Their names are Jennifer, Lisa, Coralli, Marc and Wendy. They are five young medical students who were graduated from Boston University Medical School last week--just as President Clinton seems poised to dramatically revamp their chosen profession.
To these newly minted physicians, the deliberations of the Administration's health care reform task force are like the first rumblings of an earthquake that threatens to send giant fissures through the foundations of their lives. Understandably, they are nervous about their futures.
When they entered medical school four years ago, these students were embarking on an occupation that offered them the personal satisfaction of healing people, the professional autonomy to prescribe whatever treatment they deemed necessary and the promise of a handsome income.
Now, as they brace for the changes that would be produced by the President's reforms, they know that they probably are going to have to settle for less money and less professional freedom than they once expected.
And even though they see a need for reform, they are stubbornly resisting Clinton's dictum that the medical profession needs more general practitioners and fewer high-priced specialists. Of the five students, only Wendy Buffett, 30, of Arlington, Mass., aspires to be a family practitioner.
About 15,500 students will graduate from the nation's medical schools this spring, many driven by a humanitarian impulse. Yet most will find themselves saddled with huge student loans to repay and weighed down by misgivings about the direction in which medicine is headed in the United States.
The five students interviewed by The Times expressed the hopes and fears of a new generation of physicians as they anticipate a massive government effort to reform the medical delivery system.
Comfortable, Not Rich
When today's graduates were growing up, most often the local doctor was the person in town with the nicest house and the most expensive car. In 1991, doctors earned an average of $170,600 a year--more than 11 times the national average.
But the President's efforts to cut medical spending, combined with insurance practices that already are forcing doctors into group practices or salaried positions with health maintenance organizations, are causing the students to trim their earning expectations.
"My salary expectations are certainly lower than generations in the past," said Marc Mitchell, 29, of San Francisco, who expects to specialize in internal medicine. "My expectations are to make a living, to be comfortable. But they are certainly not in the realm of hundreds of thousands of dollars or millions of dollars, as in the past."
Yet while most medical students--like Mitchell--will tell you that they expect to earn less than their predecessors, Dick Green, spokesman for the American Assn. of Medical Colleges, said many of them still secretly hope to get rich.
As Green put it: "They say, 'People aren't going to make as much money,' but they are thinking, 'I am going to.' "
No matter what they expect to earn, the students seem to find it necessary to defend physicians who earn big salaries practicing medicine.
"A lot of the time, when people talk about doctors' salaries, I resent it," said Jennifer Lynch, 22, of Clearwater, Fla., an outspoken student who intends to specialize in one of the profession's highest-paying fields, obstetrics and gynecology. "They imply that that's why they are a doctor, to make those salaries. It's not."
She noted that doctors often work 80 hours, or twice the normal workweek.
Even those young physicians who hope to combine work and family see themselves making a better living than most people. One of them is Buffett, a fourth-year student at Boston University.
"I expect, actually, to be able to work half-time and still make about $50,000 a year," she said. "That's in my fantasy. I'm talking about being part of a two-income family."
While these students say they recognize that there will be a growing number of openings for doctors in health maintenance organizations, none of them expressed any interest in working for an HMO, which usually pays less than other alternatives.
As these medical students are keenly aware, physicians are widely being blamed for many of the faults of today's health delivery system. Lynch said she has been disturbed to observe how many people have "a love-hate relationship with their doctor."
"Individuals, when it comes to their own care, love their doctor," she said. "If they are sick, they want you to go the full 10,000 miles to make sure that they are going to get better. If it's their loved one, then do everything you can.
"But when it comes to talking about doctors as a group, we're sort of like the devil. We all charge exorbitant prices. When they talk about doctors as a group in general, we're the evil that needs to be conquered.
"Starting out, I sense both of those things, and it makes me feel apprehensive. I don't know which direction the reform is going to go in--how people are going to feel about their doctor after this."
Likewise, Lisa Lee, 24, of San Jose, whose interest tends toward radiology, said she is so disturbed by the fraying reputation of physicians that she wants to speak out.
"Because I respect my colleagues," she said, "it's made me want to have them be seen in a better light by the public--to see what it is they actually do, the hard work that they go through, the love they have for the people that they treat. I think that's something that people don't see sometimes when they are not in the field."
Trends in Medicine
At the same time, the students say they recognize why medicine is gaining a bad reputation, and they welcome reform.
Even as students, they have encountered many of the problems inherent in today's system--excessive paperwork, second-guessing by insurers and the threat of malpractice suits.
Coralli So, 24, an aspiring surgeon from Seven Hills, Ohio, says she knows well the frustration that her parents--both physicians--have experienced in recent years as insurance companies have become more aggressive in challenging the medical opinions of doctors.
"They feel their autonomy is being taken away," she said, referring to her parents. "You can't get certain tests or certain policies won't cover certain things that are definitely necessary to benefit your patient."
Lynch said that because of the frustrations that come with practicing medicine these days, many experienced physicians have told her that if they had it to do over again, they would surely choose another profession.
"The paperwork and the stresses of money--that's not why we're in it," she said. "These are like extraneous things that we don't like to have to worry about. We are a very idealistic people. That's why we went into this field. The very basic thing of taking care of people--that's what we always wanted to do."
The students cited a recent poll of U.S. physicians published in the New England Journal of Medicine that found 78% had problems getting reimbursement, 73% had patients who could not afford needed care and 53% complained that insurers were reviewing their clinical decisions.
More than their predecessors, medical students who are graduated now have been taught to conserve medical services to hold down costs and avoid clashes with insurance companies.
"Our generation is more trained to think about the things we do--don't just do them by rote--than previous generations," Lynch said. "Honestly, we are told: 'Think about a test. What are you going to do with the answer? If you aren't going to do anything with the answer, don't give the test.' "
Nevertheless, the students said that the ever-present threat of malpractice suits makes it difficult for doctors to ration services.
"Some things you have to do just to cover your rear end," Lynch said.
Even though the students say they can appreciate the complaints of older physicians, they see themselves as different from their predecessors and more in tune with the Administration's proposals for reform.
"Our generation, the younger generation, is more flexible and more adaptable to reforms that will be upcoming," So said. "My parents are both established physicians and I think it's more difficult for them and they are more discouraged. But I think today's generation (is) more optimistic."
Unlike older doctors, Buffett said, many younger ones see the latest wave of criticism as an opportunity for improving medicine in ways that have been disregarded by the previous generation.
"I went into medicine fully expecting it to change," she said. "I sensed it was on the threshold of change, that things were going to open up, that people would be more receptive to alternative health care, holistic health care and also, eventually, national health care."
Because of what they see as a generation gap in medicine, the students say they worry that the American Medical Assn. and other established groups are not representing their best interests in Washington. They think the President's wife and chief health care adviser, Hillary Rodham Clinton, ought to listen to the views of medical students before deciding on a health care reform plan.
Advising the Clintons
If the First Lady were to seek their advice, the students said they would tell her that the President's reform package ought to provide for increased access to care for the uninsured, preventive medicine, controlled drug prices and limits on awards in malpractice suits.
Ironically, these proposals do not differ markedly from those put forth by the AMA and other groups representing older doctors.
"Certainly malpractice plays an important part in the balancing, in holding doctors accountable," Mitchell said, "but when you have these overwhelming, these exaggerated compensations for situations like in obstetrics, which are outside of people's control, that's what increases costs."
From their own experience as student doctors, they say they know that there are ways to ration care and save money without compromising the interests of patients. In particular, the medical students cite a number of ways to economize on the care that is lavished on elderly patients during the last days of their lives.
Boston University requires fourth-year medical students to work in a program that provides home care to elderly patients, and the students said they think that the program--perhaps relying on physicians' assistants, not doctors--could become a model for all other hospitals. The reason: It provides low-cost care and allows people to die in a dignified way in their own homes.
Paying Off Big Debts
When they talk about the need for reform, the students mention one problem that is not often raised by older doctors: the high cost of a medical education.
Even though compensation for doctors may be declining, the cost of a medical education continues to skyrocket. Annual tuition at Boston University is about $25,000. As a result, students are emerging from medical schools with bigger debts than ever.
According to the Assn. of American Medical Colleges, more than a third of all graduates of private medical schools this year will have to repay student loans in excess of $75,000. According to the students, the accumulated debt of BU graduates often ranges between $100,000 and $200,000.
In the past, aspiring doctors freely took on big debts, confident that their future salaries would enable them to pay them off quickly. Now, students say they fear that if health care reform drastically limits their income, it will be hard for them to repay the loans.
"It's not like as soon as 'M.D.' is attached to your name, you're wealthy," Lynch said. "You go through years of training after that where, for the hours that you're working, you are relatively poor. You are working 60 to 80 hours a week, making $22,000 to $28,000 a year as a resident with loans of $100,000 or more that you're paying back. That's not wealthy. Some loans can be deferred through residency, but others can't. You have to start paying them off right after graduation."
For that reason, the students say they want Clinton's health care reform proposal to include new financing for medical education or perhaps a program offering to forgive education loans for those who sign up for national service.
The students say they understand the need for more general practitioners in the United States. Yet when it comes to choosing a future for themselves, they are inclined to go into high-paying specialties.
Of a class of 147 about to graduate from Boston University, the students said, only about 50 are going into primary care types of medicine--general practice, internal medicine or pediatrics. Nationally, experts estimate that only about 15% of this year's medical graduates will choose primary care.
One explanation for this trend is that graduates often select a high-paying specialty so they can pay off their education debts faster. But the BU students insisted that they were just following their personal interests.
In fact, So said she picked general surgery even though she expects health care reform to limit specialists' incomes. "To me," she said, "that's not one of my main concerns. I chose to go into the field of surgery because I desire to help people, and I feel that health care reform is necessary to try to equalize the distribution of funds so all physicians could benefit."