For me and most of my med student peers, talking about lifestyle and talking about money are two very different conversations (though I know for some, that’s not the case). For me, talking about lifestyle means having a residency and career that allows me the time and energy to take care of my own personal health. I would like to be able to go to yoga classes sometimes, or go for a run, and have the ability to cook food that not only tastes good but is healthy for my body and mind. All too often, it seems we sacrifice our personal health for the health of others, and that, in the end, leads to burnout.

Of course money is a major factor in deciding what career I choose, especially since I will graduate with at least a quarter of a million dollar debt to pay off. More important than money, though, is good personal health. Sadly, that means certain residencies are not a possibility. I just recently took Step 1 of the boards, and I spend a month of studying almost 12 hours a day, every day. It worked for a month, but it wouldn’t work for a lifetime.

Others may call it a weakness, but I want to be humane and compassionate to my patients, and that means I have to be humane and compassionate to myself

Good post. It always astounds me to peruse the residency choices of a graduating class’ AOA recipients. You might find one or two going into primary care. The list is dominated by the high paying, good lifestyle professions like dermatology and radiology. While reassuring to know that the ravages of eczema and psoriasis will be properly cared for in the future, it does seem a bit of a waste for our brightest and most disciplined medical students to spend the bulk of their careers prescribing topical steroids. My generation has this sense of entitlement, it seems, where we expect to be well compensated with weekends and nights off. Remember, this is the era of work hour reform, driven in part by medical student organizations. Job satisfaction, then, doesn’t seem such a high priority when you live in a giant mansion, drive a lexus SUV, and get to spend the entire weekend hanging with the family. And lifestyle seems to trump even financial compensation, as evidenced by the plummeting applications to general surgery programs (off set somewhat recently by the implementation of work hour restrictions.) And from a Utilitarian perspective, it seems to be just a little unethical for an intelligent young medical student who, in applying to medical school and thereby affirming an ostensible desire to help people, instead funnels his or her self into a specialty strictly because of financial or time considerations. It cracked me talking to these genius AOA cats after the match, trying to convince everyone (themselves included) how “interesting” and “provocative” they found dermatology on that 4 week rotation they did late in third year. As if dermatology is what they always dreamed of doing, as far back as college. Give me a break.

Ultimately, medicine is a job. That is, a part of your life, but, ideally, not your entire life. Your spouse and children should be able to remember who you are. Those who see family life as secondary in a person’s life are delusional. Lifestyle does matter. You want the best and brightest, make your residency, and the career thereafter, attractive. Students can see where a residency in family medicine, internal medicine, and pediatrics takes them: overworked, uncompetitive salaries, and no respect. Most who see that want no part of it. You’re asking them to sacrifice themselves at the altar of idealism. Oddly enough, some refuse. Why is this hard to grasp?

For those who would find one of those careers personally fulfilling, and would excel in it, you have people like Matt S., who seems to be under illusion that all are called to be Mother Teresa. God forbid that a person feel fulfilled in providing high quality service to some-one who appreciates it, and can afford it. Good, personal care is hard to get, and is worth it to those who pay extra for it. Hey, if you want to be a martyr and serve several thousand, feel free. Just remember that the knowledge of a job well done is worth a lot too, as opposed to the rush jobs you have to do to see those thousands of patients. Will they be happy with the level of care you can provide in 10 minutes or less? Maybe those concierge docs are actually getting paid what they’re worth? Just a crazy thought.

Medicine has changed and the people going into it have changed. Married medical students with families don’t want to spend three to seven years getting beaten up in a malignant residency program which will require them to sacrifice their families and their marriage.

Personally, I find the thought of spending five years working as an indentured servant, sucking it up and not complaining for fear of offending the old school, revolting. Why, for example, is sleep deprivation necessary for medical training and why is the training so inefficient that it takes three years of 120 hour weeks to get a handle on it. These kind of things are ridiculous to my generation.

Unless we want to go back to the times when medical students were all young single men and medical training was run along monastic lines there is no going back.

Dr. Centor,

It makes me uncomfortable to disagree with you, having agreed with so many things you say. I think if anything, we gloss over the sustained time committments of primary care. Most people who do primary care do not do academics. Most have offices that have patients who call 24 hours a day needing care. There is no house-staff to admit those patients at night or on the weekends. There is no urgent care clinic to “fit in” same day calls.

It is exciting to matyr yourself when you are 24 and all you want to do is help people, even if it takes sacrificing your personal health and all of your hobbies. To do that when you are 50 is pathetic. To encourage people to go into a field to matyr themselves for 30 years is sadistic. Please be careful how you influence our young. You are often the person they respect the most and have a huge influence on their choices.
b

Visual artist:

You are trying to win your argument by an ad hominem attack, which is very weak. An appeal to facts might be better.

Despite your wish to categorize me as knowing nothing about careers besides my own, the fact is that I do not live in an information vacuum. I certainly don’t believe every educated occupation has seen it incomes keep pace with inflation or with the costs of education to qualify, but many have. Your dismissive editorializing notwithstanding, those professions you call “corporatized”, makes my point all the same. There are many other occupations for which a person in undergraduate university might find themselves attracted to besides medicine that will return the costs of education quicker and leave the student financially better off and more secure sooner, on average, than will medicine. This was not always the case, both because other professions did not pay as well as they do now, and because doctors were able to earn relatively more in the past. Graduating attorneys can find starting associate work, with no prior experience save a summer job, at firms in any of several cities in the US at annual salaries in excess of $100K. Business MBA grads can easily find jobs at similar salaries. By contrast, medical incomes have not seen similar increases, despite the fact that costs of medical education have increased along with costs of education for other professions. A specific case from my own specialty: a common, in even cardinal, surgical procedure reimburses in actual dollars the same as was paid by Medicare in 1967, which in constant dollars is less than 20% of its initial value. That means working much harder to generate the same buying power for your practice and for yourself.

I don’t doubt that some other occupations have seen relative decreases in earnings. With medicine, which has the longest course of any modern occupation before being able to start productive earning, the requirement to produce satisfactory income to offset the lost years of earning, (which despite Dr. Centor’s beliefs also includes residency in a practical sense) has to be met, and met credibly. Right now, that credibility is suffering. That is the root from which the new “lifestyle” choices of certain specialties springs and that Dr. Centor laments.

It is fine to say that you have chosen your field because you are who you are. But surely you understand that there have to be practical limitations to your choices. Would you choose an expensive educational path where there was little hope of gainful work in that field when you knew that no matter what you did you would have to both support yourself and repay the costs of that education? Even if a lender were willing to lend you the money to do so, if you were wise you would give that idea great consideration. Did you ever wonder why there aren’t more architects being trained, or more theologians, or archaeologists?
It is fine to want to do something you like, but it is foolish to spend a small fortune educating yourself for an occupation with few opportunities for gainful employment. The kind advisor knows both how to encourage and when realitiy dictates, to discourage, without cruelty.

As to the general appreciation of GS and IM by the lay and medical communities, I stand by my statement as an insider and experienced observer. You can say you respect GS all you want, but the general public votes with its feet and goes to supspecialty surgeons when it can, to colorectal, hepatic and thoracic subspecialty surgeons. The same is true for IM with respect to its specialties. GS is finding itself with a smaller domain except for trauma. IM is unfortunately finding itself with irksome “gatekeeper” assignments and the unfortunate choice betwen hospitalist practice and sweatshopped office practice. You can say you respect IM, but the public that votes with its insurance and Medicare dollars shows on the whole that it feels differently.

As a colleague/fellow physician in the trenches, who happens to be female, I take offense to the comments of Greg P. Your indication seems to be that only men have worthwhile careers or have gainful employment, while we women sit around scheming on how to take advantage of men. The road goes both ways my friend. Two failed marriages later, where men with good careers and good earning potential decided that the could just be the doctor’s husband and hang out and spend the money, I am certain that as long as I can be identified as an MD, I will never choose to marry again. Quit deriding others people, whether it be for their genders or their choices of professions. As for concierge medicine, people with the ability to pay deserve good healthcare, but more importantly, if they are willing to pay extra to get more service, then so be it. I can’t afford to drive a Lamborghini, but if somebody else can afford to pay for the car, then by all means, I would expect them to get the high end service that comes with it’s price tag. If I am going to shop at Walmart and pay Walmart prices, I don’t expect to get Rodeo Drive pampering when I purchase. I do believe that those of us who choose to embark upon the concierge journey should know that we do still have as much of an obligation to charity as do our colleagues who choose to serve less affluent clients. You can choose lifestyle and even high financial recompense without being a bad person or a traitor to the medical professiton, but you should remember that it is stated in some way shape or form in almost every religion in the world that “to whom much is given, much is expected in return.” Those who buy back their lives and their time by going into concierge medicine should also take on the responsibility to spend some of that time providing for the care of some of the most time consuming patients, one’s who would also benefit from a concierge level of care, because of their higher health care needs. There must be balance. We also need to focus on revamping the system, so that all of our colleagues are more fairly compensated. Afterall, Mother Theresa was only able to give herself to the masses, because her creature comforts were already provided for by the church. Our ministers serve the masses, making themselves forever available to spiritually comfort the masses, because their creature needs are met by the congregations. Therefore, when we expect our physicians to give up more of themselves than we demand of any other profession, why should we expect that they should not be well taken care of? Yes, in the “olden days” of Marcus Welby, he worked endless hours, always available to meet the needs of his patients, their families, their communities, etc. They rewarded him with not only their hard-earned money, but with their respect. Many patients now will argue about even making their co-pay, but wouldn’t dream of going into a mechanic and thinking they could get anything done at all without paying their bill before they leave. Yes, an unexpected medical bill at the doctors office can be a bigger ticket item, but if your car goes caput, I haven’t found that to be anything but expensive lately either. Not to mention, my plumber always walks out with a bigger payment than any of the office visit bills my patients have ever received. We need to take back the control from the insurance companies, charge and get paid for what we are really worth, focus on making medical education truly affordable again, subsidize the incomes of those who choose to work in areas of higher volume and lower affluence to bring their incomes more on par with those who choose to work in areas of higher affluence, and to give each other the respect we each deserve no matter what our choice of specialty or what style of medicine we choose to practice. The only thing constant is change itself, so we have to be flexible enough to find new models that work well for everybody…and that will sometimes mean a few growing pains.

DB, I agree it doesn’t solve “the problem.” But first lets identify the problem.
1) Access- pay docs more, and access goes up. Pay less, add headaches, and make us chase our tales, access goes down.
2) Uninsured – this is dollar to dollar financial issues. We already have medicaid for those who below that level of aaccess (Of course, medicaid means charity work since none actually gets paid the proper amount)). Use tax breaks (forget the it supports the rich BS) – use tax breaks for the income level that are uninsured and don’t qualify for medicaid.
3) Medicare age patients – almost all practice still accept medicare. What they lack in reimbursement, they make up for in efficient reimbursement systems and a population that can be seen every some many weeks.

What concierge care does is, for those that wish to spend the $125 per month, is to get better care. It’s not that the docs are better, it’s jsut a better healthcare delivery model. Spend more time with patients, talk to them, take the time to look at options – not everything has a 100% prescription based fix. Despit the cherry picking claims, isn’t it obvious that closer monitoring of patients prevents hospitalizations. It does in my world of Geriatrics. I don’t need any RCT to prove that.

All the retainer does is afford us the abiltiy to do what the insurers and gov’t won’t – pay use to take care of our patients to the best of our abiltiy with nothing to prevent us from operating at our highest level. All patient’s deserve that. But only concierge care is equiped to deliver it (at this point).

I’m sorry, I disagree with you completely. Lifestyle and money are very important in choosing a specialty. You would have no way of understanding as you don’t have the debt that we do. Whether you agree or not, medicine is JUST A JOB. The fact that your generation has made medicine into some type of “calling” is why resident and medical student abuse continues, why reimbursement continues to drop, without us being to defend ourselves, and leaving behind tons of unhappy physicians. People such as yourself make the rest of as martyrs, to where everyone else calls the shots, except actual health care providers. ENOUGH. Your generation has done enough in bringing down our profession vs. look at Dentistry.