Young Doctors Weigh In On Health Care

MELISSA BLOCK, host:

Rising costs and fears of rationing were two things I discussed yesterday on the program with a pair of veteran doctors. Today, we'll hear perspectives on health care and primary care in particular from two young doctors who've just finished up residencies in internal medicine.

Brian Southern started out thinking he wanted to be a primary care doctor - it was a childhood dream. But he changed his mind during his residency at the University Hospital's Case Medical Center in Cleveland.

Nicole Loeding wasn't sure where she was headed when she began her residency at the University of California, San Diego. But she found what she enjoyed most was building relationships with patients over time, and that led her to primary care.

Dr. NICOLE LOEDING (Internal Medicine): A big part of it is that you have this relationship almost to the point where sometimes, the patients come in, and it's almost like you're seeing one of your friends again, and they know about your family and your pets and you know about theirs.

And you build that trust so then when there are important things, they feel comfortable telling you when they have a problem or something is concerning to them or something is important to them, to be able to filter out and be able to take care of the things that are urgent health care matters, and to kind of help filter through and prioritize and accomplish goals, you know, for both you and the patient.

BLOCK: Now, Brian Southern, you've made a different decision. You are going to be specializing in pulmonary critical care. Why did you decide...

Dr. BRIAN SOUTHERN (Internal Medicine): That's correct.

BLOCK: ...to specialize, not go into primary care?

Dr. SOUTHERN: Well, since I can remember, I always wanted to do primary care for many of the reasons that Nicole mentioned. But my experience was a little bit different. I felt rushed all the time. And I felt like I had to see so many patients and I had to meet certain criteria, such as getting their blood pressure below a certain level. And I didn't really have time to talk to the patients, to interact with them, to listen to them.

So I really became disillusioned with primary care not too long after starting my residency.

BLOCK: Well, Dr. Loeding, what about what Dr. Southern was just talking about there? And you do hear complaints from doctors all the time that they don't have enough time to spend with their patients. They would probably say you have a very starry-eyed view of what your practice is going to end up being.

(Soundbite of laughter)

Dr. LOEDING: Right. And I think there are certainly challenges. I'm kind of lucky in the clinics that I've had the last three years and the clinic that I'm going to join this fall. They do have 20-minute visit slots with patients, which is not a great amount of time, but enough that I'm hoping to be able to prioritize. And you may only be able to focus on one or two things each visit, but get done what you can in the visit, get done what's most urgent.

And then, also, I think some of it will need to be a greater role of support staff. Take care what can be done on the phone with your nurses or your NPs, do the things that can be done outside of the office visit. And I do think it will be challenging.

BLOCK: As you both were going through medical school, and then into your residencies, is there a stigma attached to primary care? Did you feel that and hear that from people?

Dr. Southern?

Dr. SOUTHERN: I think so. I know that I was in the minority when, you know, I voiced my interest in primary care. And often, it wouldn't be directly said but I would, you know, feel that people looked down on me a bit because I showed an interest in primary care.

BLOCK: What did you hear specifically from people?

Dr. SOUTHERN: Well, you know, I heard things like, do you know how much money a primary care doctor makes? And, how are you going to pay your medical school...

(Soundbite of laughter)

Dr. SOUTHERN:...loans with that type of salary? And, you know, with the way things are going with health care in this country, you're referring patients most of the time. And, you know, those were just not things that I wanted to do.

BLOCK: Hmm. Well, Dr. Loeding, I heard you laughing in there, as Dr. Southern was talking. But the pay gap is a real concern, I would think. I mean I was looking at one study that showed the average annual income for a family doctor: $173,000, for a cardiologist: $419,000.

(Soundbite of laughter)

Do you think about that?

Dr. LOEDING: There is a significant gap.

(Soundbite of laughter)

I think, I also, I think you have to be honest with yourself and say, what am I going to enjoy doing? And I'm not a procedure person. The technical aspects of doing a cardiac catheterization or a colonoscopy, it's not something that I enjoy or that I think I would want to do for the rest of my life.

BLOCK: How important was quality of life when you thought about what kind of doctor you want to be?

Dr. LOEDING: It was quite a consideration. I prefer to work during the daytime. I'm not really a night person. So I didn't want to be - have to be called in and go into the hospital in the middle of the night to either admit a patient, or do a procedure or take the patient to the O.R. So it was important to me to have more of a regular kind of predictable, kind of normal daytime-hour schedule that I could be with my family, and doing things that I enjoy in the evenings and the weekends. So that was a big factor for me.

BLOCK: And Dr. Southern, how did quality of life factor into your decision?

Dr. SOUTHERN: Well, it factored in but, you know, in the opposite regard. I love being in the hospital. I love waking up at three in the morning and having to deal with an acute crisis. Those are the types of things that really appeal to me in pulmonary and critical care medicine.

BLOCK: Dr. Southern, do you think there would be anything that could be done that would make primary care more attractive to you, steer you away from specializing and into primary care?

Dr. SOUTHERN: Well, you know, to be honest, this is one of the reasons I chose critical care and pulmonary medicine. I know a lot of pulmonary and critical care doctors who ultimately go back to primary care.

The big problem that I had with primary care was the time constraints, pay-for-performance measures that are becoming more and more common, where you are essentially graded on certain criteria. Did you meet a blood pressure goal? Did you meet a blood sugar goal? And I felt like that was not what I wanted to do.

I felt like, you know, medicine is composed of science and art. And I felt like the art of medicine, which is what I loved about medicine, is being taken away by these things. And I think that if we're going to judge doctors, part of what they're judged on is patient satisfaction, and did the patient feel like you listened to their concerns, and was the patient able to talk about all of the problems that he was having? And, you know, I feel like if somehow, we could get back to that, then primary care would be much more appealing for people like me who enjoy the art of medicine.

BLOCK: Well, Dr. Southern and Dr. Loeding, thanks very much, and best of luck to you both.

Dr. LOEDING: Thank you.

Dr. SOUTHERN: Well, thank you very much.

BLOCK: Brian Southern has just started a fellowship in pulmonary critical care at the University Hospitals Case Medical Center in Cleveland. Nicole Loeding will join a primary care practice in Minneapolis this fall.

And one last note from a health care veteran, one of the doctors we heard on the program yesterday, family physician Greg Darrow. He talked about the ways in which the health care system can whirl the mind of young doctors, and I asked if he had any advice for the doctors you just heard from.

Dr. GREG DARROW (Director, Jemez Pueblo Health Center, New Mexico): Always, you need to be an advocate for your patient and to realize that no matter what corporation it is, the most important relationship is the one in that room with that patient, to be an advocate for that patient and to always look out for the welfare of that person in front of you.

BLOCK: You can hear my earlier conversation with Dr. Darrow and surgical oncologist George Knaysi at our Web site, npr.org.

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