Southern California Physician interviews physicians just getting settled in medicine. Generally, they like their work (and their time off), have warmed to managed care and see opportunity in technology.

Make no mistake about it. Andrew Corr, MD, loves his job. The Riverside-based internist says he can't think of anything else he'd rather be doing and sees no reason not to continue practicing medicine as he does today well into the future. His enthusiasm is evident when he talks about how content he is with his professional life and his place in the medical group.

But Dr. Corr, 39, is like many physicians of his generation in that his love of medicine is his love of a job. For many under-40 doctors, medicine is just that: a job, not a calling.

The distinction is clear and Dr. Corr is uniquely qualified to point it out. He comes from a long line of physicians--including his father and grandfather--so he has seen firsthand the relationship older-generation physicians had with the field. "They just loved medicine," he says. "I don't love it as much as they did."

What's changed? Physicians and medicine both, of course. Young doctors face administrative hassles that their older peers never imagined in their worst professional nightmares. But they also spend more dinner hours at home with their families and actually take vacations where they don't spend time on the phone with frantic patients.

"A lot of older doctors got calls at home and didn't seem to mind," Dr. Corr says. "But I wonder how much of the stress that produced translated into their bedside manners. I think it's a give and take."

Work-Life Balance
Carl Knopke, MD, 34, is a family practice physician based in Riverside. His view of personal time typifies the way young doctors tend to balance their commitment to patient care and their need for time off. The key, he says, is understanding that physicians don't just want time off--they need time off. That's something that's changed in comparing the younger and older generations of doctors.

As medicine becomes more of a business and less of a mission, its practitioners treat themselves more like businesspeople and less like missionaries. "Time to myself is very important," Dr. Knopke emphasizes. "I am just now getting to a place in my career where there is the option to take more time off. Optimally, I would like to be able to take long weekends on a regular basis."

Taking breaks from work is a learned behavior--and one that many of Dr. Knopke's colleagues need to relearn. "I was talking to a surgical associate of mine a couple of weeks ago," he recounts. "Surgeons are notorious for working extremely long hours in residency. I am convinced that by the time they get out of residency, they have forgotten how to take time for themselves. To a more limited extent, I think all doctors are like that. They have spent so much of their time in training for their careers that by the time they are done, they do not know how to do anything else. Doctors as a group need to learn to take more time off."

That's exactly why Brian Bearie, MD, medical director and chair of the emergency department at St. Bernardine Medical Center, San Bernardino, chose emergency medicine. "It's shift work," he says. "And most people who gravitate to it greatly value their personal time. Most of us don't even carry pagers."

The arrangement gives Dr. Bearie, 33, plenty of time to travel and, as he puts it, "go to Mammoth for three days of snowboarding." He notes that medical school graduates pursuing residencies in emergency medicine have the toughest time finding open slots. "There were more of them interested in emergency medicine this past year than in any other specialty," he reports. "The generation that's coming up and joining the physician ranks sees it as an opportunity to be a doctor, but still have a real life."

That elusive "real life" is also the reason Brian Eichenberg, MD, a plastic surgeon in Temecula, chose his specialty. The 37-year-old likes having a set schedule and being the king of his professional castle. "My family time is very important," he says. "It's the main reason I am in my profession. I want to spend more time with them and the position I am in makes it possible."

Irritants and Disappointments
Another benefit of time at home, of course, is time away from the things doctors don't like about medicine. Young physicians find certain business aspects of the profession particularly frustrating and disappointing. For 36-year-old Scot Richardson, MD, a Ventura neurologist, those irritants include the cost of insurance for his practice staff and office overhead. And, of course, there's reimbursement. "All of our contracts with private companies are based on the Medicare fee schedule," he says. "But Medicare is threatening a pay cut over the next few years, which means an across-the-board cut."

The medicine-as-business philosophy also has troublesome elements for Dr. Knopke. "I would like to make medicine more customer service-friendly," he says. "We should be able to get people in and out of the office in a timely manner and provide the services to our patients that they expect. Probably my biggest disappointment is with how difficult that is."

He also finds fault with the costs and burdens of regulations, such as the Health Insurance Portability and Accountability Act. "Most people do not understand HIPAA," Dr. Knopke says. "And it has made records requests from other physicians very difficult. The whole process has caused more problems than it has solved."

Finally, it's no surprise that the malpractice liability environment bedevils physicians young and old. "It forces us to practice defensive medicine, which is very inefficient and poisons the relationship between doctors and patients," Dr. Corr says. "Any patient is a possible litigant."

Organized Medicine Involvement
Interestingly, the organizations that have done the most to protect physicians from spiraling malpractice insurance costs don't stir a lot of emotion in young physicians. For many, organized medicine is something that can wait until their practices are built, their families are grown and their zest for hands-on clinical care is tempered by time.

The apathy is something that irks the doctors interviewed for this article, many of whom are exceptions in their peer group when it comes to organized medicine involvement. Dr. Corr is the Riverside County Medical Association representative to the California Medical Association's Young Physician Section. As such, he attends the CMA House of Delegates. Other than the YPS delegates, there are usually just a couple of doctors around his age there. "Everyone else is 55," he quips.

Young physicians are missing the boat big time, Dr. Corr says. "We need to get people to understand the benefits of organized medicine. A lot of that is through one-on-one education." A key focus of that lesson is that organized medicine is not just about lobbying.

"The CMA offers many services to young physicians," explains Lynn Mortensen, MD, MPH, chair of its YPS. "Its work on MICRA has kept malpractice premiums more affordable than they would be otherwise, for example. Also, when reviewing contracts or dealing with difficult practice issues, young physicians can contact the CMA legal department and receive guidance [that] can help them make the best decisions."

And there's more. Roger S. Eng, MD, MPH, chief of radiology at San Francisco's Chinese Hospital and a CMA YPS leader, sees opportunities for community service in organized medicine. "It provides the best means to give something back," the 39-year-old says. "We have very little power as individuals to make a difference in Sacramento and Washington, D.C., whereas belonging to these groups allows me, through them, to do so."

Dr. Richardson says organized medicine can even get personal. He works at Community Memorial Hospital in Ventura, which, years ago, adopted a code of conduct that allowed it to discharge physicians at will and required physicians to sign noncompete contracts. The county, state and national doctor groups provided amazing support for physicians' counterattack, he says. "We were able to succeed in a battle that could have adversely affected physicians throughout the country," he reports. "We couldn't have done it without the support of organized medicine."

Contemporary Views
Older physicians shouldn't worry about young physicians' emerging, pragmatic view of medicine. It doesn't mean they're rushing for the doors. It means they're combining clinical skill and business acumen with a healthy dose of real life and just a touch of politics. And they're finding that the mix makes for a pretty awesome way to live.

Upland urologist Christopher K. Tsai, MD, 37, speaks for many of his generation when he assesses the situation this way: "When I came through medical school there was already the gloom-and-doom view that medicine was a bad profession, that it was not as good as it used to be. But I've been surprised that it's still really good. Technology continues to advance. We're able to help people, make a difference and be appreciated for it. That's been more rewarding than I thought it could be."

FEATURE STORY SIDEBARS

Trying Out Technology
Doctors under 40 generally embrace technology faster and more enthusiastically than older-generation peers. But they're still far from being techno-geeks.

Some don't use the Internet at all, and the ones who love electronic gadgets generally stick to time-tested devices that enhance the way they practice now.

Perhaps the most popular technology is the tried-and-true hand-held PDA, or personal digital assistant. Riverside internist Andrew Corr, MD, 39, says he likes having medical databases at his fingertips while making rounds. Carl Knopke, MD, 34, a family practice doctor in Riverside, agrees. "I've been using a Palm Pilot since medical school," he says. "I use everything from Epocrates for drug lookup to clinical references such as the 5-Minute Clinical Consult. I also use image readers so I can copy tables and charts from reference books that I use frequently."

Not surprisingly, basic Internet research is a young physician's most common technology interface. "I use the Internet regularly to look up recent articles and research cases," says Scot Richardson, MD, a 36-year-old Ventura neurologist and a young physician with a common view of computers. "I also do some online continuing education."

And then there's Christopher K. Tsai, MD, a 37-year-old urologist in Upland. His favorite new medical technology is robotic surgery. "It's not only technically a lot of fun to do," he enthuses, "it has many advantages for patients."

Electronic medical records--hailed as the best boost for practice efficiency--elicit a wide array of responses. "I am still not sold on EMRs," Dr. Knopke says. "Prior to medical school, I worked for several years in computer support services. I did everything from software programming to hardware purchases and maintenance. I am acutely aware of the problems inherent in a large computer system. Nobody has yet shown me that an EMR makes your practice more efficient. It seems to me that the people who are for the systems have minimal computer experience and are not aware of the potential problems. I have seen many more EMR failures than successes."

On the other hand, doctors like Dr. Corr see EMRs as "definitely the way to go." But even his enthusiasm is tempered by reality. "So far," he says, "no one has made one that really works. Maybe in the next five to 10 years."

Another new technology frontier is the widespread use of communicating with patients via the Internet. Experts say it is a key element of making online disease management a clinical reality. Still, most young physicians feel the technology isn't ready yet--and that the legal, clinical and patient-relations ramifications haven't been adequately explored.


Managed Care and the Younger Set
Forget what you've heard about doctors and managed care. Young physicians don't hate it the way some of their older peers do, but they haven't embraced its 9-to-5 mentality the way many thought they would. The truth, of course, lies somewhere in between.

Upland urologist Christopher K. Tsai, MD, is a good example. "Managed care has its place," he says. "Like any other business, there are plans that are good to patients and to physicians and there are others that make it difficult for patients and for physicians."

One thing is certain, managed care plans are here to stay. Indeed, Dr. Tsai, 37, says his practice is "willing to work with PPOs willing to work with us to make things easy for patients and for us."

Andrew Corr, MD, a 39-year-old Riverside internist, agrees. Because of his Midwestern medical training, he says, he started his practice with a fairly anti-managed-care stance. But that's changed since he relocated to California. "After participating for a while, I've seen that it's a reasonable way to control costs," he says. "I personally switched from PPOs to HMOs this year, partly because of costs and partly because the attitude of many plans has changed. I now see that HMO participation isn't necessarily a conflict of interest for physicians."

Carl Knopke, MD, 34, a family practice physician in Riverside, is actually enthusiastic about managed care. About one-third of his practice is HMO-based, and the rest is a combination of PPOs, Medicare and cash. "I think managed care is a good idea," he says. "For the doctor, it represents a regular income, and for the patient, it is an economical alternative to PPO care. Because there's even distribution, doctors and patients have a choice."

Dr. Knopke has this advice for young physicians who deride HMOs: Don't do it. "Competition, in the form of a variety of healthcare products, is good." But he's no fool. "Managed care exists so that it can restrict access to care while promising to patients that it will not restrict that access," he concedes. "That subterfuge is what I find wrong with managed care."

That's actually a pretty fair characterization of the internal conflict with which many young physicians approach managed care. Brian Eichenberg, MD, 37, a plastic surgeon in Temecula, puts it this way: "Managed care could be a way to make medicine more efficient and more economical, but it is not right now."