Doctoring Ain’t All it’s Cracked Up to Be
The rat race of becoming a physician and maintaining one's license is more intense than popularly understood.
A few days ago, Tyler Cowen asked, “What is wrong with physicians?” He was prompted by an NBER working paper titled “The Effects of Becoming a Physician on Prescription Drug Use and Mental Health Treatment,” the abstract of which is:
There is evidence that physicians disproportionately suffer from substance use disorder and mental health problems. It is not clear, however, whether these phenomena are causal. We use data on Dutch medical school applicants to examine the effects of becoming a physician on prescription drug use and the receipt of treatment from a mental health facility. Leveraging variation from lottery outcomes that determine admission into medical schools, we find that becoming a physician increases the use of antidepressants, opioids, anxiolytics, and sedatives, especially for female physicians. Among female applicants towards the bottom of the GPA distribution, becoming a physician increases the likelihood of receiving treatment from a mental health facility.
A pseudonymous commenter pipes in with a longish answer:
My top candidates:
1. Loss of locus of control. People go into medicine to save lives. They believe that they will use their demonstrated intelligence and skills to make a difference. Unfortunately, modern medicine is ever more about turning physicians into box checkers. CPT codes, checklists, facility mandates, perpetual boards … a physician quickly loses control of their working day unless they are weird freaks who do extensively more work to retain control. And beyond that the average physician becomes enculturated to this much earlier. Which medical school you get into is largely a function of where you grew up, went to undergrad, and exactly how well you did on a test that everyone aces with a side of barely legal implicit racial quotas. Your residency is determined by where you went to medical school, where you went to medical school, where/what the top candidates want, and how well you did on a test that everyone aces with a side of barely legal implicit racial quotas. You spend a decade where your locus of control in life is minimal. Then you hit the real world and rather than being set free, you get hit by unending paperwork and yet a thousandth petty demand on your time. If you do research it is not uncommon to spend multiplicatively more time on compliance paperwork. If you head out to make money, you will find that your charge capture is more relevant than the quality of care you provide by an order of magnitude. All of this is a textbook case of loss of locus of control that we know is highly correlated with drug use and depression.2. There is a wild disconnect between “being a physician” as understood by the public and what you actually live. The public thinks this is still the 1980s when you could pay for medical school working a summer job, residency was three years, and salaries were higher in real terms than they are today. Instead, physicians spend much closer to fifteen years going through training as the needed resume padding has grown at every step along the way. This means that they live longer at resident salaries which are close to US median, but typically are located in high population areas with expensive housing costs. And being a resident physician is not cheap. You have high commuting costs because the regs allow your boss to work you 24 out of 28 days. You can, and will, have weeks with over 100 hours of actual patient care. And again, remember that something like half of residencies are in violation of these rules. And all of this is while nursing a second mortage in undischargable medical school debt. Everyone will think you are rich and that you take fine vacations to Europe and the you will drive a flashy care. And maybe you will, but it will not be until after you are 40 and often 45 that the full physician lifestyle of the movies really comes into play.
3. And then we have the stakes. At every step in a physicians formative adult years you face massive ultra-high stakes events that we know are bad for mental health. College admissions (where you will hit a ceiling for medical schools if you get in too low), MCAT and medical school admissions (which will drastically lower your access to certain specialties if you end up having to go DO), Step and the Match (where you will spend five figures to beg for interviews, the folks on the other side will be unable to differentiate you from the thousands of other applicants, and when you get the interview the only thing of meaning that will come forth is if they like you and if you grew up nearby). Then you have boards and your first job. All of these are massively high stakes and they all require performing quite well relative to your peers. This sort of setup is known in experimental animals and people to lead to depression, anxiety disorders, and drug use.
3. Then we have the punctuated nature of the physician’s life. Going back to medical school, you routinely have long weeks with minimal time to enjoy because studying is rampant. Your entire career can theoretically hang on if you memorized which ultra-rare cancer is caused by which mutation in which gene – even if you want to be a psychiatrist. When you have time “off” this may be the only time you get and there is a very strong tendency toward binges and bacchanals. This will continue to residency where you might have one free weekend in a month (the others being taken up with working and studying), which again lends itself toward binging. And it may continue from there with horrid call schedules and long weeks punctuated by long vacations.
4. The stakes never get lower. You go through with your career riding on high stakes tests and your studying time never being accounted for in your official duties. Boards are now never ending and you face ever more theoretically threatening liability for your decisions.
5. And then there is the obvious stuff. Day in, day out you meet people at their worst. And all your coworkers are doing the same. People cry, threaten, swear, and otherwise abuse you. And nobody wants to get mad at somebody who was just paralyzed from the waist down. Likewise, you can only become so inured to death and dying, we are a social species with extremely large portions of our brains dedicated to feeling empathy for others, physicians see the 5% of humanity who is most obviously suffering as their modal patient.
6. Lastly, whatever you think about physician renumeration, it becomes painfully evident that the golden days were decades ago and there is a small army looking for ways to reduce your renumeration. It will fall disproportionately on you even when the major growth in medical expenses has been nursing, administration, and other warm bodies. Whatever you got paid for a highly taxing job last year, there will be a thousand signs that people think you should do it again for less. People who believe wholeheartedly in the stickiness of wages for reasons of morale and who hold that pay cuts are sufficiently difficult that we need to order international finance around inflation and obviating the need for explicit wage reductions will turn around and concoct wild schemes that explicitly reduce your income in real and nominal terms and question your character should your professional organization (to which you don’t belong) object. All, of course, while the administrators who are generally incompetent at understanding medical practice rake in an ever larger share of the money.
Some of this is US specific, but we have set up medicine to be highly backloaded with its rewards for physicians. We have risen the profession to a vocation and made it a truly arduous task to get through. And at every step along the way physicians have not had access to healthy coping mechanisms and repeated psychic injuries of the sort known to cause or exacerbate these conditions. Major life protective events (e.g. marriage, children, home ownership) are routinely delayed and disrupted by the demands of the training. Why again are we surprised that physicians come out bruised, batter, and willing to take the short term fix for some relief?
Now, of course, this only answers Cowen’s question directly if the Dutch system is similar in this regard. But, certainly, it captures the frustrations of a lot of American physicians.
Beyond that, the same basic critiques apply to the lifestyle of attorneys and, to a much lesser extent, professors and other professionals. We have expanded the amount of time in school and postgraduate school-like activities required to succeed in all of the learning professions while slowly ratcheting up the hurdles to achieve full status in the field. And a large chunk of the much-discussed student debt burden falls on those with graduate and professional degrees, where much less student aid and scholarship help is available.
Still, the conditions described above apply most heavily to physicians. It’s extremely competitive to get into even a third-rate medical school because the cartel has worked assiduously to keep the openings tightly capped. Medical school is far and away the most gruelling of the graduate and professional tracks. And even the most competitive of the Big Law firms, which require an insane amount of billable hours for years and years to achieve junior partner status, don’t keep their associates sleep-deprived for years on end.
And, yes, there is increasing pressure to push down compensation to keep costs in check. The combination of Medicare covering the most expensive part of most people’s lifetime medical bills and private, for-profit insurance covering most of the rest means that there are caps to payouts that encourage an assembly line approach to practice.
I’m pretty sure the Dutch system does NOT resemble the US system. Half or more of a private doctor’s staff in the US is just for dealing with insurance, who second guess everything the doctor does in an attempt to avoid payment. I have a couple of Dutch friends and the impression I get is that they don’t deal with insurance as we know it and find the American system ridiculous.
Since it is not a US study, that makes it more interesting. The pressures on US doctors that Cowen lists are largely limited to the US. What I see happening here is that new doctors are less and less likely to set up their own shop. More and more are working for large group practices or directly for hospitals, because they don’t want to deal with insurance and such.
The situation is even worse for veterinarians (very high suicide rate). I have to think that going into a field to care for others would be hard on the soul.
There was an editorial in the Journal of the American Medical association a few years back which contained a memorable phrase, saying that the practice of medicine was an ideal “combination of doing well with doing good”. What physicians actually do today threatens both of those.
However, the statistics being called out (substance abuse and mental disorder) have been true for decades so the changes in the practice of medicine, e.g. loss of autonomy and time spent on insurance, can’t be the primary culprits. My suspicion is that the way physicians are selected and the way they are trained are major culprits. The selection process tends to favor intensely focused individuals while the training process creates a separation between physicians and other support systems.
@MarkedMan:
Insurance works very differently here in the Netherlands. As consumers you hardly ever have contact with insurance (I have never called my health insurance and I am 59 with chronic disabilities and have been operated several times) and though doctors have more administration there isn’t the pressure that the US has, it is just tedious and time consuming.
Dutch doctors also have a higher percentage of substance abuse and suicide though. Part of it is access combined with high a high stress job, part of it is the fact that most doctors have a personality profile that tends to be ambitious with high self expectations, part of it is that they are less likely to search for help (doctors are the worse patients…) because they are *responsible* for patiens so they can’t be ‘weak’ themselves. Which unfortunately also leads to higher suicide rates.
@MarkedMan: I would guess that some portion of ” don’t want to deal with insurance and such” is how people respond to the question of working for a hospital or clinic when what they really mean may also include not having a spare several hundred thousand or so lying around for the start-up costs of a private practice. After which we get to issues related to uncompensated tasks related to maintaining an independent business and where to find the time to do them.
This sounds a lot like the issues and obstacles airline pilots face.
To begin with, you need a pilot’s license and a college degree. Then you need a number of flight hours (on any type). And all this before you’ll get hired by a regional airline (or a contractor of regional flights for other airlines, really), which pay much less.
There’s a huge upfront cost (or “investment”), and as regional flights get longer the major airlines were hiring fewer pilots. Then, too, as the majors have consolidated (remember Continental, US Air, America West, Northwest?), and low and ultra-low cost carriers proliferated, starting pilot salaries have come down.
Around mid to late 2019, things were changing as there were fewer pilots than needed to expand route networks. It finally hit United et al. that no one aimed to work for Mesa Airlines to do contract work for the majors. The pandemic upended all that. It may be the pandemic aftermath may upend things in the pilots’ favor again.
….and COVID, where the bulk of your patients are now those who don’t believe enough in medicine to bother to get the damn vaccine, can’t be helping matters.
We’ve got too many Americans who don’t do what is necessary to keep themselves in good health, fall sick, then abuse the medical establishment that they complain is supposed to fix matters.
I think the author of that piece probably represents the feelings of a lot of younger docs pretty well. However, since I am older, did not go straight to college after high school and was brought up fairly poor in rural areas, worked full time as an undergrad and during med school to support family, I do have a different take. I always expected to work pretty hard and have long hours. I think most people going into medicine today come from pretty comfortable middle/upper middle class families. They thought they worked hard as students, but working hard as a student is nothing like working hard at a real job. Its not as glamorous as they expected. So I think it is largely a matter of expectations. Meh. To be sure I think as James points out many other professionals are feeling some push to do more with less and that hits docs also, but I am not sure it is really worse for docs than other groups.
By and large the hours for most docs really arent that bad and if they are it is often because they have chosen a field where they get productivity pay. There are exceptions and if you are geographically limited it is more likely that you end up within an abusive practice that makes you work long hours.
As noted by Dave, there has always been some issue with drugs and mental health. Access is easy in some specialties. Some specialties made it a point of honor to abuse trainees and have 100% divorce rates but all of that is a lot better. The part I think most people ignore in the Dutch study is that the effect is seen more with women docs. Since women remain the primary caregivers even when they are physicians, this does not surprise me. My female doc married to a male teacher is still the one to stay home with the kids if they get sick. Still does most of the child care. Trying to be everything for everyone is hard and needing mental health care is not surprising. I also think it is more acceptable for docs to seek mental health care now than in the past.
Steve
The distressing thing is that none of this is new. Alcoholism and suicide rates in physicians have been known to be high for a long time. As mentioned in the posting, national borders don’t appear to be a barrier to these problems. There are interventions available for physicians who reach out for help, and screening and treatment should be a routine part of the curriculum. Training programs need to build resilience, and this probably requires decreased work hours.
Largely upper middle class smart kids forced to endure some of the overbearing supervision, chickenshit, tedium, frustration and stress that basically every single working person in this country suffers. But they get paid better, have much higher status, and can write their own prescriptions. Where’s my tiny violin so I can play a sad tune?
@Just nutha ignint cracker: It’s more then just startup costs. Hospitals and large practices gobbled up an incredible number of the non-rural private practices in the 90’s and the ‘oughts. These are single physician and small groups that were already in existence so start-up costs weren’t a factor. The physicians felt that a reduction in pay was worth not having to deal with a staff of 4 or 5 people doing nothing but insurance and billing on top of 2 or 3 nurses, and not having to deal with malpractice and business insurance, negotiate leases, etc, plus reducing their personal risk exposure. And, a huge plus, having scheduled days off that won’t get interrupted.
Initially, the hospitals and large practices treated these new recruits as royalty, but even 5 or 6 years ago I was hearing a lot of complaints from the surgeons I worked with about pressure to perform and mandates on the procedures and practices. I think in another 5-10 years, there will be a lot of complaining and job hopping. But I think the genie is out of the bottle and we won’t see a whole lot of private practices going forward.
” Training programs need to build resilience, and this probably requires decreased work hours.”
Probably because I am old and our training had a lot of hours, but I think that residents need to put in a lot of hours to get enough experience. That said it shouldn’t be 100 hours a week like in the old days but i think it will need to be at least 60 for most specialties.
Steve
“There are interventions available for physicians who reach out for help, and screening and treatment should be a routine part of the
curriculumwork environment.Or is that too radical a proposal for “professional” people?
These days, if I wanted to do generalist care, I would almost certainly go the NP or PA route rather than the MD or DO route. Nursing has had a direct career progression from CMA / CNA through to NP for decades that is built around acquiring progressive degrees while working. And PA school takes less time than residency alone.
“And, yes, there is increasing pressure to push down compensation to keep costs in check.”
No, there is increasing pressure to push down compensation to make sure the top executives and shareholders of insurance companies and hedge funds that buy medical practices and hospitals can pull out as much cash as possible without entirely bankrupting the business.
And this is the reason why so many other professionals — including professors — are feeling the same way. Like factory workers, the fruits of our labors are being directed away from us and to our owners.
@Michael Reynolds: No, you really cannot write your own prescriptions any more due to insurance regulations, among other things. It never was good thing to do, to begin with, and good docs always knew that. Best to delete that from this screed.