Medical students typically make a career choice by around spring of their third year, such that they can plan their fourth year and stay on track for landing the residency of their choice. They decide among specialties: pediatrics, obstetrics-gynecology, oncology, emergency medicine, internal medicine, cardiology, gastroenterology, neurosciences, etc. The decision is understandably difficult, and in addition to trying to satisfy pure intellectual preference, three very real non-medical considerations always rank at the top of students' decision criteria: prestige, debt, and quality of life. Predictably, in the semi-socialized healthcare system of the United States, the first of those criteria is in flux, the second is rising, and the third is much lower than it ought to be.

That combination of underappreciation and undercompensation is not attracting many new medical students, and the ones that are still early enough in their careers to choose their path are wising up to the game: Choose a market-driven specialty. It's your only hope.

Primary care is out, and ophthalmology, plastic surgery, and dermatology are in, as young doctors trade in the headaches of convoluted reimbursement forms, coverage matrices, and drug coverage lists for respect, good (and well-deserved) pay, and control of their own hours.

Primary care is so out, in fact, that on January 1, 2006, the Boston Globe reported that the editor of Academic Medicine has proposed banishing the term "primary care." Instead, he suggests calling such doctors "specialists in comprehensive medicine" in order to entice more students into that role. In other words, rename the concept of a generalist to a specialist, and maybe no one will notice the exodus or be able to track its cause.

The United States already has fewer physicians than it needs and fewer physicians than it otherwise would have under a free market system. That's called a shortage, and the fault lies squarely on those who have helped to make life as a doctor so unappealing, not on the young doctors who choose to save themselves from a sinking ship.

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