This Year...

Robert P. Roca, M.D.

President

One of my goals this year is to learn something about the dynamics of physician supply in Maryland and to see if this knowledge might help guide us to a rational advocacy position about the physician workforce in our state.  One major question related to supply is where and in what specialties our graduating residents choose to practice.  Last May - just before the graduating residents left their training programs - the BCMA sent a survey via Survey Monkey to the residency directors and their graduating residents.  Out of a total of fewer than 500 graduating residents, 97 residents responded to the survey, and their answers to our questions were very interesting.   

Who responded?  They were almost evenly divided between men (51.6%) and women (49.4%).   Thirty-five percent are going into traditional primary care specialties such as pediatrics, family medicine and internal medicine.  Only two are going into general surgery.  The rest of the group (63%) is headed for specialty practice, including orthopedics (seven respondents) and neurosurgery (three respondents).    

While it is risky to generalize from this sample, the results suggest that Maryland residents lean decisively toward specialty practice rather than primary care or general surgery, and this does not bode well for the future supply of primary care physicians and general surgeons in the state.  This preference was not entirely unexpected and may relate to the income disparities among physicians, an inevitable factor in an age when trainees often accumulate mortgage-size educational loan debt.   The income gap between specialists and primary care physicians is substantial and becomes quite large over time.  According to the Robert Graham Center this disparity “spread over a 35-40 year career can mean a $3.5 million gap in return on investment between primary care physicians and the midpoint of income for subspecialist physicians.” 

General surgeons are experiencing a similar income gap, but the low level of interest in general surgery seems to be related to another issue: a desire for a “controllable lifestyle.”  Studies show that specialties with “controllable lifestyles” are regarded as most desirable by today’s medical students.   The results of our survey are entirely consistent with this.  Maryland trainees appear to be leaning toward specialties which will allow them greater control their lifestyles and more free time.  Indeed “lifestyle” was the primary consideration in specialty choice for 41percent of respondents.             

This concern for working conditions, especially control of one’s workday, may account for one of the most striking findings of the survey.  When asked about the kind of practice setting they were seeking (e.g., solo practice, employment with a hospital, employment with a group practice or serving in an underserved area), only two respondents indicated that they were planning to open a solo practice.  By far the largest percentage (62.4%) said that they were seeking employment with a hospital.  I doubt we would have seen such a strong preference for this kind of employment arrangement even 10 years ago.   

One of our main motives for doing the study was to ascertain why many residents trained in Maryland are not staying in the state to practice.  In fact, over half of our survey respondents indicated they were moving out of Maryland to practice.  While many of us thought it was because of the malpractice climate, this does not appear to be an important factor, as 71 percent indicated it had little or no impact on their decision.   Instead, survey respondents who are leaving Maryland are doing so for two primary reasons: to be near their own family (60% of those leaving) and/or a spouse’s family (38% of those leaving) and for better working conditions (36% of those leaving) or income (42% of those leaving).   

At the conclusion of the survey we asked about the interest of the respondents in joining their state medical society following residency and their needs relative to the medical society.  These young physicians felt that the society should engage in political advocacy and provide CME.     Professional collegiality and a referral base – important and highly valued functions of medical societies in the past - were never mentioned by this cohort as reasons for joining the medical society.  

What did we learn from this first survey effort?   The results suggest that income potential is an important factor in decisions about specialty and geography, but that “lifestyle” considerations and the opportunity to be near family are often decisive.  And perhaps because of the value placed on having a predictable schedule, there was a clear preference for employment by a hospital over solo practice.  The survey also suggests that young doctors do value state medical society membership and that they view advocacy and CME – not collegiality and referrals - as the society’s most important functions.          

The results of this first survey of graduating Maryland trainees are provocative and give us lots to think about.  It has been suggested that we should refine the survey and send it out again next year with the goal of getting a significantly higher response rate.   If you have a moment, please email me your thoughts about the survey and let me know if you think it’s worth repeating.