My top post of all time addresses this question – Why become a doctor?

I received a recent email from a 20 year old college student who asked me about this issue.  As I have pondered this email, I searched for the proper words.  Readers know that I love being a physician.  But this student asked a different question.  The problem is the classic one for all who go to medical school – can you and should you delay gratification of need? 

Going to medical school and doing residency delays adolescence.  You stay a student for your entire 20s.  Looking back from age 60 this decision seems simple.

I enjoyed the last 2 years of medical school and my residency (readers know that I hated the first 2 years of medical school.)  As a 60 year old, I guess that I missed out on my 20s – but did I really.  What did I miss?

So here is my advice to 20 somethings.  The 20s only represent 10 years of your life.  You have many years after to work and contribute.

As a physician I still feel vibrant at age 60.  I still make an important contribution to patient care.  I still influence students and residents.

I wake in the morning, look in the mirror and have a sense of purpose.

At age 60 I am not worried about employment.  I make a decent living – although have many friends (non-physicians) who make much more money.  I like working – and sometimes wonder if it is really work.

So my simple advice is that medicine is worth it – not for riches – but for the work.  Helping patients feels good every time.

I would always argue that the trade-off in your 20s is paid in multiples.

Please first read my classic post – Why become a doctor redux?

Recently I have had two important questions asked about this subject.

I wanna know is it worth it to become a doctor? How much money do they got a year like a family doctor or something in that area? How many years does it take to become a doctor?

Is it worth it?  This question obviously depends on your definition of worth.  Physicians make comfortable incomes.  Family physicians make less than many subspecialists.  I would not choose medicine just for the money, although in our current economic crisis, medicine looks relatively better than many business positions.  On average, physicians may see some income loss, but we are very unlikely to be without a position (unless we commit gross malpractice and negligence or run afoul of the law.)

Becoming a physician takes 4 years of college, 4 years of medical school (piling on debt), then a residency (ranges from 3-10 years).  Then you can get a position.  The training is demanding but very educational.

how manageable is it for a woman to become a doctor, especially when raising a family is a factor that needs to be taken into consideration?

I have many female colleagues.  Most find being a physician an outstanding career.  Medicine does give you options to balance family and profession.  Usually balance involves less hours and less income.  I have colleagues who work as few as 20 hours a week.  They still love medicine, their patients, and their families.

i have heard that after some years practicing medicine things become routine, which makes sense since years of experience and encounter of the same maladies can make treatments second nature. but then what?

Medicine never becomes routine.  If you fool yourself into thinking so, something different comes along.  I am constantly amazed by the detective work that I must do.  I am constantly amazed by the advances in medical knowledge that influence my daily conceptualization of medicine.  Finally the relationships with patients are always unique and rewarding.

after four years of high school you change and go to college, after four years of college you switch and perhaps go to medical school, . . . once you become a doctor does life become static? does the academic learning process come to a halt?

As above, learning should never come to a halt.  I find that many retired physicians actively read journals and attend meetings.  Medicine for many becomes totally integrated with our conception of who we are.  I never find it boring.

Also, upon reaching this point in life do doctors have flexibility to develop other areas of interest? By this I mean, is there time or does the hospital consume most of your time. Can a doctor practice part-time? Does it depend on the specialty?

Please see the above answers.

Also, how do you go about choosing your specialty? I’ve always wondered about certain doctors, dermatologist for example. What an interesting passion to develop, does an individual wake up one day and say, I want to be a skin doctor?

Specialty choice requires more time than I am willing to spend typing right now.  Most medical students figure out who they are during their third year.  Correct specialty choice balances personality, aptitude (I would make a lousy surgeon), monetary and lifestyle influences.  Passion does occur for most students during their clinical years.

Lastly, for those physicians out there, if you could start life over, do you think you would still pursue medicine?

Many physicians would not.  This physician would.  Those who entered medicine for business reasons are most likely unhappy.  Those who truly love caring for patients can find a niche, perhaps lower paid, but a niche nonetheless that provides daily satisfaction.

I hope that these answers help the many readers who will find this rant through google.  Why become a doctor is the number one search that brings readers to Medrants.

The Pitfalls of Linking Doctors’ Pay to Performance

The program is called pay for performance, P4P for short. Employers and insurers, including Medicare, have started about 100 such initiatives across the country. The general intent is to reward doctors for providing better care.

For example, doctors receive bonuses if they prescribe ACE inhibitor drugs to patients with congestive heart failure. Hospitals get bonuses if they administer antibiotics to pneumonia patients in a timely manner.

On the surface, this seems like a good idea: reward doctors and hospitals for quality, not just quantity. But even as it gains momentum, the initiative may be having untoward consequences.

To get an inkling of the potential problems, one simply has to look at another quality-improvement program: surgical report cards. In the early 1990s, report cards were issued on surgeons performing coronary bypasses. The idea was to improve the quality of cardiac surgery by pointing out deficiencies in hospitals and surgeons; those who did not measure up would be forced to improve.

But studies showed a very different result. A 2003 report by researchers at Northwestern and Stanford demonstrated there was a significant amount of “cherry-picking” of patients in states with mandatory report cards. In a survey in New York State, 63 percent of cardiac surgeons acknowledged that because of report cards, they were accepting only relatively healthy patients for heart bypass surgery. Fifty-nine percent of cardiologists said it had become harder to find a surgeon to operate on their most severely ill patients.

Whenever you try to legislate professional behavior, there are bound to be unintended consequences. With surgical report cards, surgeons’ numbers improved not only because of better performance but also because dying patients were not getting the operations they needed. Pay for performance is likely to have similar repercussions.

Consider the requirement from Medicare that antibiotics be administered to a pneumonia patient within six hours of arriving at the hospital. The trouble is that doctors often cannot diagnose pneumonia that quickly. You have to talk to and examine a patient and wait for blood tests, chest X-rays and so on.

Under P4P, there is pressure to treat even when the diagnosis isn’t firm, as was the case with my patient with heart failure. So more and more antibiotics are being used in emergency rooms today, despite all-too-evident dangers like antibiotic-resistant bacteria and antibiotic-associated infections.

I recently spoke with Dr. Charles Stimler, a senior health care quality consultant, about this problem. “We’re in a difficult situation,” he said. “We’re introducing these things without thinking, without looking at the consequences. Doctors who wrote care guidelines never expected them to become performance measures.”

Readers of this blog actually are familiar with these concepts, but you probably share my pleasure with these concepts receiving wider exposure in the newspaper of record.  I highly recommend this well written article.

I wrote about this 3 years ago.  Interestingly with my new plugin, I find that searching this question is still very popular.  Today someone wrote this question:

Is it at all possible to keep a balance in a life of medicine? can you have the best of both worlds? having time to travel and spend with friends and family and also have a rewarding, medically driven career?

I find this question difficult to answer without a dialogue.  I have travelled.  I have many friends.  I have a single digit handicap.  I’m a proud grandfather and proud father of 2 adult children.  My wife and I just celebrated our 34th anniversary. Yes, I have had a wonderful balanced life.  Sometimes medicine needs your time.  Balance is a difficult concept to discuss, especially if you love your work.  My balance many not be your balance. I reread my post from 3 years ago and still endorse that post.  If you are interested – Why become a doctor?

Sometimes medical students and housestaff forget why they decided to become physicians. And then sometimes patients remind them why. A student of solace and love

I was a fourth-year medical student when I met the two patients. The rotation, a rite of passage, is the month or two during the last year of medical school when we get our first true hint of what it feels like to be a doctor. We take full responsibility for our patients and make day-to-day decisions, with close supervision by our superiors. It is also our prime introduction to "scut work." Scut work runs the gamut, and may include tracking down lab results, calling an outside doctor for a fax of a patient’s MRI scan or arranging a patient’s discharge with social workers. Scut work involves the nitty-gritty of making things happen in the hospital for patients. During the middle of the rotation, my enthusiasm started to dwindle. The scut work was draining. It was intellectually empty, and the long hours — staying up for 30 hours straight every fourth night — began to wear me down. That was, until I met these patients and, more precisely, their families.

Stephen Covey, in his 7 habits of highly effective people, reminds us in Habit 2: Begin with the end in mind. Medical students often have a difficult time remembering this. Their day to day life has great stress, and they focus often on the things that cause that stress. They start school with altruism, but we (medical educators) and the "system" often beat it out of them. Sometimes it takes a fresh look at why to place "scut work" in its proper understanding. Speaking about a spouse caring for her sick husband:

I drew inspiration from her at a time when some of my own was waning. She stayed by his side, sleeping on the hard hospital floor every night without complaints. She listened to him moan in pain all day. She made him feel less like a hospital boarder and more like a regular person — he was always clean-shaven. One morning, I walked into the room, which was perfumed with the refreshing scent of Neutrogena. She had moved him to the bedside commode and set up a makeshift bathing station. The patient smiled, looking fresh and clean and proud. The meticulous care that these patients’ families gave their loved ones was an extraordinary sight to witness. Neither patient, however, sang their caregivers’ praise. She was too tired — and could barely talk through her tracheotomy; he was too consumed by worry. Yet the caregivers kept on. They knew their loved ones appreciated and needed them. In that way, the families helped me put the thankless daily grind into perspective. In the complicated world of hospital care, every task makes a big difference, no matter how small or unrecognized. The serial phone calls down to the ultrasound department, the letter-writing to Medi-Cal for emergency insurance, this was my part. These seemingly mundane tasks could make a marked difference just as cleaning a wound or bathing a patient would.

Scut work has an undesirable connotation. This slang does communicate, but I believe it communicates the wrong idea. Caring for patients requires multiple skills. Like detective work, success occurs from a series of persistent steps. As I reread this medical student’s prose, I smile. I believe she has started to understand what it really means to become a physician.

A reader asks -

So I'm curious, since so many doctors I've talked to (both young and old) say "don't do it, it's not worth it” can you point to something you'd say makes it worth it? Is there something different about the path you've chosen, or is it more about your attitude? I realize that it's difficult to compare yourself to my hypothetical doctors, but I'm assuming you might know some of these naysayers.

Why do I love medicine? I can describe multiple aspects of medicine that I love.

• Problem solving
• Interpersonal interaction
• The need for continuing education – I love learning and love the ability to take new knowledge and adapt it to my patients
• My goals – I really enjoy helping patients. When I think about medicine, I think about how I can help patients achieve better quality of life
• The doctor side of the doctor patient relationship – the way patients respond to their physician; the default respect that we receive (unless our actions forfeit that respect)
• The intellectual challenge

My list does not include money (although I must admit that I have done very well financially). I tend to view the glass as 3/4 full. The annoyances of current medical practice – insurers, time constraints, the business aspect – are not a major part of my daily life. Perhaps my extremely positive attitude comes from my enjoyment of academic medicine. I love to teach – especially that moment when the student's, intern's or resident's eyes lose the glaze and gain the sparkle. I love rounds. Describing why I am so happy (while others are not as happy) is a challenge. But I do not believe that I am the only happy physician. I see happy physicians every day. I see many unhappy adults. Most adults my age (56) do not love their jobs. Fortunately for me medicine represents both a vocation and an avocation. Medicine allows one to help people in many ways. Too many have not found their best fit. Some enter medicine for the wrong reasons. But here I speculate – and I may certainly be wrong.

I often write about why I am so happy that I choose medicine as a profession. Some physicians do not share my ongoing joy. Some enjoy the profession for a period of time – then something changes. The Bioethics Discussion Blog has this interesting post on this topic – Uncertainty and the Life of a Doctor

… But then there is the day when we experience the cold sweat of personal concern: was the diagnosis correct? was the treatment the best? why did the patient die? …

Please go clickety click and read the entire post – including a thought provoking poem. As a medical educator, I believe that it is my responsibility to role model addressing bad outcomes. When patients do not do well, we pull out the retrospectoscope and try to learn what we did right and what we may have done better. Yesterday we had a noon conference – a Morbidity and Mortality Conference – on a young patient who died. The panelists participated in a spirited discussion of what was wrong with the patient and what they might have done differently. The audience learned a great deal during this session. A potentially treatable diagnosis was missed in the ER – leading to an inevitable downward spiral. At the end of the session, the moderator shared that he was the attending for the patient. He exposed all his team's decision making to an audience of over 200 physicians. He served (and has served for many years) as a great role model for all physicians and housestaff. Only by exposing our decision making to careful scrutiny can we make it more likely that we will help the next patient. Or we could just quit medicine.

Being a physician has challenges and benefits. I had this explicit discussion with my new intern and resident this morning (special holiday schedule team). When we walk into a patient’s room and introduce ourselves, the patient and family generally like and respect us. We start out receiving the benefit of doubt and only lose repect when we do something wrong. The public rates us highly. Our profession remains admired, even in these times. Patients will tell us anything. We learn more about human nature than most people ever want to know. This can cause some stress – A Young Doctor’s Hardest Lesson: Keep Your Mouth Shut

An unspoken but ever-present issue in the life of any doctor is an immodest, completely nonmedical concern: are doctors boring people? Sober and serious, surely. Respectable and educated, one hopes. A bit stuffy at times, perhaps. But dreary? As a profession, I think we do tend to run on the dry side, though till recently the reason had eluded me. Then, last month, my wife and I bumped into an acquaintance of hers while walking along the street. The person, unbeknownst to my wife, is a patient of mine, someone whom I treat for a chronic infection. After the patient and I shared a moment of mutual panic, we three chatted amicably and moved on. Except, that evening, my wife kept asking me why I was being so quiet and, well, boring. And I suddenly saw the problem: doctors are waterlogged with secrets, hundreds of them, thousands of them. Each day brings a new batch: patients’ admissions about drug use or sexual indiscretion, a hidden family, a long-held dream, an ancient heartache, undisclosed H.I.V. infection. Over the years, this begins to add up, the bulge expands, the joints get stiff. Yet the secret – the consequences of our ever-expanding repository of others’ secrets – remains, well, secretive. The situation simply is not addressed, not at the start, middle, or the end of a career.

While I am not certain that I agree with the author, he has certainly made me think. The culture of medical training leads to us having a very different view of people and illness. We do understand the consequences of indiscretion. We understand human frailty.

Other professions that traffic in secrets typically maintain silence for a fixed period: lawyers and spies, accountants and politicians, mobsters and four-star generals. Power or leverage is at stake, but once things settle, the gabfest can resume. But for us, the silence is forever. The consequence of this tight-lipped life is readily evident anywhere young doctors have congregated. Exploiting the single loophole in the code of silence – chatting up one another – they busily swap stories about patients. Near-maniacal peals of laughter are heard as the latest "I once saw this woman in the E.R. who" tale is recounted. The hilarity, the need to yelp, surely derives from something other than the quality of the story at hand. I know this because, um, I have transgressed a few times, to try out a story on someone not medical. And rather than hearing the appreciative party guy hoot of laughter, I receive only a confused squint. So we learn to keep quiet about the whole thing, trusted advisers in the persistent palace intrigue. But conducting business this way is confusing. What is off limits, and what remains in play? Can I say this or that? Pretty quickly, it becomes clear that the easiest and safest – though the quietest and dullest – approach is simply to shut up concerning just about everything.

To this day – almost 30 years since graduating from medical school – I have stories, really funny stories, that I can only tell to other physicians. Non-physicians do not see the humor and even find the stories gross or insensitive. As a 3rd year medical student, I wondered why we always talked about medical incidents when we got together. After a long work week, here we were swapping war stories. Several weeks ago I visited my medical school – where I also did my residency. I ran into one of my fellow interns (now the chief of pulmonary medicine). We quickly degenerated into remembering war stories about patients. I guess we live in a "secret society". We must hold these stories confidential – except as stories to share with colleagues (omitting names and identifiers of course). But, it really is not a lonely life. It is a life full of the privilege of caring for others. But we often cannot talk about it or explain it. And maybe that is as it should be.