincar6: "To doubt everything or believe everything are two equally convenient solutions; both dispense with necessity of reflection. ''1° We cannot afford the mistake of not looking back on history, but we must look ahead and have the will, the fortitude, the wisdom, and the resolve to speak through organized medicine. Although we may not always agree with every statement, we cannot make ourselves heard when there is dissonance. T h e choir must be massive and the anthems clear and loud. We are fortunate to have strong organizations in our specialty. Certainly T h e American College of Obstetricians and Gynecologists speaks for us in a meaningful way. But we most also speak clearly through the American Medical Association and the Association of American Medical Colleges. It is imperative that, with one voice, we place at the feet of our elected leaders our concerns for the challenges of the future for reasonable health care and also our concerns for who will follow in our paths. Without new leaders with clear visions and new shoes on the path, American medicine will become mediocre. The days of leadership, innovation, and accomplishment will be gone like a beautiful afternoon sun d r o p p i n g behind a clouded horizon. Yes, it will rise again but into a clouded day with only furtive fits and starts of sunlight. But that is not enough, and to think it so is fallacious. We must make the effort to make a difference by repetitiously challenging flawed ideas and d e m a n d i n g impeccable conscience and loyalty from our elected governmental representatives at all levels. Away with pork barrel legislation, expose dishonesty, d e m a n d
Drukker
1665
truthful excellence, reject mediocrity, praise integrity. The members of this organization must speak out, individually and collectively. T h e ballot box does matter. Are we doing it? Are we carrying out this important mandate? Is our voice heard? Pray that those who will follow in our shoes will wear them well, enjoy the challenge of the journey, and contribute to the wellbeing of a l l - l e a d i n g as beacons and watchmen for the generation to follow them. Look at your shoes! Yes, look at them! Mundane, basic, but so necessary and so very important. Who will fill them? I charge you and I challenge you t o - w a l k on and be leaders! REFERENCES
1. Rezler AG. Career choice. In: Rezler AG, ed. The interpersonal dimension in medical education. New York: Sprigner, 1985:46-100. 2. Super DE. Training for a profession: socialization through role casting. In: Proceedings of the Association of American Medical Colleges Colloquium on the Career Development of Physicians. Washington: Association of American Medical Colleges, 1974. 3. Funkenstein DH. A study of college seniors who abandon their plans for a medical career. J Med Educ 1961 ;36:92433. 4. Otis GD, Weiss JR. Patterns of medical career preference. J Med Educ 1973;48:1116-22. 5. Trends plus-U.S, medical school applicants, matriculants, graduates 1992. Washington: Association of American Medical Colleges, 1993. 6. American College of Obstetricians and Gynecologists. Manpower planning in obstetrics and gynecology. Washington: American College of Obstetricians and Gynecologists, 1994. 7. McGrath E, Zimet CN. Female and male medical students: differences in specialty choice selection and personality. J Med Educ 1977;52:293-300. 8. McElin TW. The lament of the white rabbit. AMJ OBSTET GYNECOL1972; 112:1-8. 9. Keyes JAJr. Preserving and advancing the academic mission in health care reform. Acad Med 1994;69:642-3. 10. Beck EM, ed. In: Bartlett J. Familiar quotations. 15th ed. Boston: Little Brown, 1980:673.
of Obstetrics
and Gynecology F o u n d e d in 1920
volume 172
number 6
JUNE 1995
T R A N S A C T I O N S OF T H E S I X T Y - S E C O N D A N N U A L M E E T I N G OF T H E C E N T R A L A S S O C I A T I O N OF OBSTETRICIANS AND GYNECOLOGISTS Shoes Presidential address Bruce H. Drukker, MD East Lansing, Michigan First, permit me some allegory. Slowly they walked, Just two of them. The hill was steep and the upper path had been misty with rough, gnarled roots and sharp stones protruding into the path. The lower part had been flat and pleasant. The smooth, level areas had a pleasant feel about them, and there was sun and warmth. As they looked back over their shoulders down into the mist, no one was following them along the steep part of the path. Slowly they crested the hill. Ahead, the meadow unfolded, filled with flowers shimmering brightly and moving gently in the breeze. The remaining short, winding path ahead would be easy. Then they would be able to sit and relax. The older one stopped to catch a breath. He looked down at his shoes, scratched and scuffed from walking among the sharp rock outcroppings. The soles and heels had become worn, yet there was enough of both to finish the path. He looked at his friend and asked, "Who will fill our shoes? Who will walk the path? Why should they even think about it? Why expend the effort to do this?" Have you looked at your shoes lately? They might be new or perhaps worn, scratched, scuffed, and even resoled. Who Will fill them in the years to come? To not answer this question is thoughtless. We have an obligation and an opportunity to consider those who will follow. What are we doing or what can we do to From the Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University. Presented at the Sixty-secondAnnual Meeting of The CentralAssociation of Obstetricians and Gynecologists, Memphis, Tennessee, October 13-15, 1994. Reprint requests: Bruce H. Drukker, MD, Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University, B-316, Clinical Center, East Lansing, MI 48824. Copyright © 1995 by Mosby-Year Book, Inc. 0002-9378/94 $3.00 + 0 6/6/63659
encourage new people in new shoes with new goals and ideas to walk the path of medicine, in particular, obstetrics and gynecology? Plato said, "The direction in which education starts a man will determine his life." Most physicians are comfortable sharing their expertise with residents in obstetrics and gynecology. This can be either informally in the clinical setting or formally in didactic classes or seminars, but we most look farther back down the academic road for those who will make the career choice to follow in our shoes in obstetrics and gynecology. The decision to enter medicine is affected by multiple factors, including personal, demographic, and environmental conditions.' I would like to consider each area: three points of view. Individual interests and attitudes are basic and formative, whereas demographic factors include attributes such as age, sex, community of origin, marital status, and social opportunities. We can have some influence on demographics, particularly as it relates to opportunities afforded to selected underrepresented minority students, for example, at Michigan State University the advanced baccalaureate experience program. Environmental factors are also rapidly changing, including physician supply and demand, burgeoning cutrate managed care, cost of education, medical school accessibility, and, importantly, medical school curriculum. Is the educational curriculum motivational, enabling, and molded toward lifelong learning? Who are the role models? Those in traditional academic settings are mandated to transfer the curricular content, make it relevant and motivational. Our day-to-day lives must demonstrate caring, consistency, and concern. Clinical teaching faculty in medical schools, our partners in the educational process, are an extremely important influ1661
1662
Drukker
ence on career choice; thus the influence of these physicians in obstetrics and gynecology is paramount. You are a critical part of the team. Day-to-day positive attitudes are crucial. These include positive reinforcement, fostering inquiry, personal evidence of true compassion, empathy in patient interactions, and living a life with an attitude of helpfulness. Just as positive attitudes are paramount, negative attitudes expressed by any faculty m e m b e r can be destructive. Consider the bickering physician, the uncaring physician, the economically centered physician, the u n h a p p y physician, and the carping physician. These attitudes will create immense feelings of dissatisfaction, negativity, and disillusion toward our specialty in young medical students. This type of physician is easily identified as an annoyance, a p o o r example of a true caregiver, and certainly not an appropriate role model for those who will follow. When considering an example, let me recall for you the words of Abraham Lincoln, "Character is like a tree and reputation like its shadow. The shadow is what we think of it, the tree is the real thing." Let's look carefully! How and when does the choice of medicine begin? Career choice in medicine is a twostage p r o c e s s - t h e first is tentative, occurring during years of high school. 2 This venue provides an environment for a student to begin to translate his or her own concepts of self into a career. Most often this stage is related to personal observations. T h e students compare themselves to one or more physicians they have known. Later, usually in the early years of college, a second transitional stage occurs. Here occupational preferences become molded through course choices. With some degree of frequency, however, the transitional phase may be delayed. At Michigan State University's College of H u m a n Medicine, for example, 40% of the 1994 matriculants have not followed the traditional path. Often a hiatus occurs beween college and medical school, with an alternative work opportunity before matriculation begins the study of medicine. These intervals can be from 1 to 5 to 6 years and occasionally even longer. In these interval situations underlying desires and yearnings toward medicine surface. Motivational factors can include j o b dissatisfaction or lack of fulfillment with an initial career choice, a changing economic status, availability of new financial aid, or possibly a personal life change. A converse action can also occur. During the transitional period science curriculum can a p p e a r to be too difficult, or critical nonacademic factors occurring in an individual's life can play a part in the change. A student may be influenced by a physician's unfavorable image, or there can be a change to natural sciences if physicians in general are seen as inferior scientists? Others may change to social sciences or even law if they perceive physicians as just businessmen and not humanitarians. Many evaluations have been completed attempting to evaluate the type of
June 1995 Am J Obstet Gynecol
person entering selected fields of medicine. Is the individual an extrovert or an introvert? Is the person j u d g m e n t a l (that is, structured and systematic) or perceptive (that is, flexible and reactive)? 4 Generally, those eventually choosing obstetrics and gynecology a p p e a r to be a hybrid with strong traits of assertiveness and adventureousness. We tend to have outgoing personalities and be action oriented. Yet we also demonstrate flexibility and empathy. Whatever affects personal choice, it must also include the individual's personal qualities, such as need, values, attitudes, and interests. Moral, religious, philosophic, and ethical feelings form a crucial component in the decision. How do demographics affect those who will fill our shoes? Certainly age must be considered. The mean age of students matriculating who are > 32 years old increased from 489 in 1982 to 1983 to 795 in 1992 to 1993. The overall age of matriculants from 1982 to 1983 was 24.4 years c o m p a r e d with 24.7 years in 1992 to 1993. 5 The sex of matriculants is also changing. In 1982 to 1983, 31.4% of matriculants were women, c o m p a r e d with 41.6% in 1992 to 1993. 5 This change is also mirrored in the number of women entering residencies in obstetrics and gynecology. For example, in 1975 16.2% of entering residents were women, c o m p a r e d with 58.9% in 1993. 6 In the past women tended to enter pediatrics, internal medicine, family medicine, and psychiatry. These choices were based on the observations that women tended to be more nurturant, dependent, feeling-oriented, empathetic, and social and perhaps less aggressive, less autonomous, and less action-oriented than their male counterparts. You may disagree, and, yes, there are changes. As long ago as 1977 McGrath and Zimet v found female medical students more aggressive and autonomous and less nurturant and affiliative. Today these changes are evident and even more distinct. Women are motivated toward obstetrics and gynecology because it provides identity satisfaction, a true sense of serving, and a clear opportunity for professional bonding. Will males be a minority in the next century in our specialty? It is potentially if not highly probable. Diversity in medical schools is also changing. There is a marked increase in Asian matriculants, a moderate increase in black matriculants, and a decrease in white applicants. Other minority and underrepresented minorities are also increasing, including Native Americans and Hispanics. In all racial ethnic groups, other than u n d e r r e p r e s e n t e d minorities, men predominate. However, among blacks 61% of matriculants are women. In other underrepresented minorities there are 45% women, whereas among Asians and whites 40% of medical school applicants are women. ~ These demographic observations are also affected by
Volume 172, Number 6 Am J Obstet Gynecol
reversal of declining numbers of medical school applicants from a peak of 42,000 in 1974 to a trough of approximately 27,000 in 1988. Since 1988 there has been a dramatic increase in applicants, to almost 38,000 in 1992 and 42,800 in 1993. 5 Along with this increase in the medical school applicant pool, there have been changes in overall and science grade point averages. Over the past 10 years those <3.0 have increased, whereas those > 3.5 have decreased. 5 However, because of the large applicant pool, schools still have the opportunity, should they elect to do so, to select a substantial number of applicants with grade point averages > 3.5. Multiple environmental factors influence the choice of medicine as a career. With respect to medical school, the type of curriculum is crucial, particularly as implemented in the third year. Yet the first 2 years of medical school form an important base for critical analysis and eventual empathetic behavior. The learning experience must be positive. Delivery of curriculum by faculty in a professional, friendly environment with a sense of advocacy is crucial. Clincial teaching faculty appear to be a paramount influence on career selection. The sequence of curriculum delivery may be important. Students who have made a tentative career choice even before entering the third year of medicine are infrequently led to change on the basis of the clerkship sequence, whereas undecided students are more likely to pick a specialty during the first half of the third year clerkship experience. Other important factors influence choice of specialty. These include society at large, the economic environment, and the perceived effect of other factors, such as medical liability and personal resources. There is no question that economic and educational factors are critical in guiding students to practice career choices where shortages are perceived as being present and the potential for successful practice more favorable. However, the altruism of being a physician continues as an overarching influence. I would like to further analyze this thesis regarding choice, particularly in a select a r e a - t h e environmental factors. How does today's practice and economic environment affect a student's interest in obstetrics and gynecology? Often these two influences are subtle and understated during the career selection process. During pesonal counseling Sessions with students who are considering obstetrics and gynecology economic potential is infrequently discussed. Perhaps students feel the topic is too crass and would leave a poor impression with the counselor. From the students' perspective any economic advantage at that point in their lives would seem luxurious. Economic incentives become more apparent and of greater concern for the young physician during residency. Here they can be powerful persuasive instruments. The ring of dollars may override long term
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goals, personal satisfaction, and a reasonable practice. Mistakes are made. Consider the number of young physicians entering obstetrics and gynecology who change their professional arrangements within 2 years of completing residency. I doubt it is an inconsequential number, yet I am not aware of statistics and facts. Thus the observation may be purely speculative. Residents also become aware that the practice style has changed. Groups are "in," defined hours, both office and call, are "in." An individual's life can have some organization. There can be time for personal and family life, if they are carefully fostered and guarded. These are positive enhancing attributes for our specialty. This can be supported by the fact that only a small percentage of physicians still practice in a traditional solo arrangement without some type of coverage arrangement. Yet in rural areas it is this inability to obtain coverage and the lack of intellectual cross-fertilization that leads to an environment that makes recruiting difficult. Usually recruiting to rural areas is achieved by offering high dollars with short-term guarantees, often exceeding $200,000 annually. Although the money seems good, burnout is also high: Does frequent change in rural areas really produce a long-term benefit? Not really. The solution to this problem is still nebulous. There are other factors that critically affect the environment. Consider economic naivet6 or "the head-inthe-sand ostrich syndrome." This refers to failure to recognize the changes in medicine and the influence of managed care on obstetrics and gynecology. If it is not already a component of your life, I can assure you it will shortly become a key factor in your business and patient care activities. Students considering obstetrics and gynecology are perceptive. They will learn of these changes. Will our current state of having ample wellqualified residents change to a dearth of applicants in 5 to 10 years? I am beginning to wonder: can you really make a silk purse out of a sow's ear or perhaps lemonade from bad lemons? As we listen, we hear some physician leaders state that there is an opportunity for all in managed care. Yet what a difference from the poignant presidential address of a departed colleague. Dr. Thomas McElin ~ in 1972 in his presidential address strongly supported the excellence of classic medicine and argued logically against some of the criticisms made against the specialty at that time. Yet he indicated willingness to change if change was necessary. His presentation was a brave apology for quality personalized medicine, yet it was predictive; change did occur, but did we believe that things would go as far as they have? Look at your own life. I venture it is fair to speculate that, for the majority, today you are working harder for less. Your earning power is dropping. Your expenses are increasing. Your autonomy, even reasonable au-
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tonomy, is decreasing. If you are in managed care or attempting to carry your share of care of the underserved, the integrity of your business is threatened. Your charges are heavily discounted, and you may be coerced into other discounted arrangements. Our colleagues in Kentucky are currently in the thick of such a situation. In some rural areas, where Medicare and Medicaid patients make up 75% of a practice, Dr. Robert Goodin, the Kentucky Medical Association's president elect, said, "Physicians couldn't keep their offices open on the kind of reimbursment rate cuts being proposed and then you talk about expanding that to cover maybe 90% of their practices." Yes, there may be counterarguments, but the principle is clear: if you cannot pay your costs, you are out of practice and out of business. Recall clearly, however, that everyone of us has an expected, justifiable entitlement. We are entitled to a fair economic return on an expensive, 8 year-long educational investment. If loss of that entitlement isn't enough and causing you some degree of distress, recall that with increasing frequency your practice will be guided by practice guidelines. Your medical liability is probably still a problem. You are probably spending more time on less effective committees. You can be disenrolled or deselected from a managed care contract for no cause. Check the wording in a recent contract you may have signed. Your future is clouded. Do you really know where you will be in 5 years? Who will fill your shoes? Can we identify the driving forces that control obstetrics and gynecology? Who listens to us, or perhaps we should ask, do we speak with a clear, articulate voice? I submit to you not really, not consistently, not always authoritatively, not with strong passion, not with clear vision, certainly not with a uniform, single voice. I call to your attention the words of Abraham Lincoln who reminds us that "The dogmas of the quiet past are inadequate for the stormy present." Currently we as a nation, and our Congress in particular, are consumed with health care reform. The goals are meritorious, providing all Americans affordable basic health care and reining in the burgeoning costs of health care. Can it be done and what are the sacrifices? Importantly, I ask you where is individual and personal responsibility in this complex cost-benefit equation? I submit to you that every man and woman in this country can do something of importance to reduce their use of the resources in the health care system. But do they or will they? To date, evidence for an affirmative answer is scant. Life-style carelessness still runs amok on many areas of the l a n d - drugs, alcohol, guns, smoking, overeating, and plain laziness. Do we have the fortitude to take hold and evoke change? It requires personal commitment, conscience, and involvement. What is happening right now? The debates in Con-
June 1995 Am J Obstet Gynecol
gress continue, albeit somewhat abated, but in this nation health maintenance organizations and preferred provider organizations are moving over the landscape conquering locale after locade. Health maintenance organization enrollment is burgeoning, with a 10% increase in enrollment in traditional health maintenance organizations alone from approximaely 39 million in 1993 to 43 million in 1994. As these health care alternatives grow, in their wake there is change. Medical markets are restructuring, and classic cost shifting used in the past to provide service for the underserved is being eliminated. Price, competition, market share, and survival are all part of the lexicon of medical managers. There is no more fat in the system, but without a small margin of latitude the educational efforts of hospitals and medical schools will begin to wither. When the driving force for cost reduction is barreling toward more and more capitation and discounting and carveouts and price is the only basis for choosing physicians, hospitals, and others providing care, the educational system will falter. There are suggestions that this is already beginning to happen. What does this medical education system look like in 19947 There are 141 medical schools, including 15 osteopathic medical schools. A total of 72,347 students enrolled in classes for the years 1994 through 1997, including 6888 in osteopathic medical schools. There are 998 teaching hospitals training medical graduates for at least 3 years among 5100 short-term, nonfederated hospitals in the United States. There were 101,420 residents in graduate medical education programs in the United States in 1992 and 447 registered nurse baccalaureate programs in 1993 to 1994 and 58 physician assistant accredited programs in 1994. Do you really think the system can continue at that pace and magnitude? If you take a hard, conscientious look at a medical schools funding sources, you can begin to see the problems for those following in our shoes. Approximately one third of the revenue supporting medical schools' academic missions comes from revenues generated by faculty providing clinical service. In 1993 this was almost 8.3 billion. 9 The success of the managed care machines and their insatiable appetite for clients, client control, and profit forces medical schools into the bargaining arena, scrambling and competing with others for managed care contracts. Without contracts there won't be patients, causing therefore a reduction in revenues. Medical schools need dollars for survival. They cannot be successful if they rely only on tuition or state budgets. Because medical schools now enter the bargaining pit for contracts and clients, they also enter the shady world of competitive pricing and discount medicine. Unfortunately, the faculty practices cannot afford not to bargain about the cost of physician ser
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vices. In doing this, we alienate ourselves from our erstwhile staunchest a l l i e s - c l i n i c a l faculty, community physicians, and alumni. Is it a slide down a slippery slope? Your opinion about outcome as an observer is as astute and perhaps even more pragmatic than mine. Are their solutions found in the following quotation from Jules Henri Poincar6: "To doubt everything or believe everything are two equally convenient solutions; both dispense with necessity of reflection. ''1° We cannot afford the mistake of not looking back on history, but we must look ahead and have the will, the fortitude, the wisdom, and the resolve to speak through organized medicine. Although we may not always agree with every statement, we cannot make ourselves heard when there is dissonance. T h e choir must be massive and the anthems clear and loud. We are fortunate to have strong organizations in our specialty. Certainly T h e American College of Obstetricians and Gynecologists speaks for us in a meaningful way. But we most also speak clearly through the American Medical Association and the Association of American Medical Colleges. It is imperative that, with one voice, we place at the feet of our elected leaders our concerns for the challenges of the future for reasonable health care and also our concerns for who will follow in our paths. Without new leaders with clear visions and new shoes on the path, American medicine will become mediocre. The days of leadership, innovation, and accomplishment will be gone like a beautiful afternoon sun d r o p p i n g behind a clouded horizon. Yes, it will rise again but into a clouded day with only furtive fits and starts of sunlight. But that is not enough, and to think it so is fallacious. We must make the effort to make a difference by repetitiously challenging flawed ideas and d e m a n d i n g impeccable conscience and loyalty from our elected governmental representatives at all levels. Away with pork barrel legislation, expose dishonesty, d e m a n d
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truthful excellence, reject mediocrity, praise integrity. The members of this organization must speak out, individually and collectively. T h e ballot box does matter. Are we doing it? Are we carrying out this important mandate? Is our voice heard? Pray that those who will follow in our shoes will wear them well, enjoy the challenge of the journey, and contribute to the wellbeing of a l l - l e a d i n g as beacons and watchmen for the generation to follow them. Look at your shoes! Yes, look at them! Mundane, basic, but so necessary and so very important. Who will fill them? I charge you and I challenge you t o - w a l k on and be leaders! REFERENCES
1. Rezler AG. Career choice. In: Rezler AG, ed. The interpersonal dimension in medical education. New York: Sprigner, 1985:46-100. 2. Super DE. Training for a profession: socialization through role casting. In: Proceedings of the Association of American Medical Colleges Colloquium on the Career Development of Physicians. Washington: Association of American Medical Colleges, 1974. 3. Funkenstein DH. A study of college seniors who abandon their plans for a medical career. J Med Educ 1961 ;36:92433. 4. Otis GD, Weiss JR. Patterns of medical career preference. J Med Educ 1973;48:1116-22. 5. Trends plus-U.S, medical school applicants, matriculants, graduates 1992. Washington: Association of American Medical Colleges, 1993. 6. American College of Obstetricians and Gynecologists. Manpower planning in obstetrics and gynecology. Washington: American College of Obstetricians and Gynecologists, 1994. 7. McGrath E, Zimet CN. Female and male medical students: differences in specialty choice selection and personality. J Med Educ 1977;52:293-300. 8. McElin TW. The lament of the white rabbit. AMJ OBSTET GYNECOL1972; 112:1-8. 9. Keyes JAJr. Preserving and advancing the academic mission in health care reform. Acad Med 1994;69:642-3. 10. Beck EM, ed. In: Bartlett J. Familiar quotations. 15th ed. Boston: Little Brown, 1980:673.