Interesting essay - not really sure what to make of it. I finished medical training in 1991 - the "golden age" of medicine was already over by that time. As we went into practice, even at that time, the days of "independent private practice" were just about done. My husband and I finished residency and he joined a small private practice in a surgical subspecialty and I joined a large hospital based health care system in primary care. And it has been a struggle over the past 30 years. Him maintaining his private practice has been stressful with extremely long hours and very hard work. My employment by the big system served my purposes for 20 years, but over the last 10 years, became more frustrating for a variety of reasons. I left and started a small private "concierge" style practice 3 years ago. I enjoy this more, but it is still very long hours of stressful work. I've been using Epic for the past 24 years - the EHR failed to make my daily office work easier. The notes have gotten longer, the med lists more complex, the meaningless "quality measure" check boxes more time consuming and onerous. The EHR turned doctor into stenographer and ordering clerk. 24 years in and I actually have to enter MORE clerical minutiae into the system than I ever did before - not a desirable outcome. I have found other technology to be useful overall. I like to text with patients. Texting is how we all communicate these days - why not in medicine? I use My Chart, Haiku, Canto, Telemediq, etc - I'd say these are actually tools that make life slightly easier. Medicine has never been a field where there was a defined work/home line drawn. My understanding was that in the more distant past it was even worse! Patients called doctors at all hours of the day and night. Delays in starting families has been a problem in medicine since women have been in it. Our medical school class was almost half women, so this is not a new issue either. It just wasn't discussed or considered much at that time. Medicine is just a complex field and daily work life is long and stressful. The "golden age" of medicine, when doctors had leisurely lunches at the golf course have been gone for decades (at least 30+ years). The daily "productivity" slog with no time for lunch and hours spent after clinic to complete charts and review information are here to stay unless the entire way we organize and deliver medicine changes. I don't think we need to talk about AI until AI is reliably writing office notes - when I walk out of the exam room at the end of an appointment, I need the note written and orders already placed. That will be a game changer. Until we find ways around the one-on-one office visit as the cornerstone of all medical care, until we find ways to restore some autonomy and camaraderie of past golden ages, the problems noted in the essay will continue. As it stands right now, there is no such thing as "seniority" or "senior partner" in medical practice - the 60 year old is expected to work the same long hours for the same reimbursement in the productivity widget line as the new trainee. Again - unsustainable. Good doctors with a career's worth of knowledge and experience will burn out and retire as there is nothing we are doing to make it any easier to stay in practice. It is really too bad as losing these experienced clinicians does not help anyone. I don't think it solves anything to compare older generations of physicians with current trainees and early-career doctors. What does it matter? we are ALL working in the current system and have been for decades.
“With rare exception, most hospitals get the job done but care gets delivered amidst a bizarre arrangement of disparate towers, phone lines, fax machines, secure messaging platforms, ever changing EMR updates, and the occasional beautiful atrium that tends to overshadow the original ward.”
This line stood out to me the most. It points out not only a medical but a societal issue. On mass we have so many ways to communicate now a days that we should be a well unified but we seem to be more separated and compartmentalized (polarized) than ever. Even with multiple nodes of communication we still can misunderstand each other. And with these quick access forms of communication, one mistake in data or interpretation can lead to a cascade of poor outcomes.
I hope that Part 2 addresses an issue of the need for more doctors. This is seen in the comments by Mary Lamoreaux in reference to lack of access to OBGYN’s.
Lastly the issue of corporate medical care. The line “beautiful atrium that tends to overshadow the old wards” almost made me laugh. My first thought was the image of hospital administration going through the monthly numbers and discussing how to maximize revenue for cath lab and radiology along with increasing revenue for lattes and smoothies in the atrium shops and restaurants.
I agree with the first half of the post. Indeed, the cost of attaining formal medical education to completion (whatever that endpoint may look like) is much higher than it ever used to be. At the same time, income has not kept pace with the rise in cost of living. So I don’t doubt that the financial aspects and prospects of the profession are not what they once were for any newcomer on scene.
But I disagree with the general tenor of the second half. The challenges and demands of the modern day practice of medicine are shared equally btw young and old, newbie and seasoned vet alike. If anything, trainees don’t see the brunt of the administrative realities, and they may have some unpleasant experiences in store when they are fully minted, from which they are currently insulated.
It is also fine to admit that medicine may no longer be a calling. It never has been that for me, and I’m 22 years in. I don’t think my contemporaries generally considered it one. That “calling” mindset imo is a relic from the generation before me. And while you can and should seek out all the work-life balance you desire or require, when you’re actually at work, you should expect to be working. And that’s where I see this generation losing the plot. Medicine is hard work, with long hours, stress, performance pressure, and interpersonal challenges…all day…everyday…when you are at work. If you are not prepared to work (or work within that environment and those realities)….maybe this isn’t for you. No one is owed a career in medicine. If you choose to pursue one (and are fortunate enough to have the opportunity)…well, choices have consequences. Welcome to adulthood. “Kids these days” can prioritize “work/life balance “ to their heart’s content, and that’s not the problem; the problem is even when they’re working, they’re a bunch of daisy picking little pansies about it. Examples from the NEJM article- they’re triggered cuz a patient mispronounced their name? They felt unsafe cuz they had to do some scut work? Puh-lease. Grow up already, and grow a set while they’re at it.
Thoughtful piece. As a late mid-career physician I share a lot of the angst expressed herein, and I would certainly discourage many young bright people from pursuing medicine. Not all health systems, regions, or indeed countries have the resources to create teams of 'providers' so your essay has a particularly American bent. I would add that those of us in Canada involuntary exposed to US designed EMRs aren't sending you any warm fuzzies. Thankfully the Patagonia vest wearing private equity weenies haven't yet invaded our space, likely because there isn't sufficient capital to squeeze out of our admittedly inefficient single payer system. Final thoughts.... It is still possible to practice as a quasi-solo mostly autonomous generalist (of whatever specialty) by preference or necessity in a rural area. And Cory, if you haven't yet, you should read "A Fortunate Man" by Berger & Mohr.
I have to agree with most of the responses here. I don't think it's the cost of living, the debt medical school brings, etc, as all of those were true for the boomers +/- in a relative sense. I think what is significant is the answer to the question, "Who am I post graduation?" CDL Nationwide school guarantees who you'll be after graduating - a truck driver. Plumbers Training Institute can guarantee who you'll be a plumber post graduation. Etc. But who is the person who finishes his residency and is ready to practice? These people have put it well, an employee, a puppet for the insurance companies, a slave to EMRs, and who knows what else. And, to boot, if you are a great doctor is there a place for you anywhere, because it's the exceptional doctor who will fill that position you were ready for.
It’s the relatively rapid death of a profession. And the author and commentators have given some of the reasons why. I loved medicine. Still do. Always will. And that’s why i’m still practicing and teaching at age 78. But…Would I do it again in 2024? Sadly no. Who would? No autonomy. No reward. No respect. The best and the brightest aren’t choosing medicine and those that are will be burned out before middle age. Diseases change. Times change. Work changes. One accepts what one cannot control but pines for the days when one was once a “dear and glorious physician.”
Not much room to negotiate these days. Most physicians are employees rather than independent operators. This evolution was inevitable the moment that the government intervened and was predicted by many older physicians when I first entered the field in the 1970s. It is pretty difficult to argue otherwise when doctors are being fired and losing their license to practice because they are using their own judgement and questioning the bureaucratic narrative.
Seems that the elephant in the clinic is the encroachment of the current business zeitgeist of greed is good on virtually every facet of our profession.
If that doesn't breed cynicism I don't know what would...
Who could avoid feeling fractured and discontented knowing that you're just one part of a larger set of widgets for a group of venture capitalists
The basic difference is between medicine as a profession and medicine as a job. In a profession, it's understood that the professionals do labor that is not directly compensated monetarily, but, in exchange, being a professional accords people a higher status in society - respect, esteem, an honorary title ("Doctor So-and-So.") Medicine as a profession passed away in the 20th century, as society rejected professionalism as elitist and paternalistic. Doctors were no longer the apex of the medical hierarchy, but just one of the team of "healthcare workers," which included many people who had not worked as hard or sacrificed as much. Insurance companies gained the upper hand over much of medical decision-making. As a natural consequence of society removing the professionalism benefits, doctors started to wonder, "Why exactly am I doing all of this work?" It would be crazy for medical students not to ask themselves this question. As they look ahead to their de-professionalized place in medicine, their rational conclusion is that they are not going to work for nothing.
Why would anybody want to work in a field where they are just another brick in the wall of corporate medicine. We were all much better off when doctors where independent contractors and there was a modicum of competition in the field. Large corporate medicine with huge chains and government involvement in everything you guys do has decreased your standing in the community, and contributed to the feelings of trust we older folks remember for days past. I pity you guys…
Thanks for showing us a balanced picture of what the field looks like today. As you point out, much of the behavior of trainees is a reaction to a bad system rather than self-centeredness on their part. (Some of what they're asking for makes sense, although expecting to avoid all discomfort does not. I'm not sure what percentage expect/demand the latter). There's been an interesting debate for over a decade now whether younger generations demonstrate more narcissism (the trait, not the pathology) than previous generations. I often wondered, if this was true, whether it was due to K-12 schools well-intentioned effort to boost kids' self esteem starting in the 1980's that was based on a deeply flawed understanding of Carl Rogers' notion of unconditional positive regard (link #1). But I've seen lots of young folks who do not seem overly narcissistic for their age (narcissism declines with age in most people). So I wonder if the second article might be more accurate, as things are usually more complicated than simple stories lead us to believe!
I am a retired surgeon who got out of medicine as the COVID disaster hit medicine like a sledgehammer. Your article was good but only hinted at one of the biggest problems with modern medicine, the corporate capture of treatment. I was a cynic about quite a lot of treatment recommendations made by the “experts” before COVID. Now I don’t know what to believe and always ask myself who or what is benefiting as it doesn’t seem like the patient is first on that list. Until the real scientists who are seeking truth recapture the narrative and demand good evidence in recommendations we will forget the patient in a relentless pursuit of profit.
I am an OB GYN and have been in practice for almost 25 years. I thought the essay was well written.
It is tough to be a doctor these days. Similarly, my contemporaries in other fields of work are struggling too.
The concept of an identity crisis is spot on; being part of a well functioning team is essential. By default we have to be good coaches and critics of the team. I spend a lot of time and energy teaching, coaching and motivating staff. Physicians are still expected however to be perfect and not make mistakes.
I agree that the medical students that I work with have had to do far more than I did to get into medical school. Some trying 2 and 3 times to be admitted and spending thousands of dollars on MCAT courses.
Would be interesting to hear what the author has to say about coaching medical students, residents and seasoned physicians through this odd time.
I love my job and remain hopeful that the practice of medicine evolves into something better. I practice in an rural area and have many patients thank me for continuing to work.
Maternity deserts are real; is frightening what is happening in some towns in obstetrics as well as other medical specialties.
Good essay. One thing I see is that there are no doctors to deliver babies in our area. The one who delivered by granddaughter quit being a baby doctor soon after that. If my daughter has another baby, she will have to go to a hospital 30 miles away. Is this because the doctors are too burned out, or because babies tend to come in the middle of the night and younger doctors do not want to hurt their work/life balance?
I do believe the identity crisis has a lot to do with the problem. It is impossible to be an individual doctor, the Corporations now rule; doctors are required to follow the rules of bureaucrats. The administrators have taken all the fun out of being a doctor.
Interesting essay - not really sure what to make of it. I finished medical training in 1991 - the "golden age" of medicine was already over by that time. As we went into practice, even at that time, the days of "independent private practice" were just about done. My husband and I finished residency and he joined a small private practice in a surgical subspecialty and I joined a large hospital based health care system in primary care. And it has been a struggle over the past 30 years. Him maintaining his private practice has been stressful with extremely long hours and very hard work. My employment by the big system served my purposes for 20 years, but over the last 10 years, became more frustrating for a variety of reasons. I left and started a small private "concierge" style practice 3 years ago. I enjoy this more, but it is still very long hours of stressful work. I've been using Epic for the past 24 years - the EHR failed to make my daily office work easier. The notes have gotten longer, the med lists more complex, the meaningless "quality measure" check boxes more time consuming and onerous. The EHR turned doctor into stenographer and ordering clerk. 24 years in and I actually have to enter MORE clerical minutiae into the system than I ever did before - not a desirable outcome. I have found other technology to be useful overall. I like to text with patients. Texting is how we all communicate these days - why not in medicine? I use My Chart, Haiku, Canto, Telemediq, etc - I'd say these are actually tools that make life slightly easier. Medicine has never been a field where there was a defined work/home line drawn. My understanding was that in the more distant past it was even worse! Patients called doctors at all hours of the day and night. Delays in starting families has been a problem in medicine since women have been in it. Our medical school class was almost half women, so this is not a new issue either. It just wasn't discussed or considered much at that time. Medicine is just a complex field and daily work life is long and stressful. The "golden age" of medicine, when doctors had leisurely lunches at the golf course have been gone for decades (at least 30+ years). The daily "productivity" slog with no time for lunch and hours spent after clinic to complete charts and review information are here to stay unless the entire way we organize and deliver medicine changes. I don't think we need to talk about AI until AI is reliably writing office notes - when I walk out of the exam room at the end of an appointment, I need the note written and orders already placed. That will be a game changer. Until we find ways around the one-on-one office visit as the cornerstone of all medical care, until we find ways to restore some autonomy and camaraderie of past golden ages, the problems noted in the essay will continue. As it stands right now, there is no such thing as "seniority" or "senior partner" in medical practice - the 60 year old is expected to work the same long hours for the same reimbursement in the productivity widget line as the new trainee. Again - unsustainable. Good doctors with a career's worth of knowledge and experience will burn out and retire as there is nothing we are doing to make it any easier to stay in practice. It is really too bad as losing these experienced clinicians does not help anyone. I don't think it solves anything to compare older generations of physicians with current trainees and early-career doctors. What does it matter? we are ALL working in the current system and have been for decades.
“With rare exception, most hospitals get the job done but care gets delivered amidst a bizarre arrangement of disparate towers, phone lines, fax machines, secure messaging platforms, ever changing EMR updates, and the occasional beautiful atrium that tends to overshadow the original ward.”
This line stood out to me the most. It points out not only a medical but a societal issue. On mass we have so many ways to communicate now a days that we should be a well unified but we seem to be more separated and compartmentalized (polarized) than ever. Even with multiple nodes of communication we still can misunderstand each other. And with these quick access forms of communication, one mistake in data or interpretation can lead to a cascade of poor outcomes.
I hope that Part 2 addresses an issue of the need for more doctors. This is seen in the comments by Mary Lamoreaux in reference to lack of access to OBGYN’s.
Lastly the issue of corporate medical care. The line “beautiful atrium that tends to overshadow the old wards” almost made me laugh. My first thought was the image of hospital administration going through the monthly numbers and discussing how to maximize revenue for cath lab and radiology along with increasing revenue for lattes and smoothies in the atrium shops and restaurants.
Looking forward to Part2.
I agree with the first half of the post. Indeed, the cost of attaining formal medical education to completion (whatever that endpoint may look like) is much higher than it ever used to be. At the same time, income has not kept pace with the rise in cost of living. So I don’t doubt that the financial aspects and prospects of the profession are not what they once were for any newcomer on scene.
But I disagree with the general tenor of the second half. The challenges and demands of the modern day practice of medicine are shared equally btw young and old, newbie and seasoned vet alike. If anything, trainees don’t see the brunt of the administrative realities, and they may have some unpleasant experiences in store when they are fully minted, from which they are currently insulated.
It is also fine to admit that medicine may no longer be a calling. It never has been that for me, and I’m 22 years in. I don’t think my contemporaries generally considered it one. That “calling” mindset imo is a relic from the generation before me. And while you can and should seek out all the work-life balance you desire or require, when you’re actually at work, you should expect to be working. And that’s where I see this generation losing the plot. Medicine is hard work, with long hours, stress, performance pressure, and interpersonal challenges…all day…everyday…when you are at work. If you are not prepared to work (or work within that environment and those realities)….maybe this isn’t for you. No one is owed a career in medicine. If you choose to pursue one (and are fortunate enough to have the opportunity)…well, choices have consequences. Welcome to adulthood. “Kids these days” can prioritize “work/life balance “ to their heart’s content, and that’s not the problem; the problem is even when they’re working, they’re a bunch of daisy picking little pansies about it. Examples from the NEJM article- they’re triggered cuz a patient mispronounced their name? They felt unsafe cuz they had to do some scut work? Puh-lease. Grow up already, and grow a set while they’re at it.
Thoughtful piece. As a late mid-career physician I share a lot of the angst expressed herein, and I would certainly discourage many young bright people from pursuing medicine. Not all health systems, regions, or indeed countries have the resources to create teams of 'providers' so your essay has a particularly American bent. I would add that those of us in Canada involuntary exposed to US designed EMRs aren't sending you any warm fuzzies. Thankfully the Patagonia vest wearing private equity weenies haven't yet invaded our space, likely because there isn't sufficient capital to squeeze out of our admittedly inefficient single payer system. Final thoughts.... It is still possible to practice as a quasi-solo mostly autonomous generalist (of whatever specialty) by preference or necessity in a rural area. And Cory, if you haven't yet, you should read "A Fortunate Man" by Berger & Mohr.
Always interesting to hear people's perspectives on these aspects of medicine so few people think about.
I have to agree with most of the responses here. I don't think it's the cost of living, the debt medical school brings, etc, as all of those were true for the boomers +/- in a relative sense. I think what is significant is the answer to the question, "Who am I post graduation?" CDL Nationwide school guarantees who you'll be after graduating - a truck driver. Plumbers Training Institute can guarantee who you'll be a plumber post graduation. Etc. But who is the person who finishes his residency and is ready to practice? These people have put it well, an employee, a puppet for the insurance companies, a slave to EMRs, and who knows what else. And, to boot, if you are a great doctor is there a place for you anywhere, because it's the exceptional doctor who will fill that position you were ready for.
It’s the relatively rapid death of a profession. And the author and commentators have given some of the reasons why. I loved medicine. Still do. Always will. And that’s why i’m still practicing and teaching at age 78. But…Would I do it again in 2024? Sadly no. Who would? No autonomy. No reward. No respect. The best and the brightest aren’t choosing medicine and those that are will be burned out before middle age. Diseases change. Times change. Work changes. One accepts what one cannot control but pines for the days when one was once a “dear and glorious physician.”
Not much room to negotiate these days. Most physicians are employees rather than independent operators. This evolution was inevitable the moment that the government intervened and was predicted by many older physicians when I first entered the field in the 1970s. It is pretty difficult to argue otherwise when doctors are being fired and losing their license to practice because they are using their own judgement and questioning the bureaucratic narrative.
Seems that the elephant in the clinic is the encroachment of the current business zeitgeist of greed is good on virtually every facet of our profession.
If that doesn't breed cynicism I don't know what would...
Who could avoid feeling fractured and discontented knowing that you're just one part of a larger set of widgets for a group of venture capitalists
The basic difference is between medicine as a profession and medicine as a job. In a profession, it's understood that the professionals do labor that is not directly compensated monetarily, but, in exchange, being a professional accords people a higher status in society - respect, esteem, an honorary title ("Doctor So-and-So.") Medicine as a profession passed away in the 20th century, as society rejected professionalism as elitist and paternalistic. Doctors were no longer the apex of the medical hierarchy, but just one of the team of "healthcare workers," which included many people who had not worked as hard or sacrificed as much. Insurance companies gained the upper hand over much of medical decision-making. As a natural consequence of society removing the professionalism benefits, doctors started to wonder, "Why exactly am I doing all of this work?" It would be crazy for medical students not to ask themselves this question. As they look ahead to their de-professionalized place in medicine, their rational conclusion is that they are not going to work for nothing.
Why would anybody want to work in a field where they are just another brick in the wall of corporate medicine. We were all much better off when doctors where independent contractors and there was a modicum of competition in the field. Large corporate medicine with huge chains and government involvement in everything you guys do has decreased your standing in the community, and contributed to the feelings of trust we older folks remember for days past. I pity you guys…
Thanks for showing us a balanced picture of what the field looks like today. As you point out, much of the behavior of trainees is a reaction to a bad system rather than self-centeredness on their part. (Some of what they're asking for makes sense, although expecting to avoid all discomfort does not. I'm not sure what percentage expect/demand the latter). There's been an interesting debate for over a decade now whether younger generations demonstrate more narcissism (the trait, not the pathology) than previous generations. I often wondered, if this was true, whether it was due to K-12 schools well-intentioned effort to boost kids' self esteem starting in the 1980's that was based on a deeply flawed understanding of Carl Rogers' notion of unconditional positive regard (link #1). But I've seen lots of young folks who do not seem overly narcissistic for their age (narcissism declines with age in most people). So I wonder if the second article might be more accurate, as things are usually more complicated than simple stories lead us to believe!
https://www.theguardian.com/lifeandstyle/2017/jun/03/quasi-religious-great-self-esteem-con
https://greatergood.berkeley.edu/article/item/the_surprisingly_boring_truth_about_millennials_and_narcissism
I am a retired surgeon who got out of medicine as the COVID disaster hit medicine like a sledgehammer. Your article was good but only hinted at one of the biggest problems with modern medicine, the corporate capture of treatment. I was a cynic about quite a lot of treatment recommendations made by the “experts” before COVID. Now I don’t know what to believe and always ask myself who or what is benefiting as it doesn’t seem like the patient is first on that list. Until the real scientists who are seeking truth recapture the narrative and demand good evidence in recommendations we will forget the patient in a relentless pursuit of profit.
I am an OB GYN and have been in practice for almost 25 years. I thought the essay was well written.
It is tough to be a doctor these days. Similarly, my contemporaries in other fields of work are struggling too.
The concept of an identity crisis is spot on; being part of a well functioning team is essential. By default we have to be good coaches and critics of the team. I spend a lot of time and energy teaching, coaching and motivating staff. Physicians are still expected however to be perfect and not make mistakes.
I agree that the medical students that I work with have had to do far more than I did to get into medical school. Some trying 2 and 3 times to be admitted and spending thousands of dollars on MCAT courses.
Would be interesting to hear what the author has to say about coaching medical students, residents and seasoned physicians through this odd time.
I love my job and remain hopeful that the practice of medicine evolves into something better. I practice in an rural area and have many patients thank me for continuing to work.
Maternity deserts are real; is frightening what is happening in some towns in obstetrics as well as other medical specialties.
Good essay. One thing I see is that there are no doctors to deliver babies in our area. The one who delivered by granddaughter quit being a baby doctor soon after that. If my daughter has another baby, she will have to go to a hospital 30 miles away. Is this because the doctors are too burned out, or because babies tend to come in the middle of the night and younger doctors do not want to hurt their work/life balance?
I do believe the identity crisis has a lot to do with the problem. It is impossible to be an individual doctor, the Corporations now rule; doctors are required to follow the rules of bureaucrats. The administrators have taken all the fun out of being a doctor.
Good read. We have similar issues on engineering.