Jill*, a neurologist who completed her fellowship last year and has been in practice as a member of a large university-based physician group in the Midwest for the past 18 months, wishes she had not selected neurology as her career.
She was first struck with the realization when she began to interview for employment and learned about expected work hours and salary structures.
“I think I became disenchanted with medicine, in general, the further I went in my training, but when I started my job search, it became suddenly obvious to me how much I had really sacrificed for this career,” she said.
Her former college friends had been working for eight to ten years at decent jobs, had already paid off their undergraduate student loans, and had 401ks in the $200-300,000 range. ”Here I was at the age of 35, sitting with $160,000 in medical school debt, and only about $5000 in a Roth,” she added.
Jill is far from alone. A Merritt Hawkins survey released in October revealed that 52 percent of residents owed at least $100,000 in student loans, 41 percent owed at least $150,000 and 19 percent owed $200,000 or more (up from 6 percent in 2008).
The survey, which was sent out to about 10,000 final year residents and fellows in a wide range of specialties, but did not include neurology, also asked if they would study medicine if they had their education to do over again, or if they would select another field. Of the over 300 physicians who responded, 29 percent stated that they would select another field, up from 18 percent who had replied to a similar survey it had conducted in 2008. While neurologists who had recently completed their training responded mostly positively to an informal similar inquiry by e-mail, there were quite a few who expressed buyer's remorse.
It's not just financial realities that have weighed heavily on newly-minted neurologists, but also the recognition that their lifestyles are demanding compared to those in many other specialties, several told Neurology Today. “I missed out on most of my children's first few years while working 60-80 hours per week during my residency,” Jill explained. “My family was looking forward to my graduation as a point when we could finally spend some time together…unfortunately, that didn't really happen.”
“I want a break,” pleaded a neurologist who recently completed his residency, and regrets entering medicine altogether. “It's the long hours, being on my pager all the time, and having to do CME on my little time off,” he explained.
“Neurology patients are sick, asking for a miracle and fast fix that does not exist…I'd probably choose dermatology if I could do it all over again. There's more success in treatment, happier patients, and a much better quality of life,” another wrote, and yet another lamented the difficulty in obtaining research funding and a perceived eroding respect for physicians as among the reasons for his regret for not having chosen another profession.
Jill is still working over 60 hours a week, especially when covering the neurologic inpatient service. For the first year, she brought a lot of her work home because she had nine half-day clinics per week, leaving one half day to proofread dictations, call patients, work on her research and prepare lectures, she said.
It's not just the absolute time commitment that dismays new trainees in neurology, but also the shock of having to spend so much of it on business issues for which they were not prepared during their residencies and fellowships. Indeed, in the Merritt Hawkins survey, almost one half of residents (48 percent) said they were unprepared to handle the business side of medicine, and only 9 percent said they were very prepared to handle the business side of medicine. The majority of residents (56 percent) said they received no formal instruction during their medical training regarding medical business issues such as contracts, compensation arrangements, and reimbursement methods.
Jill said that she is frustrated by decreasing reimbursements and the amount of work that neurologists perform that is not reimbursable: hours of paperwork, answering phone calls, speaking with other physicians, writing letters for patients, for example.
“I really didn't enter this profession to think about the money all the time, but it feels like that is all I can think about,” she admitted. ”We are constantly hearing about how to document accurately so that we can claim a certain billing code, and how to enter an order so that it gets paid properly,” she explained. ”I just want to take care of patients; I really didn't expect to be doing so much paperwork, most of which was not even discussed during training.”
A DIFFERENT PERSPECTIVE
Seasoned neurologists may be more content in their career choices. In response to a similar query posted on www.neurolist.com, a longstanding neurology listserv run by Michael H. Rivner, MD, the posts were nearly unanimous in favor of choosing neurology again.
Howard R. Krauss, MD, replied: “I have had the privilege of helping a few tens of thousands of people and contributing to the education of thousands of medical students, residents and physicians in practice, each of whom, hopefully, will help tens of thousands of patients, so thus I have, or will directly or indirectly, help tens of millions of people; I could not possibly think of a more rewarding endeavor.”
After 28 years in practice, Dr. Krauss, a neuro-ophthalmologist and clinical professor of ophthalmology and neurosurgery at the David Geffen School of Medicine at University of California, Los Angeles, is saddened to witness neurologists fighting increasingly tough battles, not with disease, but with gatekeepers, utilization review coordinators, and regulators in order to advocate for the well-being of patients. Although he has gladly taken that as his duty to his patient, he finds that clearing the cogs out of what had been an efficient mechanism of medical and surgical practice wearisome. “The boulders given to us Sisyphean physicians keep getting heavier,” he summed up.
Perhaps even sadder, he suggested, is that the new generation of doctors may be schooled to represent the interests of society — however that will be defined by the “protocols of care” — before the interest of their own patient who sits or lays before them, and sadder yet that the doctors of the future may need to pledge allegiance to their employer above and beyond their allegiance to their patient.
While the practice of medicine will undoubtedly continue to change, many new graduates find themselves making compromises to accommodate their fledgling careers. After a few months, Jill decided that her time at home was more important and vowed to not take work home anymore. She cut back her clinics to seven half-day clinics a week and said that while still not perfect, it is getting better. It also meant a salary cut.
“If I didn't have the large debt, I would feel better about cutting back hours, transitioning to another career, or moving to private practice where I would have more control,” she reflected. ”I am constantly reconsidering my situation and might be looking to make a move in the next year or two; I am still brainstorming what will happen at that time. Meanwhile, I fantasize daily about something different, something where I can use all of my talents, enjoy what I do and truly have time off.”
Dr. Avitzur, a neurologist in private practice in Tarrytown, NY, holds academic appointments at Yale University School of Medicine and New York Medical College. She is an associate editor of Neurology Today, as well as the editor-in-chief of the AAN Web site, AAN.com, and chair of the AAN Practice Management and Technology Subcommittee.
E DITOR'S NOTE: Thirty-four neurologists who completed their training in 2009 and 2010 e-mailed responses to this story query about career satisfaction. Nearly 25 percent of the respondents said they would have chosen another field if they had a chance to do things over, but most respondents said they would choose neurology again. The responses here, largely anecdotal, are not intended to reflect a scientific sampling of attitudes. Due to the sensitivity of their current employment situations, several neurologists agreed to be interviewed only if their names were kept anonymous. Still, others had e-mailed their responses — expressing dissatisfaction with their career choice — but did not respond to requests for follow-up interviews.