By Dr. James M. Dahle, WCI Founder
Medicine is a wonderful profession which does vast amounts of good. I attended my 10 year medical school reunion recently and I was even more impressed with the accomplishments of my classmates than I was 14 years ago when I first met them. As a fourth year medical student, I served on the admissions selection committee. Ours was the final committee, and we only really saw the applications of students who were more than qualified to be there. They had passed the initial academic screens with high GPAs and MCAT scores and had checked all the relevant boxes showing they had done research, had experience in health care, had shown leadership skills (and not just potential), and a desire to serve others. They also had already impressed their two interviewers. We were left with 300 applicants, all qualified to be there, to select a class of 100 from. It was no surprise to me to see the quality of the people I attended school with after helping with that process.
One of my classmates was working 120 hours a week as a trauma and emergency surgeon. I was impressed with the dedication that leads someone to come out of residency and sign up to work MORE hours than they did as a resident. Another, a small-town family doctor in Canada, is the classic country doctor. He takes ER call, does colonoscopies and EGDs, does C-sections, and performs appendectomies in addition to the usual stuff big-city FPs do. Another does sports medicine and is heavily involved in running a ski clinic at a local ski resort. Several, like me, were working 3 or 4 days a week and pursuing other interests with their time- One is raising her family, another works in health care IT, and another literally just won the world championship cycling race for her age and gender. As a general rule, doctors are wonderful people, with immense ability and dedication. I hope people like this continue to choose medicine as a career. But I can understand why many talented people may choose something else these days.
Pessimism Abounds
The Bogleheads recently had a thread titled “Why are so many physicians unhappy with their careers?” that generated 110 comments within the first 24 hours. I find it amazing to compare the general attitude toward medicine between online forums. Everyone is mostly optimistic on Student Doctor Network, which primarily caters to pre-meds, medical students, and some residents. Everyone is mostly pessimistic on the physician-only Sermo, which includes residents but is primarily composed of attending physicians. There you can see countless physicians trying to figure out how to deal with declining reimbursement, increasing bureaucracy, onerous student loan burdens, and difficult patients. It seems everyone is either trying to get out of medicine, or at least opting out of the 3rd party payer system. These are definitely NOT the golden days of medicine.
Keeping the Good Doctors in the Business
One of the things I hope this website does is to do some small part in keeping good people in medicine. I want intelligent, accomplished, happy, talented doctors taking care of me when I'm old and sick. One of the best ways I can do that is to help physicians deal with their unique financial issues so that medicine still provides an overall financial award sufficient to attract these accomplished individuals. I want doctors to not only be able to keep their practices open, but to be so financially successful that they wish to donate time and money to worthy causes.
Graduating medical students now have higher loan burdens at higher interest rates along with lower starting salaries (at least when adjusted for inflation, and many times even without that adjustment) and fewer opportunities for ownership. Rather than being millionaires by 40, far too many still have a negative net worth at 40! However, physicians can still have the good life. It requires more financial discipline than it used to, and it requires more time. It also requires a physician to acquire a knowledge base and skill set in personal finance and investing. If physicians can decrease the amount of their money skimmed off by Wall Street, the IRS, bad financial decisions, and poor investments, perhaps they can maintain a similar after-tax, after-expense income to what the last generation of physicians enjoyed. I hope regular readers of this blog feel they are gradually acquiring the knowledge, skills, and discipline to find financial success sufficient to allow them to continue to pursue their professional and personal dreams while providing the rest of us with world class medical care.
What do you think? Can today's pre-med students still achieve financial success in their careers? What can be done to keep medicine attractive to good people? Comment below!
I think the way to attract the current and future generation into medicine is to emphasize lifestyle over money. From my own anecdotal experience, most of my friends who are either my age or younger value free time far more than making piles of big money.
When adjusted for inflation, I make about 25% of what the predecessors in my specialty made back in the 1980’s, but it’s still far more than what I need (in part thanks to resources like this website and bogleheads.org), and I work nicer hours and take significantly more vacation time than the old guys took back in the day.
Very articulate manifesto.Thank you for posting.
I agree, the level of pessimism on Sermo is at times overwhelming.
It would be agonizing to go through a 30 year career with that attitude.
It is definitely more challenging than it was in years past but I think it is still possible to have a wonderful career in medicine, be financially secure, and be there for our families. The keys are getting educated and making good choices early on, and being disciplined. Thanks for doing your part in educating the masses.
Debt loads and heavy, but most of the pessimism that I hear in medical school is from clinical instructors and attendings who have made poor choices or who lament for the “good old days”. Most of my classmates and myself are very aware of the challenges that face us, but I have a very hard time seeing the woe is us point of view. Physicians aren’t going to get wall street rich anymore, it just isn’t realistic. However I’ve run the numbers for a variety of scenarios, and with a simple 20% savings rate for retirement… I don’t see myself ever having anything but financial success in the long run.
It won’t be an easy or fast road to financial freedom, but neither is the path to being a physician.
I think this is missing one important piece to the story of what being a physician is today and in the near future. Several studies, surveys, and news stories have highlighted physician burnout, linked most often to the depressing bureaucracy of practicing medicine these days, as the greatest threat to a happy long career in healthcare (acknowledging that this is also negatively affecting mid-levels and nurses). The data entry, the government mandates, the obscure threats to our reimbursement in the name of whatever compensation model is trendy this month, etc., etc. If anything drives people out of medicine, whether early retirement or dissuading bright young people, it will be this more than anything else.
My wife is a fourth year, and we talk all the time. From what I’ve seen, the biggest worries/complaints come from all the regulation and inefficiencies. The student loathe going to the VA due to the system and the lack of care. They enjoy the patients, but the bureaucracy drives most of them crazy. Reimbursements do keep getting cut, but I don’t have a solution for that. I think the way to keep new doctors coming into the system is to show them financial literacy early on. My wife will graduate with “only” $100k of loans. She went to a state school on a full ride, and then took loans for her tuition and fees (in-state) only. I was able to cover all living expenses as I work currently. I’m certainly not saying you have to get a full-ride then get married before med school. However, that minimal amount of debt will allow us to pay it off during residency using both incomes instead of having to defer them. I plan to urge our children along the same path (medicine).
Also, I forgot to add, my wife is going into Internal Medicine, and is heavily contemplating eliminating third-party payers in order to ease her office life. Less overhead, and she can still choose to give charity care when she likes. This is obviously if goes clinical vs. hospitalist. There’s an FP in Wichita (AtlasMD) that has an interesting model. She does not look forward to arguments over the right code.
Via email:
I think I’m lucky to be a Doc,it’s not a job but a vocation with a sense of duty. However, I’m sad for all the administration regulatory insurance bureaucratic time consuming hassle.
I stopped visiting Sermo. I found it downright depressing.
Having practiced for 25 years, I also “miss the good old days.” What was the good old days, very simply simply less government interference and getting paid for the work that I do.
Currently in my practice, Medicare, Medicaid and other monikers for government healthcare reimburse me at around 27% of what the private carriers do. Also, reference article Wall Street Journal Friday November 22 where plans on the new healthcare exchanges are reimbursing physicians at medicare rates. Yes I do remember they reimbursed at 90% level. Don’t even get me going on the additional paperwork, signatures etc, etc required. I am currently working much longer hours than ever before for less money.
So would I actively encourage my son or daughter into the field of medicine? No I wouldn’t encourage, nor would I discourage. I have attempted to gently steer them in the direction of dentistry, or some specialty within dentistry.
I feel bad saying that, as we will all patients someday and we want the best and the brightest taking care of us. But I don’t have much optimism on the future of medicine. Call me old, bitter and/or burned out, but like the umpire I have to call it like I see it.
Thanks to everyone for their comments. I’ve been reading WCI for a while now and am trying to learn a bit about finances in the little time I can allocate to this. I don’t want to hijack this comment thread, but I would be interested to see what you all would recommend to those who will graduate with $300k+ in debt. What would your game-plan be if you were in this situation? I am a second year student right now and I think by the end of medical school I will be a little over $300k in debt. It is definitely discouraging to think about this kind of debt, but my wife and I are trying our best to make sure we are being smart with our spending and with the small income we have. I’m glad that there are positive physicians out there and I am anxious to hear of any advice you might have.
The best advice I have (aside from minimizing your loans, refinancing them, taking advantage of IBR/PSLF etc) is to live like a resident until they’re paid off. It used to be you could do that for a year and be done. Now you might have to do it for 3 or 4 year or longer.
I agree, the best thing I did was moving away to do fellowship (non ACGME). During that time I continued to live like a resident and it made the transition into Academics financially very easy. I think the biggest trap for physicians are in trying to keep up with the Dr. Joneses. I remind myself that even as an academic physician, my annual salary is more than my parent’s income and they both worked full time (plus several other part time jobs).
As a second year ED attending in an academic center I am acutely aware of this problem. I actually think that the difficult patients are among the largest stress on physicians these days. When we start med school they teach us about these encounters that are presented as one small step below the priest and the sinner in the confessional. Now I have entire shifts where all of my patients are openly hostile, intoxicated, or violent. The number of times when I see a patient who actually thinks something is wrong with them, I help them, and we part ways with smiles and handshakes are I would say only about 25% of my practice. The medicolegal system is insane. We have patients that come to our ED on a daily basis and we are afraid of throwing them out because what if that is the day that they decide to have their PEA arrest from any number of their chronic medical conditions for which they are noncompliant?
There’s no doubt this affects all physicians and emergency physicians in particular. I just woke up from a night shift where we had 8 patients waiting for the crisis worker to evaluate them. Most had been drinking. It is frustrating to have a suicidal patient with a BAL of 443 because you get to hang out with him for an entire shift or two before he is sober enough for a decent psychiatric evaluation. It’s even worse if you have to get him to hold still while suturing up his self-inflicted laceration (the mechanism for which he is repeatedly lying about) for which he is repeatedly requesting dilaudid.
But there is also the Vietnamese gentleman with the 10 mm ureteral stone who is refusing narcotics and is extremely grateful for some toradol and an appt with urology tomorrow. Every job has downsides and a positive attitude (and a reasonable number of shifts per month) goes a long way toward overlooking the ones in the ED.
Financial literacy among docs is poor. You are a saint in teaching physicians about the Boglehead/Dave Ramsey philosophy. My favorite post was when you talked about the negatives of permanent life insurance and all the scumbag life insurance agents came out of the woodwork. It really showed what those guys are about. Keep teaching us how to minimize risk with disability insurance, backdoor roth ira’s, 529s, 401ks….
I’d be interested in seeing a post about the impact of EMCARE, especially in light of the threat of HCA changing contracts in Utah.
There is a constant threat of large contract management groups moving in and taking contracts from small and large democratic emergency medicine groups. I see that move as bad for the doctors, the patients, and the hospitals, but short-term profit-centered thinking often drives decisions like that. I have no idea how I would expand that into an entire post.
The hours are terrible. That is why we get burned out. Just sayin.
As a 2nd year resident I would say the following:
[1] Less hours = happy physician
–this goes for any worker, but it would help physicians who usually work 40-50hours and during those hours we go “all out”.
[2] Those with lots of debt
–find a job that gives loan repayment (say $30k/yr) and then accelerate your payments, you will have loans paid off in <5years or less
[3] For my generation (i.e. those born in 1980s) the good old days of medicine are so far behind they might as well be forgotten. We have no idea what it was like. We are growing up (i.e. doing residency) in a time of EMRs, obamacare, lower re-imubresements, more documentation/paperwork. And we find ways to make ourself efficient and succeed. I can't mention how many times I see some 50-60yo doc trying to type with one finger their notes. While we type without looking, while answering pages, and talking to nurses and using all types of shortcuts in these EMRs.
–Even though our salary as physicians is less than during good old days it is still far far better than many young adults who were screwed by the 2008-2010 downturn.
As a new attending, I have about $300K in all med school loans. I am still living in an apartment and plan to do for the next few years while I pay off about half of my post tax salary to loans and the other quarter for savings. Resulting in about the same lifestyle as a resident. I still manage to take vacations and buy the things I like. Remember, the small things add up. Minimize eating out, pack your lunch, learn how to cook (big one). Use credit cards in your benefit by utilizing their bonuses and NEVER carrying a monthly payment. I have always been financially smart and reading WCI helps even more. Did I say NEVER CARRY A MONTHLY PAYMENT!
Money should always be on the top of your mind. This does not mean you become an “extreme cheapskate” or the opposite, but it should influence your daily activities. Those of us earnings RVUs as employed docs- learn the math behind the numbers. By detaching us from the actual money, they want to confuse and conquer. Learn billing. Learn learn learn
I do think there is hope for us yet. It might not be like the “golden days”, but then again, I never saw that era. I agree with WCI and think that even right now, with the right mindset, docs can save and live an upper middle class life and even retire in the mid 50’s. It will require strict discipline which is unusual to the debt happy USA, but can be done. good luck
1. Don’t buy a mercedes or porsch or bmw ever
2. Don’t buy a house that costs more than one year of your salary
3. Contribute the max to your 401(k) and IRA every year without fail
4. No more than one vacation per year that requires an airplane
5. Have realistic expectations about your earning potential. If is declining.
6. Remember that you are usually happier when you have enough sleep, you have time to exercise and eat right.