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First, the Demographics

There has been a consistent emphasis on recruiting minority students to medical school and there has been a steady increase every year in women accepted to medical schools in the U.S, according to Dr. Kelly McMasters, professor and chairman of the Department of Surgery, U of L School of Medicine.

“Women now account for nearly half of all medical students. In addition, there has been greater emphasis and acceptance of older medical students, who are termed ‘non-traditional’ applicants - those who do not go to medical school right after college,” he says.

Dr. Glenda Callender agrees. “There is a greater number of people who have done something else before entering medical school, notes Dr. Callender, a surgeon with University Surgical Associates, who graduated from Harvard Medical School in 2000. “Younger people seem to be more likely to make a career change if they are dissatisfied with what they did before,” she says.

Work-Life Balance

Then there is the matter of work hours.

“There is a difference,” says Dr. David Salvatore, a 33-year-old doctor who practices with Baptist Neuroscience Associates. “Doctors in the older generation are more the workhorses; they work long hours, and always have their pagers on.”

Or their cell phones. “My patients have my cell phone number. They can call me any time,” says Dr. Howard Pope, who originally joined Floyd Memorial Hospital in 1969, retired, then rejoined Floyd Memorial. “Medicine doesn’t stop at 4:00.”

On the other hand, many younger physicians are seeking greater life-work balance.

“It is clear that there has been a shift in the attitudes and priorities of medical students. Medical students value ‘lifestyle’ issues to a greater extent than ever before, including time and activities outside of work,” says Dr. McMasters.

Studies bear out their observations. A study lead by Dr. Douglas Staiger, professor of economics at Dartmouth College, reviewed U.S. Census Bureau data from 1976-2008. The study determined that, though the number of hours doctors spent at hospitals had been “stable at around 55 hours for decades,” in just the past decade the hours physicians spent at hospitals declined by about 7%, from 54.9 hours to 51 hours per week.

More young doctors are taking salaried jobs, working fewer hours or part-time, and refusing to be on call, according to an article on the Doctors in Training Student Center web site, http://www.ditstudentcenter.com/news/2011/4/7/modern-young-doctors-reject-the-old-lifestyle.html

Dr. McMasters agrees. “Trainees these days definitely do not want to be on call as often as their predecessors.”

In addition, the article says, “Students have been increasingly foregoing specialties without a preferable work-life balance, such as obstetrics, general surgery, orthopedics, neurosurgery, urology, and primary care, in favor of those with a more controllable lifestyle, which are all the rest.”

Why

Spokesmen attribute the difference in attitude to a range of factors, including the relatively recent imposition of a cap on residents’ duty hours, evolving employment models, the emergence of multidisciplinary practices, the influx of women in medical school, and generational priorities.

Cultural Change – a cap on residency hours on call

“There has been a cultural change in residency training,” says Dr. Robert K. Salley, a thoracic surgeon with Cardiac Surgical Associates in Lexington. “Things are dramatically different now.”

Throughout most of the 20^th Century medical residents served unlimited duty hours at a stretch – frequently they were on call until 7:00, 8:00 or 9:00 at night, then back at 6:00 or 6:30 the next morning. Then in 2003, The Accreditation Council for Graduate Medical Education (ACGME) imposed a cap on resident duty hours, including a limit of 80 duty hours per week, per resident.

As a result, doctors are training with the concept of clearly defined work hours, notes Dr. Dan Varga, chief clinical officer with KentuckyOne Health. “Previously doctors worked until there was no more work to do,” he says.

“It’s been a complete 180 degree change in expectations. Residents are looking for assurances – a set number of hours, number of weekends, time off. They are looking for a controllable lifestyle,” notes Dr. Salley.

“Residents coming out of school are heavily impacted by hourly restrictions,” says Dr. Kenneth Anderson, vice president and chief medical officer of Baptist Hospital East. “They are used to working limited hours.”

Changing Employment Model

In addition, the employment model is shifting - from the entrepreneurial doctor in private practice to the physician as employee of a large practice or hospital system.

“Now with physicians employed by the hospital systems, they don’t have the opportunity to make more money by working more,” notes Dr. Anderson.

“The employment model is changing. When you are employed by a hospital it is a different model than when you are employed by yourself. In many cases the differences in the generations are determined by the incentives. Now there is a marginal return for extra work,” says Dr. Matt Williams, assistant professor of surgery at U of L and a surgeon with University Cardiothoracic Surgical Associates.

Changes in Care Delivery

“Fifty years ago a diabetic patient would have a diabetic specialty internist who provided most of his diabetes-related care. The older generation of doctors thought, ‘I can take care of everything.’ That didn’t leave much of a lifestyle,” Dr. Varga says.

These days, care is more likely to be delivered by a team in a multidisciplinary setting - which often includes physician extenders, according to Dr. Varga.

“Now the patient might see the diabetic internist a couple of times a year. Routine diabetes management and support are more likely provided by a certified diabetic nurse educator, plus specialists like a podiatrist, and an ophthalmologist. Previously, the length of time it took for an internist to provide all that service was substantial,” he says.

Medical practice patterns have changed in other ways, such as the widespread incorporation of ‘hospitalists,’ according to Dr. McMasters. “Few primary care physicians these days actually go to the hospital to take care of their patients. Patients are seen by the on-call hospitalist - a doctor they have never met - who provides inpatient care,” he says.

Patient information is available online for multiple people to deliver care, and as Dr. Williams observes, “The younger generation is more comfortable with delegating care.”

“This generation does not believe that comprehensive care can be delivered by one person,” Dr. Varga says.

More Women and Multi Physician Households

Some people see the influx of women into medicine and the rise of multi-physician households as having a significant influence on the younger generation’s priority for greater work-life balance.

“Women offer a positive perspective; they are cognizant of the realities of raising a family,” Dr. Salley says.

And it is not always the woman in a busy multi-physician household who needs to modify her schedule to accommodate family needs – in a reverse of traditional roles, the husband is often making accommodations as well.

Generational Differences in Approach

These days medical students are trained to take a more collaborative approach to patient care.

Medical school is now focused on making sure patients are involved in their own care, according to Dr. Callender. “We are taught to spell out the patients’ options, then listen to the patients’ priorities. Some patients want to do everything possible to treat their disease, while some choose a greater quality of life. Even older doctors have a less paternalistic – more collaborative – approach,” she says.

Generational Differences in Proficiency

Not surprisingly the younger doctors tend to be more proficient with computer systems and technology. “The younger doctors have better usage of electronic medical recordkeeping (EMR). The older generations are learning a new skill, and in some cases, falling behind,” notes Dr. Salley.

Moreover the younger generation is more comfortable with changes in technology, Dr. Williams says.

On the other hand, some observers say that the cap on resident duty hours has caused a decline in medical proficiency among young doctors who are completing their residency requirements. “Overall knowledge is down; many people in specialties that require technical skills, such as surgery and interventional radiology, are inadequately trained. New graduates are not quite prepared to pick up a scalpel or enter into solo practice. They need additional mentoring,” Dr. Salley says.

As a result, a lot more people coming out of surgical residency are going on for more training, according to Dr. Callender, who has been in practice for two years following 10 years of surgical training. “A lot of surgery residents choose to pursue additional training and fellowships after their residency is completed,” she says.

That may become more commonplace as medicine becomes ever more complex. “Technology is so advanced; no way is a trainee completely trained. You can’t do everything,” says Dr. Salley.

Yet even as the practice of medicine continues to change at lightning speed, Dr. Pope’s approach still rings true, “If you take care of your patients, everything else will fall into place.”