Dear Colleagues:
As Doctors’ Day (March 30) approaches, I thought I would share the insight of two esteemed physicians addressing the status of the medical profession as a career choice. The first was a guest article on www.forbes.com and the second, a blog post written in response to that article.
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Mamas, Don’t Let Your Babies Grow Up To Be Doctors
by Steven Higgins, MD, Chairman, Department of Cardiology and Director of Cardiac Electrophysiology at Scripps Memorial Hospital in La Jolla, California.
In 1978, Waylon Jennings and Willie Nelson sang their classic country cover warning mothers to not let their children become cowboys because of the tough and busy life of cowboy culture.
Today, this admonition to parents is more common for those wanting to become physicians. In a recent survey, nine out of ten physicians were unwilling to recommend healthcare as a profession. In 2014, the American Medical Association found that 47% of practicing physicians reported high emotional exhaustion, 35% saw less value in their work and 41% were satisfied (not happy, but satisfied) with their work-life balance. The survey went on to identify the three problem areas:
- Loss of autonomy (75% now are in hospital-owned practices)
- Mental exhaustion (listing heavy workloads and increased clerical work, due to cumbersome electronic medical records)
- Asymmetrical rewards (success is expected, but mistakes come with heavy punishments)
And then there is the stress, as suggested by that asymmetrical rewards issue. When I was in medical school, an attending’s patient had a cardiac arrest and was in the last stages of a failing resuscitation. As a medical student, I was told to give a bolus of a drug during this “code” while he instructed others to shock the heart for what must have been the 15th time, in an attempt to stop incessant ventricular fibrillation. Instead of giving the medicine slowly, I injected it over a matter of seconds. “You just killed my patient,” he yelled at me. As a naïve med student, I thought I had. I was devastated for days until a more mature resident pointed out that the attending was just taking out his frustration on me. In business school you may have pressure but not like that.
To become a specialty physician, it typically requires 4 years of college, 4 of medical school, 3-5 of internship/residency and 3-5 of fellowship, thus 7-14 years after college! And that doesn’t even account for time potentially spent in other education, work, childbirth or childcare. Thus, the typical physician finally enters the workforce close to age 40. Now, for comparison, a college graduate looking at alternative professions can graduate from law school or business school (MBA) with three years of training and begin gainful employment by their mid- to late-20s.
Medical students pay a huge tuition for those four years (average $278,000 for private med schools, $208,000 for public schools) on top of prior college expenses and thus leave with an average debt of over $180,000, less only because many get help from their parents. When I graduated from med school in 1975, the average debt was $13,000 (adjusted for inflation, that would be $57,000 in today’s dollars, not $180,000). Today, the post-medical-school years (internship, residency and fellowship) typically pay these doctors still in training about $60,000 a year for 3-8 years. Don’t forget that the average post-graduate physician works 80 hours a week, so that translates to around $14 an hour! Thus, when you factor in the interest on the debt as well as the lost income, by their late-30s, doctors are about $500,000 (yes, a half a million dollars) behind a college graduate entering other professions. Even former Fed Chairman Ben Bernanke’s son graduated from med school with a $400,000 debt.
Of course, there are still plenty of applicants to medical school these days. However, some of those are leaving without doing a residency, particularly those that live in med tech areas like Boston and the San Francisco Bay Area. Last year, nearly 60% of Stanford Medical school graduates said they plan to go into a business, research or consulting role rather than practice medicine. Those that go into clinical medicine are increasingly choosing areas where the lifestyle is more manageable with distinct shifts and no call, like emergency medicine or hospital medicine. The “entitlement generation” may actually have it right; often they will choose a specialty where their hours are limited, avoiding the greater stress and on-call responsibilities necessary in other medical specialties. However, as my generation retires, who will be there when we get sick?
So, what do physicians recommend to that college student insistent on medicine? There are many areas in medicine with less rigorous educational demands. Work as a nurse practitioner (NP) and physician assistant (PA) offers an attractive option of patient care with only an average of 2-3 years training after college. Typically, these allied health practitioners start earning $85-$120,000 a year, more than their classmates still in medical residency training. The “curves” where the physician’s debt is finally paid off and the salary exceeds the NP or PA only goes to the doctor’s advantage when they reach their late-40s.
As physicians are currently working longer due to diminished incomes, the aging physician is another problem currently plaguing medicine. Unlike our sister professions, law and banking, the senior physician does not have a guaranteed income enhanced due to seniority or prior contribution to the field (there are no senior partner positions for docs). Medicine is piece work; you make money only for work performed. In private practice, time off for vacation or illness is not paid. If you aren’t depressed enough, consider this: So are doctors. Older physicians’ suicide rate is 70% greater than the general population for men, 300% for women. One study found that one in three residents (doctors in training after med school) are clinically depressed. Now, so am I.
Of course, the grass is always greener, if, that is, you are on the right side of the grass. As I mentioned, few professions allow you to directly help people, truly saving lives, and the satisfaction from that is priceless. When I get to the Pearly Gates where money won’t buy anything, I will have that to take with me, which is nice. That reminds me of the old joke of the lawyer who goes to heaven and is ushered in to a nicer room than a recently deceased Pope. St. Peter explains, “We have lots of Popes up here but this is our first lawyer!”
Hopefully, as the new Administration reconfigures healthcare financing, they will also review the training requirements, compensation and debt load required to become a physician. Until then, Mamas, don’t let your babies grow up to be doctors, at least not without understanding the necessary sacrifices.
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Why I would still encourage my daughter to go into medicine
By Shikh Jain, MD, Health System Clinician of Medicine (Hematology and Oncology), Northwestern Memorial Hospital and Feinberg School of Medicine, Northwestern University
There was an article recently published in Forbes titled “Mamas, Don’t Let Your Babies Grow Up To Be Doctors.”
It was a well-written piece that outlined the multitude of reasons that many physicians have become disillusioned with a field they once felt a passionate draw to. The reasons listed in the article were accurate and included the loss of autonomy, mental exhaustion, and asymmetrical rewards.
Many physicians feel there is an overall lack of appreciation for the sacrifices we make. With Press Ganey patient satisfaction scores influencing patient care in many hospitals where patient satisfaction is paramount, many physicians feel an adversarial relationship has developed between physicians, patients, and the administration that is focused more on the bottom line than patient health and well-being. With a rise in fake medical news, celebrity endorsements vilifying scientifically proven interventions such as vaccines, and many patients who feel their “Google MD” trumps a physician’s years of training, our jobs just seem to be getting harder. In many cases, electronic medical records have improved the way we coordinate and deliver care, but it has come at the cost of more paperwork, increasingly complicated diagnosis coding, more time in front of a computer, and less hands-on time with our patients.
But for all the challenges we face, there are also many things that we as physicians can, and should, continue to find fulfillment with. The fundamental role of being a doctor still remains. We are there to help our patients, and by doing so, we are often able to change people’s lives.
I grew up in a physician household. My father is a vascular surgeon, and many of my fondest memories growing up were of rounding with him on the weekend or running into a former patient of his at the grocery store. The one thing I remember the most from each of these encounters is that I could see that my dad had touched each of these people’s lives. As I grew older, he would remind me that a physician’s job doesn’t always end when they get home. He told me to think very hard about whether I actually wanted to enter into this very unique world. When I decided to apply to medical school, he reminded me again that the sacrifices I make are going to be hard, but the reward at the end is that I will have the privilege of effecting change in each of my patient’s lives. When I chose to apply for a fellowship in hematology and oncology, he expressed some concern for the emotional toll such a field could have on me and my family. But he always came back to his original mantra. You must love what you do. If you do that, it won’t feel like a job. And you must always remember that whatever you do, you do it to help your patients.
We have entered a very different era in the world of health care. As physicians, we carry an important responsibility to continue to educate our patients and the general public on peer-reviewed and evidence-based science and facts, while continuing to provide exemplary care. The challenges we face are different than those my father, and others in his generation faced 30 years ago, and the challenges future physicians will face will change further still.
However, with change and advancements also come unique opportunities. These should not be looked at as reasons to run from the health care system, but rather reasons to equip our future colleagues with the tools they will need to be successful no matter what challenge they may face. We as physicians must learn how to advocate for our patients with the tools we have available to us within the current system and work together towards positive change not only for our patients, but also for ourselves. We need to take responsibility and take charge of our field and work towards changing the issues we are frustrated with instead of wringing our hands and walking away. Instead of seeing these difficulties and challenges as insurmountable hurdles, we must find ways to continue to improve the system and work together to find solutions. We have a unique vantage point of the system, and at some point, we let go of the reins of change and lost the ability to significantly impact and influence the way medicine was heading. We must find ways as physicians to improve upon the system we have by working together to overcome the challenges that we face as an institution and regain some control.
I remind my fellows, residents and medical students that what we do is a privilege. People let us into the most intimate aspects of their lives, and they look to us to help guide them through very complex and delicate situations. In ten years, you may not remember your patient, but when you deliver someone good or bad news, your face will be forever etched into that person’s mind. Do your job with dignity, and respect the Hippocratic oath we take at our white coat ceremony. Choose this job because it is, and will always be, more than a job. No matter what challenges medicine as a field, or you as an individual physician face, remember your patient, and that you do this ultimately for them.
So, when my two-year-old daughter puts on her Doc McStuffins lab coat and wants to listen to my heart, or answers her phone stating proudly, “This is Dr. Jain” I tell her the same things that my dad told me. And I hope that when it is time for her to decide where her career path will take her, I can impart on her the same wisdom my father gave me: Choose medicine if that is your passion, and continue on in medicine because that is your privilege.
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I look forward to your comments and thoughts and am hoping this finds each of you well and in the best of “ready for spring” spirits. Best wishes for a Happy Doctors Day!
Sincerely,
William E. Huffner, MD, MBA, FACEP, FACHE
Chief Medical Officer, Senior Vice President – Medical Affairs
219 S. Washington Street
Easton, Maryland 21601
Phone: 410-822-1000, ext. 5867
Fax: 410-822-2147
Email: whuffner@shorehealth.org