Why Physicians Choose Specialties

Jaded Julie:

“Curmudge, now that Mack is back from the other side of the world, he might occasionally join our conversations.  He can enhance this blog with some expertise, which heretofore has been totally lacking.  Perhaps he can help with these questions: Why do physicians become specialists and how do they choose their specialty?  And do financial considerations influence their decision?”

Curmudgeon:

“Let me start with the easy answers, Jaded Julie.  We hope that all physicians have chosen medicine because they are humanists who want to be of service to mankind.  Medicine is the highest calling that matches their interests and above-average abilities.”

Julie:

“I’ll buy that.  Now can we refine our query and consider their choices of specialties?  Will you help us, Mack?”

Doc Mack, MD:

“It would seem that the easy answer comes from the medical students’ experiences in clinical rotations or possibly in a transitional internship.  They have concluded that a particular area is ‘what I’d like to do.’ “

Curmudge:

“But, Mack, other factors must come into play.  Consider surgery.  One who started med school a few years late might avoid surgery because the long residency (5+ years) would shorten his career.  Also, he would have to be temperamentally comfortable with the residency’s ‘macho’ environment.  Female surgeons must be extraordinary people.”

Mack:

“Both of those factors influenced me.  Another specialty involving mostly hands-on procedures is gastroenterology.  They are among the physician-artists that you mentioned a couple of weeks ago.  Although these docs don’t usually spend much time talking to patients, during a colonoscopy they can have the satisfaction of finding and curing cancer in 15 minutes.”

Julie:

“I perceive, Mack and Curmudge, that we are progressing from specialties that are heavy on procedures but don’t require a lot of communication with patients toward those—like psychiatry—that are all communication.”

Mack:

“The surgery part of orthopedics appears more mechanical than artistic, but the surgeon has the ability to transform a patient in constant pain into one enjoying a pain-free existence.”

Curmudge:

“I see plastic surgery as requiring a very artistic person, and like sculpture, there’s little room for error.”

Mack:

“To me, plastic surgery seems to be in a world by itself.  The docs have to have artistic ability and the dexterity to do very fine stitching, even finer than mine.  By reconstructing a disfigured face, they can restore a patient’s self-esteem.  They also set themselves apart by being paid cash on the barrelhead for cosmetic surgery, like eye jobs and tummy tucks.”

Julie:

“Also requiring fine stitching but not up-front cash was the Mohs surgery on Curmudge’s ear by a dermatologist.  A dermatologist has to have a discerning eye to distinguish a cancerous lesion from a benign spot.  It helps to have warm, sensitive fingers, which is why Curmudge’s regular dermatologist is a young woman.”

Mack:

“And of course, a dermatologist doesn’t get phone calls in the middle of the night.  Traditionally, an internist was a diagnostician.  Now many are also family physicians.  We used to joke—it’s probably an urban legend—about internists who ‘couldn’t stand the sight of blood.’  Nevertheless, it will always be a very cerebral specialty.  It often takes a lot of questioning before the patient leads the physician to the correct diagnosis.  I envision an internist as a problem-solver, and perhaps that’s what leads residents into that specialty.”

Julie:

“Clinical oncology is typically a sub-specialty of internal medicine.  In our Kaizen Curmudgeon posting on prednisone we mentioned your former neighbor, Bernie, an oncologist.”

Curmudge:

“You know, Julie, that Bernie left oncology and returned to internal medicine.  He found oncology too depressing because most of his patients died.  Of course, that was back in the 1960’s.”        

Julie:

“At the other end of the people-oriented scale are the pediatricians.  It requires a cool, competent doc to diagnose a screaming baby who can’t say where it hurts held by a distraught mother.  A new physician starting a peds residency already knows that he/she has what it takes.”

Mack:

“Right next to the pediatricians in their need to communicate are the emergency medicine physicians.  I rarely see the same patient twice, have to diagnose everyone who comes in the door, and it’s often a mother with a screaming baby.  A typical day (or night) might consist of a string of minor injuries, pains, and illnesses punctuated by a heart attack or major trauma victim who is trying to die.  This requires an encyclopedic mind, the ability to treat several patients almost simultaneously, and much of the physical dexterity of a surgeon.  This residency is popular despite the specialty’s high burn-out rate.”

Julie:

“You should know best about ER docs, Mack.  We haven’t talked about OB/GYN. Curmudge, even after having been married for 52 years and the father of three children, I’ll bet that’s a subject you still don’t know much about.”

Curmudge:

“You’re right as usual, Julie.  Many years ago I studied emergency childbirth in an advanced first aid class, but thank goodness, I never had to use it.  Here’s another true long-ago story.  When I was a graduate student in chemistry I commented to a dentist that I was glad my profession didn’t require me to work inside someone’s mouth.  His reply was, ‘you might have been a proctologist or a gynecologist.’ “

Julie:

“Curmudge!  Back to our original question.  Do you think that any physicians choose their specialty on the basis of anticipated financial security?”

Mack:

“I’ll answer that indirectly, Curmudge and Julie.  It would certainly surprise me if one who planned to live in Alaska wanted to become a specialist in tropical diseases.  Nevertheless, my hope remains that most would choose their residency on the basis of  ‘what I’d like to do.’ “

Curmudge, Julie, and guest author, Doc Mack, MD

       

Specialists--Introduction

“Curmudge, back in October 2011 we talked about specialists and how medical students decide what kind they want to be.  Whatever happened to that draft?”

“It was a strange situation, Julie, but in the end it was literally tossed into the wastebasket.”

“Because we have been talking recently about physicians, this might be an appropriate time to resurrect the old draft.  We can revise it with the help of Doc Mack, MD, who can add authenticity to our perceptions.  He has one unpublished book manuscript and is working on a second.  It would seem that he has literary talents as well as combat medicine in his black bag.”

“Great idea!  We’ll pull the draft out of the trash can, revise it, and post it next week.”

Kaizen Curmudgeon                                                

Docs and Teamwork

“I trust that you recall, Julie, our mention of a physician’s paradigm (the window through they see the world) a week or so ago. I personally feel that a physician at the end of residency is better prepared to practice his profession than one at the end of training in law, science, theology, or whatever. Physicians probably also feel that way, and that may be the source of their paradigm. We know, however, that there is a lot more for them to learn, and the body of essential knowledge is expanding every day.”

“That’s for sure, Curmudge. Doc Mack has said that four years seems too short for medical school. And it seems as if everyone is suggesting that their favorite topic ‘ought to be taught in medical school,’ everything from nutrition to sociology to data management. Even the Medical College Admissions Test (MCAT) is being expanded to include ‘critical thinking and the sociocultural and behavioral determinants of health.’ O course, you and I know that those who write about Lean and patient safety want future docs to learn more about collaborative teams and standardized work. I certainly don’t envy anyone on a medical school’s curriculum committee.”

"As an outsider, it seems to me that medical school is not entirely free of wasted time. It may just be tradition and a rite of passage, but docs-to-be spend time and effort learning the language of medicine…words like febrile and syncope. Why not just use ‘fever’ and ‘faint’?”

“It’s like our use of Japanese words in Lean, but we use only a half-dozen of them. I think we’ll have to conclude that Lean, with all of its applications in efficiency, quality, and patient safety, will not be taught formally in medical school. But what about teaching teamwork during residency?”

“Julie, a lot of people feel that time spent in residency is already too short, especially with the new 80-hour per week work limit. The limit keeps residents from fully managing a patient’s continuity of care. And I certainly wouldn’t want a surgeon fresh out of residency operating on me without having lots of experience with the procedure.”

“Let’s face it Curmudge; Lean training for physicians will have to be an informal, ad hoc undertaking.”

“Well, not entirely informal. Physicians can earn CME (continuing medical education) credit by taking a course offered by a provider accredited by the Accreditation Council for Continuing Medical Education. Lean Overview, offered by the Kaizen Promotion Office at Affinity Health System, is such a course.”

“Great! Now we need to find ways of encouraging physicians to attend. Perhaps we can document ways by which Lean touches a physician’s two most common hot buttons, better outcomes for patients and a less harried personal life for the doc. Can we do that in later postings?”

“I hope so, Julie. Additional encouragement should also emanate from the organization. Physicians listen best to other physicians. Physician leaders can stress that course attendance is time well spent.”

“Hey, Curmudge, these approaches sound like winners. Let’s do it.”

“Before we take the weekend off, Julie, here’s something hot off the web. Eastern Virginia Medical School is requiring for graduation that their students complete the IHI (Institute for Healthcare Improvement) Open School Basic Certificate. It includes online courses in Quality Improvement, Patient Safety, Leadership, Patient- and Family-Centered Care, and Managing Health Care Operations.”

“Wow! That should give the students something to do in their spare time.”

Kaizen Curmudgeon

The Teamwork-Artistry Spectrum

“Hey Curmudge, I’ve been reading about the differences between cognitive and procedural specialists. Do different types of physicians need to be better team players than others?”

“Let’s start with definitions, Julie. The cognitive docs—like the primary care physicians and internists—listen, diagnose, prescribe, and communicate. The procedural specialists—such as surgeons and gastroenterologists—perform procedures and usually don’t need to communicate as much. Of course, they are the extremes on a continuum with emergency medicine docs in the middle. There is also an artistry continuum with the skilled surgeons—especially plastic surgeons—at he upper end.”

“I think I see where you are heading, Curmudge. Although the surgeon must communicate with his/her OR team, the patient’s outcome is, for the most part, in his hands. That contrasts with a doc in a patient-centered medical home who personally might not even see the patient and whose whole team are involved in the patient’s care. There’s not much artistry there, but there’s a lot of teamwork.”

“Nevertheless, Julie, physicians of all stripes need to learn enough about teamwork to apply it appropriately to their own practice. They especially need to embrace the ‘respect-for-people’ Lean mindset and carry it to their team or even solo practice. Shall we discuss how that might be accomplished in our next posting?”

"You hobble on ahead, Old Guy, and I’ll meet you there.”

Kaizen Curmudgeon

Doc Talks--Introduction

“Curmudge, what is the most challenging task faced by the Lean facilitation team in any health care organization?”

“Jaded Julie, I think it’s convincing physicians to learn, practice, and lead the Lean transformation. The physician’s paradigm, the window through which he or she sees the world, has developed over his years as an undergraduate and in medical school, residency, and practice. This is likely to be different from the collaborative, standardized world that we see in the future of health care.”

“It sounds as if we are going to talk about physicians. Isn’t that a sensitive area for discussion by people like us who are so low on the organizational totem pole?”

“On that scale, Julie, we are below ground. However, to avoid disturbing anyone, we’ll post our discussions on Curmudgeon’s Wastebasket with a brief introduction (like this one) and link here on Kaizen Curmudgeon.”

“So Curmudge, what gives you license to discuss physicians, anyway?”

“First of all, most of the stuff we discuss was originally written by physicians. You and I are just word-carrying messengers. Then there are the anecdotes based on the years I spent with pre-medical students. We chemistry majors took many of the same chemistry, physics, and math courses as the pre-meds. They were bright, studied hard, and earned A’s. Ten years later at the same college, I taught a new generation of pre-meds, and they also earned A’s. Teaching those people was easy; I just tossed them the material, and they snarfed it up. My conclusion: Pre-med students and the doctors that they become are intelligent, quick learners, hard-working, and very knowledgeable."

“Do you realize, Curmudge, that most of those docs whom you taught 45 years ago are retired?”

“They and I have something in common. When one considers the present-day status of medicine and industry, both medicine and the paper industry are good professions from which to be retired.”

“I trust that we have more to say about medicine, Curmudge?”

“We sure do, Julie. It can be found in Curmudgeon’s Wastebasket.”

Kaizen Curmudgeon

Explanation--Explication (Fr.)--Erklärung (Ger.)--Spiegazione (It.)

“Do you suspect, Curmudge, that our readers might wonder why our postings have been erratic and less frequent for the past several months?”

“Jaded Julie, let’s speculate on what might have happened to the Old Guy who puts words in our mouths. He just got lazy, his fingers became less nimble, he ran out of things to write, dementia finally caught up with him, he lost his creative spirit…”

“Perhaps a little bit of each of those. Back on October 29, 2009 we agreed that there’s a wealth of ideas out there to write about, but we also concluded that the creative spirit of most people—if they have one—tends to be fragile.”

“Maybe it’s like the spirit of an athlete or a virtuoso musician; they perform better with competition or in front of an audience. It’s difficult to do your best when you are the only one who gives a hoot.”

“So back to the Old Guy. What’s been going on?”

“Toward the end of last year, he and his colleagues began to consider ways by which they could derive more value from the blog. Remember? We speculated on this in our Curmudgeon’s Wastebasket posting on November 19, 2011, but we were wrong. The path forward was more draconian than anticipated. The bottom line is that we no longer have our former sponsors.”

“I’m dead? But I’m too young to die! I’m only five years old. Some fictional characters, like Blondie and Dagwood, live for generations.”

“No, Julie, I am not saying that you and Curmudgeon are dead. You will live on in full feistiness in Curmudgeon’s Wastebasket. The Old Guy will have other stuff to write, and he can write Kaizen Curmudgeon in his spare time. You’re not dead; you’re just irregular. Health care is dynamic, and there is a lot for us to share with our readers. Of course, we’ll continue to discuss Lean in health care.”

“But what about reviewing the Old Guy’s drafts?”

“He will write carefully, as he did in the past, and the topics won’t be controversial. Although you weren’t aware of it, several postings in years past were reviewed by a neighbor. He’ll ask Doc Mack to review medical drafts.”

“And what about that fragile creative spirit?”

“It has taken a pretty bad hit, Julie, but let’s hope it’s not terminal.”

“Keep hanging in there, Curmudge.”

Kaizen Curmudgeon

Standardized Clinical Processes

“Curmudge, we’ve talked about standard work and its antithesis, autonomy, in July 2008 and in January 2011. Why are we doing it again? Do you suspect that people have forgotten these concepts?”

“It’s possible, Julie. That’s why we discussed nemawashi a week ago. Today’s discussion will be revised and focused on clinical processes.”

“Clinical processes! Won’t we be trespassing on physician territory? Docs can be fierce defenders of their autonomy, and they sometimes refer to checklists and standard work as ‘cookbook medicine.’ Might they be upset when they read this blog?”

“Don’t worry. Docs seldom read anything written by a person without an M. D. after his name. And if they read this, they will note that we are quoting Brent James MD.”

“As we have discussed earlier, Curmudge, a physician will be reluctant to follow a procedure written by someone else and plopped on his desk. Doc Mack has told me what he would think of something created by some ‘nurse in an office,’ and in the Army she might be a lieutenant colonel.”

“Dr. James described a team’s study of a specific treatment that they designed based on the literature. ‘Physicians were instructed to vary from the protocol if they judged it to be in the best interest of a patient. Each time this happened, the case would be discussed among the group. Over time the protocol was modified when there was a scientific basis for doing so, and over time variation from the protocol diminished.’ “

“That sounds like developing standard work the hard way, but it’s the best way to gain the support of clinicians.”

“Here, Julie, are the five steps comprising James’s process:

1. ‘Select a high priority clinical process;

2. Create evidence-based best practice guidelines;

3. Build the guidelines into the flow of clinical work;

4. Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;

5. Meanwhile, learn from and (over time) eliminate variation arising from professionals, while retain variation arising from patients.’ “

“Step 5 is the main process goal to be attained from evidence-based medicine, ‘Eliminate variation arising from the professionals while retaining variation arising from the patients.’ Should I go out and shout that from the top of the parking ramp?”

“Only if the weather is good, Julie. Note that James also says, ‘This is very different from the free form of patient care that exists generally in medicine.’ The title of James’s presentation, ‘Don’t Wait for Washington,’ suggests that if clinicians don’t make their processes more efficient, ‘Washington’ may do it for them.”

“That’s a bit intimidating, Curmudge. Now let’s run up the steps to the top of the parking ramp.”

Kaizen Curmudgeon