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No, I’m not announcing my departure from medicine. (At least not yet!)
Instead, this week, I take on the controversial topic of physicians quitting medicine. It’s a natural follow up to last week’s post on Optimizing Physician Career Longevity, but was honestly mostly inspired by reading several Twitter threads shaming physicians for leaving medicine.
Leaving your career behind is an individual decision. But if the internet police have taught me anything in the few times I’ve seen this topic come up, everyone else and their granpappy feels like they can and should weigh in.
So here we’ll look at what makes it contentious and why the shaming has to stop.
For physicians who want to leave medicine, I’ll keep my message simple.
I'll Sum it up In One Sentence
It’s your &#$%ing choice!
Allow Me to Expound
It’s your &#$%ing choice!
Got it?
Now That We Got That Out of the Way
It’s important to look at why this topic even comes up.
We know that an increasing number of physicians are experiencing burnout. The latest report from The Physicians Foundation showed that figure to be 61% of surveyed physicians.
I’ve taken a systematic look at the underlying causes of burnout previously.
I’ve also examined the opportunity costs of practicing medicine, which are many and extensive, to demonstrate that we’ve already given so much of our lives to medicine, sometimes in ways we didn’t realize or would not have chosen to had we recognized them at the time.
The repercussions of this burnout, moral injury, and disillusionment are physicians cutting back their clinical time or leaving medicine altogether—some retire earlier than planned, others transition to non-clinical (but still medically-related) careers, and still others go and do something completely unrelated to medicine.
Sir William Osler’s post-physician career.
The Lucky Ones
You can consider all those buckets of physicians the lucky ones.
Why? Because an alarming number instead die by suicide. An estimated 300 to 400 per year. That’s a rate of 28 to 40 per 100,000 physicians, or more than double the rate of the population at large.
That same study above by The Physicians Foundation found that 55% of physicians know a physician who has contemplated, attempted, or died by suicide.
A whopping 20% know a physician who has contemplated, attempted, or died by suicide just in the past 18 months during the COVID-19 pandemic.
It’s all so sobering.
Dereliction of Duty
With that context, why are physicians shamed so much for choosing to leave medicine, even if their lives depend on it?
The age-old criticism that I see from those within (yes, including other physicians) as well as outside of medicine is that physicians have a duty to society to keep working.
Specifically, this is how I’ve seen this play out on the interwebs if physicians talk about leaving or authors post blog articles (like this one) about the subject:
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- You are obligated to take care of patients. You took an oath. If you leave, you’re abandoning them. You’re a deserter who wasted a residency spot!
- Money was invested in your training with the expectation that you’d work a “full” (whatever that means) career.
- It often then degenerates into finger pointing and blaming women (yes, I know!) or the newcomers.
Let’s take a brief look at each one of these.
Oath Breaking
Most medical schools upon matriculation have med students recite the Hippocratic Oath (or some derivative thereof). There is no standard for this and most offer modern takes of the Hippocratic Oath to give it more context.
As much as I would have liked to swear by Apollo, Asclepius, Hygieia, and Panacea, the oath I took did not mention them.
Brienne of Tarth would have none of this, what with her Valyrian steel sword named Oathkeeper!
The original text did call medicine an “indenture” and referenced “indentured pupils” (trainees, specifically). But it also said that “this art” of medicine should be taught “without fee,” and I certainly was charged hefty fees for learning it. In fact, like many, I had to take out student loans just to pay for my medical education.
There’s nothing in the oath about subrogating our humanity in the process of caring for patients. Instead, we are called upon to use our humanity in connecting with patients to remember that they are more than just their disease process.
So why can’t we be looked upon as more than just the interchangeable cogs who do the healing?
If we truly value the humanity of medicine, then that should go both ways. The social contract should ensure that medicine is sustainable for us, and not something from which we are trying to escape, sometimes at all costs.
Furthermore, the physician shortage burden cannot be borne by any single physician.
Physicians are not quitters by nature. We certainly have ample opportunities to quit along the way: weedout courses in college like organic chemistry, MCAT, med school applications and interviews, all of med school, residency applications and interviews—I could go on and on.
Please note: I am not passing judgment on those who left medicine anywhere along the training continuum, often for similar reasons to those discussed here. However, the focus of this post is on those currently practicing medicine.
You could argue that we are paragons of commitment and delayed gratification. The issue is after all those years of delaying gratification, we reach the destination and are forced to ask, “Is this it? This is what it was all for?”
Do not hold an oath we recite as medical students or a residency spot we filled over our heads as if it’s some binding blood pact and worth more than our lives.
Society's Investment in Us
Moving on to the second criticism, there is truth to the first part of this claim.
Most of our resident/fellow salaries are paid for by the Centers for Medicare and Medicaid Services (CMS) (Yes, I know there should be two “M’s!”), state government Medicaid programs, and Veterans Health Administration (for training sites at VA hospitals).
The CMS funding for 100,000 residents (the number of trainees Congress is willing to fund—literally, there’s a cap in place…during a physician shortage…) amounts to about $5 billion annually.
Then there are the fees to run the Graduate Medical Education programs and offices which amount somehow to another $5 billion or so.
If you take the $5 billion that is paid to residents, divide it by 100,000 residents working 80 hours/week (some work up to 150% of this!), you get a resident hourly rate of $12 per hour.
The return on this investment for not only residency training sites, but also society is tremendous. That’s some serious bang for your buck, especially when you’re talking about caring for the sickest and most complex, not to mention expensive, patients!
We pay off society’s financial investment in our training during training with our labor and its unbeatable costs!
The second part of this claim is the idea of a “full” career.
What defines a “full” career? I can’t tell you because that’s an individual’s choice. And again, in my opinion no career is worth your life.
This Wouldn't Happen if it Weren't for Women
That final part of the beaten refrain often ends up blaming women or younger residency/fellowship grads.
Let’s start with the women. To prove my point, a quick Google search yielded the following example here (go to the comments section). I also read a few Twitter threads recently with similar comments lambasting women leaving (which prompted this post as noted in the intro).
Women are blamed because the physician shortage happens to correlate with an ever increasing percentage of women in the physician workforce, from 28% in 2007 to 36% in 2019. The percentage of women residents in the pipeline also continues to increase and as of 2019 sits at 46%.
Compared to their male counterparts, a higher percentage of women physicians scale back their clinical time or leave medicine within a few years after entering the workforce.
Misguided critics misinterpret (or intentionally interpret to validate a particular worldview) this any number of ways but fail to recognize the key point: that societal and family burdens (including childcare and distance learning during the pandemic) disproportionately and overwhelmingly fall to women and pull them away from medicine.
But that’s a structural sexism issue with medicine in this country; it was built for and caters to cis white male physicians. And obviously part of the issue is the larger, US cultural context with it’s historically defined, gendered roles.
It's Those Dang Millennials
Alternatively, some try to blame younger physicians because they’re Millennials who, by some broad, age-based cultural generalization, possess an unwillingness to put in hard work, etc., and end up bailing on medicine.
As a Millennial (I wouldn’t identify as one, but according to my year of birth I am one), I can say that I’m just heeding all the canaries in the coal mine who came before me and hold different priorities—one of which is trying to help make medicine more sustainable.
Furthermore, while important to me, my identity and self-worth are not solely defined by being a physician. I have many labels, and “physician” is just one of them.
Oh, that’s right: a Millenial (sigh)
Under the hood of this argument, however, is that same fact that the younger workforce is skewing more towards women. So I wonder and sometimes suspect that this argument is actually the same one blaming women, just in disguise.
Inherent in a lot of this criticism is an accusatory tone of weakness or not being cut out for medicine. To some, leaving medicine represents a moral failing.
Just because the old guard went through hell doesn’t mean the new guard has to. We don’t have to do it the way it’s always been done. We can and should break the cycle. We owe it to ourselves and the future physicians in the pipeline!
I Can't Quit You...Until I Can
Needless to say, the choice to quit is often quite a hard one to make for physicians, even if we are becoming disillusioned with and/or burning out from medicine.
In next week’s post, I’ll flush out more of the specific reasons for this other than the ones discussed here.
I’ll wrap things up with an analogy and a quote:
If you put your hand on a hot stove, your body triggers a reflex arc to pull your hand back before you’ve even registered that there is danger. Unfortunately, there is no such automatic reflex to the dangers inherent within the maw of our healthcare system, mostly because they are more akin to a toxin building up slowly within your body.
It’s easy to succumb to inertia and simply stay. Our brains always fear the unknown more than the known, even if the known is painful. Uncertainty is a great motivator for maintaining the status quo.
But for a growing number of physicians enough is enough and they want out. And it’s entirely up to them.
“People too often forget that it is your own choice how you want to spend the rest of your life.”
– Berta Lippert
Our lives are…our lives.
Other’s thoughts and opinions about what we “should do” should not have any bearing on what we choose to do. (The irony of that last sentence is not lost on me.)
So if you need to cut back on or leave medicine for your own sake, then do what’s best for you and yours.
If you know of a colleague who is considering leaving medicine, engage them about it. This decision is most likely not coming easily for them. They’re hemming and hawing.
Normalize it for them. Tell them it’s okay. And, for goodness’ sake, don’t go hurling any of the criticisms I hopefully refuted here, because frankly it’s:
Have you seen these arguments discussed here deployed against physicians? Are there any others you’ve come across? Let me know in the comments below!
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