Sunday, January 06, 2008
Glass 60% empty
Patient Dave sent me this quote from today's New York Times: "As of 2006, nearly 60 percent of doctors polled by the American College of Physician Executives said they had considered getting out of medicine because of low morale, and nearly 70 percent knew someone who already had." How do you feel about this?
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19 comments:
Sad to say, but I am not surprised. The health care crisis, in all its glory, eventually lands on the shoulders of those who are already doing their best to carry a heavy load.
To address the narrow issue (not the broader one of how our kids want to be bosses from day one), I DID get out at 52 and don't miss a day. I practiced pathology, however, so it's not exactly analogous to most docs.
But I think the sentiments expressed in the article are true - the few patients I talked to treated me as either incompetent or the enemy. I remember the one great one, though, who came into the office to discuss her diagnosis of lymphoma with me, looked at her slides under the microscope, and thanked me profusely for taking the time to talk to her. One of those makes up for a lot of the others.
I'm an RN, whenever I ask a resident or attending if they think it'd be a good idea to go to med school, I inevitably get a response like "I wouldn't wish this on my worst enemy".
You know it's bad, when you read other polls that show a majority of Canadian expatriate Dr.'s are considering coming back... ;)
The low morale issue is huge, and growing, especially among primary care doctors and internists (who do much primary care in this region of the U.S.): and the fallout is greater than we've yet imagined. Who will take care of aging baby boomers (among all others, a large portion of the population)? How do we select and train those highly talented and motivated young people who enter the profession with the goal of providing top-flight patient care, when most of the demands of their daily work (accountability to the "clock" and financial managers as well as patient welfare; voluminous record-keeping, and changing infrastructure and support systems) frustrate their efforts and trash their idealism?) We're all patients, at some point, and we all have a stake in this!
I'm a research tech in a lab with several doctors who spend some time in the lab and some time with patients (being "in service"). The most recent conversation I heard was, "You have to spend two months a year in service? And one day a week in the clinic?!? How do you do it??"
I'm not sure how doctors who do research compare to the norm, but they seem to agree that if they could go back, they wouldn't have become doctors.
This is something that comes up regularly in our academic medical center (NYC). You see it less among those that chose a career in medicine later in life (after some level of previous success). In my opinion it is the result of a rigorous academic protocol that now begins in high school and which is set up to realize success as a destination (the MD) as opposed to the journey (the training). As a result many of the medical students we see, although quite bright academically, have arrested developments. This then leads to the many adolescent behaviors you see in older faculty.
I've heard a couple stabs in the comment column about the nature of the primary care disenchantment. I believe it is multifactorial. But then, it is always best to speak for oneself.
I got tired of having to meet patients expectations of cure, that were sold, promised, offered
by techno medicine, scopologists and resonating imagists about WHY it hurts.
I got tired of not feeling valued for my expertise at discerning the serious illness from the suffering of life.
I got run down by the patients who abandoned me for the guy who would promise a cure with the long acting narcotics or the discectomy.
I got disheartened because I knew the academics and the specialists didn't care about a Family doc falling, just waiting for the thump, so they could hire the midlevel...
Sorry. I forgot I was in a blog comment column....
www.poemd.blogspot.com
I think this is common in a field of rapid change, especially when change raises costs (malpractice and administrative). In a generation, nobody will remember the old days. That's why the Jews had to wander for 40 years -- they couldn't settle until the last memory of living as a slave was gone.
But please, yes, let's quit creating child geniuses who can't make friends.
How does that rank with other professions? Law, engineering, academics? Just about everyone I know has talked about going into a different line of work at some point. The difference is that most doctors can probably afford to retire earlier than the rest of us.
Well, I know the retention rate for teachers is abysmal. Nationally, the last statistic I heard is that just over 50% of all teachers leave the classroom within 5 years. I didn't realize it was happening in medicine as well.
I'm not sure if it has more to do with societal changes as far as the consumer (demanding patients/parents, lack of respect, etc) or if it has as much to do with the younger generations having shorter attention spans for a career. I believe that Gen Xers (my generation) will have an average of something like 7 different jobs in their career span. So, is it that we have higher expectations for our jobs? Less patience/tolerance for hardship? Or have the public really become that intolerable?
I don't know...interesting.
I am nearing completion of an 8 year residency/fellowship (following 4 yrs of med school) and I would say that I would definitely leave medicine if I hadn't spent so many years getting here, so I might as well make some use of it. I realize medicine is about the mission, but I'm tired of that being used as an excuse to get paid less than my friends on wall street. The training is too long, the hierarchy too rigid, and the pay, while comfortable, just isn't good enough for all the hassle. And frankly, I'd take a job in business for less money. I definitely would tell people for reconsider this as a profession.
Once upon a time I thought I would get a PhD in Biochemistry and do research and a biochemist I worked for as an undergraduage(a full professor at Columbia) dissuaded me and advised me to go to medical school. I never regretted taking his advice. About 85% of the time I love what I do which includes mostly research, substantial teaching and a bit of patient care. I'm never bored and I rarely worry about the "relevance" of my job. The 15% of the time when I don't love my job I'm either multitasking in excess or I'm applying for grant money (writing grant proposals is an unpleasant experience).
However what I don't do is take care of patients more than a little bit. What I see in my "academic style" clinic convinces me that if I had to do full time patient care I'd go nuts. For one thing the remuneration for taking care of patients - as opposed to doing procedures - is pathetic. I see patients with diabetes who are older, have multiple medical problems and take a lot of time and attention. The reimbursement from insurance positively stinks. As a full time academic researcher I'm at the lower end of the MD salary spectrum but I'd make a lot less if I had generate a salary by taking care of people with diabetes. I can see one patient every 30 minutes - they tend to be older, slower and very complicated. Then, for each patient I see for 30 minutes face to face, add another 15 minutes to finish writing a note, communicate with other providers and have follow up phone calls regarding things like test results & blood sugar control with the patient. Blood sugar control requires, one, two, three phone calls related to the initial visit. Sometimes more. That's time I don't get paid for at all. Then it's forms, forms forms. Forms for glucose monitoring equpment. Forms for Xenical. Forms for referrals to podiatry (who incidentally get more reimbursement for a 5 minute visit than I do for a 30 minute visit). I like seeing patients but I can continute only do it because I'm a "hobbyist." I see enough of the downside of medicine to appreciate how bad it is.
If my grant funding dried up and I had no opportunities to teach I don't think I could transition to seeing patients full time if I had to earn money from the activity. If I was retired I could do it pro-bono provided that no one limited the time I spent with the patient and no one made me fill out a form.
Sorry to say, I got out of full time clinical work myself. If I did go back, it'd be to a retainer medicine practice.
I became a psychiatrist because I enjoyed understanding what makes people tick. To prevent early burn-out I did not work a long rigid schedule. I didn't earn the money many doctors make, yet I saved enough so that I could semi-retire in my 60's and fully retire at age 70. Fortunately I have many interests to keep me fully involved in life. If I were younger I would be tempted to return to Canada like many emigrants are now doing. I enjoyed my practice but, as complex as American medicine is now I can easily understand the dissatisfaction.
Well, I must say that as a patient some of the docs above are familiar to me. They seem to disdain us with our slowness--I even saw one doctor come into the waiting room and go to an older patient and snap his fingers and say, "Come on, come on, chop, chop." She struggled to her feet, not smiling. Yes, we may have comordibities--including the big one, a financial comorbidity--we can't afford a procedure even with insurance! We need medical care--an organized approach. One doctor does not talk to another these days--they don't take care of you in the hospital (a stranger takes over when you are at your worst). The waits are horrible. You may think it's enough to say exercise more, eat less, see ya--but it isn't. That doesn't even work particularly well. I am sorry you can't make $200K anymore--I barely make $25K and I have to pay for this insurance and these copays and coinsurances and deductibles. Sometimes I think a doctor looks at us and thinks, "Well, this person isn;t that successful or good looking and they have aches and pains--why do they even want to live anymore anyhow? I know this is a generalization. But sometimes I steam!
I am not surprised either.
In Israel where I did my internship and started my residency ( 1999-2003) , probably 20-30% of the interns in general left medicine. Many who just finished medical school (with some investment!) did not even start internship. 50 % of my closer friends and colleagues left after internship or during residency. All to small businesses, mostly medical or biotech, and start ups....
One of my best friend in the hospital, a shooting star in Urology, the "heir of the chairman" already in his second year of residency; the chief resident; the "perfect young doctor", with several top publications as first author ( as 2nd, 3rd year resident) left too, because of all the nightshifts, the calls, the permanent stress and the missing time for his young family.
He went to Kellogg School of Management, got his MBA and is a successful manager in a medical/biotech investment company. He is very happy with his job AND his family.
Another close friend worked after his internship worked first in a fitness center! and then invented and developed an orthopedic tool, founded a start up and owns now a successful company.
Both friends always worked hard, but could manage their time better than in medicine, had their personal rewards, and a fulfilled family life.
The very sad and concerning aspect of these two examples is, that medicine LOST two most promising physicians and scientists.
Another similar topic and phenomenon is the loss of potential clinical researchers: Many smart and actually research interested MDs don't even think about research, because it is not rewarded as business/private practice.
Look at the research fellows here in the US. The majority is from abroad. Look at the labs.
Most of US doctors (and many of those show talent and success in research during their clinical fellowships or residencies) prefer to go to private practice after expensive medical school, poorly paid and exhausting internship and residency. They want to earn 3-6 times more in private practice than they would earn as research fellows or clinician researcher. I cannot blame them.
If it were easy....
we would let anyone become a doctor...
We would only pay the average wage....
We wouldn't hold them to a high standard...
get over it. I really don't know too many folks who who work in professions where moral is great these days.
As a clinician for a decade some time ago, I can see why doctors are demoralized, cynical, and fight apathy daily. As doctors, they need to call the shots on the intrinsic need to restore the health of thier patients, yet instead, some insurance company or health care system, which many doctors belong to because they can no longer afford thier own overhead or malpractice insurance, directs and controls these professionals. What's next, punch clocks and break times scheduled for them?
Doctors, by definition, restore health. It is thier judgement, and not a capitalist who coerces doctors to see a certain number of patients a day.
Dan Abshear
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