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After the Match

After the Match

Does More Money Make EPs Happier? Here's a Hint


Cook, Thomas MD

Emergency Medicine News: May 2020 - Volume 42 - Issue 5 - p 18
doi: 10.1097/01.EEM.0000666320.47139.5f
    career, salary, career satisfaction

    Humans relentlessly pursue the abstract concept of happiness. Some do so in hedonistic ways, while others pursue goals they think will make them happy in the future (e.g., medical students and residents). Typically, this delayed gratification strategy is tethered to the prospect of a higher income, and the conventional thinking is that more money begets more happiness.

    Research on human happiness over the past several decades, however, generated a consistent and surprising finding: There is a limit to how much money you need to maximize happiness. Despite the common assumption that one can never have enough money, once someone earns above a certain income level, he may become less happy.

    Two somewhat conflicting theories dominate the discussion on how much is enough. The first theory holds that there is a decrease in the positive effect at higher levels of income. One research paper stated that emotional well-being is reached at an annual income of around $68,000, and income satiation occurred at approximately $95,000. It's like drinking beer: You feel better and better with the first couple, but then you do not get the same degree of euphoria with each subsequent bottle. (Nat Hum Behav. 2018;2[1]:33,;;

    The other theory is a bit more depressing for those craving lots of cash: Making more past a certain income level makes you more and more unhappy. Using the beer analogy again, you start to throw up after a few too many, and the fun is over. (;

    So why do some individuals pursue so much wealth? For hypercompetitive people (like many medical students and nearly everyone on Wall Street), they look for metrics to compare themselves with their peers. Beating the others in their group is important to their self-esteem. It is grade point averages and test scores while in school. Folks with great SAT and USMLE scores are likely to drop those numbers in casual conversations with their peers. But after residency, those metrics are moot, and they instead use materialistic markers like wealth for comparison.

    The Devil of Debt

    Unfortunately, it can be challenging for medical students, residents, and physicians to avoid the pitfalls associated with the pursuit of greater levels of income. Most of us make a deal with the devil of debt from the moment we enter higher education. Some may say that you have to spend money to make money, and time and again we are told that the best investment a person can make is in his education. But new graduates matriculating into residency training are forced to think about how they can maximize their income as soon as possible seeing that the median four-year cost is $232,800 for public medical school and $306,200 for private institutions. (AAMC. August 2017; Discussions about seeking happiness over gold get drowned out by student loan interest rates that average at about six percent. (Six percent on $300,000 is $18,000 per year.) (Credible. Feb. 26, 2020;

    There is limited comfort when financial advisors tell medical students not to worry because they will make plenty of money. Entering the workforce with more than $300,000 of student loans, a car loan, a growing family, and a mortgage will make any reasonable person apprehensive.

    Add to these two impressive (or oppressive) workforce trends dominating the emergency medicine marketplace: too many EM residencies and a dramatically increasing number of advanced practice providers. A wave of potential labor is churning its way through EM academia like never before, as I have detailed in past columns. (“The Unchecked Growth of EM Programs [and No Sign of Stopping],” EMN. 2019;41[10]:1;; “The Invasion of the Physician Assistants,” EMN. 2019;41[12]:1;

    It is difficult to predict the impact of 75 new EM residencies and 246 physician assistant schools on the supply and demand for jobs, but there are a lot of frayed nerves out there. I participated in a medical student symposium on matching into emergency medicine last month, and more than one question dealt with whether there will be enough jobs for aspiring emergency physicians when they graduate from residency in 2024.

    I have also seen some of my residents with a keen interest in fellowship training pass it up to make hay while the sun shines. They feel they will forfeit not only $200,000 of income but also a great job that might not be available when all those new residency grads and APPs hit the streets.

    There is also the reality that chasing material wealth has made many, many physicians fantastically unhappy. Saddled with debt from school and perceiving the need to have a big house, beautiful cars, and private school education for the kids, emergency physicians choose jobs based on income rather than the potential for happiness. It is all too easy to think that just a couple more shifts each month will allow them and their family to get what they want in a specialty where one day of work can generate more than $2000 of income. All experienced emergency physicians have seen the guy working too many shifts for too long to satisfy the beast of overconsumption, when in reality what he needs is to arrive home happy and healthy to share his life with his family.

    In the end, the dangers associated with this phenomenon are higher than ever. Medical schools will continue to jack up tuition simply because the market will bear it; it is a highly lucrative business for universities. On the flip side, corporate medicine is desperately looking to control costs to maintain profitability, and stabilizing labor costs is a massive component of this. In the end, it is the residents (and eventually the physicians) who will pay more and make less. They must carefully realign their expectations of material wealth with whether they need so much in the first place.

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    Dr. Cookis the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound ( Friend him, follow him on Twitter @3rdRockUS, and read his past columns at

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