Punch-clock docs

Two career paths diverge in a wood and the current
crop of med students takes the easier one

By Giancarlo La Giorgia

The face of medicine in this country is changing and it's more than just skin-deep. There are fewer medical school graduates than there were a decade ago, more than half of them are women and most of them, about 60%, are choosing medical or surgical specialties, one of the most popular being dermatology.

"I'm very lucky to have gotten in and feel grateful for the opportunity," says Dr Mark Krasny of his acceptance last year after graduation from McGill University into one of five dermatology resident positions at the Université de Montréal Hospital Centre. Says the young physician, "dermatology is like a lot of specialty programs out there -- radiology, nuclear medicine, plastic surgery, ear-nose-throat surgery, orthopedic surgery --that have a very limited number of training spots, and as a result are more competitive to get into than, say, family medicine."

The popularity of general and family practices in Canada is decreasing -- there was an almost 40% drop in new family physicians between 1992 and 2002, according to the Canadian College of Family Physicians --and there's well-founded worries of a move away from general practice to specialized disciplines. Dermatology ranks among the most competitive residencies to get into, at least in part because it promises fairly regular hours, little or no on-call duties and weekends and holidays off -- the closest thing to a nine-to-five lifestyle it is possible to have in medicine. It can also be very lucrative, especially with the rising popularity of cosmetic treatments like Botox (though Dr Krasny is quick to point out that doctors in a range of fields, from FM to neurology, have ventured into the Botox craze.)

Dr Krasny says that Canada's 500-odd dermatologists face a "pretty huge workload" because of high demand, but concedes that they do have more regular hours than other fields and "aren't up all night." Still, he insists that if personal time was the biggest consideration in his professional life, he "probably wouldn't have chosen medicine in the first place." If time isn't the motivating factor for the decline in the popularity of general practice, money is, suggests the young doctor. "Family practitioners are often overworked and aren't [sufficiently] compensated for the work that they do," he says. "If family medicine was made more attractive in the way that doctors are paid, I think it would make a big difference in the number of candidates willing to go into the field."

FAMILY PRACTICE VS SPECIALIZATION
Dr John Jordan, associate professor in the Department of Family Medicine at the University of Western Ontario, is the author of a study entitled Choosing Family Medicine: What Influences Medical Students? He doesn't agree with Dr Krasny and points to a number of factors causing students to choose more specialized careers, from cutbacks in government funding to shifting demographics and attitudes. "What's much more important these days to physicians and those in training is time protection, rather than money," he says, alluding to the higher priority students now place on their personal and family time within an increasingly unmanageable public healthcare system.

Dr Jordan laments the fact that, to protect their time outside of work and to make the fee-for-service system work to their advantage, younger practising physicians tend to "just see patients in their office. [They] don't go out of the office, don't go to the hospital, don't do obstetrics and after hours, they're off -- that's how they cope." He says it's mainly the physicians over 45 or 50 who are staying broad-based: "The younger the physician, the more likely they are to select a narrower scope within the discipline."

According to Dr Jordan, another disincentive to choosing a general discipline is that, since the early 90s in Ontario and other parts of the country, medical students have been forced to make a career decision by the end of their third year. "The stakes are higher for a student to choose what career direction they want to go in than when I was a student," he says, adding that if he was faced with the same pressures today, "I wouldn't be a family doctor, I would have chosen to become a surgeon... but I might not have been a happy surgeon."

Waël Hanna, a third-year med student at McGill University and the president of his class, does hope to become a happy surgeon. But the odds and his own feelings are against him.

Hanna ranks family time over career or financial considerations, but figures he'll be working between 90 and 100 hours per week, including on-call duties, as a staff surgeon. He realizes the advantages that a nine-to-five discipline would allow him, but says that he is committed to becoming a surgeon because of what he refers to as the instant gratification of healing someone after performing an operation: "It's challenging. You're always facing new problems and have that adrenaline rush in the operating room, as opposed to a dermatologist who sees people in a clinic every day and treats the same moles or acne."

For his part, Dr Jordan points to rising med school enrolment and hopes for changes in the system to improve earnings and working hours enough to again attract young doctors to general and family practice.