By Christopher Guadagnino, Ph.D.

Fourth year resident Yvette Brown, M.D.

Published May 2001

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Physicians in southeastern Pa. are well-acquainted with the challenges of clinical practice in an environment dominated by two powerful managed care companies and characterized by some of the lowest reimbursements and highest medical malpractice burdens in the nation.

Recent data reported by state and county medical societies, as well as officials at the CAT Fund, indicate that physicians in some specialties are leaving the region because of these burdens, while some physician groups and hospitals are having difficulty recruiting physicians.

These challenges are not lost on physicians who are in their final year of their medical residencies in some of Philadelphia’s largest residency programs. The significance of these pressures is borne out by residents’ views of the medical profession and by the ways in which they have modified their career plans as a result, including avoiding private practice, switching specialties well into their residency, and avoiding clinical practice.

Private Practice Not Viable

Having come into medical school with an idealized view of physicians as being able to work in conjunction with their patients to develop a plan of care that is best for them, "I now realize that the clinical aspect of medicine is not all there is," notes Yvette Brown, M.D., who is completing her fourth year of residency in OB/GYN at MCP-Hahnemann. Residency has introduced her to the frustration of having managed care representatives intervene in her medical decisions by suggesting therapy options from flowcharts that were not appropriate for the individual patient in question. "I realized that I sometimes had no say over what management plan the patient should undergo. It was more what their HMO wanted than what I wanted."

Her main concern, however, is the medical malpractice environment in Philadelphia, which she says has gotten so out of hand that it has led good physicians to either abandon the obstetrics portion of their practice, completely leave the field of medicine, or retire earlier than they otherwise would. She fears that the problem exists in most major cities and will discourage people from entering OB/GYN, leading to a shortage of women’s health practitioners.

"Before medical school, I always thought I would be in private practice, but I realize that it’s not financially feasible to be in a private group any longer. The malpractice rates are so astronomical, it is very hard to generate enough revenue with the reimbursement you get from HMOs and afford to pay for your ancillary staff and yourself," says Brown.

She says that those financial pressures forced her to consider being in a health clinic rather than in private practice. Brown has chosen to work as an employee of a federally-funded health clinic in central Pa., which will take care of those financial concerns and allow her to focus on the clinical aspects of patient care.

A National Health Corps Scholar, Brown wants to practice in a medically underserved community, where she hopes to become active in public health initiatives. Being an employee of a clinic, she hopes, will allow more time for meaningful patient interaction to address a wider spectrum of their needs than would be possible in a private practice environment, which she says forces physicians to focus on the bottom line by seeing many more patients per day and reduce patient encounter times.

Brown says she would like to become a medical director of a health clinic and pursue her interest in public health issues, including a focus on social issues facing the local community.

Currently a member of the Pennsylvania Medical Society (PMS) and the American College of Obstetricians and Gynecologists, Brown says she wants to maintain at least a cursory involvement in the political activities of organized medicine, which she believes are essential to push physician-friendly legislation and to counteract changes that hurt physicians and which were passed, she says, when physicians were complacent and had little input. She believes that junior physicians are much more cavalier about the state of medicine now than are their senior counterparts.

Although she says lobbying is an important activity of organized medicine, Brown believes more attention should be paid to initiatives designed to educate patients that physicians are not the stalemate in the system, and are the ones lobbying for them. "We sometimes get blamed for the faults of the health care industry, when it’s not necessarily our doing," she adds.

Pressures Lead to Change of Specialty

After completing two years of surgical residency at Abington Memorial Hospital, Dale Wilson, M.D., switched careers and did three more years at Temple University Hospital, where she just competed her residency in anesthesiology. In a region dominated by two health care insurers and "inundated with surgeons," she says, "I wasn’t really looking forward to struggling to find a job and then work lots of long hours to continue to struggle on and not be able to pay my bills."

She says that most of the surgeons she worked with "were actually pretty unhappy with the difficulty they were having paying the overhead and taking care of the financial part of their private practices."

Wilson is the newest member of a seven-physician private anesthesiology practice at Doylestown Hospital, where she says she enjoys being a hands-on clinician able to perform invasive procedures of the sort that attracted her to medicine in the first place. But reflecting on the amount of time and debt accumulated in getting to her first job as a professional, together with the region’s reimbursement levels and malpractice risks, she says, "I don’t know if I’d do it again, knowing what I know now."

Wilson’s husband has been an anesthesiologist in the region for seven years. "If I had not married someone who is already established here," she adds, "I had absolutely no intention of staying in the Philadelphia area. I know a number of docs already who have closed up shop and gone across the river to New Jersey" because the practice environment is more favorable there.

As a Chief Resident in anesthesiology at Temple, Wilson was nominated by her department chairman to serve on the House of Delgates of the American Society of Anesthesiology (ASA), "Which started opening my eyes, politically, to what is happening in anesthesia," such as the widening scope of practice of nurse anesthetists. Wilson believes it is important for more residents to become active in organized medicine at an early stage, and plans to remain a member of the ASA, AMA, PMS and Philadelphia County Medical Society.

Shift Away From Academic Medicine

Originally intending to pursue a medical career within an academic medical center, Michael Nagy, M.D., decided instead to pursue general surgery in a community setting. Chief Resident of general surgery in his fifth year at Thomas Jefferson University Hospital, Nagy says his interest shifted after seeing the pressures academic physicians were exposed to in the current reimbursement environment.

"As research dollars and hospital reimbursements have decreased," he observes, "more clinical productivity pressure is being put on academic physicians at the expense of teaching and learning."

Nagy says he will now pursue those interests on his own, as part of a five-physician general surgery group in New Jersey.

Nagy says that he probably would not have stayed on the east coast at all because of what he has heard from attending physicians about the medical malpractice environment and salaries of surgeons. "What few jobs there were pay 25 percent less in starting salaries than in other parts of the country," he notes. He says he knows of one general surgeon who has left Jefferson because of the cost of malpractice insurance, as well as two urologists who have also left the area to practice elsewhere.

Nagy chose to go to New Jersey, where his family is, and where he says the cost of malpractice insurance is less than in the Philadelphia area.

Nagy believes that financial changes in the health care environment have made medicine a less desirable profession, and concedes that other professions offer more financial reward for less investment. "But it is still a great profession because you get to take care of patients," he adds. "You better do it for the right reasons."

Concern About Eroding Quality

The image he had of health care professionals compassionately caring for others and always working toward the interests of the patient has been sullied by witnessing the effects of continual cutbacks of reimbursement to physicians and hospitals by health care insurers, says Michael Goodyear, D.O., a fourth-year emergency services resident at the Albert Einstein Medical Center. "Although technology and our professional knowledge is increasing," he says, "The level of expertise that we’re actually putting in the hospital is declining."

Hospital administration does not always make cutback decisions in the best interests of patient care, Goodyear says, pointing to decreasing numbers of nurses per patient on a floor and facility upgrades that target services that are the biggest money-gainers—like cardiology and oncology—rather than services that may lose money, like emergency services or radiology.

Goodyear is also concerned that cutbacks are degrading the level of expertise in the emergency room, pointing to an increasing proportion of staffing by critical care associates, technicians and paramedics, as well as nurse anesthetists and respiratory therapists.

Before going into medicine, Goodyear had heard about financial pressures in the profession. After completing his residency, he says, "Now I see that it’s not just that physicians aren’t making much money, but that there are cutbacks in the level of patient care that we’re providing."

Goodyear hopes to stay involved with the most current care practices and cutting-edge technologies by taking on a teaching role, an interest he says was stimulated by his role models at Einstein. He is taking a staff position in an osteopathic emergency medicine residency program in the Frankford Hospital System.

Switch to Non-Clinical Career

G. Caleb Alexander, M.D., went into medical school viewing issues of health care cost and quality as somehow distinct from the practice of caring for patients. Now in his final year of residency in internal medicine at the University of Pennsylvania Health System, Alexander says he has become aware of the tension between the best interests of patients and of health care institutions. He notes, for example, how a patient with a rare disease may not receive an expensive screening exam because of cost-reduction efforts to reduce overutilization of services.

"I had never really considered anything other than a clinical career prior to the end of medical school," says Alexander, who notes that exposure to the clinical setting has made him more interested in issues related to the equity and efficiency of allocating scarce medical resources.

In July, he begins a Robert Wood Johnson Clinical Scholars fellowship to pursue training in the non-biological health sciences, including epidemiology, bio-statistics, sociology, ethics and law. He anticipates a career in academic medicine focusing on health services research and medical administration, but says he may pursue a career within managed care or as a consultant outside the clinical setting.

In an academic medical center setting, Alexander says he would anticipate less exposure to clinical productivity pressures as a physician-scientist than is felt by clinician-educators.

Physicians get a skewed exposure to managed care in the acute care setting, Alexander says, because that context frames it "solely as an outside force restricting care." A two-week, non-clinical rotation at HealthPartners Medicaid HMO introduced him to the functions and structure of a managed care organization, which he says taught him about the challenges of providing quality care in today’s health care delivery system.

"My relative sympathy to managed care companies is also due to my perception that many physicians may not be playing as large a role as they could in controlling costs," notes Alexander, a perception he says has been borne out by clinical decisions he has witnessed. Physicians should lobby for necessary procedures, but should be more sensitive to "the fallacy that more care equals better care," a conflict he says becomes more important when physicians stand to gain financially from the care they provide.

"Physicians are part of the problem. They can play a more active role in being part of the solution," Alexander believes. He also points to structural barriers to cost-effective care, such as efforts to reward quality care being stymied by difficulties in defining proper case mix and quality-of-care indices.

Alexander is a member of the AMA and the Society for General Internal Medicine. He says he supports the efforts of organized medicine to defend physician autonomy, but says that those efforts should also focus on improving physician behavior to control health care cost and increase quality.

Change of Career to Medicine

After teaching high school for seven years, Michael Devon, M.D., says he wanted to serve young people in a more enduring way. Now Chief Resident of pediatrics at Children’s Hospital of Philadelphia, he has spent ten years retraining for his new career.

At the start of that training, he had only a cursory knowledge of the increasing pressures on physicians in clinical practice. He says that the knowledge he has today of those pressures has not changed his view of the profession, and notes that a primary care specialty is less vulnerable to low reimbursements and high malpractice insurance costs than are other subspecialties. "I’m not in it to make money. Most of those who choose medicine nowadays have the sense to know that."

He is not an active participant in organized medicine, other than being a member of the American Academy of Pediatrics, primarily for its continuing medical education opportunities and educational materials.

He believes that the additional burdens and constraints placed on physicians by managed care haven’t changed the central core of the profession. Says Devon, "Maybe there are more hoops to jump through and a longer road. But the idea of taking care of patients, being their custodian, hasn’t changed."

Devon says he is committed to Philadelphia’s underserved population and will practice primary care pediatrics as an employee of a community clinic while his wife completes a residency in radiology.