Pulmonary and Critical Care : The

Unattractive Specialty
Kevin L. Kovitz

Chest 2005;127;1085-1087
DOI 10.1378/chest.127.4.1085
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Pulmonary and Critical Care
The Unattractive Specialty
T heicinespecialty of pulmonary and critical care med-
(PCCM) is in trouble. Not a meeting goes
by without someone bemoaning the fact that we have
too few people choosing the field. Couple this with a
projected shortage of just such specialists for an
aging population and the general public has a prob-
lem as well. How do we fix this problem that is of
obvious import to both our specialty societies and
society at large? Lorin and colleagues (February
2005)1 have made a good start. They begin to
quantify the problem by looking to the source of
trainees, internal medicine residents. It is they who
must choose to enter our training programs, and if
they are unwilling to do so, we must query them
directly to understand the reasons. What are the key
factors that influence decision making, and what can
we do to not only keep from driving trainees away
but also, more importantly, draw them to us?
A good place to start is the survey made by Lorin
and colleagues1 of internal medicine residents (re-
sponse rate, 61%) in university hospital training
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© 2005 American College of Chest Physicians
programs. Although 41% had “seriously considered”
pulmonary and critical care, only 3.4% actually chose
the field. There were attributes of the field that
respondents perceived as attractive; however, life-
style issues appeared to be significantly dissuading.
Lack of free time, stress in potential role models,
chronically ill patients, incompatible personality, and
treating pulmonary diseases were most cited as
reasons for avoiding PCCM as a specialty choice.
When people have a choice, lifestyle plays a major
role in decision making. The scope of any given field
will be attractive to some and not to others. The
breadth of illnesses in PCCM, including many
chronic disease processes, will interest residents in
different ways. The attractiveness of the field will
likely vary over time based on our capacity to manage
the range of illnesses and the impact we can have on
patients. As a field, we will attract more quality
trainees as we broaden the range of clinical interven-
tions available to improve the quality of life of our
patients. The chronic cardiac or renal patient is not
as debilitated as in times past thanks to new and
expanded therapeutic options. We will also see the
impact on the chronic pulmonary patient as our
interventions for COPD, lung cancer, pulmonary
fibrosis, and other entities improve.
The article posits that it is important to focus on
the lifestyle issues of lack of free time and stress of
the fellows and attending physicians who are the
potential role models. Such is the choice we all face
in the practice of medicine. The consequences of
this choice become apparent comparing a field of
daily life and death with long hours to a field of more
leisurely scope and pace. However, I do not believe
that the lifestyle issues above really play a definitive
role in deciding against PCCM when one looks
internally at the competing specialties within internal
medicine. I do not know many cardiologists or
oncologists with abundant free time or limited stress,
yet these were among the preferred fields. A future
iteration of this excellent study could compare these
lifestyle barriers to entry among internal medicine
subspecialties. However, is the problem really one of
the lifestyle issues cited, or are these merely surro-
gates for something more fundamental?
One of the oldest clichés is that “you get what you
pay for.” Could financial considerations really be the
root cause of the dearth of trainee interest? We like
to think that people will choose the field they find
most interesting and that they will be purely altruis-
tic in making this choice. Ultimate income would
therefore be secondary. This idealized paradigm may
be true for some, but what about the more realistic
scenario that most trainees find many different
specialties interesting? Income potential likely plays
CHEST / 127 / 4 / APRIL, 2005 1085
a substantial role in decision making in this scenario,
and a second look at the authors’ data supports this
conclusion.
Recent data from the American Association of
Medical Colleges2 once again notes the high cost of
medical education and the subsequent $100,000 to
$135,000 median debt burden held by 2003 medical
school graduates. The first choice, general internal
medicine (19.6%),1 is likely influenced by lifestyle
and the need to get on with paying such a debt. But
once someone chooses to subspecialize, it is impor-
tant for us to apply income potential to this analysis
of choice. Economic forces are real and, no matter
how couched in other terms, have dominant impact.
Table 1 lists academic and private practice total
compensation means based on 2003 data collected
by the Medical Group Management Association
(MGMA)3 alongside specialty choices, in decreasing
order of preference, found by Lorin and colleagues.1
The MGMA is a standard benchmarking group
that is used by many organizations to understand
their practice environments. Listed are the average
total compensations of the fields chosen for both
academic and private practice. I have also accounted
for the range in the fields that have subtypes. For
example, I have averaged the values for the MGMA
reported subtypes of interventional, electrophysiol-
ogy, and noninvasive and invasive cardiology and
similarly averaged values for any other specialty with
multiple subtypes. The preference of career choice
directly correlates with the size of the total compen-
sation for the academic environment and nearly
matches up for private practice. Keep in mind that
the article surveyed residents in an academic envi-
ronment, so that is the environment with which the
residents are most familiar. It is possible that a survey
of community-based residents would match up more
accurately to private practice. Also, there are likely
other lifestyle factors in play as the authors claim.
Economic markets adjust to information. That is why
regulators try to mandate a fair distribution of informa-
tion and frown on insider knowledge. The assumption
is that allowing equal access to knowledge will allow for
the most informed decisions and balance the markets.
As residents gain a further understanding of compen-
sation, they may even improve the correlation between
income and career choice.
What does all this mean? First, the authors have
made an excellent start at looking for the root cause
of the dearth of trainees choosing pulmonary and
critical care as a subspecialty. Lifestyle, disease
range, intervention potential, and role models will
always have an impact on career choice. There will
be always be a baseline of individuals who chose a
field based purely on interest. We can also work at
the edges and improve mentoring, role models, and
subsequently our disease intervention options to
make PCCM a more attractive option to trainees.
However, we cannot simply look internally to the
field to solve the problem. Given a wide range of
options, dedicated individuals who are willing to
work hard will simply choose the better income
potential between fields that are of similar interest to
them. They will also be more likely to overlook
shortcomings in a field if the income potential is
sufficient. To solve the need for pulmonary and
critical care specialists, we need to improve reim-
bursement. Critical care is reimbursed at a higher
rate than a high-level evaluation and management
visit. However, in reality, most critically ill patients
and their care do not qualify as critical care by the
Centers for Medicare and Medicaid Services guide-
lines. Critical care coding requires substantial time in
the direct care of a critical and unstable patient.
Airway stenting is reimbursed at a much lower rate
than coronary stenting. These are not complaints,
just facts, and there are many such examples. With
reimbursement being a “zero sum game,” it will be
difficult to ameliorate the situation. We must advo-
cate for our representative societies to advocate for
us. If not, market forces will solve the increasing
acuity of the shortage of pulmonary and critical care
specialists. Either less-qualified practitioners will
step in to fill the void, lowering quality and reim-
bursement for all, or patients will increasingly de-
mand and pay for the qualified specialist. The laws of

Table 1—Subspecialty Choice by Descending Order of Preference Listed Alongside MGMA Mean Academic and
Mean Private Practice Total Compensation for Each*

Specialty % Mean Academic Total Compensation, US$ Mean Private Practice Total Compensation, US$

Cardiology 16.2 230,278 † 404,251 †

Gastroenterology 12.3 189,120 † 345,540 †
Hematology/oncology 8.9 174,542 † 377,196 †
Nephrology 8.4 166,668 261,919
Pulmonary and critical care 3.4 159,817 † 242,792 †
*Reprinted with permission from the MGMA.
†Average taken of the mean reported total compensations for all the subtypes of this field.

1086 Editorials

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© 2005 American College of Chest Physicians
supply and demand will then kick in and trainees will
gravitate toward an improved income potential. This
can easily be subverted if our lobbying potential is
less than others or if we work at cross-purposes. It is
better to work among our overlapping societies and
improve the “lifestyle” for all of us. We can no longer
keep our heads buried in the sand. You get what you
pay for. . .
Kevin L. Kovitz, MD, MBA, FCCP
New Orleans, LA
Dr. Kovitz is Director, Interventional Pulmonology and Medical
Critical Care, Tulane University Health Sciences Center.
Reproduction of this article is prohibited without written permis-
sion from the American College of Chest Physicians (e-mail:
permissions@chestnet.org).
Correspondence to: Kevin L. Kovitz, MD, MBA, FCCP, Director,
Interventional Pulmonology and Medical Critical Care, Tulane
University Health Sciences Center, 1430 Tulane Ave SL9, New
Orleans, LA 70112; e-mail: kkovitz@tulane.edu
References
1 Lorin S, Heffner J, Carson S. Attitudes and perceptions of
internal medicine residents regarding pulmonary and critical
care subspecialty training. Chest 2005; 127:630 – 636
2 Jolly P. Medical school tuition and young physician indebt-
edness. American Association of Medical Colleges, March
2004. Available at: http://www.aamc.org/publications. Ac-
cessed March 3, 2005
3 Medical Group Management Association. Academic Practice
Compensation and Production Survey for Faculty and Man-
agement: 2004 Report Based on 2003 Data. Available at:
http://www.mgma.com.
End of the Idyll
Farming and the Risk of
Occupational Allergy
A gricultural workers are a particularly important
risk group for work-related respiratory disorders
and, at the same time, comprise a population that is
notoriously difficult to study effectively. The range of
conditions of the lower and upper airways to which
farmers are prone includes zoonotic infections, ex-
trinsic alveolitis, irritant inhalant injury, organic dust
toxic syndrome, and asthma.1 As Chatzi et al2 show
convincingly in the January 2005 issue of CHEST,
this list of conditions should not omit allergic rhinitis.
The challenges encountered in studying agricul-
tural cohorts are legion. Because by definition they
are rural populations, agricultural workers are re-
mote from most medical research centers. Even
within the target geographic area of study interest,
potential subjects are typically dispersed and often
are difficult to contact. Identifying potential study
subjects in a way that systematically reflects the
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© 2005 American College of Chest Physicians
underlying population-at-risk and successfully re-
cruiting such subjects is time-consuming and labor-
intensive. Choosing a reasonable referent population
to compare with a farming cohort (a population that
must also be recruited in parallel) is doubly difficult.
On all of these counts, Chatzi et al2 have done an
admirable job, allowing their study to make a notable
contribution to a growing body of medical literature
on occupational airways disease in farmers.
The report is significant for a number of other
reasons beyond its methodologic strengths. Despite
a substantive number of research publications focus-
ing on the epidemiology of airways diseases among
farmers, especially asthma, relatively few studies
have actually been performed that concern those
farmers who cultivate field or orchard crops in
outdoor settings. The excellent studies in the Finn-
ish-language literature on occupational asthma in
farmers, for example, have largely been driven by the
study of cow handlers.3 Other prominent agricultural
groups that have been studied in the past few years
include swine-confinement workers,4 grain dust-ex-
posed farmers,5 and cultivators employed in green-
houses.6 The powerful European Community Respi-
ratory Health Survey7 has provided interesting
observations on asthma risk across a range of occu-
pations including farmers, but because of its largely
urban-based and suburban-based sampling design,
there are relatively few agricultural workers in that
cohort. The largest population-based study of respi-
ratory disease in agriculture that includes substantive
numbers of field and orchard crop workers is the
European Farmers’ Project, although three quarters
of that group have concomitant exposure to cattle,
pigs, sheep, or poultry.8
By focusing on farmers who are cultivating a single
crop (eg, grapes, predominantly raised for raisins
rather than for winemaking), the investigation of
Chatzi et al2 is well-positioned to provide insights
derived from a highly specific environment that
nonetheless may be generalized to other settings.
The principal findings indicate a substantially greater
prevalence of rhinitis symptoms and positive skin-
prick test reactions to aeroallergens among grape
farmers compared to control subjects. This latter
finding appeared to be driven by pollen sensitivity,
especially to allergens associated with plant species
that are common weeds in Mediterranean grape-
growing regions, consistent with likely occupationally
related exposure. The far lower prevalence of sensi-
tization among inhabitants of the same rural locale
studied as referents argues against these pollens as
simply being regional aeroallergens with exposure
that is unrelated to work practices.
CHEST / 127 / 4 / APRIL, 2005 1087
 Pulmonary and Critical Care : The Unattractive Specialty
Kevin L. Kovitz
Chest 2005;127; 1085-1087
DOI 10.1378/chest.127.4.1085
This information is current as of November 13, 2010
Updated Information & Services
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