Is an M.D. worth it any more?

Ever since she was a child, Dr. Yvonne Mason knew she would be a doctor. With her family's strong support behind her, she toiled many sleepless nights at her studies at Hunter College and Harvard Medical School in an effort to reach her goal.

In mid-1994, as the end of her residency at New York's Columbia-Presbyterian Hospital neared, Mason eagerly awaited the opportunity to finally practice as a full-fledged anesthesiologist. "Like everyone else, I thought, I'm a doctor, I shouldn't have a problem finding a job, but no one was grabbing me up," says a thirtyish Mason, who holds a master's degree in public health as well.

The market for anesthesiologists was bleak, Mason explains, and she, like many of her colleagues, faced stiff competition in a city where many hospitals were not hiring due to lack of funds. Seven months before the completion of her residency, the Brooklyn native mailed out 40 resumes to local hospitals. But solid job offers were few and far between.

With a seven-year-old daughter to care for and student loans to pay, Mason briefly considered several unconventional options, such as freelancing her services to local clinics. In the end though, she received five job offers, accepting one from Brooklyn Hospital. The unexpected difficulties she encountered in trying to carve out a successful career in the midst of a rapidly changing industry have not dampened her enthusiasm for what she still regards as her calling. As for what lies ahead, Mason says her success as a doctor is not a finite destination, but something for which she continually strives.

Young doctors like Mason are getting easier to find these days. Thanks to managed health care, the once predictable guarantees of independence, prosperity and prestige are no longer in the offing. Thus, those entering medicine today tend to be motivated more by altruism and a true desire to serve than by money. Mason, for example, was lured to the profession by traditional idealized notions. Like many before her, she finds personal success in the faithful discharge of care and the knowledge that she provides comfort to the needy, despite the cost.

As managed health care transforms once autonomous professionals into "employees," the demand for fewer specialists and more generalists increases and doctors are racing to keep up. But perhaps more importantly, they are being forced to adapt their goals and expectations as the image and the options for physicians go through a dramatic overhaul. Adapting, for some, is proving hard to do.

A stubborn resistance to change has already caused some doctors to abandon their practices altogether rather than give up their independence. In the end that may be shortsighted. "We need to protect our patients," says James Harold, a Baltimore psychiatrist who advocates the if-you-can't-beat-'em-join-'em approach to tackling the managed health care behemoth. Harold says many blacks on Medicaid and Medicare will find fewer black doctors if those doctors don't become more proactive. In an effort to galvanize strength, Harold, along with a group of other psychiatrists, formed the partnership Urban Behavioral Associates, which contracts with the Baltimore Hospital Liberty Health Systems.

Others - particularly those still drawn to medicine for the money - are less conciliatory. Six - digit salaries have long been a major enticement to medicine, and with good reason. Burdened with student loans, the average young doctor leaves medical school with a debt load of $100,000, the equivalent of a small mortgage. "Those thinking of entering the profession must be clear about what drives them," says Dr. Gregory Morris, a health care consulting partner at Ernst & Young L.L.P. in Atlanta. "If you are drawn for income potential, status, independence and autonomy - some of the strongest motivators - then you should reconsider."

Others agree. "Being a doctor is going to get worse before it gets better," warns Leonard Yaffe M.D., health care analyst at Montgomery Securities in San Francisco. "My concern is that we will make it so unattractive that the applicants will decline in quality and quantity by the time we do anything about it."

But students considering the field should not be discouraged by disgruntled doctors or recent efforts by some to reduce medical school admissions by 20%. What they do need to be is realistic about what it takes to become a physician and what one's career options are once that medical degree is signed, framed and ready to be put on display. If you have the science and math acumen, a capacity and enthusiasm for difficult work extended over long hours and can work efficiently under heavy responsibility, the field may be right for you. Furthermore, if you are African American to boot, the field desperately needs you.

THE NEED FOR MORE

BLACK DOCTORS

Although newspaper headlines heralded the record number of medical school applicants in 1995 - more than 46,000 - there was a 1.7% decline in the number of black applicants. Of the 3,595 blacks who applied to the nation's medical schools last year, almost 40% were accepted, and that's not enough.

The search for minority physicians available to improve the health care of the poor and to practice in underserved - largely black - communities, began in the early 1970s. Despite recent attacks on affirmative action, that search continues. In 1991, the Association of American Medical Colleges (AAMC) launched Project 3000 by 2000 to combat the lack of minorities in U.S. medical schools. Its goal is to have at least 3,000 of the matriculating medical school students be composed of underrepresented minorities - African Americans, American Indians, Mexican-Americans and mainland Puerto Ricans - by the year 2000. The AAMC works with local school systems and colleges to improve educational opportunities and prepare disadvantaged groups for careers in medicine. The project is close to reaching its goal. Last year, 2,010 designated minorities entered medical school: 1,290 were black, almost 800 of whom were women.

THE ROAD TO AN M.D.

The road to practicing medicine has always been among the longest and most daunting of any profession. Those considering medicine as a career must determine if they have the intelligence, scientific aptitude and inner strength that are essential for success.

To remain competitive, minority students need the educational support that concentrates on math and science in order to prepare for college entrance exams, the Medical College Admissions Test (MCAT) and, ultimately, the national medical boards, all standardized tests where African American results pale in comparison to those of whites, says Arthur Hoyte M.D., assistant professor at Georgetown University School of Medicine and director of the office of minority student development. Going to the right undergraduate school helps - and that doesn't mean just Harvard or Yale.

Xavier University in New Orleans has developed an impressive reputation in the medical community. On average, 70% of Xavier's pre-med seniors are accepted to medical school each year, making the historically black college No. 1 in the nation for African American medical school placement. J.W. Carmichael, a pre-med advisor and chemistry professor who for the past 20 years has guided Xavier's M.D. hopefuls, says black students must still be good enough academically to survive. But grades aren't everything.

"Anybody who has their skills cultivated can compete," Hoyte insists, adding that at some medical schools, the interview view alone can mean the difference between acceptance and rejection. During the interview, African American students should seek to highlight their leadership skills, community service and co-curriculum activities, he advises.

M.D. AT LAST

For many, getting into medical school is not as difficult as landing plum residencies, where grades and, more importantly, recommendations from medical school professors and deans make all the difference. For African Americans, this can be particularly tough.

According to one doctor, who insisted on anonymity, "We have to play by the rules. We must get the best grades and go to the best schools in the hopes that we are selected. We don't have the fathers and grandfathers - those generations of doctors who can open doors for us and be mentors," says the New York surgeon. "The thought is that we're not supposed to be here anyway, so why help us."

Those pursuing primary care (these areas usually include internal medicine, pediatrics and obstetrics and gynecology) should expect to spend three-to-five years in residency or on-the-job. In the age of HMOs, primary care specialists are in the greatest demand a plus for African Americans, who have always pursued these areas in great numbers. Residencies in some of the other, more lucrative specialties such as neurology or plastic surgery can last as long as six years. Residents earn $25,000 to $40,000 a year, depending on their specialty, geographic location and years in training.

Fellowships or sub-specializations take another one-to-five years to complete. For example, an Ob-Gyn might pursue a fellowship in fertility, or an internist will become a fellow in endocrinology. Some medical experts say that while fellowships, currently optional, they will become an increasingly important credential as health maintenance organizations require them. Fellowships pay in the $30,000 to $40,000 range, depending on specialty and location.

ONCE IN PRACTICE

For many black doctors in private practice, racism and discrimination against their poorer, sicker patient base - who are deemed by HMOs to be highrisk, thus not cost efficient - proves an insurmountable barrier to their participation in HMOs.

"There have been instances where a physician has been to the top undergraduate and medical schools and has prestigious residencies and fellowships and has been told that he or she was noted, says Yvonnecris Veal, president of the National Medical Association. To counteract the backlash, black doctors have been seeking cooperative partnerships amongst themselves to handle the large African American patient population that is often forsaken without them, she adds.

For those who do end up working for HMOs, the positives include less paperwork and decent hours. On the downside, HMO physicians must grapple with paper patient loads and tough requirements instilled by the HMO - namely, keeping costs down while administering quality care. And, of course, there are capped fees.

Things have changed, but not necessarily for the worse, says Ernst & Young's Morris about the managed health care landscape. Morris, who has held senior medical director positions at Cigna, Metlife and Blue Cross/blue Shield in Atlanta and Washington, should know. In 1985, he gave up his staff physician post at Emory University in Atlanta and a nephrology (study of the kidney) fellowship at the University of Texas to become associate medical director at Health America, an Atlanta HMO "I made a decision early on that there were other things I could do besides treat patients," says Morris, who wanted to have a greater decision-making role in the care of patients.

He sees today's medical profession as a team-oriented "sport" that will be played primarily in large HMOs, hospitals and physician management companies. Independent practice is quickly becoming extinct, but there are other medical career opportunities that show promise. Most of these, however, lie in HMO administration rather than in patient care.

REALIGNING THE MARKETPLACE

Charles Kennedy saw the managed care handwriting on the wall while a student at the Charles Drew Medical Education Program at UCLA. The signs were clear: the age of independent practices, a la carte fees and comfortable autonomy for doctors had all but vanished. Not wanting to be "just another doctor" in California's managed care system - the nation's HMO bastion - Kennedy decided to diversify his skills.

In 1992, two years after completing his internal medicine residency, Kennedy entered the M.B.A. program at Stanford. "I knew that when managed care became the dominant way doctors were paid, it would have dramatic implications for doctors and job security," says the 33-year-old, Hayward, Calif., resident.

Now as a senior consultant with A.T. Kearney in San Francisco, Kennedy advises hospitals, insurance companies, pharmaceutical firms and academic institutions on management and medical issues. His $100,000 internist salary jumped slightly (some consultants make $150,000 or more), but Kennedy insists it was not money that drove him into consulting. Rather, it was the security of knowing he will always be a player.

"A physician who has a business background as high as his or her M.D. will be valued in a managed care system, and no one will question my business or medical credentials," he says.

Yet, Kennedy, who was medical director at a small Berkeley health facility while a resident, and who practiced at a Kaiser Permanente HMO as well, has not abandoned his physician's role. He continues to practice part-time, citing a moral obligation to care for patients. "I'll never forget what medicine is all about, Kennedy says. "I'll lose the value of the profession if I stop being a physician."

As managed care companies continue to realign the marketplace, wooing general care physicians, high-priced specialists, such as cardiologists and orthopedists, are feeling the pinch. Internists, pediatricians, Ob-Gyns and psychiatrists - the primary care front line - have become managed care "gatekeepers," entrusted to absorb many of the responsibilities of the specialist and make fewer specialist referrals as a result. Thus, unlike specialists, they have lost little in terms of salary.

Other specialists, however, continue to see HMOs, with their primary care armies, as a threat not just to their more specialized practices, but to the sanctity and appeal of the profession as a whole.

Despite the ongoing debate and infighting, there are legions of young black students who are intent on practicing medicine with unswerving passion and commitment. Tanya Savage, a third-year medical student at Howard University College of Medicine in Washington, is one of the soldiers.

As a child growing up poor in Pensacola, Fla., Savage endured an unnecessary tooth extraction and fillings because the dentist wanted to increase the bill. Trips to Burkina Faso, Africa, and Austria while in college convinced the 29-year-old there had to be a bridge between the lack and abundance of health care. "I've seen the best of care, and I've seen the worst of care. My objective is to give high-quality health care to those who cannot afford it." Savage plans to go into internal medicine and one day open a free clinic staffed with volunteer medical professionals.

So far, she has not thought twice about pursuing medicine, despite the hard work, long hours and declining pay scales she knows lie ahead. "There seem to be few benefits, but every time someone asks for you because you're a good doctor, or you give somebody hope, those are the times when I know that I'm doing what I'm supposed to do."