The Future of Doctors

Dr. Manish Shah is trying to figure out why Thelma Shoe's nose keeps bleeding. At least once or twice a week, the 73-year-old has been getting nosebleeds that last up to an hour. Shoe's no stranger to the clinic; she has emphysema, cirrhosis of the liver (from medication she took for tuberculosis), and has already had heart-bypass surgery.

Shoe was Shah's first patient at Duke's outpatient clinics three years ago, when he was a first-year resident, and the two have established a comfortable rapport. "Oww, that hurts!" she says, wincing as he inserts an otoscope into each nostril. "That hurts? I'm not even touching you," he counters as he peers into her nose. Shah suspects that the bleeds are triggered by her dry nasal cavities and recommends an over-the-counter nasal saline spray, available at any drugstore. He spends a few more minutes chatting with Shoe, then reminds her to return in a few weeks for a flu shot.

This is Shah's classroom, and patients like Shoe are his textbooks. Now in his last year of residency in internal medicine, he spends two afternoons each week at the clinic, seeing patients under the supervision of an attending physician who must approve every medical decision he makes. Only the short length of his white coat betrays his status as a doctor-in-training--an M.D. after four years of medical school, he examines patients, writes prescriptions, orders tests and fills out insurance forms.

Even at a hospital like Duke, where the emphasis is on specialty and cutting-edge medicine, almost half the 130 residents in the department of medicine are training to become primary-care physicians. This is the future of health care--a back-to-basics return to the profession's roots, when small-town doctors made house calls and were expected to deal with everything from births to a burst appendix. "Our mission is to train residents in the reality of where medicine is practiced, and that's in the outpatient setting," says Dr. Barton Haynes, chairman of the department at Duke.

Shah is one of five residents participating in an innovative program that allows him to act as a primary-care physician in an HMO. All five doctors share a PCP number and take responsibility for 10 patients each week. "When I went to medical school, I don't recall learning anything about managed care," says Shah. "But working here has helped me to think about prevention more. Now I ask my patients about health-maintenance things like diet, nutrition and exercise."

The forces that have changed Shah's career path are changing Duke as well. In the department of surgery, the faculty once relied exclusively on hospital patients as case studies for teaching residents, but the average number of days that patients spend at Duke has dropped from 8.3 to 6.9 in the past five years. That prompted administrators to scrap plans for a nine-story inpatient addition to the 1,124-bed hospital and opt instead to construct the ambulatory surgery center, completed last June, which houses seven operating rooms for same-day surgery procedures. "We spent hours deciding [on the] best way to involve the residents there, because that's the way medicine is going--up to 70% of surgery is going to be done on an ambulatory basis," says Dr. Robert Anderson, the surgery department's chairman.

As HMOs shift patients away from long stays at hospitals and shrink reimbursements for services, Anderson and Haynes are seeing not only their patients but their revenues trickle away. Anderson estimates that the faculty makes 25% less money now for the same amount of work than it did several years ago. That devaluation carries over to the residents; unlike medical students, the 800 residents at Duke are paid, up to $40,000 a year. It costs Duke an additional $100,000 a year to train each one. Traditionally the funding for residents has come from faculty members, who contribute 20% of their earnings in the clinics to support education efforts, and from subsidies by the Federal Government through Medicare.

The current Medicare-reform bill being debated in Congress, however, proposes abolishing this subsidy because other insurers are not obligated to support medical education. Duke's government-relations representative, Paul Vick, is hoping to impress upon Congress the importance of a fiscally sound hospital with a steady flow of patients running a good residency program. "You can't just build four square walls and put in a faculty," says Vick.

Anderson and Haynes are bracing for what could be an even leaner future. Already they have begun to spend more time at their least-favorite activity: fund raising. Their other, even more painful, option is to train fewer doctors. The triage has already started. "With the advent of angioplasty and better medications, for example, we did not feel that the world needed more cardiothoracic surgeons," says Anderson. So Duke now admits three new cardiac-surgery residents each year instead of four.

Will such measures be enough? As revenues shrink, the department heads are forced to dip deeper into the coffers. "At some point," says Anderson, "we will have to say we do not have enough funding to educate this many residents, and we may have to cut back more."

--By Alice Park

http://www.time.com/time/magazine/article/0,9171,989319-2,00.html