We face an unprecedented time in health care. The states, responding to major budgetary challenges of health care, have accelerated the changes beyond anyone’s expectation. New changes in Medicaid and Medicare will add an afterburner effect. Some of the contributing factors:

• Never have Americans been so fed up with health care costs. This is particularly true for US businesses facing increasing global competition for goods and services.
• Never has there been an excess of as many physicians as there will be in the next decade.
• Never have residency graduates had to face so much competition from other residency-trained and experienced doctors displaced from other locations.
• Never has there been such a diversity of practitioners of various types: physician, physician assistant, nurse practitioner, gender, ethnic groups, etc., particularly in primary care.
• Never have physicians had as much flexibility as is possible in many medical careers today, but never have doctors faced more challenge as they continue to give up control to others to manage their practices, etc. In the years from 1983 to 1994 the per cent of physicians who were employees almost doubled from 24% to 42% while those self employed in group practices fell from 35.3% to 28.4%. Solo physicians fell from 40.5 to 29.3% (Kletke, JAMA Aug 21, 1996 pg 555). Younger physicians have the highest rates of employment by others and the highest lifestyle expectations.

Any predictions are difficult in such an environment, but some things will remain constant. There will be continual pressure to use the same or less resources for health care in the next decade, in other words more managed care. Of course managed care in 1996 is a misnomer. Managed care today means little more than managed cost. A more appropriate term is the corporatization of medicine. The penetration of corporate medical enterprises will be determined by how much physicians give up to them through contracts or as employees. Subspecialists will still be working closely with the inpatient part of hospital care, but hospitals are moving in other directions.....

The use and abuse of cost-saving measures is the issue of the day for physicians. This is both good and bad. Previously young and likely health patients with chest pain or those with mild to moderate acne could bully primary care physicians into allowing care by cardiologists or dermatologists, but many physician groups and HMOs are forcing such referrals to be reviewed by the medical director or a panel of family physicians before any such referral is allowed. Patients will not be as happy, but costs will go down as will many unnecessary tests.

For many years the choice of specialty dominated medical student’s career decisions. You should be aware that other factors have become just as important. Future job security is increasingly a concern. Tied to this is a decision for a specialty, but also eventual practice location.

• Schools are graduating more family physicians, pediatricians, internists, ob-gyns, physician assistants (soon to be 4000 per year), and nurse practitioners than ever before.
• Male and female physicians and practitioners continue to marry professional spouses with increasingly complex job and educational needs. Many workforce researchers and recruiters think that the spouse is more important than the physician in the decision on practice location. In any case there is increasing pressure on practitioner families to locate in more urban areas where their specific job and educational needs are more likely to be realized.
• Positions will be open in primary care, but there will be less choice, especially in urban locations.
• Salaries may increase in primary care for a few years, but then not much change would be expected, especially in urban areas where salaries may decrease.
• The salaries of subspecialties will face consistent downward salary pressures and they will be able to use less ancillary staff. The salaries of subspecialists will still equal or exceed those of primary care, but job security will be more of a challenge. For example, orthopedics has recommended a 50% cut in the number of orthopedic residents and an extension of training to 6 years.
• Primary care rendered by physicians will increase in complexity, with routine cases treated by others.

Careful study, career planning, and extra training or fellowships may be needed

to be able to find the position that you want.

1. There will be two to four years of continued primary care expansion in metro areas as corporate medical groups attempt to buy market share with excesses of primary care physicians (by improved availability, service, and convenience). Then....
2. One - two years of status quo while corporate mergers and other deals are made and then two or three corporate medical entities will dominate. Those unfortunate enough to be employed by the unsuccessful corporate groups will be out of jobs unless they are fairly experienced or have needed skills. After this time....
3. Physicians will face some layoffs in metro areas, even in primary care. The fuel for this is the need to be increasingly efficient so that your Health Company can bid the lowest and obtain the most covered lives.
4. Physician assistants and nurse practitioners will have urban opportunities for a few more years, depending on how fast their salaries rise in relation to physician salaries. Remember that cost drives the decisions of corporate medicine. The faster the rise and the greater the primary care excess in urban areas, the sooner they will face urban difficulties. PAs and NPs will continue to be pursued by subspecialists who find that they can see more patients and more complex patients, and keep more of the revenues, even though this means less demand for those of their specialty.
5. PA and NP folks and newer urban practitioners are also likely to have more evening and weekend hours.
6. More primary care and family practice physicians will join urban poverty practices, either to obtain jobs in urban areas or as a result of diversification of those completing training (more women and minorities)

There will be a need for practitioners in areas such as geriatrics, rehabilitation, preventive medicine, and mental health for the next 10 - 20 years. There will be increasing uses of urban physicians as reviewers and administrators. The demand for physicians and nurses who understand quality and can work with other physicians or administrators will skyrocket. Others who plan urban careers should consider some work in administration (MBA courses or degree) to anticipate work involving managed care administration and quality of care. There will be some primary care positions for teaching, care of the indigent, or prisoners. A few select subspecialties will be able to show their cost-effectiveness and may have open jobs in the metro areas, but these will be rare.

Current urban physicians and new primary care graduates will take some of the above jobs, some temporary jobs, or work weekends and evenings, in order to stay in metro areas because of lifestyle preferences and spouse needs. Most will eventually find full time employment as urban physicians. Situations like this already exist in Canada where doctors turn down $120,000 or more for rural practice opportunities to stay in Toronto and other cities doing irregular work for two or more years while making half as much. Others will live in the cities and commute to full or part-time rural positions.

Current family practice and primary care residents, if they choose jobs well, may be OK as they will have a few years of practice experience before the physician excess is felt in metro areas. When considering medical positions, residents should be sure to examine the physician-hospital relationship, the cooperation with other physicians and groups, the finances of the corporation or organization, its survivability, and the physician leadership of the group. Too many residents get information overload and make decisions by default. The first two interviews for a job or a residency almost always result in re-arrangements of priorities. When nothing measures up, it is time to keep looking and talk to an advisor.

What do you really want to do with your life? Being happy with what you do every day is most important. If your plans involve an urban location, the best choice is to predict which specialties and which health systems will do best in your eventual practice location. For those graduating in the next two years and choosing urban, they need to find a job and keep it and do well. Experience and connections do count when being evaluated by employers.

If times get hard for the company, the rule is that the last one hired is the first one fired. There will be less chance to change jobs and get a better deal after the next few years are over. Some will trade benefits and salary for longer guarantees and job security.

The situation for graduating students and their schools in 2001 is more difficult to predict.

Primary care choices are increasing to 60% or more of each graduating class. New physician assistant programs are opening. Specialist nurses and nursing faculty are facing pressures to leave inpatient care and go into ambulatory training and primary care careers. This is a relatively large pool of practitioners that could move into primary care in only a few years. The most difficult prediction to make is how much patients will continue to demand convenience in health care. If this continues, care will continue to be more expensive, with more ratcheting down by third parties and governments, etc. This increased demand will allow more to choose urban areas, but will businesses eventually revolt and force layoffs of the excess to save costs?

Emergency medicine in the large urban areas remain in the hands of ER physicians, but the trend is for less ER and more outpatient care. This continues to put ER and primary care in conflict over who will care for the outpatients after hours. Another difficulty in ER is what are ER docs going to do in large urban areas if they tire of seeing urban misery? Ob-Gyn will continue in demand because of the need for obstetrics and primary care, but it continues to be an urban specialty with continued training in high-resource urban locations. Training volume is down in many programs due to changes in Medicaid and this may have an impact on the value of new graduates and their starting salaries. Surgery is a mixed picture with some flexibility to move physicians around to meet various needs, but many areas face oversupply. Rural general surgery will be needed for the next decade or more as there are few sources of broadly trained general surgeons.

Internal medicine and pediatrics will continue to broaden their scope of practice to involve more primary care (gynecology, wider age range), but they will continue to choose mostly urban locations similar to those they trained in. Medicine-pediatrics will likely follow this path.

Psychiatry is the medical specialty that may present the most problems rural states. There are few psychiatrists providing care now and several planning to leave. Rural areas face geographic barriers and psychiatrists must cover large territories. This often does not allow them the luxury of colleagues or much time away. Commodities much valued by physicians and their spouses.

• All but the smallest rural areas have reversed population declines. Population increases are expected across the state. A significant portion of population increase will be in older adults and in migrant populations, both have increased needs for medical care. Without increased efforts directed at admissions and training, there will be a continued trend nationwide for less production of rural doctors. There will be continued retirements and deaths of physicians in rural areas. There could also be more turnover of rural physicians since current health policy changes lead to loss of ownership, a key retention factor in some studies. The lack of other opportunities may keep physicians staying longer in rural locations.
• Rural primary care practices will still offer better opportunities for autonomy, procedures, and self-direction, but only in larger groups of physicians or in integrated physician-hospital systems with effective leadership and expertise in management and negotiation.
• Rural areas face the dilemma of working with larger corporations for survival while potentially giving up their self-determination.
• Numbers are what count in negotiations and the groups and associations that have more patients will retain more control. Multiple networks of various types already are working in rural Nebraska and more will come and go and consolidate, similar to urban situations.
• There will be attempts at regionalization of some health care services, with some hospitals changing to primary care centers.
• There will be more confusion in smaller rural areas with managed care and health policy changes such as Medicare and Medicaid changes, restrictions, etc. Small rural communities will have more trouble holding on to their hospitals and physicians. Rural areas, already less visible as practice opportunities, will have to do much better to attract new recruits. Some graduating residents planning rural locations will have to find their own opportunities by working closely with communities in their final years.

Larger systems of towns from 15-25,000 will hold their own and expand and collaborate with each other and larger groups. There will be few and very competitive positions available in any given year in these locations.

Medium sized rural locations with 6-25 practitioners will have to work closely with other groups of physicians or local hospital networks to do well. A few will choose these practices each year.

Isolated sites in smaller towns may have some protection, but they will also have to work with others to get the leverage to negotiate well.

The smaller rural health systems which currently have two or less physicians will most likely be satellites of another larger entity or they will be without health providers. Some solo and small group physicians will continue, but they will have one or more contracted relationships with larger groups and practice management contracts.

There is no benefit in worrying. Worry never helped you during studying or other preparation. This is meant to be realistic information that can assist you with career planning. Look at this information and other sources of information. Be sure to talk to advisors, faculty, and physicians. Attend Recruitment Fairs, dinners, noon conferences, and other opportunities. Rotations allow visits and interviews and education on practice management, networking, and the cooperative efforts needed to do well. Participate in student associations to learn as much as possible about upcoming situations and to learn leadership and management skills.The key areas:

• Examine yourself to see what you really want to do for yourself and your family.
• Be more careful with scholarships, loans, overspending your budget, and other obligations that may be more difficult for your to handle in the future. Your finances, if not properly managed, will force you to give up your flexibility in location and career choice.
• Look carefully at spouse issues and anticipate the impact of spouse needs.

If you truly have a dream for a certain specialty or location, you still must follow your calling. It will still be possible to subspecialize or locate in even crowded urban job market, but if your career dream leads you into a more difficult employment situation, be prepared for it and be willing to accept the timing, the income, and the location consequences. Above all, don’t worry!!!

Too many students graduate and expect to be rewarded immediately for their long years of training. The fact is that many physicians and eventually all health practitioners may face a time of declining income. They may not be happy about this, but income does not equate with wealth.

Wealth is not what you make, it is what you do not spend!

Similarly happiness is not what you are losing, but what you truly value. Do not get any fixed idea of what you should make or compare it to national standards. Salaries vary tremendously for the same type work.. If you think that you should make what someone else does, especially when this is an average based on people with more experience, you will only be frustrated.

every chance to be truly happy.