In which I become a curmudgeon


Category : Medical Rants

I have had several discussions with residents and medical students over the last few years in which the student (or resident) invoked “lifestyle” as an important decision factor in choosing a career or residency. I never know how to respond to these conversations.

Not all students and residents have this attitude. I am often surprised when this point arises in conversation.

I do understand the trade off between money and lifestyle after one finishes a residency. When I finished, I could have increased my income greatly in private practice. I liked the atmosphere of the academic center and thus chose to make less money but have a job I loved.

Too many students now let their love for a field of medicine be trumped by the promise of a “better lifestyle.” Too many students choose an inferior residency to avoid a slightly heavier call schedule.

I assume (and that is a dangerous word) that most who enter medical school want to become excellent physicians. Medical students are highly motivated and used to success.

We know that expertise requires hard work and experience. One cannot become a great golf, violinist, chess player, speaker, brick layer, etc without hard work and experience. I worry that some students and residents overemphasize the short term benefit of an easier work load and thus do not develop the necessary experience and instincts to become great.

I also worry about medical student specialty choice. Too many students seem to look at money and call schedule. I guess some students lose their love for medicine, and just view it as a job. I worry that many students choose a specialty for the wrong reasons, and I predict dissatisfaction 15-20 years after finishing their residency.

The medical schools are not innocent here. We psychologically abuse students during the first 2 years (much less so in the 3rd year). We charge exorbitant tuition, leading to many students accepting major debt. We know that the size of debt does influence specialty choice.

Maybe I am just grumpy today. Maybe I have become a curmudgeon. I would like to see more students enter family medicine, internal medicine (without subspecialty) and pediatrics. These specialties should attract our best and brightest – but they generally do not. And this saddens me.

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Comments (17)

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

Everything teaches. Residents spend 3 to 8 years directly observing the inner workings of an academic medical practice, the policies and politics of a teaching hospital, and the personal and professional lives of our attendings. What does this reveal?

One, that academic physicians have among the lowest job satisfaction of any group of practicing physicians. While in training, interns and residents usually are the recipients of displaced frustration and aggression (active and passive) on to them. We learn something very important about the how much feeling valued by your company or employer matters.

Two, when housestaff do out-rotations at “cush” community hospitals and private practices the contrast is even more revealing. At these venues, physicians-in-training are treated like physicians and peer professionals. The nurses are more respectful, the patients are more responsible, and the physician are–in general–happier. Why not choose lifestyle?

Three, when we watch medical education and hospital industrial trade groups (AAMC, AHA, ACP, AMA, etc) spend hundreds of thousands of dollars directly opposing resident work hour reforms, housestaff unions, etc we learn whose priorities and interests our “mentors” are really looking supporting. I once heard a lobbyist from the American Hospital Association say to group donors that they would oppose resident work hour reforms at all costs.

Finally, the “pecking order” in an academic institution is obvious. Hot-shot surgeons and proceduralists who bring a teaching hospital millions of dollars in direct and indirect revenue call the shots and the “cognitivists” are left fighting for scraps. Even among the serf class (house-staff), most surgery residents get away with behavior that other residents could not.

Residents don’t live in a vacuum. We watch our non-medical peers in the legal, information technology, business and finance industries enjoy being treated with respect and move up their career ladders. Why should we settle for less?

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.

This up a conversation I had yesterday with a fellow resident. It concerned one of your hot-button topics: concierge medicine.

Although we both picked family med, the lifestyle and money imp is now whispering in his ear. He told me in he was considering starting a concierge practice after a few years with a group. He said it supplied for a demand created by the medical bureaucracy: poor access to care.

And yes, patient access sucks. And yes, there are rich people willing to pay for the access they can’t get. But I hope I managed to convince him that concierge medicine only worsens the problem. Rather than being available to several thousand patients, he is only accessible to a few hundred!

Some may say “I did not put myself through this to be overworked and undercompensated.” But I would say “I did not put myself through this to only help a few rich people, who would get medical care anyway.”

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.

I have no delusionis of martyrdom, and do hope that primary care will soon be paid on a more reasonable scale. And I do think concierge docs get paid what their worth.

And no, patients won’t be happy with their 10 minute visits. I won’t be happy with the ten minute visits either. But we will all be less happy with the 5 minute visits that would result if half of family docs decide to treat only the rich.

So when I try to discourage my colleagues from going into concierge, there’s a lot of selfish motivation in there too.

I will continue to disagree that concierge medicine fixes the access problem, rather than worsening it.

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.

It’s official DB, you are a curmudgeon. The certificate is in the mail.

I have to laugh at those who bemoan that those with the widest latitude of choice in residency, the top-performing medical graduates, are doing what top performers have always done, choosing the most attractive programs in the most attractive specialties. Are they to be blamed because the world around has changed in the past generaion and IM and GS can’t automatically expect to attract the best graduates? Who has failed to keep pace here? Who should be blamed for the decline in reimbursement to practitioners in those specialties? Who is responsible for the outsized rates of increase of medical school tuition fees and resulting enormous increases in personal educational debt? The medical students? I don’t think so. The big gripe here is that it is more and more nakedly apparent that internal medicine and general surgery residencies prepare residents for jobs that have poor quality of personal and professional life, relatively less pay per unit of work done and generally less appreciation by the broader medical and lay community. Whose fault is that? It seems to me that the so-called leaders of these fields have lacked imagination and foresight and simply presumed that the conditions that prevailed for them when they entered their residency, now many years ago, had remained unchanged. They are out of touch, and everyone but them, including many of the students, knows that.

Now it wouldn’t be fair to lay the blame for shifting favors of Medicare and general trends in health care on geezerly medical educators; those forces are larger than those charged with educating doctors have ever had the power to control. Patients, and their general expectation that medical care should be paid for by insurers and that advanced and expensive procedures should be available have added to these conditions and the kind of economizing that underpays ever busier internists and (seemingly, although I doubt it) favors procedure-intensive specialties.
The concierge doctor, despite those who criticize that model, is making the conscious choice to offer quality above price. There is risk in that model, we should not forget, the risk that there won’t be enough patients who value good care done without overscheduling or haste to keep him in practice. That there won’t be some who think the price worth paying is the way of the world, and the doctor is not the one to blame for that.

The non-medical world has changed and talented university graduates with far fewer years of graduate education enjoy much more pay and better benefits and working conditions than in the past, despite their higher educational debts. Relative to people in medicine, they are far further along in relief of personal debt and general accrual of wealth than the typical medical grad who delays productive earning until after age 30.

I don’t hear the same voices expressing outrage at the mountainous costs of medical education. I don’t hear calls from the “leaders” of the residenct programs to creatively use the funds they are given by the government to train residents, funds that greatly exceed what is given to those residents in pay and benefits, by the way. Where have I heard any suggestions that those resources be used to relieve the residents of their loan payments? Not from the “leaders”, that is for sure.

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.

Clearly, CHenry, you attempt to speak of areas with which you are not adequately familiar. (Given the indignantly pompous tone of your reply, I can’t say I’m surprised.)

You state: “The non-medical world has changed and talented university graduates with far fewer years of graduate education enjoy much more pay and better benefits and working conditions than in the past, despite their higher educational debts. Relative to people in medicine, they are far further along in relief of personal debt and general accrual of wealth than the typical medical grad who delays productive earning until after age 30.”

As someone who went the full terminal degree route in the visual arts, I can tell you from personal experience that your comments are just not accurate. I would imagine the same inaccuracies would be reflected in any number of the humanities and, as I hear from the experience of friends, in education as well. Outside of law, certain sciences, medicine and business –what I call the “corporatized” professions, money, benefits, and “lifestyle” have not adequately kept pace with tuition costs and time and energy spent in gaining the requisite education and training for our chosen fields. Yet we have continued to choose these paths because it is who we are. I don’t expect you to necessarly understand that, but please, at the least refrain from making inaccurate generalizations about the state of those of us in the non-medical world to support your own reasons for making the choices that you do. (And regardless of what you are able to convince yourself are your reasons, to me, as someone on the outside (i.e. non-medical), your reasons sound very much like more of the “keeping up with Jones kind of stuff, excepting, of course, the arguments made about family and the abusive hours of aspects of the residency training. (Though in actulality it was another commenter who most emphasized those concerns.)

I also take issue with your statement that there is “generally less appreciation by the broader medical and lay community” for internal medicine and general surgey. I find, in nearly every conversation I have ever had with the lay community via friends and family, that there there is a great deal of appreciation for these practices. Immense in fact. Unless by appreciation you mean monetary compensation. Though on that front, I can tell you that we (the lay community) are as offended by the practices and dictates–including renumeration–of the insurance industry as you are. But I also know that it is a yet another symptom of a deeply broken system and in my mind, just another indication that we need massive reform of the health care and insurance industries.

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.

The most important thing about choosing a career/specialty is choosing one that fits your personality. You have to look at the mix of person-to-person contact, intellectual stimulation, ability to master some kind of difficult physical task (eg, surgery) and how important these are to you.
I agree with Dr. C here that letting the monetary aspects carry too much weight is hazardous. As I look back on my career, if money was an overriding factor, I would have been better off not to go into medicine at all, but rather some area of business where I could have made more money and had less responsibility. And I could have changed from one fancy car to another, one pretty scheming wife to another as fast as I would want to.
I’ve always been skillful doing things with my hands, so my family assumed I’d go into surgery. I came from a small town and thought I’d be an FP when I entered medical school. As I got into it, I found I didn’t like being in the OR so much, and that my personality didn’t fit being an FP, so you have to open your mind before you make a choice.

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.

no matter how bad i had it in residency and through three brutal fellowships (total 9 years clinical trainnig) all before 80 hr work week rule, every single year was still easier than any year in practice.
the demands on your time, energy, and attention just get worse. the money certainly gets better, but i think for most people, the increase in responsibility offsets the protection you get in training. even if you feel abused during those years, you are still in a very protected environment.

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).

“Our ministers serve the masses, making themselves forever available to spiritually comfort the masses, because their creature needs are met by the congregations.”

I am a minister, and that is a bunch of bull. My “creature needs” are met by my wife and I because we both work hard. The congregation barely pays me a livable wage. I have no retirement. I live with debt and doom hanging over my head.

Being a doctor would be a piece of cake compared to all that I have to put up with as a minister – hence my decision to pursue medicine instead.

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.

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