Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, May 18, 2007

Is it Worth It? A Response

Panda Bear MD has written a provocative post about the pros and cons of a medical career. After a careful discussion of the economics of medical education (including a terrific didactic discourse on the concept of opportunity cost), the earning potential in the context of the present political climate (including the risks of potential changes in that climate), and an fear-mongering yet anecdotal presentation of the issue of medical malpractice, it would seem very difficult to justify the decision to pursue a career in medicine.

Panda's analysis is flawless. It is also meaningless.

At the risk of being labeled by Panda and others as a creepy fanatic, I assert that it is not about the money. Nor even about the lifestyle, really. At the end of the day, the week, the year, the career, it is about the life lived. Medicine is about a life lived impacting the lives of others. To call it Noble is old-fashioned, out of style and downright hokey. None of that changes the fact that it is true.

In this season of graduations (kvell: younger son garnered FOUR academic awards at the banquet last night) (/kvell) and kids coming home from college wondering what they want to do with their lives (realizing that now is the time to begin making those decisions) this whole process of introspection -- and providing guidance -- is very near to my heart. How does one go about making these kinds of choices?

You can go through (or read) elaborate analyses of the various pros and cons of assorted possible careers, balancing the financial issues with the lifestyle ones. But this approach assumes that the only role of a job in one's life is economic; the option that generates the most possible money in the least unpleasant manner is what will come out on top every time when looked at this way. But what about passion? What about "doing something with one's life"? Life should be about more than just work. Medicine is one among many opportunities to make a difference while making a living.

People wonder why I and my fellow Family Physicians keep on doing what we do. It's because even in the face of all the hassles, bullshit, declining reimbursement and everything else, the deep satisfaction we get from making a difference in the lives of our patients is real, worthwhile and meaningful. We don't talk about it because it's such a part of our soul that among ourselves, it's assumed. Showing a mother something she didn't know about her new baby, even if it's her third; steering an adolescent away from drug or alcohol experimentation; reassuring someone they don't have cancer...and that was just today!

Medicine is more than a job. It is more than a career. It is a calling. (Perhaps that's what Panda means when he says that fanatics "...hear things that normal people do not.")

Is it worth it? I would answer, is it worth what?

Don't pursue a career in medicine because you think it would be a good idea. Don't do it because you want to. Don't do it because you love it. Do it because you cannot possibly imagine being happy doing anything else.

23 Comments:

At Fri May 18, 06:59:00 PM, Blogger N=1 said...

How I enjoy your glimpses into your wonderful children and family! Congratulations on the 4 awards!

As for the financial basis of pursuing medicine - it does have meaning - but maybe not the kind of meaning for which you referred. There are some people who pursue careers for prestige and for the tangible rewards. Panda's post will steer them away, and that's all good. Those are not people who will probably do well in relating to patients in any meaningful way - as you do.

If it saves two people from deep dissatisfaction: the unhappy doc and the unhappy patients, then it's advice well-heeded.

In all other respects, I agree with you. There's nothing like feeling that you helped someone, and that you were able to attend a significant life event for them from ushering them in and ushering them out of this world. That's a rare privilege.

 
At Fri May 18, 07:01:00 PM, Anonymous Val Jones said...

I'm with you, Dino. Don't be ashamed of being labeled a fanatic... your patients love your caring nature and the satisfaction you get from helping them is priceless. Thank goodness we have family physicians out there still willing to help in the midst of this broken system. I'm glad you "answered the call." :)

 
At Fri May 18, 08:42:00 PM, Blogger Dr. Deb said...

As with most professions, I think those who feel passionate about their work have that calling.

It is the same in my field - psychology. Years of training, hours spent in one's own analysis, supervision, etc. It IS a calling. And one that befits me well.

 
At Fri May 18, 08:50:00 PM, Anonymous Anonymous said...

I don't think you really addressed the substance of his post, which was that there are many unnecessary abuses and hurdles in medicine. The "fanatics" of the sort you describe only act to enable the problem, since they are the type to (to paraphrase the infamous med school admissions board) "eat a poop hot dog" if that's what it takes to get in.

This sort of martyrdom, at the extreme, ends up at the sort of perverse pride displayed by neurosurgery residents at their failed marriages and unhappy children and makes it unnecessarily hard for those of us who (gasp) want to have families and (gasp) not live and breath medicine 25 hours a day. If people going into medicine were a little more rational about the costs and benefits then the Overlords of Medicine(tm) would have to shape up a little or they would lose good people. The fact that people will take whatever mistreatment they dish out and say "thank you sir may I have another" is exactly the point of Panda's post and is what perpetuates most of the problems with medical school and residency training.

 
At Fri May 18, 09:43:00 PM, Blogger Sid Schwab said...

I agree with you, Dino. Either it's a calling or it isn't. If it is, then the other stuff matters less. The essense of medicine is the doctor-patient relationship, the opportunity to help. It's deeply rewarding. As I've said, at the center, nothing can touch that relationship; HOWEVER, it's also increasingly true that the center is harder to tap, as the layers of bullshit get deeper and more manifold. So it remains a question, given the general direction of things, whether one will always be able to find that satisfaction amongst the impediments. Were I to do it again, I'm quite sure I'd do it again, because I can't imagine being anything else than a surgeon. But I'd have done it differently, at least a little. Forced myself (so I say) to take more time for myself...

 
At Fri May 18, 10:19:00 PM, Blogger Mom MD said...

I've actually been asking myself the 'is this worth it?' question a lot lately; I'm an intern in family medicine so it pops up more than (hopefully) it will in later years. Sometimes it is worth it...sometimes I'm not so sure.

When I'm post call and I only have time to briefly talk with a patient because I have loads of paperwork to do...and then I see the nurse go in and have a real, meaningful conversaton with the patient I just saw...then I rethink things.

Perhaps I misheard my calling? Wouldn't it be easier to be a nurse or a nurse practitioner? They actually get to talk with the patients. They actually get to sit at the bedside with patients when they need someone right away. They actually get to go home at night and tuck their loved ones into bed. They make at least twice as much per hour as I do right now. I think I would let these thoughts percolate more if I wasn't in a good bit of debt from medical school.

But then there are privileges of the White Coat. Patients share with the White Coat things they don't share with others - even their nurses. The White Coat gets to be the one actually catching the baby and actually writing for the medicines to make grandma comfortable in her last hours (as n=1 mentions).

But is it worth it? Ask me after July 1st.

 
At Sat May 19, 02:59:00 AM, Blogger Sara's Sad Alter Ego said...

Amen. Wish docs would get together to refuse so much paperwork and ten minute appointments and all the things that wreck it for them.

 
At Sat May 19, 08:58:00 AM, Blogger The Independent Urologist said...

Thank you for saying what needs to be said. Too many crepe hangers out there. I do what I enjoy, make some money, and have satisfaction that I am making a positive impact on people. And I do it all on my own terms, by myself. No other way!
Thanks for the positivity.

 
At Sat May 19, 09:31:00 AM, Blogger CrankyProf said...

One of the reasons I absolutely adore my family practice doc, and one of the reasons we've stuck with him through a lot of ups and downs, is that it is very clear that he's in it because he loves it. Our doc is practically family; he knows us inside and out (literally), and can alter his treatment to suit. He knows when we need a boot in the ass (weightloss!), and he knows when to soft-pedal.

His former partner was a "Push 'em through/ five-minute consult" person, and was unpleasant to deal with -- at best.

I'll wait in Doc L's waiting room for three hours to see him, because I know he actually cares.

 
At Sat May 19, 10:38:00 AM, Anonymous Lisa said...

I couldn't agree more, Doctor Dino. I've worked at a bank, a telephone company and a retail store. I was making double at the bank than what I do now. However, I wasn't happy. I finally couldn't take it anymore and decided to get into health care (the field I've always be interested in).
I make half of what I made at the bank but I am infinitely happier as a Certified Medical Assistant.

Sometimes patients ask me my title and how long I had to go to school for. The third question is usually "is it good money"? Nope! Hehe... but I don't do it for the amount of money I make. I do it because I love it and because I wouldn't be happy doing anything else.

I'm proud of what I do at the end of the day and I never got that pride out of those other jobs I had.

 
At Sat May 19, 01:17:00 PM, Blogger Bongi said...

well said!! if it's about worth it, time wise i suppose not. but it is so worth it on so many other levels i can't even really consider the question. as you and sid say, i can't imagine doing anything else, so the question of worth it is mute. sometimes at work i take a moment to consider how lucky i am to be where i am doing what i'm doing. it is so worth it.

 
At Sat May 19, 06:54:00 PM, Blogger Someonetc said...

bravo (clapping loudly) ...

so much has been said about money and time spent. so many complain about the long hours (80hr weeks) and paper work. the abuse etc. and yes, i complain.

truth is i love what i do. i love going into work an seeing my little patients. many times you don't feel appreciated, but so many times you go into work and you leave with a smile on your face because you have improve on someones life.

the practice of medicine is a calling. medicine is a business.

thank you for that post

 
At Sun May 20, 12:54:00 AM, Blogger Bohemian Road Nurse... said...

It is as if you read my mind. But your very eloquent gift of language and words express it much better than I could.

 
At Sun May 20, 01:49:00 PM, Blogger scutmonkey said...

I think it is not just about following your calling, but that is what it was for me. There are many types of people that choose medicine and the romantics will always follow their hearts. This is an important personality trait for a field like medicine, but is it the only one that is important? There are plenty of people that may choose medicine for more practical reasons and they are the ones that are starting to jump to the other check-out line for some other profession. I don't think medicine should be nothing but us romantics that are following our hearts because the business of medicine is a necessary evil and it needs REASONABLE people, but just those willing to walk the plank in the name of their calling. (here I go to see if I make a big splash!)

 
At Sun May 20, 04:33:00 PM, Blogger buckeye surgeon said...

If we want to say "it's not about the money" and turn the medical profession into a bunch of Franciscan saints, then we need to address the costs of medical school. I would have no problem making middle class, average-guy money as long as I got to do something I loved. Coming out of a surgical residency, I'm already in my early thirties with no savings and $150,000 of debt. Make medical school free, or at least affordable, and Ill gladly work for high school math teacher money.

 
At Sun May 20, 05:17:00 PM, Blogger keagirl said...

I'm not sure I want to call myself a "fanatic", but I cannot imagine doing anything else with my life.

I wake up the in the morning, actually wanting the go to work. Now how many other people can say that about their jobs?

Yes, yes, surgical residency was awful and took away my entire twenties, I'm still a long way away from paying my med school loans, paperwork and insurance is a bitch and patient care can be challenging, but in all honesty, I love being a urologist! (OK, I guess I do sound like a fanatic...)

 
At Sun May 20, 05:20:00 PM, Blogger Lynn Price said...

What a terrific post, Dino. Even though you're talking about medicine, this is true for any profession. Finding that road to bliss makes the trials and tribulations worthwhile.

Not being a doc, I worry that the crap is going to beat down even the most dedicated of docs. I love my internist. He's one of those guys who just loves being a doc. He's never in a hurry to race out the door. He knows about me, my family, my fear, etc. He sounds a lot like I imagine you are. Keep rockin' on.

Hey, I started reading your book! I read a few of the Haikus and nearly laughed my Coke through my nose. My favorite so far:
True source of
civilization
the sphincter

I may have to ask your permission to use one of these in my second book. Hey, I won an IPPY on the first book.

 
At Sun May 20, 09:30:00 PM, Anonymous TBTAM said...

Great post, matched only by a great comments section.

I agree, that when the end of the day comes, I get more positive feelings from what I do than almost anything else I can imagine.

But one has to understand the frustration that some of us feel at the loss of control we feel as the field of medicine is changing out from under us....

 
At Mon May 21, 01:12:00 AM, Anonymous Dana said...

Thanks, Dino, for your perspective. I'm a pre-med who spends several hours a week shadowing a physician, and after eight months of hearing the only semi-kidding "we haven't talked you out of this yet!?!" I have to tell you that sometimes I wonder what I'm about to get myself into. It's nice to know that some docs out there still honestly love their work, even despite all the bullshit.

 
At Mon May 21, 09:38:00 AM, Blogger Detail Muse said...

I'm reading Dr. Atul Gawande's second excellent compilation of essays, "Better" -- the one titled "Piecework" discusses the financial aspects of doctoring. It's a former New Yorker piece and is archived online at:

http://www.newyorker.com/archive/2005/04/04/050404fa_fact

 
At Mon May 21, 10:33:00 AM, Blogger Voter Mom said...

I envy people who know what their calling is and are able to answer it.
And on a personal level, I'm very happy Dr Dino is a doctor -- I get awesome medical care, imo. *smug*

 
At Mon Apr 14, 10:27:00 PM, Blogger Charles said...

I get the worst responses when I say this is why I want to become a physician. I realize that some colleagues will be cynical, that I will spend my youth working for low pay and under terrible conditions, and that bureaucratic BS will eat up an enormous amount of time. Doctors, teachers, and family have all said I will change my mind after the first year or so of med school, and I have no way to convince them otherwise. Beyond knowing I could never be happy in any other job, I truly have a passion for medicine. The thrill of helping someone in the worst part of their lives, even with the mundane work, will never wear off for me. As clique as it sounds, I know the very calling of my life is to become a doctor. The encouragement I get from reading the blogs of physicians who are happy in their lives gives me hope for what I'm undertaking, but the truth is I'd continue on the path I've begun with or without this optimism.

 
At Thu Jun 19, 07:44:00 PM, Anonymous Anonymous said...

So, You Want To Be A Doctor…..

Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason stated and speculated for this decline of this health care profession that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training.
Yet considering the additional attention of shortages of students in some medical schools as well, one may ask the question as to whether or not people want to be any type of doctor in the first place in the United States. About one third of their lives are spent achieving the requirements of this profession. Reasons for not choosing to enter this profession are several and valid and include the following:
There is the issue of long hours- with primary care in particular because of the apparent lack of doctors of this specialty. Such doctors may be over-worked without an expected pay reflecting the work they do. Furthermore, those doctors employed by health care systems are required to see a certain number of patients a day, and receive a monetary bonus if this expectation is exceeded. It seems that most doctors are members of such health care systems. So burnout never anticipated certainly may occur. And I consider such a requirement mandated by health care systems demeaning to this profession, and leave the doctor without the control that the doctor is entitled to due to their training and experience, and this competes with the other adversary of doctors, which is managed care. In fact, even government healthcare programs provide financial incentives in relation to the pay-for-performance system to improve the quality of care.
However, the recent increase in hospitalists, who are those doctors that are usually Internal Medicine doctors who care for patients presently under hospital care, and they have lessened the load for all doctor specialties for the work they do that the admitting doctors would have to do without their presence. This in itself makes a doctor possibly more effective and efficient in their practice outside of the medical institution.
All doctors, I presume, face a high degree of emotional and physical stress associated with their profession, as stated in the previous paragraph, for example. And this is not to mention the incredible stress associated with patient care in the first place, with some patient cases causing more stress than others. Patient care duty is a noble and great responsibility.
Doctors, due to the changes that have occurred recently in the U.S. health care system, not only have the issue of money to deal with, but also a loss of autonomy regarding patient care combined with loss of respect that may be due in large part to the others previously mentioned who dictate how they practice medicine. Ironically and often, these others who direct these doctors are not as qualified as the doctor in the first place. This is complicated by the perception that the public, with some who view doctors as having the easy life with their pay and profession, which does not seem to be the case presently. Another frequent occurrence is the doctor’s patient directing their care with their doctor from either DTC ads or researching medical disorders on the internet themselves.
There are also reasons of malpractice insurance, which is why doctors choose to join health care systems, it is believed, to pick up the tab for this necessity, along with eliminating the concerns of running a practice in a private manner, which historically has been the case, as their offices are owned by the health care system as well. Yet having another pay their malpractice premium does not eliminate their concern about being sued for error perceived by one of their patients. To protect against this, defensive medicine is implemented by doctors, which basically involves copious amounts of documentation and ancillary diagnostic testing regarding the doctor’s adherence to recommendations and guidelines.
It has been said that up to 90 percent of malpractice cases against a doctor are baseless and without merit, so they are unsuccessful for the plaintiff, yet this still affects the rate the doctor or another system has to pay for malpractice insurance of a wrongfully accused doctor. This is combined with the amount the doctor has to spend to defend themselves in such cases, which separates them from their focus on the restoration of the health of their patients completely. Furthermore, malpractice lawsuits cost about 100,000 dollars over the course of about 4 years for such cases. A tort reform in Texas in 2004 resulted in annual malpractice premiums reduced by about a third of what they were. Soon afterwards, claims against doctors remarkably dropped by about 50 percent. Some specialties of doctors pay more premiums for malpractice than others. For example, OB/GYN doctors have been known to pay around 300 thousand dollars a year for this insurance. Certain types of surgeons experience a similar high rate of malpractice premiums. Malpractice flaws are catalysts for doctors to practice the inappropriate defensive medicine mentioned earlier to avoid potential litigation, which is a waste of health care resources with ordering unneeded patient methods or procedures to cover themselves against such lawsuits.
Also, about a third of the U.S. is insured by Medicare, which progressively has lowered what they will reimburse a doctor for regarding the care doctors give a patient they treat. This fact is recognized by other insurance companies who will eventually follow the recommendations of Medicare, usually, regarding the reimbursement issue, so it seems. This will lead to a doctor having to see even more patients in order to make it financially with their profession, as this has resulted in the overall income of a doctor experiencing a decline of about 10 percent over the last decade or so.
Further complicating the financial state of a primary care doctors is that doctors normally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed. About 20 years ago, that debt was only about a fifth of what it is today. Paying this debt off is typically about 2 thousand dollars a month that doctors on average is what the doctors choose to pay in order to eliminate this debt in a timely fashion.
Conversely, there are some who believe that doctors in the U.S. are over-paid. This may be true, but they are not absent of financial concerns as with any other profession. And as mentioned earlier, clearly doctors accept more responsibility involved with human health than other vocations, so this should be kept in mind perhaps more by others.
Most doctors do not recommend their profession to others for such reasons stated in this article so far presently, and perhaps other reasons not mentioned. This is somewhat understandable, yet extremely unfortunate for the health of the public in the future. There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state of mind that occurs as a doctor in today’s health care system, which is expressed by them at times in apathy, cynicism, and vexation regarding their limitations coerced by others.
Conversely, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession. Personally, I believe that the intentions of most physicians are bonafide. Yet in time, due to the nature of the current health care system, doctors frequently and really do become cynical, demoralized and apathetic. This may be considered a significant concern to the well-being of those in need of restoration of their health, understandably.
Not long ago, the medical profession that has been discussed had overt honor and a clear element of nobility. Such traits are not as visible or recognized anymore, which saddens many intimate with the profession and importance of public health that is needed by many.

“In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero

Dan Abshear

Author’s note: What has been written has been based upon information and belief.

 

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