"In the few years since I’ve graduated from medical school, there has been enough time to go back to medical practice in some form, but I haven’t and don’t intend to, so quit yer askin’, dammit. But of course, people keep on asking. Their comments range from the curious — “Why don’t you practice?†— to the idealistic — “But medicine is such a wonderful profession!†— to the almost hostile — “Don’t you like helping people?â€
Since it’s fairly certain that I will continue to be posed this question for the rest of my natural existence, I figured that instead of launching into my 15-minute polemic on the State of Medicine each time, interrupting the flow of yummy Hefeweizen, I could just write it up and give them the URL. So that’s what I did. Now, unfettered by my prior obligations as an unbiased pre-med advisor, here are the myriad reasons why you should not enter the medical profession and the one (count ‘em — one) reason you should enter it. I have assiduously gone through these arguments and expunged any hint of evenhandedness, saving time for all of you who are hunting for them. And here are the reasons:
1) You will lose all the friends you had before medicine.
You think I’m kidding here. No, I’m not: I mean it in the most literal sense possible. I have a friend in UCLA Med School who lives 12min away, and I’ve seen here once — in three years. I saw her more often when she lived in Boston, no foolin’.
Here’s the deal: you’ll be so caught up with taking classes, studying for exams, doing ward rotations, taking care of too many patients as a resident, trying to squeeze in a meal or an extra hour of sleep, that your entire life pre-medicine will be relegated to some nether, dust-gathering corner of your mind. Docs and med students don’t make it to their college reunions because who can take a whole weekend off? Unthinkable.
And so those old friends will simply drift away because of said temporal and physical restrictions and be replaced by your medical compadres, whom you have no choice but to see every day. Which brings us to…
2) You will have difficulty sustaining a relationship and will
probably break up with or divorce your current significant other during training.
For the same reasons enumerated above, you just won’t have time for quality time, kid. Any time you do have will be spent catching up on that microbiology lecture, cramming for the Boards, getting some sleep after overnight call and just doing the basic housekeeping of keeping a Homo medicus upright and functioning. When it’s a choice between having a meal/getting some actual sleep after being up for 36 hrs vs. spending quality time with your sig-o, which one wins, buddy? I know he/she’s great and all, but a relationship is a luxury that your pared-down, elemental, bottom-of-the-Maslow-pyramid existence won’t be able to afford. Unless you’ve found some total saint who’s willing to care for your burned-out carapace every day for 6-8 years without complaint or expectation of immediate reward (and yes, these people do exist, and yes, they will feel massively entitled after the 8 years because of the enormous sacrifice they’ve put in, etc etc).
3) You will spend the best years of your life as a sleep-deprived, underpaid slave.
I will state here without proof that the years between 22 and 35, being a time of good health, taut skin, generally idealistic worldview, firm buttocks, trim physique, ability to legally acquire intoxicating substances, having the income to acquire such substances, high liver capacity for processing said substances, and optimal sexual function, are the Best Years of Your Life. And if you enter the medical profession during this golden interval, you will run around like a headless chicken trying to appease various superiors in the guise of professor, intern, resident, chief resident, attending and department head, depending on your phase of devolution; all the while skipping sleep every fourth day or so and getting paid about minimum wage ($35k-$45k/yr for 80-100 hrs/wk of work) or paying through the nose (med school costing about $40-80k/yr). Granted, any job these days involves hierarchy and superiors, but none of them keep you in such penury for so long. Speaking of penury…
4) You will get yourself a job of dubious remuneration.
For the amount of training you put in and the amount of blood, sweat and tears medicine extracts from you (and, again, I’m not being metaphorical here), you should be getting paid an absurd amount of money as soon as you finish residency. And by ‘absurd’, I mean ‘at least a third of what a soulless investment banker makes, who saves no lives and is basically a federally-subsidized gambler’ (but that’s a whole different rant, ahem).
I mean, you’re in your mid-thirties. You put in 4 years of med school, and at least 4 years of residency (up to 8 if you’re a surgeon). You even did a fellowship and got paid a pittance while doing that. And for all the good you’re doing humanity — you are healing people, for godssakes — you should get paid more than some spreadsheet jockey shifting around numbers, some lawyer defending tobacco companies or some consultant maximizing a client’s shareholder value, whatever the hell that means.
Right? Wrong. For the same time spent out of college, your I-banking, lawyering and consulting buddies are making 2-5 times as much as you are. At my tenth college reunion, friends who had gone into finance were near retirement and talking about their 10-acre parcel in Aspen, while 80% of my doctor classmates were still in residency, with an average debt of $100,000 and a salary of $40,000.
5) You will have a job of exceptionally high liability exposure.
But wait, it gets better. Who amongst these professionals has to insure himself against the potential wrath of his own clients? The investment banker’s not playing with his own money. And even if he screws up to the tune of, oh, hundreds of billions of dollars, Uncle Sam’s there to bail him out (see: World History, 2008-2009).
The lawyers? They’re doing the suing, not being sued. But the doctors? Ah. Average annual liability premiums these days are around $30,000. That goes up to $80,000 for an obstetrician-gynecologist (who remains liable for any baby s/he delivers until said infant turns 18) and into the six-digit realm for neurosurgeons. Atul Gawande wrote a dynamite article about docs’ compensation in a recent (May 4, 2005) issue of The New Yorker entitled Piecework — check it out.
6) You will endanger your health and long-term well-being.
The medical profession is bad for you. Just ask any current doctor or med student. You will eat irregularly, eat poorly when you do get the irregular meal (and so much for the now-outlawed drug-company sponsored meals — god bless their generous hearts and bottomless pockets), have way too much cortisol circulating in your system from all the stress you experience, have a compromised immune system because of all the cortisol in your blood, get sick more often because of the compromised immune system (and the perpetual exposure to disease – it’s a hospital where everybody’s sick, duh), and be perennially sleep-deprived. If your residency is four years long, on average you will spend one of those years without any sleep. A whole year of no sleep. Do you get that? This is as bad for you as it is for patients — you’ve heard of Libby’s Law, right? Groggy doctors can kill patients when they don’t mean to.
Groggy docs can also hurt themselves. One stuck herself with a needle as she was drawing blood from an HIV patient. She’s fine now, but that was a good 9 months of panic. My good friend and college classmate James — a serious contender for the title of Nicest Guy on Earth – had a severe car accident one morning on the way to the hospital because he fell asleep behind the wheel. Luckily, his airbag deployed and he didn’t suffer long-term injuries. Everyone seems to know already that medical care can kill patients (haven’t read The House of God by Samuel Shem yet? Go get it now – brilliant and easily the funniest book I’ve ever read), but it’s usually news that it can kill the docs, too.
7) You will not have time to care for patients as well as you want to.
This is how the math works: Many patients. Few of you — usually one, unless you have florid multiple-personality disorder (no, it ain’t the same as schizophrenia). So you have to take care of many patients. And if they’re in the hospital, that means they’re really sick, otherwise they’d still be at home.
So you are scurrying around trying to take care of all of them at once, which means that each individual patient can only get a little bit of your time. Which means that you won’t have a chance to sit at the bedside of that sweet old vet and hear his stories of Iwo Jima. Or get to the bottom of why that LOL (little old lady — medical slang’s been around way longer than internet slang, buddy) can’t get her daughter to come visit. Or to do any of that idealistic stuff that you cooked up in your adolescent brain about really connecting with patients.
Get a grip! This is about action, about taking care of business, about getting shit done, about making that note look sharp because the attending is coming to round in an hour and he’s a hardass, and that’s the difference your passing and getting recommended for honors, so get on it already and quit yakking with the gomer (which is an older patient with so many problems you should have never let him/her get admitted in the first place — stands for get out of my ER, and I didn’t make it up the acronym, so direct your righteously indignant wrath elsewhere, thank you very much). It’s about CYA — cover your ass. For better or for worse, you just start to treat patients as problems and illness-bearing entities for the sake of mental efficiency (“55yo WM s/p rad prostatectomy c hx CHF & COPDâ€), which does not do much for your empathetic abilities. Which brings us to…
You will start to dislike patients — and by extension, people in general.OK, so now you’re overworked, underpaid, underfed, and sleep-deprived. Whose fault is that? Well, it’s not really the hospital’s fault — it’s just drawn that way. And it’s not your boss’s fault, because somebody has to take care of patients, and he can’t do it because he’s the boss, duh.
So whom to blame? Ah yes — patients. It’s the patients’ fault! They’re the ones creating all the work! The ones who get in the way of your nap, your catching your favorite TV show, having an uninterrupted meal, getting together with your sig-o for some therapeutic nookie. How dare the gomer in 345E have an MI while you’re watching CSI? Does she have any consideration, letting her blood pressure tank to 40 over palp at 3.30am, while you’re making out with Elle MacPherson on the shores of Bora Bora (assuming you’re lucky enough to be actually asleep)? The logic may be twisted — patients, on the whole, don’t get sick voluntarily just to spite you – but it is deeply ingrained in medical culture. Heck, there’s even a slang term for it: a hit. As in, “We got four hits on our admitting shift at the ER today.†Hit — the same way you would be struck by a mortar, or a shell, or a bomb. Getting hit is a Bad Thing.
Patients aren’t people, you see — they are potentially lethal disasters that can explode all over the place and ruin your whole day. “We got hit again†— one more patient to take care of, says the resident. But really, is that resident blameless? Or how about Dr Hardass the attending and his intransigent ways? Hell, they’re at fault, too!
Soon the circle of blame expands to the outer reaches of the cosmos, and every potentially accountable organism from amoeba to blue whale will be personally responsible for your misery. But lest you think we’ve forgotten you, patients, remember — it’s all still your fault.
9) People who do not even know you will start to dislike you.
Once upon a day, in a time somewhere between the Cretaceous and Triassic eras, physicians were held in awe and respect by the general public. Their seeming omniscience was revered, and TV shows like Marcus Welby MD glorified their empathetic sangfroid and cool grace. Heck, they were even considered sexy or something.
I only noticed in recent years that this ain’t the case no more, and doctors rank on the contempt scale somewhere above meter maids and at or just below divorce lawyers (but still much higher than I-bankers and other invertebrates). The average Joe and Janet are tired of the ever-rising cost of medical care, tired of all the stories of malpractice, tired of the perceived greed of the pharmaceutical firms, tired of the heartless profit-focussed practices of insurance companies.
But where do they pin their frustration? To whom can they direct their ire? Insurance and drug companies are nameless, faceless entities, as are hospitals. We need a person to blame, like a nurse or a doc. Nurses are overworked and massively underpaid, so it doesn’t really make sense to get mad at them. But doctors — those Mercedes-driving, Armani-wearing, private-school using, golf-playing arriviste docs! By being the most visible symbol of the medical profession, the doctor will have the dubious distinction of being the scapegoat for all its maladies. Fair? Hell no — we already told you docs are overworked, underpaid, and often railing at the same injustices Joe and Janet are. Most of them don’t even play golf! (They don’t have time. Except for dermatologists). But such it is. Just letting you know which direction the rotten tomatoes are flying so you can consciously choose to stand at the ‘toss’ or ‘splat’ end of the trajectory.
10) You’re not helping people nearly as much as you think.
So by now I may have managed to inspire your righteous indignation with some of the things I’ve said about the medical profession. But maybe in the back of your head, you were still thinking, “Well, even though it sounds like a bunch of black bitter bile, he does kinda sorta have a point.†In which case, I’ve almost certainly lost you on this one: “Whaddya mean you’re not helping people? Isn’t that what medicine is all about?â€
Well, actually, yes and no. Sure, there is the immediate gratification of delivering a baby, fixing someone’s eyesight with LASIK, catching a melanoma before it causes trouble, or prescribing some thermonuclear antibiotics to kick a nasty bronchitis.
But, depending on the field you choose, most of the time you’re not doing that. You’re treating chronic conditions that are self-inflicted: emphysema, obesity, cardiovascular disease, diabetes. Moreover, patients tend to be non-compliant — they basically don’t do what you tell ‘em to do (NB: mea culpa). In fact, you too are probably one of those non-compliant patients who doesn’t exercise more, eat healthier, and take pills as they’re prescribed. Anecdotally, 50%+ of prescribed medications are taken incorrectly or never.
So there you are, like Cuchulain the legendary Celtic warrior, wading into the ocean and, in your rage, trying to fight the invulnerable tide and improve the health of your patients. You pour all your earnestness, good intentions and expertise into it, and — not a whole lot happens. Your efforts bear no fruit. So you suck it down and move on, sustained by the occasional kid who does get better, that eyesight that does improve, that bronchitis that doesn’t turn into pneumonia. Win some, lose many more.
And the one reason why you should go into medicine:
You have only ever envisioned yourself as a doctor and can only derive professional fulfillment in life by taking care of sick people.
There’s really no other reason, and lord knows the world needs docs. Prestige, money, job security, making mom happy, proving something, can’t think of anything else to do, better than being a lawyer, etc are all incredibly bad reasons for becoming a doc.
You should become a doc because you always wanted to work for Medecins Sans Frontières and your life will be half-lived without that. You should become a doc because you want to be the psychiatrist who makes a breakthrough in schizophrenia treatment. You should become a doc because you love making sick kids feel better and being the one to reassure the parents that it’ll all be OK, and nothing else in the world measures up to that. Or as my general surgery resident put it, you should become a doc because “my dad was an ass surgeon, my big brother’s an ass surgeon, and by god I’m going to become an ass surgeon.â€
But woe betide you if there’s anything else, anything at all, that would also give you that fulfillment. Because pursuit of medicine would preclude chasing down that other dream and a whole lot more – a dream that could be much bigger, much more spectacular, much more enriching for yourself and humanity than being a physician. Just ask John Keats, Walker Percy, Sir Arthur Conan Doyle, Giorgio Armani, or Michael Crichton (some of these guys being more alive than others these days). Or you can just ask me a few years down the road, by which time I should have a blog entry for that question, too."
http://blogs.law.harvard.edu/abinazir/2 ... ased-rant/
