People who go to medical school are generally very selfless people. So selfless, in fact, that they sometimes feel compelled to work at a job they hate mostly out of feeling too guilty to quit. Here's a good example from a comment on a blog post a few months ago:
I could retire financially, but I look at it differently than the early retirement enthusiasts. [Consider Fortune 500 execs, athletes, and performers.] Why in the world are these people still working? They certainly can retire, RIGHT NOW and not have to work again?
I think the answer, for pro athletes, Fortune 500 CEOs and lots of doctors and other working stiffs is the same.
In a sports metaphor- “they want to leave it all out there”. Do their jobs as hard and as long as they can….It is not ONLY the pay that keeps them on the field, in the corner office or in the OR. The pay is part of it, particularly for doctors. But the drive and ambition that got them that successful practice, big contract or corner office were not just about saving enough to scrape by while doing nothing.
The goal was never to do the minimum amount of work for a lifetime. In a medical analogy, why not save a bit more and then hire someone to stick a tube down your trachea and pump an ambu bag so you are relieved of the work of breathing for the rest of your life? Is indolence a goal?
I plan to retire in my mid 70’s, not because I want to, but because I project that is around the time I will no longer be able to produce at the level required. If that time comes and I am still able, then I have no intention of quitting.
I do NOT like my job, let alone love it, but it is the best job I can get, so I will do it as long as I can. Retiring because you have to is part of life. Retiring because you want to is just laziness.
I was 100% with him, right up until the point where he confessed that despite his financial independence he not only didn't love his job, but he didn't even like it. Financial independence is about doing what you want to do, whether you get paid well for it, paid poorly for it, not paid at all for it, or pay for it yourself.
Today we're going to talk about guilt and our careers and some of the arguments I have seen well-meaning people put forth against early retirement, part-time work, and sabbaticals. I've invited our own Physician on FIRE to assist me in addressing these issues. It's not really a Pro/Con, since we're both pretty much in agreement, but I hope to give you two perspectives on each of these subjects.
Q. Don't Physicians Owe Society For Putting Them Through Medical School?
I hear this a lot from all kinds of docs. I guess the idea is that because the state government paid some portion of your med school tuition and Medicare dollars were used to pay your salary during residency that you cannot retire early. I think people who believe this simply haven't really thought the whole thing through logically.
First of all, the state government didn't pay any of my tuition. The military paid the whole out of state tuition bill. And what did they demand for doing so? They demanded that I be at their beck and call for four years. After residency, I was at their beck and call for four years. Obligation paid. Since your state government contributed an even smaller fraction of the cost of your education then the military contributed to mine, at most you might “owe society” 1-2 years of time practicing to fulfill that “debt.”
More importantly, what are the real inputs to making a doctor and how many of them came from government/society? While there is the cost of tuition, and there is the cost of a resident's salary and benefits, those pale in comparison to the other inputs- the doctor's efforts and the prime years of that doctor's life. The doctor put FAR MORE into her education than society did. So who is really at a loss when a doctor retires early, goes part-time, or has large gaps in her career? The doctor is. So if the doctor is the main one losing out, whose business is that besides the doctor's?
I don't remember all of society waking to round at 0400, staying in the OR until midnight, or pulling all-nighters for exams. That was me!
I suppose the question refers to society “putting me through medical school” as financial support. The same could be said of residency, which is partially funded by Medicare dollars.
As a product of public schools from kindergarten through MS-4, my education has been supported by tax dollars every step of the way, as has the education and training of every single classmate of mine. That investment results in some people who serve the public altruistically for many decades, some who drop out before finishing high school, and every permutation in between.
If the expectation is that everyone who has benefited from public education goes on to do something that benefits society, I feel pretty good about what I've done, even if I only work a dozen years as an anesthesiologist. I've added value and provided a needed service. That is not true of numerous professions, some of which genuinely hurt people and exist largely for personal gain.
I can't say I haven't benefited from personal gain in this career; in fact, I've earned enough to never have to work again if I so choose. I see my career not so much as a contribution to society, but as a transaction with society. I do something useful and am handsomely rewarded. If I did it for free, I would be inclined to call it a contribution.
Speaking of contributions, I will have contributed about $1.8 million in taxes over a 12-year career. If I owed society a return on its investment in me, I've already paid that debt back several times over.
Q. Given the Rarity of Your Knowledge and Talent, Is It Morally Wrong to Not Work As Much As You Can?
This is a bit of a riff off of the previous question. But let's apply it to some other professions. Can you imagine someone asking this to Lebron James? “You're so good, why don't you play in a game every night?” “Why can't you play all 60 minutes?” At a certain point, it becomes nonsensical. Nobody asks this to performers, athletes, executives, janitors, teachers etc, so why would it apply to physicians?
It's a supply and demand issue. If the supply becomes too low or the demand quite high, perhaps changes could be made to make the job more enticing. Instead, we see increasing layers of bureaucracy, frustrating implementation of electronic health records, lengthening and tedious credentialing applications, new metrics and patient satisfaction measurements, etc…
I question the morality of those who increase the burdens of practicing physicians, often to their own benefit, such as those forcing Maintenance of Certification on us while padding their pockets with the proceeds. In a free society, we should be able to work as much as we choose, not as much as we can.
Q. How Could You Take A Med School Spot From Someone Who Would Have Worked A Full Career?
Who hasn't heard this one? But usually, it is applied to an underrepresented minority or a woman who is presumed to have “stolen” a spot from a white male. It gets applied just as easily to those who retire early, go part-time, take time off to raise a kid, etc. Here is my response to that: There was no contract you had to sign when you applied or matriculated to medical school specifying a certain amount of work would be done later. The applicant most likely had no idea how much he would like to work in his 50s, and the school had no idea if this student really “had an interest in rural family practice” as he wrote in his essay. 10 years later, he's an ENT in the capital city. Life changes. Both the school and the student took on that risk when they hooked up for this crazy journey.
Woulda. Coulda. Shoulda.
To be honest, as a college junior applying to medical school, I had no idea what my future would look like. I would not have guessed that I would end up in anesthesia, or that I would find the possibility of retiring early appealing. I didn't pursue this path; early retirement chose me.
If we apply the question more broadly, we need to consider those dozens of students who graduate from medical school in the Bay Area or other places with no intention of pursuing a residency, choosing instead to cash in by joining a tech or biotech startup.
I say more power to them. Medical school acceptance does not imply indentured servitude. If studies were to show that members of a particular gender and ethnicity work, on average, a 15% longer career, should medical schools take only people that fit that demographic? Of course not. Take the best, hope for the best, and understand that for a myriad of reasons, some graduates will not be full time practicing physicians for several decades.
Q. Don't You Owe Your Spouse A Very Nice Lifestyle For Putting Up With You Through Training and Career?
Society isn't the only one you may owe for your education. Maybe your partner busted his butt to get you through with minimal debt. He stayed up all night feeding that kiddo while you were on 36 hour calls. He sacrificed his own career, his own health, and his own dreams so you could be a doctor. Don't you think you owe him a “doctor's lifestyle” for that? My answer? Every relationship is unique. Maybe your spouse would rather have you home for dinner at 5 than some extra money and prestige. Maybe he would rather you actually get to stay for the entire vacation rather than fly home halfway through to work some shifts. Work it out amongst yourselves. Maybe you do owe your spouse something. Make sure he or she gets paid.
I'm trying to give my wife a better lifestyle by working less. The more we talk about our future plans, the less excited she is about having me continue to work.
Currently, I'm on call 20% of the days on the calendar, which means she's effectively single parenting our boys (ages 6 & 8) 20% of her life. Actually, it's more than that, because she'll choose to spend most of the summer at our modest second home, and I'm 500 miles away most of that time. I'll be cutting back to part-time this fall, and our lifestyle will improve quite a bit. It will only get better when I have the same amount of freedom she does, and we can travel the world as a family.
OK. I'll admit I've ignored what the question probably implies when discussing “lifestyle.” The word lifestyle is often equated with spending, and I strongly disagree with that notion. Lifestyle is more about having the freedom to live the life you want to live, and mine involves less work and less stress.
But, since we do talk about money quite a lot on our sites, we're at the point where we could spend $100,000 a year without violating a 4% safe withdrawal rate, but last year, we only spent $62,000. If we wanted more, we would spend more. We're not big shoppers or big spenders, but we do spend on meaningful family experiences, like our recent trip to Paris and Reykjavik
Q. Do You Owe It To Your Patients To Work Full-time? i.e. Is a Part-time/Multiple Sabbatical Doctor a Crummy Doctor?
This is one I've actually seriously worried about as I've cut back on shifts. If I'm going to do something, I want to do it well. If working part-time means I'm a crap doctor, then I'll work full-time until I can't take it anymore or simply want to do something else even more, and then quit. But I think there is some middle ground here.
I'd be pretty hesitant to go part-time in your first five years in practice. But after that? I think you can stay just as competent working 1/2-3/4 time. 1/4 time? I think you probably lose a step, but hopefully not to the point of being dangerous. One benefit of working less is you are less burned out, your compassion meter is much more likely to be at 100% when interacting with patients, and you are much more willing to come in early, stay late, and work hard while you're there knowing you have the day off tomorrow.
In my opinion, a burned-out doctor is crummier than one who has defeated burnout by working part-time (like The Happy Philosopher), or taken an extended sabbatical (like EJ from DadsDollarsDebts). Most physicians who pursue part-time work are doing so to live a more well-rounded life, making more time for family, for travel, or other pursuits that give them a life outside of the exam room.
This is not to say that most full-time physicians are burned out. A recent study has shown symptoms of burnout in more than half of the respondents, but plenty of doctors are perfectly content to work full time or more. However, if you are feeling like you'd rather take a huge pay cut to work less, you might owe it to your patients to not work full-time.
A part-time physician has more time to read journal articles, participate in CME, and engage in non-work related activities to improve the mind, body, and soul. As long as the doctor remains engaged with his or her profession, I would have no hesitation having a part-time physician care for me and my loved ones.
Q. Is It Fair To Your Partners/Employer For You To Be Taking Lots of Maternity/Paternity Leave?
Here's a touchy subject. Everybody knows it is illegal to discriminate against hiring women even though everybody knows that most women who are coming out of residency are going to have a kid or two at some point in the next five years. Now even men are getting in on the paternity leave act.
Here's how I look at it: Medicine is one of many things I do, and certainly not the most important. Sometimes things that are less important have to make way for things that are more important. Groups of physicians need to figure out a way to make sure these important things are taken care of for parents. But just as importantly, they need to make sure that those who remain single and/or childless aren't getting continually hosed by it. You shouldn't have to work every Christmas morning just because you don't have any kids at home.
This is a human resources issue, and I'm not sure “fairness” comes into play. I do believe that the guidelines should be spelled out clearly and that all affected parties should know and understand the policy.
The same is true with any time away from work, whether it's vacation time, medical leave, a sabbatical, decreasing call, you name it. There is X amount of work to be done by N number of people. When N becomes (N – 1) or (N – 2), plans need to be in place to make sure X still gets done. Locum tenens physicians can play a role here.
Resentment and anger are more likely to come into play when clearly delineated policies are not established. Legal issues can arise in larger groups (50+ employees) if policies are not consistent with the Family and Medical Leave Act. The smaller the group, the larger the impact of any kind of time off. When I start working 40% fewer shifts, each of my partners will be working 10% more. Pay will be adjusted accordingly, and everyone is happy. If my colleagues hadn't volunteered to pick up my slack, I wouldn't have pursued the issue further.
What do you think? Do you feel any guilt about working part-time, taking sabbaticals, or retiring early? Why or why not? What (if anything) have you done about it? Comment below!
Perfect timing for me at this point in my life. I am the only pediatric subspecialist who sees referrals from a 3-hr radius. For 5 months I have been getting denials from the major managed care Medicaid provider in my area. I have tens of thousands of dollars in unpaid claims I am trying to get paid. I see 50-70 patients per day, and after 18 years, I have to slow down for my own well-being. I decided to stop seeing these patients except for unusual situations, and I’ve just informed the referring docs. We will see how much heat I get for it, but I had to make a change. The guilt is there, but I also know I will be a more empathetic doctor when I cut back my pace.
The only people who should feel guilt are the parents who don’t work, and therefore need Medicaid, and the folks who vote to underfund Medicaid and not reimburse physicians for their work. You are innocent and blameless! In fact, you are helping other physicians by insisting that Medicaid actually PAY you, which, frankly, they should since you are doing the work.
No guilt, no worries. Congratulations.
I’m single and non-religious while most of my partners were married w/ children. I made a deal w/ them that I would work all the religious/family holidays for getting all the secular/non-family holidays off. And being flexible about birthday parties/soccer games, etc, I got back flexibly if I wanted a day off for some reason. Being the most flexible in the group paid off dividends as it turned out and worked out good for both. Now that I’m retired, I think my flexibility is the thing most missed by my absence. And I never minded working Christmas for getting New Years off.
I guess we could call that religious arbitrage? Sounds like it worked out well for everyone.
Cheers!
-PoF
i worked every Xmas for years. would offer to work doubles but was never taken up on that.
had no kids and i’m an atheist so figured it was silly for my partners to not be at home with their kids.
only stopped volunteering when i got married and the nieces and nephews started coming in.
I’m definitely torn too. (Un)Fortunately I am a few years off from achieving a solid safe withdrawal rate, so I have time to ruminate. I do agree that “lifestyle” does often connote “spending”, and it is tough to decide what that rate ought to be as well.
Once I pay down my mortgage/money pit, FI becomes more palatable. 😉
There is no contract that I signed with society or even my medical school when I took this on, and I know of no one who would condemn me if I did leave early. I find it sad that someone could feel compelled to do something they dislike once money is no longer a factor. Do what makes you happy. We all only have one life on this earth.
The part time thing is something I’m torn with. I have a strong feeling I will pursue 50 to 60 percent once I’m a little over 5 years in practice, at which time I will be financially able to do so. I worry though not only about a decline in my skills, but of my colleagues perception of my skills even if I am doing a good job
No guilt whatsoever. I’ll retire when my stash is big enough and I’m ready. When I’m out, that’ll provide an opportunity for a new person fresh out of training to acquire some patients, care for them, and make some money too. Everyone wins.
I’m surprised that you “question the morality of those who increase the burdens of practicing physicians, often to their own benefit, such as those forcing Maintenance of Certification.”
Most of us don’t have any question about the morals of these MOC people. I rank them somewhere below the docs who solely testify for plaintiffs attorneys (and are clearly willing to say any untruth for money), and slightly above the “Pharma Bro” CEO who jacks up the prices of generic meds by 700%.
I love the fact that the President & CEO of the ABIM is named Rich Baron. How fitting.
Strange but interesting post. I wonder if the guilt is a male thing? I don’t feel any qualms about the work/life decisions I’ve made. I don’t feel part-time affected my skills. Honestly, I have never even considered these questions. I’d be interested in hearing the perspective of female docs on this topic if any care to address it.
I felt no guilt over quitting ob but I think a lot of less financially prepared docs were envious.
I kinda had the same response as Dr. Mom. I’ve been part time since residency. Took a 3 month maternity leave. Scaled back hours even further upon my return. I don’t feel guilty at all and I don’t worry about my skill as a physician. But I’m a psychiatrist so I think it’s a bit different from a procedure based specialty. I have more time for my patients outside the office and respond quickly to phone calls and emails and I take more time with them when they’re in my office. I’m a better doctor because of my part time work not in spite of it.
What!? There are differences between men and women? Say it isn’t so!
I think you’re probably right. There is something internal among men, and certainly a societal expectation, to work, provide, be productive etc. Probably contributes to the guilt. Plus it turns out many men don’t have any friends to go do anything with if they retire!
Lol. Except for the insane number of men who have dropped out of the workforce in their prime earning years: http://www.sandiegouniontribune.com/business/economy/sd-fi-economy-workforce-20170502-story.html. Neither they (nor their mothers nor partners, ahem) appear to have any guilt.
One of the happiest people/physicians I’ve ever met was a teacher at my medical school. He was practicing one day a week and teaching the other day of the week
He did it until the day he passed away. He felt it gave him purpose. He looked forward to every July because it meant new students and new residents to mentor.
I’m not sure where my career will take me but I’ve always admired that physician and wondered if I would be healthy and happy enough with my job to pursue it into my 80s. That being said, I certainly wouldn’t begrudge others for retiring early.
I forget which poster said this but I’m fairly certain it was on this blog: “if you’ll pay my bills for me, I’ll listen. Otherwise, my life, my choices.”
The concept that someone or society is entitled to say how I spend the days of my life. No way.
I went part time (0.7 FTE) after 13 years of full time. I am in internal medicine so more cerebral and less procedural. I can very honestly say that my knowledge and ability to be a good doctor has really not declined after going part time. I worried so much that it would that I basically searched for other full time jobs for the first 4 months of my part time job until I adjusted to a new life/comfort level. I believe a person could literally take 2 years off completely, then come back, take a board review coarse, study more in depth about the 20-50 things most common in whatever job you are going to take, then practice. Within a few weeks to months you’ll be very good. This may not be true for a procedural specialty, but I really believe part time doesn’t have to hurt a doc at all in the primary care specialties.
The one thing I did notice is jealousy from colleagues. They won’t (or can’t) give up their higher paycheck but they want the part time schedule. During a recent birthday party, an FP doc was talking about another doc who works 9-5 five days a week. He said, “some docs just don’t like to work hard.” I think I quoted POF or WCI and said maybe he has other things in life he likes to do other that see patients from dawn to dusk.
my guess is that your clinical skills are mostly locked in if you practice full time for a few years after residency and work hard.
i’m 5 years out and while we’re all always learning i feel like i’ve hit a stride/plateau.
my experience has been that you get to really know you specialty and it’s hard to imagine losing that because of 0.7 or 0.5 or whatever. maybe if you stopped totally for a few years but even then…
1. I think that the patients you care for as a resident and through any unattached ER call you do over a career more than pays back any societal obligation you may have.
2. Does anyone think it is morally wrong for a teacher, police officer, firefighter, or member of the military to retire at a relatively young age when their pension kicks in.
3. Being 60 and female I was asked to my face several times if I was taking some guy’s spot in med school.
4. If your spouse is only interested in you more a nice lifestyle maybe you picked the wrong spouse.
5. I have worked 3 days per week for about 3 years. I try to be flexible when I am in the office as to working in patients. Most of my patients are glad I am still working. I constantly hear I hope you will not retire any time soon.
6. Maternity/paternity leave issues have been going on my entire career. How you look at it is totally based on if you own the practice and how many docs are involved. That does not make it right.
Love your #4!
#2 really speaks volumes. Teachers, popo and fireman all count down the days to their retirement and collecting those pension checks, and they’re supposed to be the most selfless of all.
Also love #4, but I’ll be [darned] if my wife quits before these student loans are paid off. 😀
Thanks for the mention and breaking away from clinical medicine for a few months can definitely revitalize the soul.
I don’t think we are obligated due to our training to practice until we are old. Some people love medicine and want to practice as long as they can. Kudos to them. Others spend so much they can never retire. We all make decisions.
If burn out is really affecting your work and personal life, then you have to make a change. We are given one life, one set of family and friends, and no take backs. Finding a balance to live a meaningful and fulfilled life is the key. That may be working full time or part time. Working until 45 or 75. Whatever it may be, you have the right to make that choice.
I don’t think anyone should feel obligated to work X hours or retire after X years out of a sense of societal obligation or indenture. HOWEVER, I think your overall “logic,” as you say, deserves some more scrutiny. Medicine isn’t a free market. Society affords the medical profession a monopoly on the admission and supply of medical providers. The compensation of physicians isn’t the direct result of market forces, nor is it simply because you’ve “worked hard.” You’re an anesthesiologist? Would you be able to hang a shingle and erect your own hospital and supply your own staff/equipment and still retire early? Of course not; you rely on infrastructure most likely paid for by the taxpayers, or at least with huge nonprofit tax deductions. You may have paid X dollars and years for your training, but on WHOM did you train? Most likely many of the working poor (including those cadavers). And plenty of low wage earners work the hours you’ve described and as hard as you’ve described; your compensation isn’t tied to how many hours of the week you work or how many years you’ve put into your education (see any PhD post-doc making less than six figures). Not everyone was born on third and thinks they hit a triple (e.g. 2/3 of medical students come from the top quintile of American wealth; less than 3% come from the bottom quintile – why do you think that is?). The fact is that the bloated medical establishment has afforded physicians a very handsome salary, largely at the expense of society. Should physicians be blamed? Nope – take what society gives you. But recognize where your opportunity comes from (i.e. it’s not just because you “worked hard”).
So no, one shouldn’t fault individuals for taking advantage of the situation they’ve conscripted themselves into. If you have the financial wherewithal to retire early, then so be it. But don’t think that society hasn’t afforded you that privilege. And it certainly isn’t “illogical” for people to think that you owe society a long, full career for that privilege.
Interesting perspective. I disagree almost entirely.
I started out with zero dollars, a beat up car that I bought from money earned with a newspaper route, and Pell grants at a community college. I earned a tuition scholarship to finish my BA degree. I worked in college and moonlighted in residency.
The government loaned me $70,000. I paid it all back with interest in eight years. The Pell grants, loans, and scholarship helped me to become a doctor. Society has paid me an above average wage for 12 years of schooling and NOT making any money from age 22-26, and making low wages from age 26-30 (although I moonlighted in residency and doubled my wage by doubling my work hours).
I’ve paid back the societal investment in me via my taxes, charitable contributions, and reduction in the suffering of others. If I have made more money than the average psychiatrist (and I have) it’s been via extra hours, being the Medical Director, more responsibilities, more call, moonlighting, and working extra holidays and weekends. I may have worked an extra “third of a career” in moonlighting.
When I say I’m done, I’m done. Same as for anyone else who retires when they wish.
I couldn’t disagree much more either. Was born low middle class, my parents used to borrow money from me when I was a teenager to pay bills, so no 3rd base here. First home after marriage was a 12×60 ft. mobile home. I’ve worked since I was 15 yo and now in middle age, have worked professionally at least 1.5x more than the average person will ever work in their entire career. I have paid my taxes which has paid way beyond what my education costs, payed back the small loan that I took while in medical school promptly, and have been fiscally responsible. I have missed more children and grandchildren events due to working evening, nights, and weekends that most people by far. Much of what I write here is true for physicians in general.
I don’t owe society anything but high quality, efficient and intelligent work when I practice medicine.
While I make a decent salary, it is far from bloated particularly when compared to what many other professions make without making a significant contribution to society.
Nope, when I’m ready financially, I’m done with medicine. There are many other things I can do with my life to be productive and help others.
It’s news to me that 2/3 of med students come from top quintile of wealth–me and my closest buddies didn’t get that memo.
A quick search got me to the AAMC and sure enough that is a close approximation (it looks like 1/2 from public med schools). Those data do raise questions.
It is interesting you mention the post-doc, because those same data show similar disparities among “doctoral institutions.”
It is also telling that only about 10% of public undergrad comes from the lowest quintile….
Lots of factors there. Parents not only pass on wealth, but also genes and habits. I’m not surprised at all that 1/2 of med students at my public med school came from the top quintile of wealth. When you’re trying to keep the wolf from the door, the stuff that leads someone to have sufficient interest and aptitude to get into medical school is a much lower priority. All that work you do to help your kids to succeed? Yea, that actually does some good. Who would have thought?
Not at my top twenty private medical school, but the class was 50% children of immigrants. So much, much harder working.
Compared to WHO? Or what other occupation?!?
^^ In reply to Tooth Doctor
Doctors existed long before big hospitals and anesthesia machines.
People can think whatever they want to think about our obligations to society, that’s not how anyone makes decisions.
The thing about docs coming from the upper strata of society, agree multifactorial there but not surprising.
The discussion kind of reminds me of a comment from a friend in med school about how much they pushed primary care — “they accept all these super dynamic go-getter kids from the best colleges with the best test scores and then are shocked when they don’t all want to go into the least exciting fields of medicine.”
Now that there are NPs and PAs, who supposedly can do our work better and cheaper, physicians are certainly not in control of the supply of anyone or anything.
Here is the part of the original comment that frosted my cookies and would make me discount everything else they said, have said or will ever say.
“Retiring because you want to is just LAZINESS” (caps mine).
This demonstrates the height of arrogance of this person that thinks they have ANY right to judge another person. I certainly wouldn’t want to be a colleague or patient of this narcissist.
I have been seeing patients as a resident or psychiatrist for 27 years. Had I been a better money manager and more frugal, I would have gone to half time at age 45.
As it stands, I am working full time outpatient and also moonlighting inpatient two weekends a month. I just recently took a new job specifically due to the increase in money and vacation time. All of this is focused on “early retirement”. Every “extra” penny I get goes into retirement plans. In the last two years I will have put away about $150,000.
I am totally focused on retirement to half time as soon as feasible. To me, it is the most important goal. When I say retirement, I mean from full time work. Working a day or two a week is cake. Two NP’s at my work do two ten hour days a week (one is 54 and one is 60). They talk about how easy and stress free it is to have a permanent five day weekend.
I prefer life to work: helping my children get started in life, hiking, open water swimming, family vacations, triathlons, working at our mountain cabin, travel, learning new skills, and so on.
I couldn’t care less what society or anyone thinks about how I spend my limited time from age 53 to whenever. Truth is I can’t wait to be “just a dude enjoying life” instead of being a doctor. I’ve been a doctor long enough.
Life is short. I see many who work into their 60’s and even 70’s and their health is poor. I say have some fun for a decade before it’s all about Metamucil, health problems, and doctors appointments. What good is money if it’s for ten medications, copays, and Depends?
“retirement to half time”
Words have meanings…working less at the same job doesn’t constitute retirement.
The internet retirement police have arrived. 🙂
Retirement is squishy for sure and its hard to draw a line about exactly where retirement begins. But that is the first time I’ve seen someone use it to refer to cutting back to half-time I’ll admit.
When I say I want to cut back to half time, it’s a time limited idea. I can’t draw my 401K/IRA funds penalty free until age 59.5.
I would like to file for my small pension at age 60 (it’s worth $1400/mo at 55, but $2100/mo at 60).
I have at least two more years of full time.
Then I will work ~ half time for a couple of years and cut the chord at age 60 to get to “Real” retirement.
Yes you can.
https://www.whitecoatinvestor.com/how-to-get-to-your-money-before-age-59-12/
I mean, if 60 works for you then fine, but don’t wait until then just because of the 59 1/2 rule.
As WCI alluded to, there are many ways around the 59.5 “rule.”
The simplest is the fact that you can access your entire 401(k) penalty free if you leave your employer in the year in which you turn 55 or later. It sounds like you’re already there.
Are you all certain that one needs only to “leave their employer at age 55” to get ones 401K monies 4.5 years early?
Why have a 59.5 age rule if it is really age 55?
I’m 53.5 and expect to separate from my employer at age 55.5. Do I them gave access to only the 401K of my most recent employer?
The 59 1/2 rule applies to IRAs, not 401(k)s. The 401(k) rule is 55 and separated from your employer.
Here’s one article and Google will give you many more. https://www.thebalance.com/401k-withdrawals-at-age-55-2388222
You will have access to your most recent employer’s 401(k), but not your previous employer’s 401(k). A workaround may be to rollover your old 401(k) money into your current employer’s 401(k). I would think that would work, but I would check with your plan administrator / HR to be sure.
| What good is money if it’s for ten medications, copays, and Depends?
I’m putting that on a t-shirt.
I think people are really complicating the whole FIRE thing. At the end of the day, I say people (and especially doctors/nurses) retire when they want. Why ask someone else to put aside their own personal dreams to fulfill society’s selfish perception of what a medical professional should be?
Good article, nice rehash of the WCI podcast discussion. I think it is interesting that you both are in position to work less than full time based on not only your financial prowess, but that you work in a field that does not rely on patient continuity. I strive to be FI and I contemplate a life with retiring early pursuing other passions. However, I would have a hard time walking away from all the effort that went into building my practice/patient base. If I decide to go part time, and suddenly patients can’t see me for 6+ months they will leave and worse for following some conditions I would be violating the standard of care. I would say that being a physician is a bad choice if retiring early is a goal. However it is still a descent choice if Financial Independence early is a goal. If you want a “squishy” retirement early, then pursue a field without a need for continuity of care.
An early retirement or part-time is toughest when you’re an independent business owner who put in years of hard work and lower earnings to build up a patient roster. It’s more feasible in specialties like ours (ED & anesthesia) where you can start out with a full salary and patient base.
A potential solution in a situation such as yours would be additional hired help. You may be able to work less if you bring in locums, a second part-time physician, an NP or PA, etc… There is usually a way to cut back without leaving your patients high and dry. Whether or not it’s feasible (financially or otherwise) for you will depend on your particular circumstances.
Best,
-PoF
Lots of docs have dealt with that issue. First, patients sort themselves when they realize they’ve got to wait 3 months to see you, then go elsewhere. Second, you can do it purposely and in a way that increases your profits- drop Medicaid, Medicare, Tricare, and other poorly reimbursing insurances. Now you have half the patients. You can go half time and and make more than half the money. Doing a concierge practice is another option. Third, you can also limit your practice. If you’re surgeon, you just start referring out your colons or your hernias or whatever. Fourth, dropping call or OB or trauma or whatever is also a good way to decrease your hours without losing that continuity. Fifth, you could sell your practice and become an employee. So is it easier if you’re in radiology or EM or anesthesia? Sure. Does that make it impossible elsewhere? Hardly.
Good points, much more complicated and effort to recruit in a partner. In addition to the expense. I am in ophthalmology so we cant use PAs, nurses, etc. My patient base wouild go to zero if we dropped Medicare, not really but close 🙂
Can it be done, sure. Just not as easy which was my point.
Some ideas:
We don’t have PAs or nurses in our field, but we do have optometrists.
One thing I started doing as my net worth has grown is I’ve stopped doing surgeries that A) I don’t like, and B) don’t reimburse much. All I do now is cataract surgery and a handful of minor office procedures; the rest get referred out. It’s just not worth my time anymore.
There is a benefit to PAs/NPs not being able to do your work!
As much as I agree with that statement, it is crazy how much optometrist have expanded their scope of practice. They just passed legislation in our state to allow them to do eyelid and sub conjunctival injections, not through increased education but by having a stron legislative backing. I see a future where laser surgery will be done by optometry. Optometrisy never need MD supervision, unlike most PA and NPs although that may be changing.
Although state law varies, most NPs can practice without MD/DO supervision.
Let’s talk about social status. The fortune 500 exec and the pro athletes stay on the field because the minute they leave, their social status drops to “has been”, “retiree”, or “Who?” Same drop for docs. We work for $$, purpose, and social status. I cringe at the retiree docs who cling to their lost status.
When I go visit family my social status drops immediately. I am just brother, uncle, son, cousin, etc. And I love it. I sometimes get asked questions about which injury the little ones have should go to the emergency room, but otherwise I am just family and can participate in every way they do.
Shoot, even my own wife doesn’t trust my medical opinion. What’s that saying about a prophet in his own country?
Ha, my dad was a surgeon and I had a nearly-burst appendix as a teenager. Surgeon said it was “red hot” after several days of waiting to see if it got better. Seems he thought it was just menstrual cramps. He didn’t wear his doctor hat but instead, his rather stern father hat. So I think it is better not to go with the family member as the medical advisor!
I think it’s best to try to allow your identity as a doctor define you, as difficult as that may be.
Fill in the blank that Dr. Nii Darko asks all of his guests to do on Docs Outside the Box podcast. “I’m not just a doc, I’m a _________.” Dr. Dahle answered in his interview from last summer:
http://www.docsotb.com/006-get-a-fair-shake-on-wall-street-with-the-white-coat-investor/
I’m confused about why the original commenter thinks paying work is the only thing that’s not lazy or indolent, and it’s incredibly sad to me that they will work until they can’t any more at a job they don’t like, despite being FI, simply because they think to do otherwise is lazy. Shows a severe lack of imagination to me. NOTHING else comes to mind that isn’t indolent but maybe doesn’t pay, that you might enjoy more than this job you don’t even like? Really? NOTHING?
Interesting post, and one I’ve wondered about for a while. For the FIRE types, another question I have is, how will you teach your kids life lessons about working hard, the value education, etc, when your primary focus is on retiring early so you can stop working?
My 23 year old wants to retire at 45. I applaud her efforts. Sge graduated college and works two jobs: one is direct care for disabled adults at an adult foster care home, the other is as a waitress at a posh restaurant. She makes $50,000 a year, has a paid off truck, $8000 in the bank and fully funds a Roth IRA each year. She is saving up to buy a solar powered “tiny home” with cash.
It turns out to retire early you have to work HARDER and SAVE MORE than the conventional path (35 to 40 years of work). I prefer her plan.
My 17 year old wants to be a doctor of physical therapy. I will help her get there, but will instill a “retire early” mindset in her also. I tell them to save half their income and pay themselves first.
“how will you teach your kids life lessons about working hard, the value education, etc, when your primary focus is on retiring early so you can stop working?”
Easy. Daddy worked really hard and was smart with his money so he could spend time doing things in life he likes a lot more than work, like hanging out with family. Hard work isn’t supposed to be a Sisyphean task, it’s a means to an end. If you love the work, great. But if it’s simply the most efficient/least unpleaseant way at your disposal to trade time for money, then that’s a great opportunity to teach your kids about trade-offs, decisions, and opportunity cost.
Amen.
My boys are 6 & 8 now and I know they will remember when their Dad was on call, the many days I was out the door long before they got up and got home long after they were in bed. The weekends my wife essentially single parents and all that. We frequently remind them that Dad works so we can have nice thinks like food on the table, a roof over our head, and tens of thousands of Legos.
My older boy is very in tune with the fact that I’ll be going part-time soon, and he frequently mentions how he’s looking forward to it so I will be home more, able to spend more time with them at our cabin, etc… I am convinced they will benefit more from my presence than they will from understanding that my absense means I’m working hard.
We’ll be reminding them all along that my hard work (present or past) is not only what allows us to live a good life, and the fact that we saved as much or more than we spent during my working years is what bought our family the freedom we will enjoy.
Cheers!
-PoF
Until I read about it on the internet, it never occurred to me that I had an obligation to work beyond providing for my family. Perhaps I am unusually selfish or ungrateful.
If there is an implied contract to society, perhaps society should roll back the work conditions (pay, regulations, CME requirements, medicolegal environment, status, etc.), to those that were in place in 1985, when I started medical school (and allegedly agreed to a contract). Maybe I would want to work longer, if that were the case (and maybe not).
More generally, if society wants to keep physicians practicing longer, society should not be loading more BS on the doc every year, until the camel’s back finally breaks.
You are selfish and ungrateful. 😉
Yep! System needs to do a better job of retaining docs if it wants to hold onto them.
😉
This!
10 million….in the bank…tax free. That’s what it would take me to stop TODAY. I actually just had this convo with one my colleagues. How much would it take you to quit and never practice medicine again? For me it was 10 million.
The reason for this number; I actually really like my work and I get paid well for it. My colleague didn’t enjoy it as much and doesn’t do quite as well financially as I do. For him it was somewhere between 2-5 million. Would I feel guilty? Not one bit. Neither would he. However, I wouldn’t turn into a vegetable if I stopped practicing medicine. I suspect I would initially travel, exercise, learn a couple instruments and languages, and relax some. But then I would probably return to some sort of financially earning position. Not out of need, but out of fun and mental stimulation. Financial independence or retiring early is nothing to feel guilty about. Enjoy!
Good article. I have encountered this pretty sour attitude a number of times in just a few years.
1) Yeah, but only a little bit. During the interview process you’re holding yourself out as someone who wants and is going to be a doctor and treat patients. They aggressively weed people out who they don’t think are serious or are only in it for the money or prestige. But how long is this obligation? Up for debate. Arguably you fulfill this during your extended period of indentured servitude aka residency. A career into your 60s or 70s? Meh.
2) The bible says to use your talents, be fruitful, help others, and on and on, so there’s that. But morally wrong not to work as much as you can? I think that’s pretty clearly horseshit.
3) This is semi-legit IMO. Especially when you’re talking about not having a career at all. Already my wife and I have seen women retire literally from residency to be homemakers on the perm. That’s their right and choice, but it’s clearly a waste of finite space in state-subsidized medschool, not to mention a waste of energy on the part of the physician who never ultimately practices. Quitting early engenders stereotypes that makes it harder for everyone else. But extending this to early retirement? Pretty weak.
4) OF COURSE you owe your spouse a doctor lifestyle. 😀
5) Seems like that depends on the specialty. But yeah I wouldn’t want a part time shrink.
6) Parental leave is a fact of life and an important societal value that employers need to accept. That said, taking six months+ of gratuitous leave puts an unreasonable and costly burden on employers to not only hold your position but also recruit and pay for more costly temporary service during your absence. Discrimination against female physicians, particularly of child bearing age, is absolutely prevalent, and unfortunately women have previous generations of female physicians to blame. Hopefully things like paternity leave will put a damper on discrimination, but quitting and taking extended sabbaticals for kids makes it harder for all other women physicians to pursue their careers.
I will say it again Craigy. Women physicians who own their own practice do not take extended sabbaticals.
Absolutely. My partners and PA employees can take a few months of unpaid maternity leave if they want and we cover for them. But they’re generally back in 2-3 months. They need/want the income. Could we handle a 6-12 month leave? Probably, but there would be some grumbling. And it would still be unpaid.
Yep!!!
Why not a part time “shrink”. Psychiatrists have no procedures (most don’t do ECT) and it’s easier to keep up in Psychiatry than many other specialists.
Being a part-time psychiatrist allows you to take better care of yourself so that when patients need empathy and support, you have it to give.
What you don’t want is a part-time cardiac surgeon or a part time oncologist.
Curious why you specifically wouldn’t want a part time psychiatrist?
I initially had some reservations about retiring early when the time came to pull the trigger. Some were discussed here. When I was a medical student, I decided I would work until I was 50. It was my target date from the start. Most people have a target date in mind when they start, most often age 65. But this date is arbitrary. You really don’t know how you will feel about this when you get there.
I discussed ending at age 50 with another doctor when I made the decision. He told me it would be a waste for me to quit that early. He eventually retired and did a lot of traveling. Was it a waste for him to quit when he did? Should he have worked one more year? Retirement will happen at some time anyway so what difference does it make about where you set the date? If 50 is not good, how about 51 or 52 or any other number. The argument is the same no matter what age you pick, because you could have gone longer.
Today I no longer see patients. I pulled the trigger at age 54. I did work 4 extra years beyond my planned date. At age 50, I was not ready to never operate again. I thought I would feel a great loss if I gave it up. I began a process of slowing down until I felt I could give it up for good. I switched to part time. When I finally made the move, it was easy, because I was ready. Yes I still had a little bit of guilt. I was thinking of all the patients who would not get my help. But they would still get the help they needed from another doctor.
I started a new business, Prescription for Financial Success, and began writing books to pass on what I know to other doctors so they can live a better happier life and maybe practice a little longer than they anticipated. So ironically, my retirement (repurposing) from medicine might actually increase the total available doctors in the work force. My book, “The Doctors Guide to Smart Career Alternatives and Retirement,” should come out this week and is all about this idea. It is for the doctor who is ready to cut back or quit.
Ending your practice will happen at some point, no one works forever. So when it does, don’t feel guilty. Just enjoy the trip.
You sure you’re helping them practice longer? Seems like you’re enabling them to retire earlier, no? 🙂
I’ve wondered about the cumulative effect I’m having on the medical work force. Am I contributing to the doctor shortage? But then after seeing how few doctors become super savers, I quit worrying about it.
For some yes. There are several chapters in my new book that deal with making changes to how you practice in order to enjoy it again and practice longer. So for some I would like to help them find what they are unhappy about and work to fix the actual problem to improve their quality of life so they can practice longer. For those who truly want out, there is info for that also. I’m not sure how these two issues will balance out in the end. Will there be more people I helped get FIRE, or more people I helped improve a bad situation so they could like medicine again and stay longer. I do like both options though, so either way is good.
Thank you for contributing your story of a nonclinical physician career to the book. An autographed thank you copy is in the snail mail making its way to you now.
I never had a target date, and didn’t think much about retiring particularly early until I realized sometime around my 39th birthday that we were pretty much in a position financially where I could retire anytime I wanted to. Like you, I wasn’t ready to hang it up just because I could, and the better part of three years have passed since that realization.
I think the transition to part-time (as you did) is a great idea for a financially independent physician. It’s an ideal way to learn how you’ll spend your newfound free time, whether or not you miss doctoring when you’re away, and how it feels to earn less. I’m looking forward to all of it.
Cheers!
-PoF
It’s funny how things begin to change when we have more options. I think life is happier with more available options from which we can choose. You never thought about retiring early until you saw it was actually possible. How many other times in our lives did we miss something because we didn’t see it as a possibility?
When I started practice at age 31, 21 years ago, my target date for retirement was 55, but it was a very ill-defined and arbitrary concept for me. When you have not worked, have not earned, have not saved, have not started a family, you have no idea how the next 20-25 years will unfold and no clue how you will, as a person, change over these years.
Fast forward, 21 years later, sitting at age 52 and going part time in 2018, it appears that my wild guess is probably going to be about right. I have wavered in both directions (working longer or shorter) over the years, but it should settle pretty close to 55 (perhaps a few months shy). Lady luck and happenstance were more involved in it working out than meticulous planning, but the heavy lifting of dual incomes earning, saving, investing, and ultimately delaying some gratification should allow the 31 year old me to be close to the mark.
I don’t feel guilty about retiring early at all. I miss the patients, but I don’t miss the bureaucratic nonsense that has entangled healthcare.
I signed up to be a doctor who took care of patients.
That patient physician relationship was supposed to be sacrosanct. No insurance company, hospital administrator, government agency, or any other third party was supposed to be able to insert themselves between my patients and me…and yet they did.
It was insidious at first, but by the time I retired it was full steam ahead.
We were given an electronic medical record that seemed like it was designed to produce medical ordering errors. We asked them to change it and were told no. When case after case started piling up of patients who were harmed and even killed because of this system, the hospital finally asked the provider for fixes. When they were told that the system could not be fixed, the hospital told the doctors to work around it and just double and triple check the orders to make sure the computer didn’t do something wrong.
When we found that the ER orders somehow survived upon admission, we were told to only do one-time orders or cancel our orders when patients got admitted. When we found that patients who were discharged from the ER and returned a day or two later had all of their orders from their last visit automatically reinstated, we were told to look in the computer and cancel all of those orders.
My shifts in the ER became more about computer entry and less about patient care. Every shift in that ER was about tiptoeing around landmines that had the real potential of harming patients.
Our EMR wasn’t even close to being ready for primetime. Saying it was dangerous is an understatement. In the name of protecting patients, it was imperative we returned to the paper chart until a safe EMR could be installed. But that wasn’t the answer that came from up above. After all, the government had mandated them and the hospital had paid for it…so oh well.
I’ve had too many cases in which my best wasn’t enough. Too many times I’ve wiped tears from my eyes in the bathroom because I couldn’t save a child who had drowned. Too many times have I told someone that thought they had something minor that in fact they had cancer. Too many times have I watched someone say goodbye to their spouse as they took their last breath.
Every single one of those events took a piece of me. I was willing to accept that when I was a doctor…But once they made me a computer entry person who’s responsibility was to protect patients from an error prone computer system, I was out. I admire those who have stayed in, but I couldn’t do it anymore.
I don’t look back and I don’t feel bad about it. My only regret is the patients left behind in a system that is no longer run by doctors, but controlled by third party payers whose primary concern is money.
And speaking of money, ACEP says the average ER doctor loses $138,300 of EMTALA related bad debt per year from caring for the uninsured and underinsured. I was one of those doctors. So while I believe my impact on society, as a physician was greater than just dollars and cents, after 18 years in practice, I’m confident to say that my debt to society was more than paid in full.
There’s another squishy use of the word retirement. Like the guy above who “retired” to half-time, you “retired” to another career, no?
I guess that’s one way to look at it. I don’t ever see myself as not working. It just isn’t in my nature. But I no longer work as a doctor. So I guess it would be more accurate to say that I retired from medicine (which is what I thought this blog post was about). That would be the same scenario for you if you stopped practicing but continued with the White Coat Investor website, right?
Yes, it would, but I might not use the word “retired” to describe it. That’s okay though, retirement is squishy.
I prefer the term “repurposed” to describe my switch from practicing general surgeon to Physician Writer/Financial Coach/Teacher. I’m just on a different mission now.
May we all find something so fulfilling when we stop practicing medicine.
Perhaps I should have said “step down to” half time instead of retire to half time above…
Somewhat related questions from a non-doctor. What if the US had a system of universal health care as does every other developed country in the world? Doctors would make less and would work longer out of necessity. Would this likely reduce the number and/or quality of doctors. Would those considering a career in medicine likely have different objectives and ideals? What do doctors think about that possibility?
I think the quality would go down if docs were only making $50-100K/year.
Here’s the deal when you compare salaries to other companies though. Docs make less but so does every one else. Plus, med school is free in a lot of those countries. If docs didn’t start out with a net worth of -$200K, they could make less than $200K and be okay that first half of their career.
Would there be the same number of docs? Almost surely. Med schools are turning away 2/3s of applicants.
Yes, it seems only logical that the quality of docs would go down, but the quality of healthcare in, e.g., the UK, is higher than the US even though their per capita costs are only about 40% of US. Go figure.
Don’t believe everything you read. The answer to that lies in the definition of “quality.” If you want higher quality/better value health care in the US, all we need is death panels. In the UK, they have death panels. Here, not so much.
There are other factors that lead to poor health outcomes in America that have little to do with the health care system.
We could certainly do better with the money we spend, but it will involve spending less money on stuff people want that doesn’t make a difference (or is even harmful.) Somebody has to tell them no.
it’s actually fairly amazing how badly we actually need death panels and how many problems that would solve.
i tried to describe to a norwegian critical care doc what it was like to work in a quaternary ICU in america and she was literally mouth agape the whole time.
MPMD: so what do you do when a demented person who is clearly dying rolls in and the family wants “everything done?”
Norwegian: uh, we tell them “no”
The other thing that would save a lot of money is for people (patients and doctors) to really understand what NNT means. I mean, if the NNT is 100 to prevent a stroke or whatever in the next year, and the medication runs $100 a month, a lot of people would rather spend their $1200 on something else. A fib patients think if they don’t take Xarelto they’re going to stroke out next week. When in reality, they have something like a 3% chance of a stroke per year without it and a 1% chance of having intracranial hemorrhage with it. (Numbers may be off, so don’t take this as medical advice.) It would be a very logical thing to do for a middle class person to look at numbers like that, see the $3000/year price tag (again I made up that number) and say, “WTH? I’d rather take my family to Disneyland than buy those pills.” When we figure out a way for people to make a logical, economic decision like that, I think we’ll be surprised how much “medical care” they refuse.
yeah you could make a pretty solid argument that NNT/NNH should dictate basically everything we do.
In my experience, patients are keenly aware of every possible side effect of the meds I recommend, but often unable to make a rational assessment of the net benefit provided.
This problem is especially acute with anticoagulants (like Xarelto) and statins.
They have all seen late-night commercials sponsored by ambulance-chasing lawyers warning them about the dangers of Xarelto, so even when they have a huge net benefit (i.e., decreased thromboembolic risk versus increased bleeding risk) to be gained and a low cost (because of insurance coverage), many still refuse treatment.
My average patient is not an MIT grad, but they probably represent the average US patient fairly well. Simple statistics do not help.
WCI and MPMD. Amazing. Why aren’t docs better educating the uninformed public (like me) on this stuff?
1) Don’t have time
2) Costs us money. You wanna come to the ER for me to tell you that you have a cold, that’s a profitable visit to me.
3) Some docs don’t realize/think about it.
I was thinking more in terms of MPMD’s views on of the importance of death panels (sans Sarah Palin terminology).
Well, it’s not exactly politically tenable to be pro-death panel. But let’s call it what it is. It’s the people who say “no” to more medical care that doesn’t make a meaningful difference. Not only do they pull the plug on grandma, but they tell you that you can’t have an MRI or a joint replacement or an expensive but convenient diabetes drug.
Politics aside, what is more tenable, universal health care at half the cost, or the ability to “say ‘no’ to more medical care that doesn’t make a meaningful difference”? That to me is the important discussion, where the views of docs would be most helpful. All other developed countries have been able to deal with this politically.
Universal health care has many meanings, and the devil is in the details. The reason universal health care keeps costs down is it doesn’t pay for some things. They have death panels. The UK has them. Canada has them. Everyone has them. Want to spend less on health care? Then consume less health care. You can even do that and have better outcomes because lots of what we call health care doesn’t improve outcomes. But people have to be told they can’t have what they want. And a doc or a hospital or a pharmaceutical company trying to make a profit isn’t going to tell them that. They’re not going to tell themselves that unless they are personally footing the pill and can get transparent pricing. And patients and doctors hate it when the insurance company tells them that and fight tooth and nail to get it anyway.
Cheaper health care = less health care. That’s the bottom line. Doctors and nurses and hospitals and MRIs are never going to be cheap. So if you want to spend less on them, buy less of them.
Well said WCI. “lots of what we call health care doesn’t improve outcomes”. Earlier posts indicated that much of health care has some benefit, but does not appreciably improve outcomes. If it were possible to say “no” (including MPMD’s Norwegian “no”), I assume that there would be substantial cost savings which could be applied to medical services for the un/under insured.
All developed countries but the US have a universal health care systems. If the US government won’t take this on, then the only group qualified to say “no” is the medical profession (or better yet, promote enactment of UHC). Of course you are right that saying “no” would be financially detrimental to the medical community. Sometimes it is necessary to do the right thing.
Our first obligation is to the patient, not society. The right thing for the patient is often different from the right thing for society. When they align, it’s easy. When they don’t, it’s hard. Health care is complicated. Anyone that thinks the solution is easy doesn’t understand the problem.
You said: “lots of what we call health care doesn’t improve outcomes”. I take it that in these circumstances the right thing for the patient is to say “no”?
The right thing is for the patient, their family, the doctor, the hospital, the insurance company, and the government to say no. But patients want it, doctors and hospitals make money by giving it, their family can’t deal with not doing everything, the government stays out of it unless it’s Medicaid/Medicare/Tricare, and the insurance companies are seen as just looking after their bottom line (which they are, it just happens to often line up with good care.)
But, where the health care doesn’t improve outcomes, if asked for his/her opinion, should the doctor say no?
Second that response! Death panels would result in a big coat savings. Something we should be able to standardize if it only had a better name.
So much time and money wasted on inpatient care that could be replaced by hospice/palliative.
It is related to calibrating the patient’s expectations and also our inability to inform them of low life expectancy. Those G-tubes and pacers are a mixed blessing.
Depends on your definition of quality. Somethings are better in the UK but not if you say need an organ transplant or dialysis. A debate for another time.
Yes, best to move away from the political. I have no problem with choosing a career for financial reasons; my career choice was international tax because it was a good way to make a buck. But are there those docs who are largely motivated by the desire to help others? If so, maybe the quality of docs would not decline if the US adopted one of the various systems of universal health used by all other developed countries, even if compensation declined?
What we are already getting is midlevels- NP PA for 2/3 the cost of an FP/GP. And worth about 1/2 (work less hours and cost more/ save less money since they refer a lot more) or 1/4 of what a doc is worth.
You said “Politics aside, what is more tenable, universal health care at half the cost, or the ability to “say ‘no’ to more medical care that doesn’t make a meaningful difference?” But the point is you get BOTH. Or neither. I am a big proponent of single payer or universal health care (whatever covers everyone, though some argue nothing will) and note that we don’t have less death panels than the NHS Canada etc- our death panels are just operated for profit and only answerable just barely to ill patients and stock holders (guess who wins out) not to the public or the taxpayer. (In case that’s confusing- when a health insurance company denies payment for something potentially lifesaving it is operating as a death panel.)
You’re right, I intended to phrase it as an either/or and it came out as a both/neither.
Good post. I’m hoping docs will stop using Sarah Palin’s emotive “death panel” language. when describing what most believe to be a necessary procedure.
By destigmatizing the phrase, we take away its power.
The power of the phrase would seem to be the power to delegitimatize death panels (Palin seemed to think so). I take it you disagree with MPMD, “it’s actually fairly amazing how badly we actually need death panels and how many problems that would solve”?
No. I agree we need death panels. And people need to hear that intelligent people support them. Obviously the politicians will have to call them something else- “Resource Utilization Authority” or “Health Care Appropriateness Decision Panel” or whatever. But when I say death panels, everyone knows what I mean.
I’m so glad to see you write this (and sorry for peppering your post with so many responses- it really spoke to me and I’m enjoying the discussion). It stuns me that people think we will have the same quality of care with lower physician salaries, midlevels practicing independently, and decreased physician autonomy. Our system is not perfect, and I think a reasonable argument can be made that, on a societal level, America’s vastly higher health care costs are not worth marginal improvement in outcomes, but there is a reason people from all over the world come here, not to the UK, Canada, or France for specialized care. Of course our care is better! Ask anyone who has practiced in other places.
And I appreciate your point that we need death panels, and that what’s good for the patient is not necessarily what’s good for society. It’s complex, as you say, and I’m disturbed the number of otherwise well-educated people that seem to think otherwise.
Thank you.
When healthcare quality comparisons are made for society as a whole in developed countries, the US does poorly, e.g., lower life expectancy. If the comparisons were instead made for the wealthiest top half in each country, the US would excel: higher life expectancy; greater comfort of service (less pain); more convenience (short wait-times); better technical service (better qualified doctors); etc. The US medical care for the bottom half, that includes the uninsured and underinsured, is inferior to that in the other developed countries that have universal health care. That is the correct basis for a societal level argument.
I believe the point about death panels is not that society’s interest trumps the patient’s interest, but that much of the costly end-of-life treatment is not needed or even wanted by the patient.
We’re not just talking about end of life care, but also beginning of life care. Death panels have to make a lot of tough decisions.
Have you read ‘An American Sickness’ by Elisabeth Rosenthal yet. I must admit to be very cynical regarding the state of healthcare in the US but after reading this I feel much worse. There are many views but at the end of the day it is hard not to feel that America should be doing much better.