• Doctors as martyrs

    There was an op-ed in the NYT over the weekend, written by an anesthesiologist, that I’ve been grappling with for days. Every time I sat down to write about it, there was so much to say that I couldn’t focus. I wasn’t upset about one small part of it; the whole thing made me shake. So we’re going to have to go through it bit by bit.

    The premise is that a female physician is arguing that doctors who aren’t willing to sacrifice everything on the altar of professional martyrdom are selling their patients, and society, short:

    I’m a doctor and a mother of four, and I’ve always practiced medicine full time. When I took my board exams in 1987, female doctors were still uncommon, and we were determined to work as hard as any of the men.

    Today, however, increasing numbers of doctors — mostly women — decide to work part time or leave the profession. Since 2005 the part-time physician workforce has expanded by 62 percent, according to recent survey data from the American Medical Group Association, with nearly 4 in 10 female doctors between the ages of 35 and 44 reporting in 2010 that they worked part time.

    This may seem like a personal decision, but it has serious consequences for patients and the public.

    She begins by claiming that choosing to work part-time is cheating society out of a public investment, specifically the money you all pay to help train doctors:

    Medical education is supported by federal and state tax money both at the university level — student tuition doesn’t come close to covering the schools’ costs — and at the teaching hospitals where residents are trained. So if doctors aren’t making full use of their training, taxpayers are losing their investment. With a growing shortage of doctors in America, we can no longer afford to continue training doctors who don’t spend their careers in the full-time practice of medicine.

    First of all, lots of education is subsidized by federal and state tax money, and that doesn’t make you an indentured servant for the rest of your life. Regardless, this argument is weak. Doctors wheel it out whenever they’re upset a colleague isn’t working as hard as them. But they never think about it when choosing how they want to practice.

    If you feel physicians are so indebted to society for the tax money spent on education, how can you tolerate a doctor that refuses to accept Medicaid patients? How can you tolerate a doctor who refuses to accept Medicare patients? How dare they take tax money and then go practice only in the private insurance world? Where’s your outrage for doctors who practice boutique medicine? Is that not an abuse of subsidized education and the public trust?

    Or does the social contract only apply when it offends your sensibilities?

    It isn’t fashionable (and certainly isn’t politically correct) to criticize “work-life balance” or part-time employment options. How can anyone deny people the right to change their minds about a career path and choose to spend more time with their families? I have great respect for stay-at-home parents, and I think it’s fine if journalists or chefs or lawyers choose to work part time or quit their jobs altogether. But it’s different for doctors. Someone needs to take care of the patients.

    This is where I started to lose it.

    It’s completely fashionable to criticize “work-life balance” or part-time employment options. I see it every day. In fact, the author is doing it right there in the NYT.

    My father (now retired) was a general and thoracic surgeon in private practice, who was triple-boarded in critical care, and ran a trauma unit. He worked harder than anyone else I’ve ever known. I love my Dad, and I understand his decisions for choosing that career path. But guess what? I don’t want the same things.

    That’s my right. I chose a different career path. First, I chose Pediatrics, because I didn’t want to work like a surgeon. Then I chose to be in academics, because I wanted to have time to educate as well as practice. Then I chose to be a health services researcher, because I wanted to work on the system more than individuals.

    At this point, I spend a half day a week in clinic at most, seeing patients with residents, helping to train them. I won’t ever be a master clinician, but I have skills and something to offer. It may not be the career path that the author of this op-ed chose, but I’m sorry, it doesn’t make me less than her.

    Next, we hear about the doctor shortage in the US:

    Today 53 percent of family practice residents, 63 percent of pediatric residents and nearly 80 percent of obstetrics and gynecology residents are female. In the low-income areas that lack primary and prenatal care, there are more emergency room visits, more preventable hospitalizations and more patients who die of treatable conditions. Foreign doctors emigrate to the United States to help fill these positions, but this drains their native countries of desperately needed medical care.

    Perhaps there’s a doctor shortage because people don’t like practicing medicine; perhaps it’s because it’s a field that criticizes “work-life balance” or part-time employment options.

    But maybe there are ways to fill the gaps with other types of providers?

    We often hear the argument that nurse practitioners, nurse anesthetists and physician assistants can stand in for doctors and provide cheaper care. But when critical decisions must be made, patients want a fully qualified doctor to lead the health care team.

    This paragraph made me laugh. The author provides no evidence that nurse practitioners, nurse anesthetists, and physician assistants provide sub-standard or less cost-effective care. She just states that “patients want a fully qualified doctor”. There’s the US health care system in one sentence.

    Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It’s fair to ask them — women especially — to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency. They must understand that medical education is a privilege, not an entitlement, and it confers a real moral obligation to serve.

    Again with the “moral obligation”. Does this apply to providing care to the uninsured? The poor? The elderly? Or does it just apply to some vague work ethic?

    I have met far too many physicians with this sense of higher purpose, as if this was more of a calling than a profession. They feel that if you’re not sacrificing, then something’s wrong. It’s as if suffering translates into worth.

    I don’t deny that one of the reasons I went into medicine was to do some good, and I’m sure that applies to most physicians. But I’m also realistic that I went into medicine because I enjoy the work and find it rewarding. I further specialized, as I’m sure the author did, because I found this specific work to suit me the best.

    I’m sorry, but I found much of this op-ed to be troubling. I spend no time whatsoever judging the morality of the work-life balance choices of my colleagues (male and female) any more than I spend time judging the morality of their choices to be surgeons or primary care physicians. And I hate to break it to the author, but most of us think that anesthesiology is one of the specialties with the most desirable lifestyles.

    Moreover, I remember what I was like in residency. I was overworked, exhausted, miserable, angry, and depressed. I was a terrible human being sometimes. There is no doubt in my mind that since I’ve gotten more control over my lifestyle, I’ve become a better husband, a better father, and a better friend.

    The drugs don’t work better if I’m crabby. The scans aren’t more accurate when I’m tired. The laboratory tests aren’t faster when I’m miserable. But I’m much more comforting, much more approachable, and much more of a human being when I’m happy. That’s what makes me a good doctor.

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    • I’m a social worker and I find similar martyrdom in my field. It’s not so much in dealing with work-life balance but so often you hear social workers talk as if they’ve chosen the profession (or rather it called them) and alluding to working for no pay to “help people.” Oh, woe is me. But, like you, while I like to help people, I also find this career personally interesting and rewarding. And, get this, I make a decent living as well. Yes, social workers have to want to help people (if they don’t, it’s not the career for them), but I can do without the pity parties many throw so as to solicit the ever indulgent, “That’s so great of you” response from others.

    • Dr Carroll,

      I’ve been following you regularly since Pete Dominick started having you on his show. I believe that it’s likely that because you have chosen to establish a balance between life and work that you have been able to inform me, along with the general public, about healthcare policy in a way that is grounded and compassionate. I can’t believe how much better educated I am on the issue!

      Keep doing what you’re doing. People like me benefit so much from it!

      Sincerely,

      Jacqui Sutton
      Houston, TX

    • Sibert implies that physicians who do research are also bad doctors since it detracts from clinic time. Does Sibert’s commitment trump Salk’s work on Polio?

    • Well said Aaron! Sounds like someone who is angry about the choices they made and are jealous of the options people, especially women, have available to them now. This is part of why women have a harder time getting ahead in this world. They get criticized and broken down by other women in their same field! I sometimes feel like if I go off to private practice so I can lead a life that is easier than academic life, I would be letting myself and everyone around me down. Too much Catholic guilt, I guess.

    • Bravo!

    • “First of all, lots of education is subsidized by federal and state tax money, and that doesn’t make you an indentured servant for the rest of your life”
      Well said. Thanks.

    • There is a lot to unpack in what she said. To keep it brief, I suspect she may be reacting to a common phenomenon I see. Younger docs coming out of training are much more insistent upon having a decent lifestyle, while also wanting the same salary. They want to get off work at a reliable time, like an hourly employee, while getting paid like a salaried employee. I used to think this was something I saw just because I am getting old, but it is a complaint I hear from many other practices, even those being run by youngsters in their 40s.

      Steve

    • You write that you “grappled” with how to respond “for days.” But the opinion piece is dated Sunday, and you posted your response Tuesday morning. Even if the piece was online a day or two earlier, I still have to say … you grapple very quickly.

    • Aaron, you hit the nail on the head. We’re being criticized by an anesthesiologist. I’m sure I’d love to work full time in her field!

    • This isn’t a physician thing, its an arrogance thing. It results from the puffed up opinions that people have of themselves that some how if you are not doing what they are doing, your work is less significant. How can this doctor determine that her work is more important than that of a mother who raises her children rather than giving them to others to raise, as she does.

      I’ll offer a historical example. The infamous Battle of Midway. The praise and focus is usually on the leaders, airmen and sailors who valiantly fought. But there were two other groups (among others) who were just as critical, by making it possible in the first place. The code-breakers and the welders. Without the code-breakers there would have been no knowledge of the attack and without the welders and other shipyard workers our defense force would have been reduced by 50%. After the Battle of the Coral Sea the torpedo stricken USS Yorktown was made sea worthy in 3 days and was able to join the task force, albeit late. Without her, most historians and tacticians believe we would have lost.

    • Thank you so much for writing this article in response to the recent NY Times Op Ed piece. I similarly was very upset reading it. As a new intern I realize that I will work long hours and sacrifice my free time for the next few years but that is because I have so much to learn. Once I am an attending I look forward to having a little more balance in my life and more time to spend with my family. If lawyers, chefs and journalists can choose to work part-time or fewer hours, I see no reason why doctors shouldn’t have the same opportunity to lead balanced lives. Thanks again for writing this article!