“What is wrong with physicians?” (from the comments)

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?

That is all from Sure.


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