By Dr. Charles Patterson, WCI Columnist
On a frigid day in late fall, my wife came home after her shift at our local hospital and announced plainly that she intended to resign. She was clearly frustrated from the happenings of the workday, and she proceeded to unload the cornucopia of reasons why her next shifts would be her last.
As it was, she was working on an as-needed basis, typically between one and four shifts per month. We had small children at home, and her time with them was much more valuable to her than the weekends spent in patient care. While the income was nice, it didn’t “move the needle” meaningfully. The shifts kept her skills current but barely, and the time in between them eroded confidence in her medical decision-making. Importantly, when encounters didn't go well or a case had a bad outcome, she would experience terrible doubts for days afterward.
For my part, I work full time in clinical medicine as a pediatrician. I am privileged to do so, and the fact that our children are at home makes life a whole lot easier than it was when we were both working full time (her as a PA in the ED, and me in Residency). We are fortunate to have a strong partnership: any big life decisions (such as quitting medicine for the foreseeable future) are made together—and only after an extensive discernment process.
Despite persuasive arguments and legitimate reasons to hang up her white coat, however, I was still unnerved. Was there a less drastic alternative? How would this decision impact our financial goals? More ephemerally, is medicine a career or a vocation? If it's the latter, did that incur a moral obligation to serve society? And if so, what did society owe her? How did her role as a mother to young children factor into this decision? Would her opinion change in the future? What were the long-term career implications of being out of practice? Could she ever return to medicine? Each question, it seemed, created two more when answered in any particular way.
The questions were numerous and would be tediously considered, but the first step in their unpacking was recognizing my own biases. I am a male in a high-earning career field with a contract that does not allow part-time work. My family is my first priority, and at this early stage of my career, I have knowingly put hobbies, social pursuits, and extracurricular activities on hold. I enjoy my practice immensely, and I am working feverishly now so that I may securely claim more time with family in the near future. All of these factors played a role in my approach to this quandary. Placing my preconceived notions aside as much as possible, we continued the conversation with the shared goal of arriving at the most correct solution for our marriage, our family, and ourselves.
Financial Implications of Quitting Medicine
If the decision to taper back to resignation were to be made on a purely financial basis, then the question would be quite easy. Even after taxes, childcare costs, a jump in our income tax rate, and the ancillary expenses incurred in order to practice, there was still a generous net monetary gain by virtue of her employment. Full-time (and depending on the practice, even part-time) work opens the door to otherwise unavailable retirement savings accounts and more options in healthcare coverage.
Interestingly, the price of an extended sabbatical is not relegated to opportunity costs and significant licensure expenses. For instance, if a disability insurance policy does not stipulate current employment as a condition of coverage, then keeping it might be a sound (yet financially impactful) decision. Thus, taking time away would only result in lost income; keeping the door open to return would be a relatively expensive venture.
Choosing to step away from medicine raises a host of logistical challenges, particularly if there are plans to return to practice in the future. While state licensure requirements vary, this typically means currency with the governing board for the medical specialty, CME credit, life support certification (BLS, ACLS, PALS, etc.), and DEA and NPI registry at a minimum. For procedural specialties, extensive time away will corrode tactile and operative skills. Then, there are the institutional requirements: credentials policies of many hospitals and practices require a minimum number of patients seen in a given period to be in good standing (or hireable).
Difficult is not impossible. There are certainly ways by which a medical professional can return to practice after a period of time away. However, given the time and financial implications of such a recertification, it would behoove one to consider when, where, and how they could see themselves returning to the exam room. How much time was spent in other endeavors, what those endeavors were, and what, if anything, was done in the interim to maintain currency all affect future career trajectories.
Is There a Moral Imperative to Practice Medicine?
Unlike trades, crafts, contracted labor, or other forms of skilled expertise, to be in a profession is to be a part of a culture with strict standards of behavior, practice, and moral and ethical obligations. This professional structure is paramount to physicians, physician assistants, and nurse practitioners who routinely wield their highly-sought skills in caring for the ill, injured, and vulnerable. Of course, similar obligations exist for lawyers, dentists, veterinarians, pilots, military officers, and a myriad of other professionals whose rare gifts fill a unique societal role. Uniformly, these gifts are cultivated at a great personal and financial cost.
Society pays a price, too; not all who are otherwise capable and willing are selected to enter these professions, and the subsidies that incentivize schools and the training pipelines are invested with taxpayer dollars with an expectation of service in return.
What, then, is the obligation that the professional has to society—and society to the professional? I appreciate that this is a loaded question, particularly in an era when the average medical school indebtedness upon graduation is approaching a quarter-million dollars, the price of undergraduate education in the last 30 years has more than doubled (even with inflation-adjusted dollars), and reimbursement is growing ever tighter.
For practices to remain solvent, premiums are placed on volume and “value-based care”. Less time with patients, increased administrative burden, and the stresses of balancing sick patients and personal commitments all contribute to that insidious plague we call burnout. These competing factors impact the doctor-patient relationship and obfuscate the symbiotic dynamic that has existed between medical professionals and the communities that they serve.
The evolving state of play in our healthcare system has raised a plethora of other important questions. If there exists a moral obligation to serve as a physician (or PA, lawyer, dentist, etc.), how long does that obligation last? Or shall such servitude be measured in patients seen or outcomes achieved? Is this compulsion fulfilled as a researcher, volunteer, or humanitarian? Does raising a family supersede this vocational responsibility? Does the concept of physician FIRE represent a moral failing (and if so, for whom)? The answers are elusive, specific to each circumstance, and unlikely to be relevant given the rate of structural change in our healthcare system.
A World of Alternatives After Quitting Medicine
There are many palatable ways to break away from the typical medical career, and they all begin with understanding why a break is necessary. Options abound: one can cut back time (even to as-needed), increase volunteer or pro-bono work, take a sabbatical, try locum tenens, find a new employer, open one’s own practice, or even pursue administrative positions within a group, hospital, or insurer. Taking on new roles (chief of medicine, compliance officer, information technology, etc.), can reinvigorate the monotonous grind that is clinical medicine. Even monetizing a skillset or nurturing a side hustle outside of medicine can belay the untoward effects of a demanding medical career.
Of course, these options are all dependent on the person and life circumstance, and by no means would I mean to infer that they are a cure-all for burnout. But the take-home point is clear and salient: there are many options aside from hanging up the white coat completely.
Several months later, after many heartfelt conversations, my wife found her path away from medicine. Our world-view and lifestyle informed this decision. For us, having a parent at home consistently for our young children felt every bit as morally relevant and socially contributory as being in the hospital. From a financial perspective, my wife worked very hard in her first two years of practice to pay off student loans, and in subsequent years, we have lived comfortably off of a fraction of my income (an unforeseen but immeasurably important benefit of preventing lifestyle creep).
Not having her income while paying for continued licensure and insurance in the meantime didn’t change our financial goals, but it did highlight the importance of being content in my own career. Unfortunately, the work alternatives available to us in our neck of the woods did not lend themselves well to the balance that she sought. Our thoughtful consideration led us to a conclusion, one that was acceptable and even exciting.
Perhaps the most challenging aspect of this process was projecting what our goals and priorities might be in a decade or two or three. While we were confident that they will change, knowing how they will be different and how best to keep our options open was a formidable task. Frankly, much of this forecasting and planning boiled down to faith: faith in each other, in our work ethic, and in our intentions for our family. We don’t know what returning to medicine will look like in the future, but we are fully informed of the process for licensure and certification, and we are content with the challenges that such a return might pose.
There was never a moment of epiphany that made all of this clear. But in retrospect, our answer is as obvious to us now as it was difficult in the intervening months. In medicine as in life, I have found that the best decision is often the one that helps you sleep best at night. Curled up next to my wife, I doze soundly, comforted by the knowledge that we are doing what is best for her and for our family.
Have you or another family member seriously considered leaving medicine? Has burnout been a big factor for you? Do you think there's a moral obligation to stay in medicine even if your own personal goals have changed? Comment below!