Tuesday, April 5, 2011

Life in Medicine: A Reality Check

This was posted on a discussion forum for physicians. It's a draft of an e-mail from an anesthesiologist to a medical school applicant who has not been accepted to medical school and has subsequently written to him/her for advice. I've changed the name of the student in question to just "Student."

Many physicians on the forum commented, "I'll sign it too" or "Put it up for all of us to sign" or "You could almost certainly get every doc [here] to sign this" or "It's the truth. She should know the whole story."

The e-mail draft is reposted here by kind permission of its author. I think it's extremely thought-provoking and worth reflecting on, especially by any students contemplating applying or reapplying to medical school.


Sorry to hear things didn't go as well as you would have liked this cycle. It is a difficult process and I too had a tough time getting into school. That being said the road is long, hard, filled with debt and financial uncertainty. The federal government and a series of large multi-billion dollar companies provide their CEO's 10's of million dollar bonuses on taking payments and distributing a small fraction of them for your services. This is typically deemed as "efficiency in medicine" but Ii can't exactly see any efficiency out of a $22.2 million dollar bonus to the CEO of AETNA. Everyone says "I can work hard" or "I can get through it", but when it comes down to it you get 8 years into it and you start to see for the first time and question why nurses are running the show at the majority of hospitals, why the lawyers are so "involved" at work, and how no one with an MD after their name ever gets educated about expense, cost, and reimbursement.

The interesting thing about medicine is that by the time you see what it really is you are already committed to it. The paperwork, insurance, and contract negotiations don't show up until you are already in your 30's. Insurance companies establish a team of individuals dedicated to finding reasons not to reimburse your services, fortunately residency and academic medicine protects you from a lot of this, but that soon changes. By this point most people find themselves >$100k in debt and feel that there isn't any other job they are qualified to do which provides some significant barriers to exiting. As a physician you are expected to be the first one in the door, the last one out it, and the ultimate individual responsible yet a body of administrators / insurance companies tell you what drugs you can and can't give as well as what studies you can perform.

To this a lot of people say "but I want to be a doctor and help people" but which type of people do you want to help? When some entitled patient walks in your door and complains about a $20 copay do you want to help them? Is your time not worth $20 after a decade of your life, $200k in medical school, $50-100k into college, and 3-7years of earning less than a first year nurse (out of a 2 year school) while you were in residency? How about when you are anesthetizing a 60yr old HIV positive heroine addict with no veins who thrashes when you attempt to put an IV in? Most people want to run away from that one, but someone has to help her and you happen to be the person on call.

Truth be told, [Student], there are lots of great jobs out there. Jobs where you can come out of college and earn a decent living with less sacrifice of your time, effort, and finances. Dental school is an excellent option. Dentists make anywhere from 150-300k/yr as a 3 day/wk General Practicioner (+/-call). The training involved is 4 years of dental school and 1 year of residency. Endontists make $500-700k/yr working 4 days a wk with 4 years of dental school and 2 years of residency (no call). Now why do they make more pulling/drilling teeth than you do prolonguing lives? You can thank the federal government for medicaid/medicare and the hippocratic oath for your moral imperative. There is nothing like a patient walking into the ER with a tattoo on their arm (tattoos are expensive ranging from $300-800 typically) complaining that they want a prescription for motrin because they can't pay for a bottle at the store (medicaid covers prescriptions written even for diapers). A dentist seeing the same financial complaint for a dental extraction would tell the patient to reschedule.

For a physician to make anywhere near 300k they would have to enter a top-competitve residency at a minimum of 4 years length with what is typically a significant call burden. The only specialties avoiding this are radiation oncology, dermatology, and radiology which have a lessened call burden. The time sacrifice also has social implications as a woman, most people don't like hearing this, but most physicians don't have more than 2 kids. By the time they have time to have children they are typically approaching advanced maternal age (AMA is age 35, residency typically ends at age 30 if no breaks were taken) and the risks start to outweigh the benefits.

Now do I hate medicine? No, actually I am fairly satisfied with my job. I get to take people who just met me then poison them with drugs to slip them into a coma so that they don't feel the lacerations, saws, and needles that we poke into them to raise their overall quality of life. Not only do i spare them the trauma of the experience, I off set my poisons with other drugs to keep the patient alive, well resuscitated, and from going off the physiological deep end. The job itself is amazing, unfortunately it is surrounded with lawyers, politicians, and white haired physicians pronouncing a "follow what i've said not what i've done" mantra while lining their pockets. This is then wrapped around the recent scandals of states equating an anesthesiologist to a CRNA, because 4.5 years of school is just as good as 12. I am actually quite fortunate to have no debt outside of what I plan on marrying into, but have friends with easily $500-600k in debt with the juice running (rates are currently 6.8% on loans). If i could spend all day in the OR and not have to hear administrators tell me about "hospital compliance training" or "annual compensation reviews" or "drug shortages" it would be heaven.

[Student], from what I know about you there were top grades at a good school but your boards were a little weak. You should look at this as a blessing and really review why you are drawn into this and investigate alternatives if you find those reasons wanting. One universal constant in medicine is that people applying to medical school and subsequent people applying to residency don't know a thing about what they are getting into. The only exceptions possibly family of a physician who is open about the experience. Be careful of blind leaps.


ZMD said...

Excellent post. It is depressing to realize how much sacrifice doctors have to make in order to help others while the financial industry gets billions from the government while destroying the world economy. Why should this poor student enter medical school at all? There is a whole world of opportunities for eager young students to try without all the hassles and indignities doctors suffer and still make a difference to humanity.

Serena said...

And why, in all this health care debate, is nobody talking about the ridiculousness of those Aetna and TeamHealth and other CEO's getting huge bonuses? Why is nobody talking about how much money rules the roost in medicine (just like everything else in America)? The MBA's and money people are making this job worse and worse for doctors (and NP's as well). I'm glad to see this post, and wish the general public would start to understand it.

I know when I was trying to get into medical school I wouldn't have listened, but as a nurse practitioner, I finally get it. I feel so grateful for my physician colleagues, and wish that we could all practice in a better environment.