By Dr. Jim Dahle, WCI FounderI am often told, usually by an experienced doctor, that other doctors owe something to society, usually in exchange for the expense of their education. This is in response to different scenarios. It might be:
- Someone retiring early
- Someone working part-time
- A doc having a baby or “going on the parent track”
- Someone who burns out and changes professions or becomes a stay-at-home parent
- A physician taking parental leave, or most recently
- A doctor choosing a concierge or direct patient care business model
Here's an example of how it gets said:
“I just finished listening to your video explanation of concierge . . . I mean for this to be an open discussion and harbor no hostility toward you or your excellent presentation. What about the moral/ethical aspects of this? Almost all physicians in the United States received their education heavily subsidized by the federal government. When they go to concierge, they may go from an actual average patient load of 2,000 down to 200. Where do those 1,800 others go? Right now, they go to a rapidly expanding queue for either general or subsequent specialist care which is why the waiting lists are unconscionably long right now. Do concierge physicians take this into account? This explosion seems to track exactly with the explosion of concierge medicine. What do you think? I can’t begrudge a physician who’s been at it for 40 years to spend the last five or 10 years as a concierge, and I have some friends who have done that. But to see people go directly out of training into concierge seems to be a blight that we should discuss with open minds.”
Hippocratic Oath?
I'm really not sure where this view comes from. Maybe it's from the oath that many new doctors repeat at graduation, i.e., some version of the Hippocratic Oath. This is one of the older versions:
“I swear by Apollo Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.
To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the Healer's oath, but to nobody else.
I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. . . . But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.
Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.
Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me.
As I read that, I see nothing that obligates a doctor to work long hours, many years, or for free—except for teaching the children of those who taught me medicine. So, maybe there's an obligation to teach medicine for free, but nothing there says I have to practice it for free or that I am responsible for the access to care issues seen in our modern healthcare system.
Do Doctors Owe Society for Their Education?
Who pays for the education of a doctor? In the case of many doctors, they do—to the tune of literally hundreds of thousands of dollars. Sometimes that debt is carried well into mid-career and beyond. This is quite different from today's senior doctors, who may have faced a mere four-figure annual tuition bill. If they went to a state school, perhaps the state subsidized the education somewhat, usually in hopes that the doctor would choose to continue to live and practice in the state. But if the government actually wanted to contract the physician to stay in that state, it should have done so. Those contracts exist, but they generally pay a whole lot more than the difference between in-state and out-of-state tuition.
Perhaps the doctor paid for their medical education the way I did—with a contract. I contracted with the US military. The military paid for school, and I agreed to work there for four years, no matter where the military sent me or what it asked me to do. The military fulfilled the contract, and so did I. Neither of us owes the other anything anymore. The same goes with a National Health Service Corps, Indian Health Service, or MD/PhD contract program. Yes, if you signed a contract, you need to fulfill the terms of that contract. But that isn't the case for most doctors.
What about residency, you say? Hospitals that offer residency programs receive a substantial amount of funding via Medicare, which is paid for using payroll taxes. The most recent data I saw suggests that Medicare pays $150,000 per year per resident. My first question when I hear that is, “What the heck? Where's it all going?” Most of it is certainly not going to the resident. Even a well-paid resident has a compensation package worth no more than $80,000.
Now, I'm not going to argue that a PGY1 resident is worth $80,000. But a senior resident is worth a heck of a lot more than $80,000. Heck, more than $150,000. On average, the compensation is probably about right for the value provided. What is a supervised practitioner worth? That's relatively easy to see, given the prevalence of Advanced Practice Clinicians (APCs like PAs, NPs, CRNAs, etc.) in our system. They get paid a lot more than a resident, even a senior resident. At any rate, there is no contract, and there is nothing in the Hippocratic Oath or in their contracts requiring doctors to work for long periods of time—much less for free—just because Medicare helps pay for residencies.
Docs don't owe society anything for their residency training. And even if they did, doctors and similar high earners suffer most under the progressive tax code. The more you earn, the higher your tax rate. There is no REPS status for medicine. There is no carried interest for medicine. There are no stock options in medicine. Everything you earn gets taxed at the regular old ordinary income tax rates. And every bit of that income (barring an S Corp being involved) is taxed at 2.9%-3.8% for Medicare.
We all pay for those residents. A doctor making $800,000 pays around $30,000 a year in Medicare tax but gets no more benefits than someone who pays $1,500 a year in Medicare tax. It doesn't take very many years of that to pay back the cost of your residency to Medicare.
More information here:
Are Physicians Who Retire Early Abusing the System That Made Them Rich?
How to Retire Early as a Doctor
Why Is This Argument Limited to Doctors?
For some bizarre reason, I never hear this about any other profession. Nobody says lawyers have to work 80 hours a week until they're 75 because society educated them. Nobody applies this to engineers, astronauts, pilots, teachers, judges, or anyone else that society helped to educate. I don't even hear it about nurses. Just doctors. And interestingly, it's almost entirely BY doctors. Maybe it's time to quit shaming each other into a burnout-inducing amount of work.
What About EMTALA?
As long as we're talking about obligations, let's talk about the biggest unfunded legal obligation doctors face, the Emergency Medical Treatment and Labor Act (EMTALA). This is the anti-wallet biopsy law. While it applies primarily to the emergency department and labor and delivery, it does include any doctor officially on call for an emergency department, which is an awful lot of doctors.
Basically, you cannot ask a patient to pay for their medical care until after you have stabilized their emergent medical condition. I don't actually have a problem with EMTALA. I think it's a pretty good law. My problem with EMTALA involves funding. It's mostly the fact that there is no funding. It's an unfunded mandate. Unlike anyone else in America, emergency doctors are federally mandated to work for free. And yes, patients do take advantage of that. Uninsured patients are technically “self-pay.” In reality, if you don't collect the money up front, self-pay equals no-pay. The self-pay rate in emergency departments I've worked in is about 3%, which is effectively 0%. Given an uninsured rate of 20%, that basically means I work every Friday for free. And I have it good. Lots of emergency departments have an uninsured rate of 40% or even 50%.
No, I don't owe society anything. And if I did, it was paid off long ago with all the free care I have provided to every fifth patient for the last two decades.
Workforce and Patient Access Issues
Yes, there are workforce issues involved when doctors work less or retire early. Yes, there are patient access issues when doctors decide not to see seven patients an hour or adopt a concierge model. These are very real, complicated problems. But they are problems for our entire society to solve, not problems that can or should be solved by doctors alone. Anyone who thinks these are easy problems to solve doesn't understand the problem. But doctors can't take the entire medical system on their shoulders and carry it to the promised land. They might try, though—which explains the 37%-63% burnout rate, depending on specialty.
More information here:
Which Medical Specialties Are the Most Burned Out?
What Emergency Docs Can Do to Beat Burnout
The Bottom Line
If you want to go part-time, have a baby, start a concierge practice, take Wednesday afternoons off, cut back to full-time, retire early, or leave medicine altogether, go ahead and do it. You should feel no guilt about doing so. You don't owe anything to society. You didn't steal anyone else's spot in medical school or residency. Give me a break.
What do you think? Do you think doctors owe anything to society? Why are doctors the only ones who ever feel guilty about not working enough?
This is more common in countries where education is almost free like France or other Western Europe countries. In America since you pay for your vacation nobody is going to ask you pay back. In France in particular there is a big deficits of doctors coupled by a financial crisis in the country. The government is asking more from the medical profession without signicant pay to already overwhelmed doctors, especially Primary Care and in emergency medicine, and they’re using the argument that society has paid their education to force them to more labor and use the hippocratic oath as a moral tool. Result: they are no more primary care or ER physician….
“Maybe it’s time to quit shaming each other into a burnout-inducing amount of work.” Bingo. Physicians are usually our own worst enemies. Unlike teachers and lawyers and other professions, we carry our competitive natures with us to the grave and we’re all worse off for it. Perhaps that’s why our incomes aren’t really increasing like they should compared to some professions. It would be a stretch to blame other doctors for most of burnout though, in my opinion. I’ve largely done it to myself. I would be lying if I said that one of the principal reasons that I’m still working is because I feel I owe a debt to society. LIke you, I paid that off with 12 years of active duty service. No, it’s more selfish than that – I don’t know if I’ll be happy not working, and not quite ready to hop into my second favorite activity (sailing) yet as a full time job, but I’m working on it. Thanks for another great article on the WCI!
“Unlike teachers and lawyers and other professions, we carry our competitive natures with us to the grave and we’re all worse off for it. ”
…. My friend, have you met any lawyers?
Yes I have two close friends who are lawyers, friends since high school. They both do well, one does extremely well. Neither work overnight shifts, weekends or holidays like I do. Neither one had long residencies or fellowships like I did. Even the one who makes a bit less per year than I do had such a head start and has worked much fewer hours, they are in a very good financial position now, better than me. So, when you break things down per hour work, especially if you consider the extended training and educational debt and value of nights and holidays, they are better compensated than I am. If their firms asked them to work 12 hr overnight shifts over Xmas, they’d tell them to F off. Physicians just say “thank you Sir, may I have another.” We talk frequently about how lawyers know that physicains are naive in terms of business, are easily manipulated and don’t realize their own worth. They just laugh and say “and you studied harder than we did!” But I am not a victim – I like what I do and have found side gigs outside of medicine that I am transitioning to and will be retired from medicine in a few years, before age 50. Critical care is a young man’s game, at least where I work it is. Our kids watch the way my wife and I work (and the stress and responsibility) compared to their friends parents (mostly also high earning professionals) and they wonder why anyone would want to do it. Smart kids!
I appreciate the sincere response to my cheeky comment.
I am a lawyer in a small firm in a rural market. My sense is that many of us become lawyers because of our competitive natures. Litigation is a particular kind of grind and too often brings out the worst in us.
I’m surprised by your sense that lawyers are generally better off financially than doctors.
Perhaps it’s a function of the fact that doctors tend to make more in rural markets, while lawyers assuredly don’t. Our state bar association put out a document suggesting that fewer than 10% of lawyers in private practice were making over $200K. While I doubt the accuracy of that survey, I’ve never seen a job paying over $180K advertised on our state bar website either.
As we say in the south, it sounds like someone is good starting an argument in an empty house. Don’t like the profession? No one made someone become a doctor. Want change to funding, tuition, the tax code, get it done, don’t whine. Want to give up one’s status, fine; I have seen it in my lifetime – the Marcus Welby model is gone anyway. A lot of people work overtime, odd hours, give up holidays: law enforcement, firefighters, the plumber on call (my HVAC company always has one) – heck, when a tree fell on my house, even the insurance adjuster and the contractor were there on a Sunday.
Education is expensive, but at least when the model changed in VA for funding for VCU and MCV (now VCUHealth)- it’s been over 20 years now – the medical profession endorsed it. Its only going to get worse for those doctors who remain as many age out; but they were silent this year as one candidate advocated for change to the model for paying more for physician education.
One last issue is the inability to deduct losses when self paying patients don’t pay. Technically, you are burning through overhead ie, canceled visits, fuel, malpractice ins etc.. yet you cannot write off any of this, let alone the uncompensated bill but attorneys and other professions can. This issue was glaringly overlooked when EMTALA was created.
Dr Dahle: Perfectly said. Thank you.
Thank you for addressing this. I have seen this argument many times and have always been confused by it. I recently decided to drop to part time at work, which so far has been an amazing change for myself and my family. But this “debt to society” argument was still bouncing around the back of my head! I appreciate you debunking it. Regardless, the world will probably get more years out of me now than it would have if I’d stayed on my burnout-inducing full-time schedule!
Thanks for all you do!
This comment was originally misidentified as spam by software. It has now been restored in its original form.
I’m sorry, but this argument gets no sympathy from me and I’ve met to many “if they don’t pay me enough, let them die” type doctors.
How about doctors acknowledging that the US system is effectively tailor made to make so many of them rich relative to any other country on the planet (including many countries with predominantly free market healthcare).
What other marketplace:
-Allows for mass scale upbilling tacking on higher level billing codes and extra procedures codes with zero patient input in the process of what is being billed. Few 2 providers bill the same things the same way and almost none of it matches insurance, government, etc. code criteria
-Has almost every single doctor agreeing with zero price transparency because they know it’s good for business. Providers just as much don’t want to publish negotiated rates with insurers as insurance companies don’t.
-What other industry does the government essentially mandate the primary payer of your customers (private insurance not government) essentially always agree to and overpay for essentially all of your services).
And you don’t have to look hard to see it. Hop on any Reddit discussion about quality of life of doctors around the world and you’ll see everyone in agreement that it’s by far better in the US than the rest of the world by a wide margin.
The answer is simple you have a goverment that simultaneously prevented you from coming into a fully socialized medicine system, but also artificially restricted the supply of doctors in order to limit the costs the same government paid by trying to limit the amount of services charged.
This artificial restriction of healthcare supply has made many American specialists fantastically wealthy.
Even though it’s extremely short sited and stupid approach to running a healthcare system, I would argue that doctors in the US should at least acknowledge these flaws in the system are making them fantastically wealthy relative to anywhere else on earth and relative to any other American profession even close to its size and you know… maybe not try twist the screws into everyone else even more?
If direct primary care or conceierge is right for you, sure do it. But you maybe try to figure out a way to give back a little. To maybe acknowledge that you’re getting wealthy off of a weird confluence of policy that probably shouldn’t have happened and one that is effectively screwing the population of where you serve.
Or you can effectively take the view “Doesn’t matter how much money I make elsewhere, if I don’t get paid enough on this patient let them die”… as you go back to your $2M home paid for by insurance companies who paid you $800+ for 15 min of work on your other patients. Whether you want to admit that the situations are linked or not is up to you, but again you will get no sympathy from me.
Yes, the medical system rewards brilliant people whose chosen like of work has very low demand elasticity, but the entire premise here is utterly flawed.
Can you think of a single physician who would not succeed in a different career field? How lucrative are these alternative career fields (factoring in the sunk time/expense of going through a likely much more demanding education process). Even the very pedestrian example of being a public school teacher, the break-even age for a physician after factoring in taxes is deep enough into a career that for anybody contemplating FIRE the choice to attend medical school is already one worth reevaluating.
If you think getting paid $800 for a 15 minute call is absurd, just wait until you engineer a system that nobody else knows the correct single line of code to fix, but can print money once fixed…
Once again consider the notion of opportunity cost and you’ll see why most people reading this comment are more likely to react with bemusement and being mildly affronted by the assumption that somebody who has already taken on the tasking of being a doctor in a society that does provide the highest possible standards of care (albeit at often ruinous cost for those with the ‘wrong’ amount of wealth to be able to afford it unsubsidized) should somehow give MORE of themselves than they already have.
Premise is not flawed at all and only need to highlight a couple of things to point out why your argument doesn’t hold up to scrutiny:
1) If all of these physicians are so great at their work, knowledgeable, and making the system better than why do even doctors themselves (including Dr Dahle) so much bemoan the state of quality of care in the US today when they’re on the receiving end of it? This seems especially true even comparing peoples evaluations of quality of care today vs. only as recently as 10-15 years ago.
2) But more importantly its the comparisons with doctors income vs. quality of life in the rest of the world where this falls flat. Hop on an online discussion of doctors around the world and it is accepted that not only do US doctors enjoy substantially higher pay and quality life vs. doctors in essentially the entire world, but also its a quite noticeable jump in quality of life vs. even the next few countries in line. This is true regardless of people working in mostly free market, socialized, or quasi socialized medical systems. And lord knows that at least some of those countries turn out decent quality to their patients so its not like you need highly paid doctor talent to deliver good medicine to a population.
Taking that one step further, I think it would be a pretty good discussion about whether it is even a good thing for people going into medicine picking it for mostly pay and quality of life reasons. Particularly in the US where our system is so susceptible to billing manipulation relative to anywhere else on earth, loading up our medical system with doctors who are primarily in it for the money may not be the best idea anyway.
And on the topic of engineers who know the “correct single line of code”; I do count some of those types as friends of mine and I’ll tell you that:
1) While occasionally you can bid out a project on a result you know won’t take you much time, is super valuable to a client, and can’t be done by many people… those are far more rare than you think. Usually most of the solutions they’re asking for can be done by quite a few talented people and there is no way you’ll be able to bill $3,200 an hour and get anyone to accept it. But maybe 1/10th or 1/50th of your projects you can bid $100,000 on a project basis and spend 30 hours on it. It’s not a realistic to compare an infrequent example like to a medical profession that is doing it for 100% of every patient they see on private insurance.
2) Lets also talk about scale. Specialty work in lets say in a particular engineering sub category may involve only 100-1000 people nationally who can command seriously high income on certain projects. Your comparing that to an entire country of medical specialists where typically multiple or even several dozen exist in every single city (large and small) billing that way multiple times a day, every single day, system wide… and often for basic check up or commoditized appointments & deliverables. On a scale basis its not even the same league.
***I don’t bemoan anyone for following the incentives that exist before them to better their life. I don’t fault any doctor from wanting to make choices that better their life or income.
What I have a problem with is doctors not even being willing to acknowledge that they’re the benefactors of a system that has a principal side effect of making them very well off and that once they paid off their student loans they’re no longer receiving any help/benefits/etc. from the US government or US society. That is patently false; you could line up 100 economists and almost certainly 90+ of them would tell you that not only are doctors still benefiting enormously from this system, but it’s economically distorting the level of that benefit. Our country realized that if they limited the supply of doctors they would also limit the quantity of Medicaid and Medicare payments they had to pay out. They then gave every doctor/provider an amazing deal… let us under pay you for our patients and we’ll give you all of the tools/leverage to hose private insurance payers which has been no doubt an enormously valuable deal to the entire doctor profession. Now it’s not surprising that you have doctors who realize that they’d just rather take only the private insurance payers or want supplemental concierge payments because they know they can with the doctor shortage (and “I’d rather let a Medicaid patient die than accept less than $100 for my work”)… okay fine, but to act like society and the US government didn’t artificially create the circumstances where you get to hose the population for a little more money… is just extremely self centered.
Again no sympathy from me on that argument.
Anonymous- Mostly your posts are too long and rambling for me to effectively respond to point by point. I just don’t have the time, sorry. But a couple of points ought to be made about them.
# 1 Comparing doctors in the US to doctors in other countries assumes everything else is equal. It isn’t. Lawyers, tech bros, entrepreneurs, pharmacists, engineers etc etc etc all do better in the US than in almost all other countries. We just make more money and have more money here on average. So that comparison isn’t worth much.
# 2 I’m not sure doctors have much to do with the lack of price transparency in the system. I agree it’s a problem, but I’m not sure doctors are even in the top three groups to blame for it. I don’t think I’ve ever heard a doctor advocate for less price transparency. Those going into DPC etc are loudly advocating for MORE transparency.
# 3 The health care system certainly has flaws. It’s embarrassing to be part of most times.
# 4 I don’t recall ever complaining about quality of care issues for me personally. I’ve received great care over the last year and a half from multiple docs, hospitals, and other entities. Overall I think quality of care is dramatically higher than even when I started my career. I mean, I get a stroke patient now and 30 minutes later there’s somebody yanking a clot out of their brain. I couldn’t even get an MRI in the ED 25 years ago.
# 5 I disagree that people are generally “overpaying” for the health care they purchase. It’s a VERY expensive service to provide. If health care is 18% of GDP, the average family should probably expect it to be 18% of their annual budget. Health care should feel less like your cell phone bill and more like your mortgage. Don’t forget that the vast majority of that cost is not going to doctors. I think 10% gross goes to doctors. After overhead, the docs take home even less. Maybe half that.
# 6 Many doctors are not well off. I can’t tell you how many doctors in their 30s and 40s I’ve met with negative net worths. Surveys show 11-12% of doctors in their 60s have a net worth under $500,000. Most docs do fine, of course, and retire as multimillionaires. But frankly that’s a pretty low bar in my book. Max out a Roth IRA every year from 25-65 and you’ll retire a multimillionaire.
FV(8%,40,-7000) = $1.8 million
Doctors don’t have to rip anyone off to become very wealthy. All they have to do is manage their money well. Pretty much the same as any other professional. Some will choose to FIRE (and those folks will concentrate in places like this) but most won’t.
# 7 I have NEVER met a doctor, and I’ve met many, many doctors, who would let a patient die in front of them before taking care of them, even if they don’t get paid to do so. Suggesting this happens in any significant amount is not only insulting, but reflects a lack of insight and knowledge into how things really work. When I’m taking care of patients actively trying to die I don’t even know their insurance status. The only time I ever know insurance status is when I have a clerk look it up to arrange follow-up care with someone who takes it.
At any rate, this blog probably isn’t a place you’re going to find much sympathy for your views given 75% of our audience is docs. You’re welcome to have those views, just be surprised if expounding them here is not a lonely experience for you.
I’m also usually too busy for this; I maybe comment anywhere online a few times a year tops. I felt in your post that “Doctors are mostly a rational and good hearted” maybe I can provide another perspective that may just alleviate the idea that doctors only benefit they’ve received from the US is their education.
#1 We could take any industry in the US and compare to international counterparts and you would see compensation levels in the US that may be a little higher then 2nd best, 3rd best, 4th best, etc. countries (sometimes not even the highest comp). In medicine US pay is very noticeably higher than 2nd, 3rd, 4th best countries in the world. Now you may say “but high end Tech bros” and “Corporate lawyers”, but that isn’t the entire industry. If you lumped all software developers (or even just all senior developers) into one group or small city lawyers with big corporate law firms you’d see more normalized compensation levels in line with the top 5 countries in the world. In the US the 3rd worst radiologist or ENT in a small lower income city is still paid way more than even the top 10% of any of those specialties anywhere else in the world. There is no equivalent comparison in any other industry.
#2 I agree that doctors are probably not in the top 3 cause of price transparency issues, but outside of DPC there are many doctors that have the ability to improve this and choose not to. It only takes some providers to introduce competition on an issue and yet you see no doctor owned clinics, private practices, etc. remotely willing to take a lead on price transparency because clearly they prefer the opacity.
#3 Agreed
#4 I’ll quote you: “My daughters are experiencing terrible healthcare that they pay for mostly out of pocket, from botched shoulder surgery, to an inept gynecologist first year who may have caused infertility, to 6 month waits for no answers for hearing loss, to only seeing APP’s with a lack of knowledge that I can find answers to on Cleveland Clinic, it is clear that the lack of doctors has resulted in unqualified, unskilled doctors.”
#5 This type of comment really puts into question your credibility. Let’s set aside the insanity that 18% of GDP is higher than any other country in the world by a noticeable margin (over 6% higher than the next country) and that includes both market based healthcare systems (Switzerland, Singapore, etc.) and socialized healthcare systems, but also private insurance reimbursements are about 2.5x Medicare rates, 3x Medicaid rates. If you think private insurance reimbursement rates are reasonable then if those rates were also applied to Medicare and Medicaid we wouldn’t be at 18% of GDP, but healthcare spending would be ~34% of US GDP. Yeah you have that right? Over 1/3 of every dollar spent in the US would go to healthcare expenditures. But also its just absurdity of trying to claim that none of the reimbursement rates or billing rates are an overpay in healthcare. Lets start with which set? The same procedure can be $150 on Medicaid, $200 in Medicare, $500 on negotiated insurance basis, and $1,000 via the providers chargemaster price. So none of these are an “overpay”? Like how ridiculous of a comment is that? Furthermore, we’re talking about doctors often encouraging the highest code available if there is a set to pick from, tacking on extra codes for basic tests/question based tests, facility fees, etc. so that a 15 minute visit where a few questions get asked, no real analysis/commentary occurs, and the patient gets sent home with zero effort can easily be billed over $1k. And if the doctors coders accidentally screw up the coding they can get knocked off the negotiated rates to the higher chargemaster rate to attempt to collect more money from the patient… do many private practice docs even want to agree to then agree to the price in the negotiated rates? Nope… insurance denied, pay me the chargemaster rate please or I send collections! And then the idea that for a person who just does a few check ups a year and maybe a couple of medications should spend equivalent of a mortgage every year for healthcare is insane! Like what warped bubble did you fall into?
In an emergency room or large clinic primary care it may be 10%. But you and me both know the anesthesiologist or the podiatrist operating out of their own clinic isn’t walking away with 10% of insurance reimbursements. Much, much higher!
#6 The fact that you use 30s and 40s as your age group just shows your intention is to mislead not actually be serious. Clearly given the typical age residency ends, its not doctors net worth’s at age 35 that drives people to be doctors; its a different age. Well north of 12% of professional athletes are broke not long after their career ends… gee some people will make bad decisions with their money, get divorced multiple times, etc. It doesn’t mean they weren’t given plenty of opportunity to be well off.
#7 Well you see I have; they are almost certainly not going to be emergency room doctors. And yeah maybe its after a few drinks and sure they’re likely mostly complaining about low reimbursement rates in some areas, but they still said it. I’ve never implied its remotely close to a significant minority… but those types of attitudes do exist. And unfortunately there are far more that will never admit something like that, but will make only 100% self interested decisions without any other considerations that may as well have the same affect as that statement.
As I said above my assumption is that most doctors are rational and kind hearted. My intention isn’t to comment in an echo chamber. I didn’t comment here to get US doctors to feel bad about the system, to really influence their decisions at all, but to at the very least maybe consider that the US system is still supporting them every single year in a big financial way beyond just that they got trained here. Most doctors aren’t economists so I don’t fault them if they didn’t realize this before, but I’m hoping that they at least use an open mind and their smarts to at least consider/evaluate whether this likely true so we don’t have to hear more doctors say “Oh yeah the US hasn’t really done much for us besides my college degree so next stop $1 million a year as I wouldn’t even give 10 minutes of my time or $10 of money to any cause beyond myself.”
# 4 I’m not sure who you’re quoting, but it isn’t me. My daughters are all very healthy.
# 7 It’s a VERY small percentage of doctors being paid a million a year. Average is about $375K.
#4: Do more than one people share “The White Coat Investor” profile? Real comment 11 below which is where I copied and pasted it from. Is that someone that emailed you?
#7/8: Sure; that is why I said “next stop” $1 million a year as in they’re aspirationally making selfish decisions designed to further skyrocket their income without any other consideration.
A side note: I do have a quite a bit of respect for Direct Primary Care (because they’re agreeing to not bill insurance too); I don’t really have much respect for concierge. Talk about selfish to collect high private pay reimbursements and then also collect additional fees on top of that to cash in more on the doctor shortage… and essentially violate any spirit of the insurance agreements/contracts signed with your payers.
Honestly society should hold about as much respect for that group as they would an aggressive pharmaceutical rep for Purdue Pharma… because you know those people “don’t owe society anything” either apparently.
18 people work here, but that comment was from an email sent to me about this post. Mostly it’s me responding to blog comments here though. Others work on Reddit, Facebook, Instagram, the WCI forum etc. etc. etc.
The concierge model sells access. It doesn’t do much good to have insurance if you can’t actually get in to see anyone. My parents went on Medicare a few years ago and after their primary retired they literally couldn’t get in to see any doctor in their town/state. They had to go to a Medicare clinic staffed primarily by APCs. So they ponied up an annual subscription fee in addition to whatever Medicare would pay the doc to care for them. But they got a doctor. So feel free to disrespect them, but they’re offering a valuable service to many. I get it because I’m familiar with my own practice’s finances. 20% of our patients don’t pay us at all (self-pay/no-pay/uninsured etc), 20% are on Medicaid (we lose a little money on those due to overhead) 20% are on Medicare (we mostly about break even on those) and 40% are privately insured (we make enough on those that it’s worth staying in business to take care of all the other folks too.) There’s no doubt our health care system is screwed up, but recognize it’s primarily a systems issue that shouldn’t be laid at the feet of health care practitioners who are mostly just trying to do the right thing for the patient in front of them. Anyone who thinks this issue is easy to solve doesn’t understand the issue.
Not saying the issue is easy to solve and not blaming doctors for it.
I’m asking doctors to acknowledge that their benefits of being an American doctor aren’t just a good education, but that they’re benefiting far more financially from an artificially created doctor shortage… and they should at least be able to list that one when they’re talking about the advantages of being an American doctor.
I suspect the fact that you very selectively respond to my points is that is not something you want to acknowledge because I guess that may draw some harder personal questions on whether “Doctors owe society anything”.
I’m not saying doctors owe society a particular role, an amount of hours, a pay rate, etc. But I do think doctors owe society at least themselves having a basic understanding of what that society did to most improve their success… it wasn’t a partially subsidized college degree… its the much larger artificial doctor shortage it created as it prevented sufficient competition from entering your market to compete with you.
I think it’s time for me to stop responding at all to your comments. Our interaction started with you accusing me of things I didn’t do, progressed to long rants blaming my profession for many of society’s ills, moved on to misquoting me, and now accuses me of refusing to acknowledge things because I don’t have time to read the literally thousands of words (longer than the original article) you have now posted as comments on this article. No wonder most bloggers turn off the comments on their posts.
Maybe someone else will engage with you in a way you enjoy, but I’ve got 3000 other blog posts on this website, all of which periodically get comments and questions on them. I prefer to spend my time where I can help the most people. I’m not sure responding to you is helping either of us so I’m going to move on. Have a nice day!
Anonymous seems to be leaving out something very important. I’ve been practicing medicine for over 20 years now, but at least when I was in college, acceptance to medical school was very difficult and they only took the best and brightest. 95% of college kids couldn’t get in if they tried. At least historically, US physicians are people who not only can do the science but also have the social skills and well roundedness needed to practice medicine. That is a very small subset of the population If they wanted to do something else, they could have. Not all countries are like this. I’ve lived in Europe and it’s not the same there. In the US, we expect our physicians to be smart, dedicated etc and the unofficial tradeoff is that they will be paid well. If you propose changing to a different system, that is fine but realize that the quality of the physicians will go down and these very smart people will go into something else and beat out everyone in sales or law or whatever else they go into, just like they did in college. Most physicians I know who have left medicine (I know two), are making more money and working less than they would have had they stayed in the field. They are successful at whatever they do because they have the secret sauce.
Please don’t complain, though, when you make less money after cutting back. And don’t ask to pay less than your share of the practice overhead.
Same thing I said here a decade ago: medicine changed the contract on me. I had hoped and planned to work into my 70s for the VA or military. My kid with a GS job (like me but lower pay and actual 40 hour work week and able to do 9 long days then one off) expects to do so. However I can no longer see 4 patients in an hour unless I postpone another 20+ minutes of paperwork on them to the end of the workday. The admin (computer) and nursing support most private docs are able to arrange has vanished. THe patients are sicker and waited longer to come in and have 2 new problems on a baseline of 3 chronic ones. THe growing hours of CE I have to perform for the job came on top of CME and a schedule that didn’t grant me any time for either during the workweek.
Add to that my own health issues plus a combination of frugality and good pay and decent planning (thanks WCI!) I no longer NEED to work 70 hours a week, and they wouldn’t offer me 40/ week (a 50% schedule). I repaid the Army decades ago with 4 years post residency, and haven’t repaid Pennsylvania for their support of my medical school there- never worked a day there. The night shifts, long hours, and exposure to sick people contributed to my health issues and you don’t even (except sometimes now covid) get workmen’s comp for days out for complications of URIs the patients kindly pass on to you.
We see now the ACA is no longer affordable when the Republicans get through with it, and all this stems from employer provided health insurance to bypass wage limits of a century ago. Good luck to us all and to the American people. Doctors can’t overwork us out of this problem and we shouldn’t try.
Money wise – absolutely not. But I think we owe society the obligation of putting our patients’ interests first and passing along what we’ve learned to the next generation. Society has given us the great privilege of looking into the bodies and lives of some of the most vulnerable and learning from them. I think we do have an obligation to give back in that sense. I agree 100% that does not mean working until we burn out, working for poor pay or in poor conditions. We have earned and deserve some respect.
Email box filling up this morning on this one:
# 1 Bizarre notion. Who thinks that? I know ppl assumed we were rich while homeschooling 4 and paying back $250k debt at crazy high interest rates, 7-10%, starting salary at $75k bc well, MD. We received no help from the govt. nor anyone unless you count deferred interest while a student. Took us the full 10 years to pay it back. Never occurred that we wouldn’t. Made $14800 first year of residency. That’s when it was still competitive to get matched. My daughters are experiencing terrible healthcare that they pay for mostly out of pocket, from botched shoulder surgery, to an inept gynecologist first year who may have caused infertility, to 6 month waits for no answers for hearing loss, to only seeing APP’s with a lack of knowledge that I can find answers to on Cleveland Clinic, it is clear that the lack of doctors has resulted in unqualified, unskilled doctors. When our generation finishes retiring, I’ll be loathe to go in even for an emergency. It is a mess, and govt. involvement has made it much worse. Imagine if there were actual competition in the market for schools and medicine? Costs could not have sky-rocketed bc without govt subsidies, ppl couldn’t pay it. That’s my ramble. Feeling very frustrated by this generation’s entitlement. I don’t see a solution bc work ethic and service begins in the home.
# 2 From one ER doctor to another….I needed this today! Long time follower. Probably since just about the beginning. 44 years old with six kids in private school and still over 4 million net worth. Nothing is impossible!
# 3 I wholly agree. I retired at 45, mostly due to following a plan of living below my means and heavy investment in equities, as well as building a strong RE portfolio that spins off 1M/year in gross rental income. I do not miss the grind of being the highest producer, managing 4 associates and 35 staff and at the same time, running a large, 5 location practice. I spend my days golfing in between my real job of trying to be the father and husband of the year. “No ragrets”.
Oh so your one of those bloggers who control comments on your page so only posts that agree with you are allowed on the page?
If true losing a lot of respect for you and your website.
Didn’t stop you from emailing me a marketing email from my comment though…
I guess the self serving money focused business practice matches the self justifying of selfishness blog post match each other nicely.
Hope you sleep well at night.
I have no idea what you’re referring to. A comment on this website is occasionally deleted usually due to it being an ad hominem attack on the author or another commenter, and of course we delete tons of spam comments every day. But no comments on this post have been deleted yet as far as I know.
And no, there is no requirement for a commenter to “agree with me” for me to leave their comment up. We did set up the software to email you what we think is pretty useful when you leave a comment here with your real email address.
Yes, this is a for-profit blog. No, I don’t sleep great at night, but that has nothing to do with “self-serving”, “self-justifying”, or “selfishness.” I could probably be more selfless though. Thanks for the feedback.
There was definitely not anything close to an ad hominem in my original comment… just a well reasoned argument as to why in the US doctors should feel some moral obligation to the society… not to the level that I would fault anyone from picking direct primary care/concierge medicine.
But that we’ll reasoned argument also aired out a couple of things maybe doctors would prefer not talk about so…
And it never appeared on the comment list while others kept doing so. My assumption was that you blocked it; if that is not correct than can you maybe look for another post in your system and explain why it wasn’t posted?
Josh (content manager) says he found it in the spam folder. The software does that sometimes but the alternative is to turn off the software (Akismet) and have literally hundreds of spam comments on every blog post on this website every day. I instructed him to restore it as long as there isn’t anything objectionable in it and it doesn’t sound like there is.
Thanks and sorry for the likely overreaction above.
Looks like another comment I just submitted likely just got pulled in by the same spam filter.
I’ve restored that comment as well. I’m not sure why it’s getting caught up in the spam filter. Sometimes, specific words or phrases will trigger that filter. But I’m not seeing anything like that in your comments.
The longer the comment or the more links in it, the more likely it gets held as spam.
Elephant in the room: The reason why a blog like this is vastly popular is because an ever increasing proportion of physicians, even while in training or in medical school, never actually intend to work a full career, whether they believe that or not. Being fiscally responsible and investing for the future goes hand-in-hand with not being dependent on your job, and it is not implausible to believe that many doctors don’t find higher meaning and/or job satisfaction in what they do. I can’t even predict what my reimbursements are going to be next year, let alone whether or not I will be practicing in 10-15 years. In my opinion, it is also completely okay to say that you are practicing medicine, simply as a job (hoping for some job security), because you need it to pay your expenses, take care of your family, and maintain the lifestyle you’re striving for in exchange for the hard work you have put in academically. Good luck using that as an explanation to get into medical school though.
You have to lie during med school and residency interviews just like any other profession.
Now that I’m established, when people ask me why I chose my specialty I tell the truth: lifestyle, income potential, and the ability to sleep as much as I want to without being required to visit the hospital at odd hours. It’d be nice if we could just say that to begin with.
That’s pretty cynical. In my experience most docs, even when established, retain at least some small amount of that idealism they started school with and discussed on their admissions essay and in their interviews. Your “truth” probably isn’t the whole truth if you’re like most docs. But that doesn’t mean you don’t owe society anything more than you’re willing to give at this point.
There’s definitely more to it. I enjoy most of what I do and it feels rewarding to help people. But without the excellent sleep and regular hours I would have been a miserable person and a worse doctor for my patients. Some folks thrive on or at least tolerate this hectic lifestyle while for me it would have been a disaster. It would be nice to be able to be honest about this during an interview without getting immediately crossed off the list but that’s just how it is and unfortunately you have to play the game.
Did you even know you were like that at 23 applying to med school and at 27 trying to match into your specialty? Probably not. We’re all different people at 35 than we were at 25. I signed up for the military at 23 thinking it would be a fun adventure. At 32 and leaving two small children on the other side of the planet to deploy to a war zone, one of whom did not recognize me when I came home, it did not feel like quite as much of a fun adventure.
As a med school applicant no; as a residency applicant absolutely. I spent most of 4th year of med school burnt out due to lack of sleep and this burn out unfortunately carried over throughout my entire residency which is why I never even considered fellowship. Life is awesome now, but it was a rough five year stretch until I started my attending job.
As a 4th year, my starting point was the ROAD specialties and figuring out what I enjoyed from there. This approach is likely frowned upon by medical faculty, but I really do believe lifestyle considerations should take more priority in choosing a career.
You had a very different fourth year than I did. I worked 120 hours on some rotations during third year, but I can’t think of one I did that on during fourth year. If there was, it came very early in the year.
I’m willing to argue that the unifying factor here is that the learned trauma response of physicians IS precisely what you’re on about – in order to guard against the burned in calluses of having the idealism from that 25 year old med school entrant to somebody who has come out the other end ‘wiser than they every intended to be at the outset’, it’s an entirely valid overreaction to a society that for the most part doesn’t fathom the sacrifices required to arrive at that point, so might as well be fatuous about it and drive on.
I’d argue GK isn’t being cynical about it, just realistic that the system as a whole would work a lot better if the game theory optimal point of getting into residencies and landing the first job out wasn’t so reliant on those masking behaviors in order to be successful.
Like Jim, having experienced coming back from the other side of the planet (albeit more directly on the arse end of an M16) while the average American spent that time at the mall, myself I have the exact same response about finishing my own educational journey at negligible cost to myself and turning that into a career of my choosing. To those who can understand the argument, I don’t have to make one. To those who can’t, the pragmatically easier one is to be entirely flippant about it.
Amen
Not a doctor, just a high-earning fan of this blog and content. I agree with everything Dr. Dahle posted, but I’d argue this is one reason to proactively work to increase medical school and residency slots unless/until we get early data about AI’s forthcoming labor impact on the profession.
No issue with med school slots right now. The bottleneck is residency slots. If you want more docs, expand residencies.
The AMA heavily lobbied to artificially limit residency slots in the early 2000s to protect doctor salaries from falling (believing that there would be a surplus of doctors). They have since stopped doing that and now advocate an increase but the shortage resulting from this will take awhile to resolve.
On the plus side for doctors, this has lead to higher salaries than there would be otherwise. It be better for everyone if there were more doctors but then doctors would probably complain that salaries are too low despite lower burnout.
Quite a Catch-22 isn’t it? We want to work less and be paid more…just like everyone else on the planet.
Whenever I have admitted that I have always wanted to optimize my income per hour while working fewer hours, I’ve been told something like “you have a blue collar mentality.” Ok, then.
I did this with a paper route at age 19-21. Instead of working for minimum wage every weekend night at Red Lobster, I made $1000 a month in 1983 driving a forty mile paper route on dirt roads with 500 customers from 0400 to 0700 every day.
Many years later, this was taking jobs as a Medical Director and taking night and weekend call. Now, it’s occasional weekends and holidays for a better wage per hour and telehealth from home. I prefer bigger cheese for fewer hours.
As you say, seems like human nature to me.
True enough. And-just like everyone else-expect to be called out on it if you complain about being burnt out while at the same time bring up your high salaries all the time. Working a ton and being stressed is kind of the tradeoff if you want exceptionally high salaries.
The issue, was, always was, and remains residency slots. The system there is beyond stupid, and there are structural reform methods there on top of just taking the needlessly regulatory bottleneck of it that need to be implemented.
The AMA artificially limiting slots, and the hospital systems being entirely dependent on that added subsidy of Medicare (plus the looming realization of DEI hiring having been an objectively bad idea) is the reason we haven’t imported all the worlds’ best physicians and achieved the domestic throughput needed, and as a result wound up with a lot of surplus non-practicing MDs. That latter group still goes on to more than contribute to society in ways that honor the investment in their education, but quite often the roads there are needlessly complicated, and worst of all continues to deprive entire geographical areas access to competent physicians.
I’d argue it’s not a Catch-22 – the field has basically been denied true performance differentiators by being in statutory labor undersupply, and has now had the insurance companies ram the ‘net throughput is the only metric’ answer come down, which is worse for everybody, especially patients.
As bad as you think things are in medicine, they’re far worse with law school.
Students are encouraged to write essays claiming they’ll work for little to no pay at do-gooder non-profits to change the world. In practice, they hire on at Big Law as an associate helping Insurance Company A do battle with Insurance Company B. If they can’t get into Big Law, they spend their time on divorces, DUIs, criminal defense, and questionable personal injury and med-mal cases that make life more expensive and onerous for the rest of us. (Any time you see an idiotic product safety instruction, remember that there was a successful million dollar product liability suit that made that warning “necessary”.)
Imagine if law schools withheld diplomas from their students who don’t go out and “save the world” in the way they lied about to get into law school in the first place.
I’d argue that’s at least an apropos solution, as teaching lawyers how to lie is honestly just basic tradecraft.
At least with law school, it’s implied that the graduates are going to head off in their own self interest and maximize the ROI on their time sunk into that process, and they get to be – ironically enough – completely honest about it outside of the clearly performative pro bono work (not that there aren’t excellent people practicing law and actually doing passion project pro bono work that is sorely needed – just that it’s not misperceived the same way).
I mostly agree with your argument here.
However, I also believe certain residencies that are highly competitive, take a long time to complete, and only train a small number of graduates each year should be filled with applicants who are willing to put in a full day of work over the course of their careers.
It’s not that those individuals owe anyone anything, but it is the opportunity cost of filling that slot with somebody not interested in working full time, when the spot could’ve easily been filled by a different someone who is. Taken to the extreme, the whole system starts to fall apart. In theory, you could solve the problem by increasing the number of residency positions, but there is a limited number of diverse patients/cases in any geographic location to provide an adequate breath of experience to each graduating resident.
So it is in this context I think your defense of part time docs needs a more nuance discussion.
In my own specialty, we are severely short handed. And that shortage is amplified by so many recent grads who work part-time, or not at all.
How do you propose filling residencies with applicants “who are willing to put in a full day of work over the course of their careers.”
Just ask their intent? What’s to keep them from lying?
Make them sign some sort of contract? And what are you going to incentivize them with to sign that contract besides allowing them to match? And what is the consequence if they don’t fulfill their contract? And what are the consequences to that specialty with that sort of contract in place? Do applicants drop by 90%? And if so, how does that impact the workforce in that specialty? Do you get “bottom of the class” or more DO or more IMG docs and does it matter? Your proposed plan has all kinds of potential implications.
No contracts or requirements. We are in agreement those are impractical.
I would suggest it starts with laying forth expectations during residency recruiting. True, candidates may lie about their intentions. But many won’t. The only reason I didn’t submit my secondary application for Loma Linda Medical School was because I had to sign a promise I would not drink any alcohol. I am not a drinker (I have about half a beer every 6 months when on vacation—that’s it), but I didn’t want to make a promise I wasn’t intending to keep. [I later found out that the majority of the class drank alcohol anyway!]
Some expectations for physician recruitment are already widely acceptable. Some medical schools recruit specifically for ‘primary care’ and make it known that’s what they are looking for—actively discouraging pursuing a specialty. Some residency programs recruit for rural or disadvantaged populations. And I’m sure you know better than most of us the recruiting expectation and service commitment for those pursuing the Military Health Professions Scholarship.
I don’t see why setting forth the expectation that working 1.0 FTE (most especially in highly selective and short staffed specialties) is such an offensive concept.
Many specialties in health care do not lend themselves to part time work. Sure you can work as a part time EM, Radiology, hospitalist, anesthesia, and many, many others where it’s either shift based, or per-diem. But if you’re a proceduralist, who do you expect to take care of your post-op complications when they present while you’re “off”? Since you’re an ER doc, I’m darn near certain you’ve occasionally had a heck of a time trying to track down one of your surgeons who cuts patient and…….”sorry, I’m off now….. Good luck.” With many surgeons, you’re lucky if they even return your call.
My point here, is that recruiting capable physicians and surgeons is important. But it’s also equally important to set the expectation that there is in fact a debt to society that all physicians carry, in payment back to all those who trusted you to “see one, do one, make a few mistakes, and teach one” on their bodies. Residency training is a finite and highly coveted resource (surgical training in my case), and should be able to and expected to select individuals who intend to put that training to full use.
I don’t really have much of a problem with “setting an expectation.” I have a problem with enforcing it. I also have a problem with discrimination. For example, if a an applicant says she will work full time but the residency program doesn’t believe her because they think she’ll become a stay at home mom 2 years out of training.
I don’t think surgical training is as finite as you believe. Throw more money at it and there will be more residency programs/positions.
Your example is perfect for why women were often discriminated against- fears of their maternity during the program or employment. OB Gyn docs (female) told me in the 1980s of residency programs which wouldn’t accept them “unless their uterus was in a bucket”. My solution: more men as likely as women to opt for lighter schedules or prolonged parental leave if they reproduce. Treating doctors like the rest of the world and thinking we’ll do better jobs if we sleep and have free time outside of a 40 (only!) hour work week.
This is an interesting dilemma.
So there has been a longterm shortage of medical providers in the US… and because they are in such demand, earnings for physicians have increased … furthermore, many US physicians, because of their high earnings, are able to save enough to leave the workplace early… which results in a shortage of medical providers.
As somebody with a PhD in system dynamics, the irony is not lost on me (and ultimately, the strong desire to leave the workplace early is the key element of all of this). All of those reinforcing loops are going to actually continue getting worse, even if somebody hits the unpopular boiloff release valve and actually reforms the residency funding sources to allow a pulse of DO/IMG docs in to try and saturate out that labor market. (And as somebody who is really good at making LLMs do super cool things – No, AI isn’t going to revolutionize the medical care process in a way that actually reduces the demand for competent physician hours outside of radiology). The demand peak is still a little ways off as the boomers arrive at their peak medical care ages start ticking through, and that’s yet another reason those well attuned to the market as a whole have such a strong desire to be able to take the retirement leap once they feel the quality of life tradeoff proposition is untenable…
The number of current physicians who started off wanting to work short careers is vanishingly small… the process of arriving at the point where you are a successful physician puts so many on an unavoidable burnout path that we’re here having this discussion. Once that early eject plan is made, it’s just too easy to start focusing on how to maximize quality of life early, and for those physicians who have, congratulations. You have already done enough, you don’t owe society anything.
That article was excellent. Thank you for writing it so well.
I think I’ve made this comment before in this blog somewhere, but the point I would like to make for those who feel we have some sort of obligation is: “Where does it stop?”
Are we supposed to work 40 years? 50 years? Until we drop dead on the floor in a patient room?
Are we supposed to see 8 patients an hour? 20?
Who gets to make these decisions?
We should be advocates for each other as much as we are for our patients. That should not require being a martyr.
As a surgeon I think the calculus changes. I have become an expert in my craft by doing thousands and thousands of surgeries. My technique and results have been optimized over time by experience and seeing outliers. The patient has been my greatest teacher. Frankly we learn the most from complications which are more likely to be experienced early in our learning curve as young surgeons. I don’t think I owe a debt to society to continue practicing beyond when I would like — however, I do believe I owe a debt to my early patients who have taught me the art of surgery and whom I carry in the small cemetery that exists within every surgeon. I plan to operate for as long as I am at the top of my game and repay a portion of that hard earned educational debt that can never be fully repaid. In my subspeciality we have a waitlist for surgery stretching 6 months to a year that is only getting worse over time. Every surgeon we lose to early retirement is a tragedy for the community who relies on our hard earned experience.
“Every surgeon carries about him a little cemetery, in which from time to time he goes to pray, a cemetery of bitterness and regret, of which he seeks the reason for certain of his failures.” -René Leriche
I think it’s fine to feel a personal debt to society or patients or whqtever. I obviously still practice after FI for various reasons. I don’t think it’s fine for someone else (“society”) to impose it on you.
I feel like the most relevant thing this hammers home is that we should normalize transition to teaching as a valid and reasonable goal for high-achieving but high-attrition professions.
Oddly, the FIRE community in general is good about this, but in actual professional fields where it matters more (because anybody can build a spreadsheet), we seem to leave that behind. Institutionally, creating some intermediate teaching roles would go a long way, but anything to alleviate that bottleneck and retain much of that implicit knowledge and pass that forward as institutionalized knowledge management products plus slightly better skilled new entrants is worth investing in.
I am near the end of my career, so this issue resonates with me. Recently, I attended a college reunion. One of my classmates was especially lauded. His major career accomplishment was that he had performed more than 400 heart transplants. When I reflect on that number, I realize that even the best doctors rarely impact society. I think if there is a general complaint about the impact of physicians on society, it would be on a more community basis. For example, doctors as a whole have only recently started to advocate for healthcare coverage for all – the group was probably the main reason that the Clinton administration’s efforts in the 1990’s went nowhere. The opioid crisis is an area where doctors as a whole got is all wrong, but then reacted well to get things back on track.
Charles J
I would not be too quick to blame doctors about “getting it wrong” r.e. the opioid crisis. I was an intern in internal medicine at the VA in the mid 2000’s when there was this big push to make pain “the 5th vital sign” and we were being basically forced to Rx opiates (since patients having pain was deemed unacceptable now). the VA was forcing us to give out methadone, (which is a dangerous drug that can potentially prolong the QT and raise risks of sudden cardiac death) in the internal medicine/primary care clinic. I distinctly recall a couple of the older internal medicine attendings clearly stating that this would lead to no place good and that opiates were habit forming and had many other undesirable side effects. Physicians (and residents/trainees) were berated for not giving out enough opiates and not treating the patients’ pain aggressively enough. Then, ten years later when all these people are hooked on opiates, now it is the “greedy physicians” who caused the opioids crisis. How short the memory of the government and then hospital administrators is…