By Tom Walsh

Growing up in New Jersey, Sameena Ahmad, M.D., had no doubt she wanted to be a doctor some day. "I had family, aunts and uncles, who were physicians," said the fourth-year OB/GYN resident at Boston University Medical Center. "Seeing them, what they did, and the impact they had on their patients, it was pretty significant."

As Dr. Ahmad nears the end of her residency training, she has begun to consider what her world might be like a year from now. Despite the specter of burdensome professional liability premiums in her
specialty and concerns about other economic factors, such as relatively low reimbursement and high cost of living, she remains determined to pursue her career on her terms.

"I'm thinking of staying in the Boston area, probably in the suburbs somewhere," Dr. Ahmad said. "I like that Boston is a big city with a small-town feel. It's the center of things."

Residents Leave Massachusetts
A significant number of Massachusetts resident physicians do not share Dr. Ahmad's optimism about the Bay State.

According to the 2003 MMS Physician Workforce Study, 49 percent of fellows and 44 percent of residents who finished their training in Massachusetts in 2002 decided to pursue the next step in their medical careers elsewhere.

"One of the root causes of the physician shortage in Massachusetts derives from the relatively large ratio of residents and fellows who leave upon completion of their training," wrote James M. Howell, Ph.D., the Boston economist who led the workforce study.

The findings of this year's report concerning residents are similar to the 2002 study and suggest that there has been no recent improvement in Massachusetts practice conditions, at least as seen by nearly half of the physicians just finishing their training here.

The 2003 Workforce Study concluded that salary level, cost of living, Massachusetts tax environment and housing costs are the factors that drive the decisions of residents and fellows to begin their professional careers elsewhere. "Of these four factors, salary level is the only one that can be relatively easy to adjust to address the issue," Howell wrote.

24 Percent Would Change Professions
Meanwhile, results of a study just released by Merritt, Hawkins & Associates, the Dallas-based physician search and consulting firm, found that 24 percent of physicians in their final year of residency nationwide would select a field other than medicine if they could begin their careers again.

"Before they even enter the world of professional practice, many newly trained physicians are wondering why they didn't chart a different course," said Joseph Hawkins, the firm's CEO. "This should be an exciting time for doctors 'coming out.' Instead, many of them are already disillusioned with medicine."

Merritt, Hawkins & Associates has been doing resident surveys every other year since 1991. In this year's survey, according to the firm's report, "more respondents indicated a higher level of concern about entering medical practice across the board than in any past surveys." The report added, "Clearly, residents have absorbed the general climate of gloom and pessimism about the medical practice environment."

Recruiting Residents a Challenge
This crescendo of pessimism and concern about the Massachusetts physician environment is being felt not just by some final-year residents but by prospective residents as well.

"It affects all of the programs," said Starla Pathak, coordinator of the OB/GYN residency program at the New England Medical Center in Boston. "This year we did not fill [our program]. It's the first time in 40 years that we have not filled [it]." Pathak sent questionnaires to potential New England Medical Center residents who chose to train outside Massachusetts. A prevalent explanation among those who replied was the cost of living, she said.

"You can make the same amount of money in North Carolina, but it costs 50 to 60 percent less to live there," Pathak said. Of the residents who finished OB/GYN training in her program over the last two years, all but one left the state. The physician who stayed did so for a local fellowship.

Ronald T. Burkman Jr., M.D., OB/GYN resident program director for Baystate Medical Center in Springfield, said declining numbers of OB/GYN residents are picking Massachusetts hospitals. Dr. Burkman said that new OB/GYNs are concerned about quality of lifestyle as well as economic issues. "Lifestyle is very important now," he said, suggesting another reason to fear OB/GYN shortages in the future.

Phillip G. Stubblefield, M.D., director of the OB/GYN residency program at Boston University Medical Center, said there are obvious professional reasons why young OB/GYNs would choose a career in Massachusetts. However, he said, "Anybody who really cares about money is not going to stay in Massachusetts. I can't think of anywhere where you do not get paid more than here."

Despite today's gloomy environment, Dr. Burkman suggested it will likely improve. "I'm optimistic," he said. "These things go in cycles, but it's going to be a rough road for a while."

A Combination of Factors
Steve Marsh, vice president for physician recruiting in the eastern United States for Merritt, Hawkins & Associates, said the combination of negative factors -- high cost of living, rising professional liability premiums and relatively low reimbursement -- deters both residents and veteran doctors from pursuing careers in Massachusetts. Marsh said there are states that have worse situations with one of these factors. "Not just one of these issues is killing [Massachusetts physician recruiters]. It's the combination of all three."

Marsh said he thinks the perception of the Massachusetts physician practice environment by out-of-staters is worse than it is in actuality. "The perception is worse than the reality, but the perception is pretty close to reality. It's not that much different," Marsh said.

Committed to Boston -- for Now
Dr. Ahmad concedes that her current view of practicing OB/GYN in the Greater Boston Area could change once she is actually practicing. ";As an outsider looking in now, it might be easy to say that it won't be too bad," she said. "Maybe after a year or two, it might be more of a detriment than it seems now."