Your Career Guide

Where the jobs are

While specialists are in high demand, primary care doctors can still find work—especially those willing to practice in Small Town, USA.

By Robert Lowes
Midwest Editor

What physician surplus?

Seven years ago, the federal Bureau of Health Professions estimated that the nation would have 80,000 excess doctors—mostly specialists—in 2000. Daunted by this projection and others like it, many hospitals reduced the number of positions in specialty residency programs.

The forecasters were wrong. Cardiologists, urologists, gastroenterologists, orthopedic surgeons—America can't seem to get enough of them. "We call it the revenge of the specialists," says Michael Taylor, executive managing partner of Cejka & Company, a St. Louis-based recruiting firm.

What's more, the conditions that created the demand for specialists aren't going away soon. Aging baby boomers will need them to maintain the health of hearts and other failing organs. With the downfall of the gatekeeper movement, boomers will find it easier to make an appointment with a specialist. And with employment high and more workers covered by at least some health insurance, most people will be able to order extra helpings of health care.

In contrast, the previously voracious demand for primary care doctors is now considered "stable" or "lukewarm." Their best bet may be to head for farm country or the inner city, where there's always a need for physicians. Georgia has 530 job openings, mostly in rural areas; Missouri has 406.

That's not to say specialists can have their pick of anyplace on the map. Coastal cities—preferred by many job seekers—are saturated with doctors, as are most cosmopolitan areas. "Your best choice is a Midwestern or Southern city with a population under 200,000," suggests Michael Taylor.

Okay, so you can't surf in Peoria. "But great opportunities are out there for all kinds of doctors," says FP David Sundwall, chairman of the Council on Graduate Medical Education. "Happiness depends on how flexible you are about location."

Here's a closer look at those great—and not so great—opportunities.

Some specialists can write their own ticket

It's taken specialists only five years to go from the starlings to the darlings of medicine. In 1995-96, only 28 percent of searches handled by Merritt, Hawkins & Associates, a physician recruiting firm in Irving, TX, involved specialists. In 2000, specialists accounted for 76 percent of searches.

Residency programs reflect this rebound. The number of doctors training to be cardiologists, for example, fell from 2,419 in 1994 to 2,012 in 1999, but was projected to rise to 2,109 during the current academic year.

Cultural trends and a graying, more disease-prone population—our median age will increase to 37.4 in 2010, compared with 30 in 1980—are putting many specialists in the catbird seat.

Cardiology: "There's a horde of 45-year-old men who see a cardiologist," says Mark Smith, vice president of Merritt, Hawkins' Atlanta office. Given supply and demand, Smith adds, recruiting a cardiologist is probably his company's toughest assignment.

Urology: This specialty is enjoying a revival because male baby boomers are hearing two unsettling diagnoses these days—prostate cancer and erectile dysfunction.

Dermatology: "It's hot," says Roberta Margolis, senior vice president of Weatherby Health Care, a recruiting firm in Norwalk, CT. "Boomers are very conscious of skin cancer, so they're having every suspicious mole removed. Plus, they want cosmetic procedures, such as chemical peels and skin lifts."

Gastroenterology: The number of doctors entering this specialty tailed off in the late 1990s due to declining reimbursement as well as a decision by most GI fellowship programs to switch from two to three years. However, increased awareness of colon cancer and other GI maladies is producing more gastro patients. "These guys can write their ticket," says Keith Borglum, a practice management consultant in Santa Rosa, CA.

Orthopedics: Many baby boomers who jog and roller-blade have a rendezvous with the pastimes' evil twins: worn-out knees and hips. Who are they going to call?

Primary care doctors: The bloom is off the rose

The bull market is for specialists only. Health care's appetite for primary care doctors has not only flattened but slightly declined, says Cejka's Michael Taylor. Mark Smith of Merritt, Hawkins adds that berths for FPs, internists, and pediatricians have become particularly scarce along the Eastern seaboard. "They're about 5 percent of our searches there," he says.

Recruiters hasten to add that the pendulum could swing in the opposite direction five years from now. At the moment, though, the outlook for primary care and its various branches is a mixed bag of nuts—some hard to stomach, some tasty.

General internal medicine:Here's a sign of the times: The internal medicine residency program at Barnes-Jewish Hospital in St. Louis is reducing the number of slots for doctors headed into primary care by almost 60 percent. Program director Daniel Goodenberger says this move reflects a reduced demand for internists as well as decreased interest in the field among medical students. "Our graduates find jobs," he says, "but usually not in great locations."

Family practice: Nobody's panicking at the American Academy of Family Physicians. "We're still in demand, although the frenzy for FPs that you saw five years ago has subsided," says AAFP president Richard Roberts.

Pediatrics:"While the job market is tighter for pediatricians, they haven't gone through the boom and bust experienced by FPs and internists," says Mark Smith. "There never was a binge here." The American Academy of Pediatrics acknowledges that the field is somewhat oversupplied, but notes that pediatricians are unevenly distributed, with rural areas and big-city ghettos shorthanded.

Obstetrics/gynecology: Demand for ob/gyns is strong, by all accounts, but not because delivery rooms are going full blast, says Washington, DC, ob/gyn Warren Pearse, editor of Women's Health Issues. "The number of births per year has nudged downward lately," says Pearse. "However, the gynecological aspect of our practice will flourish as the number of women between 45 and 65 skyrockets. This is another baby boom effect."

NPs and PAs will further cool the demand for primary doctors

Identifying trends in any industry can be a murky business, but one thing's for certain. "Market forces are more accurate in determining supply and demand than government measures, such as physician-to-population ratios," says David Sundwall of the Council on Graduate Medical Education, which advises the federal government on medical training and workforce issues. In the 1990s, COGME advocated pruning specialty residency programs based on projections of a physician surplus, but since those projections haven't panned out, the council is re-evaluating its recommendations.

Such assessments "relied on flawed, pseudoscientific formulas and ignored market forces," says Milwaukee hematologist Richard "Buz" Cooper, director of the Health Policy Institute at the Medical College of Wisconsin. "Some studies tried to come up with a number, for instance, by cataloging the prevalence of various illnesses, then calculating how many hours physicians would have to spend treating them," says Cooper, who is helping COGME re-examine the job market. "But that was all theoretical. Another study extrapolated ideal workforce figures from how staff- and group-model HMOs like Kaiser Permanente operated. But the staff model hasn't become the norm."

If those and other approaches hadn't ignored the reality of market forces, says Cooper, they'd have recognized that a go-go economy fuels higher demand for physician services. "Health care is not only a public good. It's also a consumer good. And rich countries spend more on it than poorer ones do."

Another trend also helps explain why dire COGME prophecies have fizzled: Physicians aren't the workaholics they once were. Younger doctors generally prefer to log fewer hours than their senior colleagues, and that's particularly true for women, who often choose shorter schedules so they can raise children. Add in the trend to earlier retirement, says Cooper, and you have a job market that can absorb a lot of bodies.

Given these factors, he predicts that medicine will experience a shortage of specialists 10 years from now. At roughly the same time, he sees a surplus in primary care. The reasons? Residency programs produced too many primary doctors in the 1990s. And now nurse practitioners, physician assistants, and nurse midwives are beginning to function as substitutes for them.

The meteoric growth of so-called midlevel providers can't be ignored. In 2005, NPs will outnumber FPs. Recruiters like Michael Taylor say that NPs, PAs, and nurse midwives don't appear to be taking jobs away from primary care doctors—yet. However, they're siphoning off patients with simpler illnesses and leaving the harder cases to doctors. Nurse midwives, for example, tend to handle easy deliveries, says Roberta Margolis. "High-risk deliveries go to the ob/gyns."

Cooper predicts that as the midlevel brigade gains ground, primary doctors will solidify their position by performing more high-tech procedures and supervising teams composed of their would-be competitors. "Doctors will redefine their role," he declares.

Follow the patients, but where are they going?

As physicians look at their career prospects, they must weigh not only the fortunes of a particular specialty, but the imperative of geography.

Recruiters offer a rule of thumb—look outside large metropolitan areas, particularly those on the overdoctored East and West coasts. There are exceptions, of course. "If you're a doctor with a unique skill set—such as pediatric oncology—doors may open for you anywhere," says Michael Taylor. But lacking such a niche specialty, it may be foolhardy to start a new practice in a place like Minneapolis or Boston, says Taylor. Academic medical hubs seldom have a shortage in any specialty.

When recruiters advise physicians to head to the hinterlands, they're merely echoing what research says about the nation's need for doctors. The South, stretching from Virginia to Texas, has 35 percent of the nation's population. It's also home to 44 percent of the people who, according to the government, are underserved by primary care doctors. Alabama's population is about half that of New Jersey's, for instance, but Alabama's need for primary care doctors is three times as great.

A look at the number of doctors per 100,000 in population reveals a similar pattern. The 10 states with the scantiest ratios are Idaho, Mississippi, Alaska, Oklahoma, Wyoming, Iowa, Nevada, South Dakota, Arkansas, and Indiana. Except for Alaska, they're sandwiched between the East and West coasts. Massachusetts has 348 doctors per 100,000 people; Idaho has 144.

Physician-poor doesn't mean economically poor, though. Many of these states happen to be experiencing boom times. From 2002 to 2005, the Pacific Southwest, led by Nevada, is expected to record the fastest annual growth in gross domestic product—3.7 percent, according to Standard & Poor's. The Southeast will be second, with 3.4 percent. These strong regional economies go hand in hand with population growth. The US Census Bureau projects that, from 1995 to 2025, population growth in the West will be nearly twice that of the rest of the nation. And the South will continue to be the country's most populous region, draining citizens from slow-growth New England and the Midwest.

The implications of these demographic trends are clear. If patients are moving to Nevada or Georgia, doctors need to follow. Doing so makes financial sense. While you might prefer to practice in San Francisco, you're more likely to grow wealthy in Athens, GA.

"Practices in small towns often pump up their starting salaries and even give signing bonuses to convince doctors to locate there," says Cejka's Taylor. "While the starting salary for an FP in the San Francisco Bay area might be $120,000, it could be $125,000 or higher in Athens."

Salaries also go noticeably farther in nonmetro areas, because the price of everything, from houses to groceries, is lower. The cost of living in Athens is 71 percent of the nation's average and less than half that of, say, San Jose, CA. Such financial realities give doctors all the more reason to keep an open mind about practice options.

"These days, you need to be more flexible about where you work and with whom you work," says Michael Taylor. "But if you do what you love and do it well, opportunity and income will follow."

Switching to an e-health career requires a tolerance for risk

David Gonzalez, a family physician in Hillsboro, OR, caught computer fever in the 1980s and never recovered. He even invented his own electronic medical record program.

He also got fed up with clinical medicine. "My income was shrinking, and HMOs were putting more restrictions on how I practiced," says Gonzalez. "But I was convinced that computer systems could address some of these frustrations."

Pushed and pulled, Gonzalez left his job at the Portland Clinic in June 1999 and joined MedicaLogic, an EMR company that later merged with Medscape, a health information Web site for physicians and patients. "I'm having so much fun now," says Gonzalez, who devises ways to collect and display patient data in computerized charts.

Gonzalez is one of hundreds of doctors who've cast their lot with e-health companies, particularly Internet-based ventures. He's also one of the luckier ones. Wall Street has devalued health care dot-coms—like dot-coms in general—because too many are losing money. As a result, some physicians who quit medicine to find their fortune on the Internet are sending out CVs again. Job instability is just one warning light that doctors should heed as they consider following in Gonzalez's steps.

To begin with, not every doctor is high-tech material. "It's not enough to say, 'I can help a dot-com understand how doctors work,' " says Boston psychiatrist Gigi Hirsch, CEO of MD IntelliNet, a consulting and placement company. Rather, she says, e-health companies are keen on upper-level leaders such as medical directors of hospital systems and insurance companies, who understand the business side of medicine. It might be a feather in your cap if you helped an organization implement an EMR system, adds Tom Callaway, an executive recruiter with Los Angeles-based Korn/Ferry International.

Doctors joining the e-health industry can expect to earn at least $100,000 to $150,000 in base salary as well as stock options, says Callaway. "If the company is in the development stage with little or no outside investment, you can ask for a bigger equity stake—maybe 2 to 4 percent," he says. "That could translate into millions of dollars on paper. However, if the company already has a product on the market, and its stock is publicly traded and rising in value, your options will probably equal just 30 to 50 percent of your salary."

In exchange for the compensation package, count on long hours. Fort Worth oncologist William Jordan, who joined a Berkeley, CA-based EMR company called iKnowMed, logs 80 hours a week for his new employer, in addition to seeing patients for 20 hours. He spends three to five days a week on airplanes.

By all accounts, there are fewer job opportunities in the industry than a year ago. "The Internet is not the gold mine that people thought," says C. Peter Weagemann, executive director of the Newton, MA-based Medical Records Institute. "The shakeout will continue, and even large companies such as WebMD aren't safe."

So how can you tell if a prospective e-health employer is safe? Answer these questions, says Tom Callaway:

• Does the company's product solve a problem so serious that people will spend money for the solution?

• If the product is aimed at doctors, is it easy to use, and does it fit into a practitioner's workflow?

• Does the company have ample funding to survive the initial losses typical of any start-up?

• Who are the investors? Pros accustomed to placing careful bets?

• Does the company have experienced leadership with a record of success? "An untested CEO isn't worth the risk," says Callaway.

If you're entertaining a job offer from an e-health firm, ask yourself some tough questions, too. Are you ready to give up the adulation that goes with a white coat to become a team player, reporting to someone possibly much younger, and with far less education? "You need to check your ego at the door," says Callaway.

And are you switching careers for the right reasons? It's shortsighted to sign up with an e-health company just because you're disenchanted with medicine, warns William Jordan. You must feel a passion about using computers to improve health care.

"Find a job that really grabs you," says Jordan. "Doctors sometimes jump ship to anything that will get them out of the patient care rat race. But there's a rat race in every field. So be in one you like."

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Robert Lowes. Where the jobs are. Medical Economics 2001;1:18.