I was pre-med in 2003 and started this account in 2004 before med school: why I (probably) would choose a different career if I had to do it over

[Lion-O]

Here I am on a Sunday morning and curiosity got the best of me: I wonder if that old account I had in med school still works? Sure enough, it does, and here I am. I started reading SDN in 2003 and posted intermittently from 2004~2008. I lurk occasionally still under a different name.

But man, I've aged. Reading through my old posts I was probably like you all are now: full of energy and youth and a laser-like focus on getting into and succeeding in med school. And I did that. And then I did residency. And then I've... worked. Worked as a doctor for about 9 years now.

I'm inspired to write this because I regularly work with pre-health students, specifically scribes, who are applying to health programs often including medical school. For many, I've written letters of recommendation. Undoubtedly, pre-med students can often be the brightest, most passionate, driven people I know. I'm genuinely impressed by the amazing, well-rounded folks that medicine draws in.

Here's the thing. Medicine, real-world medicine, is not great and it's getting worse.

As much as I'm tempted to say, "just don't do it," I think that would be hyperbolic. On its surface, what I do is actually pretty good. I enjoy taking care of patients in the field I work in. I take pride in the expertise I've gained over the years, knowing that I'm making a difference in people's lives. The pay is good (some would argue great); I easily support my family, and really want for nothing.

But there's the bad, and there's a lot of it. Don't get me wrong - when I was pre-med, I didn't have the ability to look 15 years down the line. All I knew was that I needed to get into med school, future be damned. I'd let future me figure that out. Well, here is future me reflecting.

Corporations have taken over healthcare: hospital systems, staffing companies, insurance companies. This isn't meant to advocate for government healthcare; I'm just letting you know the current reality. It is unlikely you will open up your own private practice. It is very likely you will be hired by a massive, national corporation who will directly dictate how you practice medicine. They will tell you how many hours to work, how many patients to see in those hours, demand that you oversee undertrained PAs/NPs who you may not trust, and possibly overwhelm you to the point of patient harm. Your practice of medicine will not be doing what is best for the patient, but rather, what is best for your corporation's bottom line. You will constantly be bombarded (daily/weekly) with emails about meeting arbitrary metrics. These metrics frequently harm patients, but they make the company more money. You will struggle with your conscience: do I do what's right for this patient, or do I follow what the company tells me to keep my job?

Tied to the above is the mass proliferation of mid-levels, particularly nurse practitioners. I'm not telling you anything new, but I'm not sure if pre-meds really "get it." Doctors are being replaced by NPs. This isn't scare-mongering, this is what's happening. Five years ago, where I work, we'd have say 50 hours of doctors per day and 30 hours of mid-levels. Today, it's 40 hours of doctors and 40 hours of mid-levels. They are cheaper, and easily make corporations money (see above). Not to beat a dead horse, but NPs are not doctors. They cause harm, real patient harm, and it's only getting worse. I don't need to tell you this - you're applying to med school. But patients think they're doctors. And hospitals prefer them due to economics.

Continuing on this thought, part of the allure of going to med school is to be a doctor, to obtain that title. There's nothing wrong with that. There is no shame in recognizing that you excelled academically, you worked hard, you sacrificed, and you achieved what most others couldn't. Most people have an idea of what pre-meds/med students go through. I know it personally and damn if I'm not proud of each and every person who puts themselves through that journey. And not only that, after you become a doctor, you have to go through residency, an unrivaled training experience that few humans on this planet will ever endure.

Why do I bring that up? There's an active dismantling of respect and reverence toward physicians. Again, this is not exaggeration. Open any medical journal today. They don't say "doctor" or "physician." They say provider, practitioner, clinician. Medical journals, hospitals, insurance companies... you are not a physician. You are now a provider and are no different than NPs or PAs. A small example: where I work, NPs and PAs park in "physician parking." Residents (physicians) do not. This is the world you're entering and it will only get worse.

I didn't even touch on student debt, but please read this: Maximum Student Loan Debt to Salary Ratio | White Coat Investor

Predicting the future is hard, and I admit enough humility to know that I probably can't guess what medicine (or the world) will be like in 15 years. That said, medicine is currently getting worse and my salary is decreasing. I'm actively living below my means and saving money for a future in which I make half of what I do now. I don't know if alternative careers are better, but consider all your options long and hard before jumping into this one...

Maybe I'll log on in 2035 for an update.

---

Members don't see this ad.

 

[and 99 others]

Out of curiosity, why is it less and less feasible for one to start a private practice? I hear this frequently but don't know the logistics.

In terms of midlevel encroachment, I agree it is a pretty pressing issue but also it doesn't seem sustainable. Like you say, unsupervised NPs are actively causing harm to patients. There are multiple studies that show this. This will only increase with increasing independent NP practice rights and after a certain point, the system will implode. Of course, by that point the damage to the patients will be done, but to me it seems like a very fragile bubble.

In any case, thanks for the insights. I could be totally wrong about midlevels but that's just my 2 cents.

 

[EdgeTrimmer]

Out of curiosity, why is it less and less feasible for one to start a private practice? I hear this frequently but don't know the logistics.

In terms of midlevel encroachment, I agree it is a pretty pressing issue but also it doesn't seem sustainable. Like you say, unsupervised NPs are actively causing harm to patients. There are multiple studies that show this. This will only increase with increasing independent NP practice rights and after a certain point, the system will implode. Of course, by that point the damage to the patients will be done, but to me it seems like a very fragile bubble.

In any case, thanks for the insights. I could be totally wrong about midlevels but that's just my 2 cents.

overhead costs and lack of power (compared to big systems) to negotiate rates with insurance companies?

 

[KnightDoc]

Out of curiosity, why is it less and less feasible for one to start a private practice? I hear this frequently but don't know the logistics.

In terms of midlevel encroachment, I agree it is a pretty pressing issue but also it doesn't seem sustainable. Like you say, unsupervised NPs are actively causing harm to patients. There are multiple studies that show this. This will only increase with increasing independent NP practice rights and after a certain point, the system will implode. Of course, by that point the damage to the patients will be done, but to me it seems like a very fragile bubble.

In any case, thanks for the insights. I could be totally wrong about midlevels but that's just my 2 cents.

The logistics are, 40 years ago, private practice is what most people did, so it was the natural path. Insurance companies reimbursed the same no matter where the patient went. You joined a practice or started your own, or joined one and later left to start your own. If you were a true risk taker, you hung a shingle and waited for the phone to start ringing.

Today, insurance companies have networks that you have to join to attract patients. Medicine is big business, and that requires a lot of capital. The corporations that OP is talking about spent the past two generations gobbling up all the private practices. Now you have to compete with them.

They have money; you don't. They have offices conveniently located all over your local area; you don't. They refer patients within their own practice, which covers pretty much anything any patient will need. Where are your referrals coming from? The one octogenarian holdout who hasn't yet sold out to them? He built his practice over the past 50 years. How are you going to compete with the corporations when he decides to retire?

 

[thumbz]

To all the pre-meds and med students out there reading this, (s)he isn't wrong. I'm entering my third year of practice and am really now starting to see and really appreciate the direction medicine is going. I think the only different opinion I have is that, as of right now, I would absolutely do this over again.

Midlevel expansion is real, and although I don't think they will ever truly replace physicians, I do think we will see our salaries stagnate (or decrease in competitive markets) because of it. These days when I call a consultant I more often than not get their midlevel - the other day I talked to a cardiology midlevel who didn't realize Lasix had an effective duration of 6 hours. And this was the person who was supposed to answer my question about advanced heart failure management.

And don't even get me started on the whole provider debacle - I want to scream every time a patient tells me what the "cardiology doctor" told them - which was invariably a midlevel, and most often wrong and would need to be re-explained after the actual cardiologist weighed in and changed the plan. Midlevels absolutely have a place in medicine, but they have overstepped and honestly I think only hurt themselves - the fact that NPs are having to go back to get their DNP to remain competitive for jobs is a shining example of them breeding themselves out of jobs (like lawyers and pharmacists before them).

So what can you do? I wish I could tell you. What am I doing? For now I've put aside my dream of the sports car and the doctor's life, and over the next 3 years I'm picking up every shift I can with a goal of being completely debt free at the end of it. If I can find enough shifts my timeline could be as short as two years. After that, if my salary decreases, if the sky falls, or if an NP replaces me (which can't happen, thank god for the ACGME) it won't matter as my fixed expenses will be around $42k/yr. Given the student loan burden we are all graduating with this means that you two should expect to do a financial residency at the end of your real residency - where you continue to live off of $60k/yr and throw every other dime at your debt. And don't take on a cent of new debt ever again.

 

[KnightDoc]

overhead costs and lack of power (compared to big systems) to negotiate rates with insurance companies?

And even the big systems take big haircuts on what insurance companies pay. Hence the move to NPs and PAs.

 

[HopeP]

Medicine is big business

~18% of GDP. Very inflated, administrative costs are keep going up at the same time medical care and benefits going down. Just like anything else, it will reach its threshold and another bubble hits. Student loans and Healthcare are 2 bubbles to burst in next decade.

 

[EdgeTrimmer]

And even the big systems take big haircuts on what insurance companies pay. Hence the move to NPs and PAs.

Not really, I know people who work in different models (salaried in a big system, practice managed by hospital system i.e. billing percentage and small group) in the midsize metropolitan area I live and they are all doing OK. My spouse chose to go with salary with defined benefits option to have less stress. My son has clear understanding all of this and still chose to pursue medicine.

 

[KnightDoc]

Not really, I know people who work in different models (salaried in a big system, practice managed by hospital system i.e. billing percentage and small group) in the midsize metropolitan area I live and they are all doing OK. My spouse chose to go with salary with defined benefits option to have less stress. My son has clear understanding all of this and still chose to pursue medicine.

Of course they are all doing okay! That doesn't mean insurance companies don't force the systems to accept big haircuts on their charges, and that those haircuts aren't managed by the system through increased use of midlevels, and the pressure OP described to see more patients, perform more procedures, etc. We are totally saying the same thing -- there is no way for a solo to compete with this, even at the same reimbursement rates as the big systems. This is why I'm thinking about specialties (like everyone else) even though primary care is what I really want to do.

 

[EdgeTrimmer]

Of course they are all doing okay! That doesn't mean insurance companies don't force the systems to accept big haircuts on their charges, and that those haircuts aren't managed by the system through increased use of midlevels, and the pressure OP described to see more patients, perform more procedures, etc. We are totally saying the same thing -- there is no way for a solo to compete with this, even at the same reimbursement rates as the big systems. This is why I'm thinking about specialties (like everyone else) even though primary care is what I really want to do.

yes, PCPs seems to be under more stress lately. You can be a Hospitalist if you want to have less stress.

 

[Zorax]

Here I am on a Sunday morning and curiosity got the best of me: I wonder if that old account I had in med school still works? Sure enough, it does, and here I am. I started reading SDN in 2003 and posted intermittently from 2004~2008. I lurk occasionally still under a different name.

But man, I've aged. Reading through my old posts I was probably like you all are now: full of energy and youth and a laser-like focus on getting into and succeeding in med school. And I did that. And then I did residency. And then I've... worked. Worked as a doctor for about 9 years now.

I'm inspired to write this because I regularly work with pre-health students, specifically scribes, who are applying to health programs often including medical school. For many, I've written letters of recommendation. Undoubtedly, pre-med students can often be the brightest, most passionate, driven people I know. I'm genuinely impressed by the amazing, well-rounded folks that medicine draws in.

Here's the thing. Medicine, real-world medicine, is not great and it's getting worse.

As much as I'm tempted to say, "just don't do it," I think that would be hyperbolic. On its surface, what I do is actually pretty good. I enjoy taking care of patients in the field I work in. I take pride in the expertise I've gained over the years, knowing that I'm making a difference in people's lives. The pay is good (some would argue great); I easily support my family, and really want for nothing.

But there's the bad, and there's a lot of it. Don't get me wrong - when I was pre-med, I didn't have the ability to look 15 years down the line. All I knew was that I needed to get into med school, future be damned. I'd let future me figure that out. Well, here is future me reflecting.

Corporations have taken over healthcare: hospital systems, staffing companies, insurance companies. This isn't meant to advocate for government healthcare; I'm just letting you know the current reality. It is unlikely you will open up your own private practice. It is very likely you will be hired by a massive, national corporation who will directly dictate how you practice medicine. They will tell you how many hours to work, how many patients to see in those hours, demand that you oversee undertrained PAs/NPs who you may not trust, and possibly overwhelm you to the point of patient harm. Your practice of medicine will not be doing what is best for the patient, but rather, what is best for your corporation's bottom line. You will constantly be bombarded (daily/weekly) with emails about meeting arbitrary metrics. These metrics frequently harm patients, but they make the company more money. You will struggle with your conscience: do I do what's right for this patient, or do I follow what the company tells me to keep my job?

Tied to the above is the mass proliferation of mid-levels, particularly nurse practitioners. I'm not telling you anything new, but I'm not sure if pre-meds really "get it." Doctors are being replaced by NPs. This isn't scare-mongering, this is what's happening. Five years ago, where I work, we'd have say 50 hours of doctors per day and 30 hours of mid-levels. Today, it's 40 hours of doctors and 40 hours of mid-levels. They are cheaper, and easily make corporations money (see above). Not to beat a dead horse, but NPs are not doctors. They cause harm, real patient harm, and it's only getting worse. I don't need to tell you this - you're applying to med school. But patients think they're doctors. And hospitals prefer them due to economics.

Continuing on this thought, part of the allure of going to med school is to be a doctor, to obtain that title. There's nothing wrong with that. There is no shame in recognizing that you excelled academically, you worked hard, you sacrificed, and you achieved what most others couldn't. Most people have an idea of what pre-meds/med students go through. I know it personally and damn if I'm not proud of each and every person who puts themselves through that journey. And not only that, after you become a doctor, you have to go through residency, an unrivaled training experience that few humans on this planet will ever endure.

Why do I bring that up? There's an active dismantling of respect and reverence toward physicians. Again, this is not exaggeration. Open any medical journal today. They don't say "doctor" or "physician." They say provider, practitioner, clinician. Medical journals, hospitals, insurance companies... you are not a physician. You are now a provider and are no different than NPs or PAs. A small example: where I work, NPs and PAs park in "physician parking." Residents (physicians) do not. This is the world you're entering and it will only get worse.

I didn't even touch on student debt, but please read this: Maximum Student Loan Debt to Salary Ratio | White Coat Investor

Predicting the future is hard, and I admit enough humility to know that I probably can't guess what medicine (or the world) will be like in 15 years. That said, medicine is currently getting worse and my salary is decreasing. I'm actively living below my means and saving money for a future in which I make half of what I do now. I don't know if alternative careers are better, but consider all your options long and hard before jumping into this one...

Maybe I'll log on in 2035 for an update.

Well this has been depressing.

 

[Kardio]

I say this with genuine respect for OP and the thought they put into their update: I have seldom met a seasoned person in any field who recommended their field to me.

 

[EdgeTrimmer]

I say this with genuine respect for OP and the thought they put into their update: I have seldom met a seasoned person in any field who recommended their field to me.

9 years enough to qualify as seasoned?

 

[Kardio]

9 years enough to qualify as seasoned?

It may be a full 1/3 or more of their post-residency career.

 

[efle]

I say this with genuine respect for OP and the thought they put into their update: I have seldom met a seasoned person in any field who recommended their field to me.

You mean in medical fields? I've seen what FAANG gigs look like up close (lived with one of their employees throughout COVID shutdown). I'm only an MS4 and it's already very apparent they made the better choice

 

[Isoval]

This was a very thoughtful post and a lot of food for thought.

I've often had many of these same concerns as a now-third-year student, particularly those of the encroaching NP practice rights. People will cry from the rooftops that NPs will never take over the jobs of doctors, that the patient harm is just too unacceptable. The reality is that a lot of patients are going to have to die before either corporations or legislation make a decisive move to halt mid-level creep. Our jobs are not safe, and neither are our patients.

 

[and 99 others]

I'm curious if OP, and those with the same viewpoint, would have the same view if debt weren't as prominent of an issue. The two most prominent complaints I see about the field is immense debt leading to financial slavery and midlevel encroachment. I wonder if the debt was not an issue, would midlevel encroachment and the looming threat of pay decreases still be enough to dissuade people from entering medicine.

 

[Lasofloxabuterol]

The physicians of today need to stand up for themselves and the physicians of tomorrow. Fingers crossed!!

 

[whataschool_classof24]

I'm curious if OP, and those with the same viewpoint, would have the same view if debt weren't as prominent of an issue. The two most prominent complaints I see about the field is immense debt leading to financial slavery and midlevel encroachment. I wonder if the debt was not an issue, would midlevel encroachment and the looming threat of pay decreases still be enough to dissuade people from entering medicine.

Debt wouldn’t be as big of an issue if salaries didn’t keep getting cut and or if physicians got their true market value of their work

 

[KnightDoc]

I'm curious if OP, and those with the same viewpoint, would have the same view if debt weren't as prominent of an issue. The two most prominent complaints I see about the field is immense debt leading to financial slavery and midlevel encroachment. I wonder if the debt was not an issue, would midlevel encroachment and the looming threat of pay decreases still be enough to dissuade people from entering medicine.

Debt, and the time and effort it takes to become trained and licensed, which also have a significant opportunity cost. Sure, if debt and training weren't an issue, the threat of pay decreases would be tolerable. Is that something that might appeal to you? Hey, I have an idea! Why not become a NP or PA?

 

[Lifeblood_20]

Thank you for this insight. I was not aware of this current state of medicine.
What avenues would you recommend to pre-meds/med students to start building up so that we can influence the field for the better for physicians?
Political activism? Entrepreneurship?

 

[Damson]

@cabinbuilder @OrthoTraumaMD @NickNaylor @Mass Effect @Roxas @jhkmd @ThoracicGuy @VA Hopeful Dr

 

[Kardio]

You mean in medical fields? I've seen what FAANG gigs look like up close (lived with one of their employees throughout COVID shutdown). I'm only an MS4 and it's already very apparent they made the better choice

I’m not saying any sort of x > y

Only pointing out that it’s rare to find veterans of any field who would recommend their line of work to a younger person.

In my limited experience, people with great lifestyles (one in non-FAANG silicon valley, another couple in banking/finance) are more likely to feel unfulfilled than someone in science or medicine (which both come with their own problems).

 

[wondervisions]

I’m not saying any sort of x > y

Only pointing out that it’s rare to find veterans of any field who would recommend their line of work to a younger person.

In my limited experience, people with great lifestyles (one in non-FAANG silicon valley, another couple in banking/finance) are more likely to feel unfulfilled than someone in science or medicine (which both come with their own problems).

No career is perfect

 

[4pf]

Is it safe to assume that such competition and salary stagnation will steer clear of surgical specialties? I'm sure the difficulties in establishing your own practice would remain viable

 

[theonlytycrane]

@Lion-O may I ask what field you're in? (I'm a curious m4)

to all the pre-meds- listen to OP and get out now

 

[KnightDoc]

Is it safe to assume that such competition and salary stagnation will steer clear of surgical specialties? I'm sure the difficulties in establishing your own practice would remain viable

I think it's safe to assume that any specialty that has a favorable supply/demand balance, and that does not lend itself to easily pushing off work onto less skilled practitioners, should be more resistant to these pricing/employment pressures than primary care, emergency care, pediatrics, etc.

 

[NickNaylor]

I've also been on this site essentially since I decided to pursue medicine as a college freshman. Since I got tagged here presumably to provide some kind of comment, here are some thoughts:

1) I don't disagree in principle with some of what the OP says. The corporatization of medicine is a real thing, though I also think that this can be avoided to some degree depending on the setting that you practice in (for example, this does not meaningfully affect my day-to-day work at an academic center). I also agree that role of physicians in general has been devalued and there has been a general "flattening" of the medical hierarchy, though physicians are still "at the top" when it comes to providing clinical care, and my concern about my placement on the totem pole falls every time I work closely with a midlevel and the gulf in competence becomes astonishingly clear. I agree that it can be (and was) demoralizing to do fundamentally identical work alongside a freshly graduated PA/NP who has done less training than you but is getting paid multiples what you're paid. It's unfair and it's not right.

2) All that said, I do think that you find satisfaction in your work if you look for it, and you find dissatisfaction if you look for it. I don't say that to say that you should ignore the downsides of being a physician. I simply say that if that's all you focus on, it will consume you and you will be unable to enjoy those aspects of the job that are truly enjoyable. Work is called work - not fun - for a reason. There is going to be a downside. Disabuse yourself of the fantasy that you will arrive in some kind of Elysium once you finish the marathon that is medical training, because that isn't what's going to happen. There are plenty of things about my job - from the actual job itself to the system that supports it - that I don't like. But, on the whole, I love my job, and I don't regret my choice to go into medicine or become a physician in the slightest.

3) Being a physician entitles you to a lot, and this should not go unnoticed or unappreciated. You are essentially guaranteed an above-average - if not top decile - income if you can simply make it through the end. You will have plenty of opportunities to work in any number of settings with a limitless variety of responsibilities. If you don't like a certain job, you will have the freedom to very easily move to something else (obviously this varies from field to field, but in my field, opportunities abound and changing to a different setting is trivial). You have more potential autonomy in medicine than you do in just about any other career path, and you have a very marketable and valuable skill that you can use to create whatever kind of business you want. Do most people do those things? No - most go on to be employees for Big Hospital System, Inc. because it's the much easier and less riskier path. But that doesn't mean those opportunities don't exist. I never have to worry about "the economy" or what that means for my employment because my work is fundamentally and inherently valuable (to my employer) and not easily replaceable. That is a reality that many - if not the majority - of Americans don't share in. If you are financially wise and make it a priority, you can be entirely financially independent and be able to retire relatively early in your life. Again, that is a reality that many people have no real contact with.

4) Being a physician is not going to result in an automatic golden parachute. As with all things, the people that end up being the most successful - whether it be financially or in other ways - tend to be the ones that work the hardest. This was true when I was in college and applying for medical school and remains true today as a faculty member in an academic setting. If you have an expectation that you will reach the summit by simply completing the training path, you are going to be disappointed. If you expect to be exceptional in your career - again, in whatever way - then your work is going to have to be exceptional. As a very concrete example, I make nearly double the MGMA mean for my specialty. I am on track to get a promotion and laying the foundation to "climb the ladder" in my current institution. Sounds great, right? What you don't appreciate is that I work 6-7 days/week, and many of those days I'm working till 11pm with additional clinical work. I work on presentations, volunteer to do teaching, and on and on to make myself more noticeable within my department and pave the way for other opportunities that can be useful to be in furthering my career. In short, I work my ass off, but I get a very nice reward for doing so (both financially and not). It helps that I really enjoy my work, but I would be lying if I said that I wasn't tired, occasionally burned out, and wondering if the amount of work pays off in the end.

There are any number of "doom-and-gloom" threads from clueless pre-meds to medical students/residents to full-fledged practicing physicians on SDN and elsewhere. You will have no difficulty finding them, and for anyone thinking about going into medicine you should absolutely read those threads because among the forest of hyperbole and hysteria there are kernels of truth. I will simply offer a counterpoint, which is that I love my job and my career and I would make the same decisions if I had to do it all over again. I did not always feel that way, and training was hard. But, at the end of the day, I have no regrets and don't think that I could find the same combination of intrinsic satisfaction or financial rewards doing anything else. I did not feel this way as a medical student or for the first half of residency, but it has become increasingly true as I finished up my training and especially as an attending.

Again, I think many of OP's points are valid and true, and there are many critiques of being a physician posted on other threads on SDN that I also think are true. But I would push back on what I perceive to be the implication that being a physician is simply dooming you to a career/life of dissatisfaction, resentment, and anger. You may feel that way at times - I certainly did. And the path isn't always lovely, satisfying, and fulfilling - there were many times in medical school that I seriously considered quitting because I got zero satisfaction out of what I was doing (and if you dig deeply enough in my post history, you will see these posts when I made them at the time). But with the benefit of a more complete view, I can say with complete candor that I would do this whole crazy thing again. I love my job. For anyone wondering if a career as a physician is "worth it," I would simply respond with a very cautious and guarded "maybe." If you investigate the career and the very real benefits and downsides and, with eyes wide open, you think you are likely to enjoy the work, then I would answer with a resounding "yes." If you are approaching this work with the expectation that you are going to make some fat stacks and be at the top of the social hierarchy but don't find the work intrinsically fascinating or enjoyable, then look elsewhere because you are likely going to be miserable.

 

[Damson]

Thanks Nick for chiming in the A2A

He's psych attending y'all

 

[theonlytycrane]

@NickNaylor 's post should be published somewhere. So good.

I was really just tryna make dose fat stacks doe

 

[NickNaylor]

@NickNaylor 's post should be published somewhere. So good.

I was really just tryna make dose fat stacks doe

Making the fat stacks is ok, and it’s ok to recognize that as a motivation. My main point is that can’t be the primary or sole reason that you pursue being a physician, because if it is, you’re much more likely IMO to find the sacrifices necessary to get there not worth it.

 

[deleted1064759]

He's psych attending y'all

The OP or Nick? I assumed the OP was FM/IM. I asked a local FM physician about encroachment and he just said to have a skill set that no one else can offer, like OMT. He didn't really say it doesn't exist though.

Does any specialist besides anesthesia deal with encroachment?

You mean in medical fields? I've seen what FAANG gigs look like up close (lived with one of their employees throughout COVID shutdown). I'm only an MS4 and it's already very apparent they made the better choice

I also have friends who went into CS and they've said that the culture (FAANG and non-FAANG) can be pretty toxic. For example, SWEs trying to out-work each other by staying later and later and establishing a norm of 12-hour workdays. It also doesn't help with the companies giving you no reason to leave work with in-house gyms and cafes.

 

[EdgeTrimmer]

The OP or Nick? I assumed the OP was FM/IM. I asked a local FM physician about encroachment and he just said to have a skill set that no one else can offer, like OMT. He didn't really say it doesn't exist though.

Does any specialist besides anesthesia deal with encroachment?



I also have friends who went into CS and they've said that the culture (FAANG and non-FAANG) can be pretty toxic. For example, SWEs trying to out-work each other by staying later and later and establishing a norm of 12-hour workdays. It also doesn't help with the companies giving you no reason to leave work with in-house gyms and cafes.

12 hours per day (and weekend work) is normal for SWE jobs at fast growing or startup companies.

 

[PikminOC]

Here I am on a Sunday morning and curiosity got the best of me: I wonder if that old account I had in med school still works? Sure enough, it does, and here I am. I started reading SDN in 2003 and posted intermittently from 2004~2008. I lurk occasionally still under a different name.

But man, I've aged. Reading through my old posts I was probably like you all are now: full of energy and youth and a laser-like focus on getting into and succeeding in med school. And I did that. And then I did residency. And then I've... worked. Worked as a doctor for about 9 years now.

I'm inspired to write this because I regularly work with pre-health students, specifically scribes, who are applying to health programs often including medical school. For many, I've written letters of recommendation. Undoubtedly, pre-med students can often be the brightest, most passionate, driven people I know. I'm genuinely impressed by the amazing, well-rounded folks that medicine draws in.

Here's the thing. Medicine, real-world medicine, is not great and it's getting worse.

As much as I'm tempted to say, "just don't do it," I think that would be hyperbolic. On its surface, what I do is actually pretty good. I enjoy taking care of patients in the field I work in. I take pride in the expertise I've gained over the years, knowing that I'm making a difference in people's lives. The pay is good (some would argue great); I easily support my family, and really want for nothing.

But there's the bad, and there's a lot of it. Don't get me wrong - when I was pre-med, I didn't have the ability to look 15 years down the line. All I knew was that I needed to get into med school, future be damned. I'd let future me figure that out. Well, here is future me reflecting.

Corporations have taken over healthcare: hospital systems, staffing companies, insurance companies. This isn't meant to advocate for government healthcare; I'm just letting you know the current reality. It is unlikely you will open up your own private practice. It is very likely you will be hired by a massive, national corporation who will directly dictate how you practice medicine. They will tell you how many hours to work, how many patients to see in those hours, demand that you oversee undertrained PAs/NPs who you may not trust, and possibly overwhelm you to the point of patient harm. Your practice of medicine will not be doing what is best for the patient, but rather, what is best for your corporation's bottom line. You will constantly be bombarded (daily/weekly) with emails about meeting arbitrary metrics. These metrics frequently harm patients, but they make the company more money. You will struggle with your conscience: do I do what's right for this patient, or do I follow what the company tells me to keep my job?

Tied to the above is the mass proliferation of mid-levels, particularly nurse practitioners. I'm not telling you anything new, but I'm not sure if pre-meds really "get it." Doctors are being replaced by NPs. This isn't scare-mongering, this is what's happening. Five years ago, where I work, we'd have say 50 hours of doctors per day and 30 hours of mid-levels. Today, it's 40 hours of doctors and 40 hours of mid-levels. They are cheaper, and easily make corporations money (see above). Not to beat a dead horse, but NPs are not doctors. They cause harm, real patient harm, and it's only getting worse. I don't need to tell you this - you're applying to med school. But patients think they're doctors. And hospitals prefer them due to economics.

Continuing on this thought, part of the allure of going to med school is to be a doctor, to obtain that title. There's nothing wrong with that. There is no shame in recognizing that you excelled academically, you worked hard, you sacrificed, and you achieved what most others couldn't. Most people have an idea of what pre-meds/med students go through. I know it personally and damn if I'm not proud of each and every person who puts themselves through that journey. And not only that, after you become a doctor, you have to go through residency, an unrivaled training experience that few humans on this planet will ever endure.

Why do I bring that up? There's an active dismantling of respect and reverence toward physicians. Again, this is not exaggeration. Open any medical journal today. They don't say "doctor" or "physician." They say provider, practitioner, clinician. Medical journals, hospitals, insurance companies... you are not a physician. You are now a provider and are no different than NPs or PAs. A small example: where I work, NPs and PAs park in "physician parking." Residents (physicians) do not. This is the world you're entering and it will only get worse.

I didn't even touch on student debt, but please read this: Maximum Student Loan Debt to Salary Ratio | White Coat Investor

Predicting the future is hard, and I admit enough humility to know that I probably can't guess what medicine (or the world) will be like in 15 years. That said, medicine is currently getting worse and my salary is decreasing. I'm actively living below my means and saving money for a future in which I make half of what I do now. I don't know if alternative careers are better, but consider all your options long and hard before jumping into this one...

Maybe I'll log on in 2035 for an update.

Don't forget about the level of responsibility people (lawyers) put on you.

And Ive seen one physician in a corp supervising several mid-level. Not one to one ratio

 

[PikminOC]

To all the pre-meds and med students out there reading this, (s)he isn't wrong. I'm entering my third year of practice and am really now starting to see and really appreciate the direction medicine is going. I think the only different opinion I have is that, as of right now, I would absolutely do this over again.

Midlevel expansion is real, and although I don't think they will ever truly replace physicians, I do think we will see our salaries stagnate (or decrease in competitive markets) because of it. These days when I call a consultant I more often than not get their midlevel - the other day I talked to a cardiology midlevel who didn't realize Lasix had an effective duration of 6 hours. And this was the person who was supposed to answer my question about advanced heart failure management.

And don't even get me started on the whole provider debacle - I want to scream every time a patient tells me what the "cardiology doctor" told them - which was invariably a midlevel, and most often wrong and would need to be re-explained after the actual cardiologist weighed in and changed the plan. Midlevels absolutely have a place in medicine, but they have overstepped and honestly I think only hurt themselves - the fact that NPs are having to go back to get their DNP to remain competitive for jobs is a shining example of them breeding themselves out of jobs (like lawyers and pharmacists before them).

So what can you do? I wish I could tell you. What am I doing? For now I've put aside my dream of the sports car and the doctor's life, and over the next 3 years I'm picking up every shift I can with a goal of being completely debt free at the end of it. If I can find enough shifts my timeline could be as short as two years. After that, if my salary decreases, if the sky falls, or if an NP replaces me (which can't happen, thank god for the ACGME) it won't matter as my fixed expenses will be around $42k/yr. Given the student loan burden we are all graduating with this means that you two should expect to do a financial residency at the end of your real residency - where you continue to live off of $60k/yr and throw every other dime at your debt. And don't take on a cent of new debt ever again.

How is the acgme ensuring a mid-level doesn't replace you? Doctors are cogs

 

[PikminOC]

Not really, I know people who work in different models (salaried in a big system, practice managed by hospital system i.e. billing percentage and small group) in the midsize metropolitan area I live and they are all doing OK. My spouse chose to go with salary with defined benefits option to have less stress. My son has clear understanding all of this and still chose to pursue medicine.

He also has parents that may insulate him from the loan burden or he can ask for money. Not everyone has that

 

[PikminOC]

yes, PCPs seems to be under more stress lately. You can be a Hospitalist if you want to have less stress.

Go to the hospitalist forums. It's about more production and supervising mid-level too

 

[PikminOC]

I’m not saying any sort of x > y

Only pointing out that it’s rare to find veterans of any field who would recommend their line of work to a younger person.

In my limited experience, people with great lifestyles (one in non-FAANG silicon valley, another couple in banking/finance) are more likely to feel unfulfilled than someone in science or medicine (which both come with their own problems).

All it takes is one lawsuit..

 

[PikminOC]

I've also been on this site essentially since I decided to pursue medicine as a college freshman. Since I got tagged here presumably to provide some kind of comment, here are some thoughts:

1) I don't disagree in principle with some of what the OP says. The corporatization of medicine is a real thing, though I also think that this can be avoided to some degree depending on the setting that you practice in (for example, this does not meaningfully affect my day-to-day work at an academic center). I also agree that role of physicians in general has been devalued and there has been a general "flattening" of the medical hierarchy, though physicians are still "at the top" when it comes to providing clinical care, and my concern about my placement on the totem pole falls every time I work closely with a midlevel and the gulf in competence becomes astonishingly clear. I agree that it can be (and was) demoralizing to do fundamentally identical work alongside a freshly graduated PA/NP who has done less training than you but is getting paid multiples what you're paid. It's unfair and it's not right.

2) All that said, I do think that you find satisfaction in your work if you look for it, and you find dissatisfaction if you look for it. I don't say that to say that you should ignore the downsides of being a physician. I simply say that if that's all you focus on, it will consume you and you will be unable to enjoy those aspects of the job that are truly enjoyable. Work is called work - not fun - for a reason. There is going to be a downside. Disabuse yourself of the fantasy that you will arrive in some kind of Elysium once you finish the marathon that is medical training, because that isn't what's going to happen. There are plenty of things about my job - from the actual job itself to the system that supports it - that I don't like. But, on the whole, I love my job, and I don't regret my choice to go into medicine or become a physician in the slightest.

3) Being a physician entitles you to a lot, and this should not go unnoticed or unappreciated. You are essentially guaranteed an above-average - if not top decile - income if you can simply make it through the end. You will have plenty of opportunities to work in any number of settings with a limitless variety of responsibilities. If you don't like a certain job, you will have the freedom to very easily move to something else (obviously this varies from field to field, but in my field, opportunities abound and changing to a different setting is trivial). You have more potential autonomy in medicine than you do in just about any other career path, and you have a very marketable and valuable skill that you can use to create whatever kind of business you want. Do most people do those things? No - most go on to be employees for Big Hospital System, Inc. because it's the much easier and less riskier path. But that doesn't mean those opportunities don't exist. I never have to worry about "the economy" or what that means for my employment because my work is fundamentally and inherently valuable (to my employer) and not easily replaceable. That is a reality that many - if not the majority - of Americans don't share in. If you are financially wise and make it a priority, you can be entirely financially independent and be able to retire relatively early in your life. Again, that is a reality that many people have no real contact with.

4) Being a physician is not going to result in an automatic golden parachute. As with all things, the people that end up being the most successful - whether it be financially or in other ways - tend to be the ones that work the hardest. This was true when I was in college and applying for medical school and remains true today as a faculty member in an academic setting. If you have an expectation that you will reach the summit by simply completing the training path, you are going to be disappointed. If you expect to be exceptional in your career - again, in whatever way - then your work is going to have to be exceptional. As a very concrete example, I make nearly double the MGMA mean for my specialty. I am on track to get a promotion and laying the foundation to "climb the ladder" in my current institution. Sounds great, right? What you don't appreciate is that I work 6-7 days/week, and many of those days I'm working till 11pm with additional clinical work. I work on presentations, volunteer to do teaching, and on and on to make myself more noticeable within my department and pave the way for other opportunities that can be useful to be in furthering my career. In short, I work my ass off, but I get a very nice reward for doing so (both financially and not). It helps that I really enjoy my work, but I would be lying if I said that I wasn't tired, occasionally burned out, and wondering if the amount of work pays off in the end.

There are any number of "doom-and-gloom" threads from clueless pre-meds to medical students/residents to full-fledged practicing physicians on SDN and elsewhere. You will have no difficulty finding them, and for anyone thinking about going into medicine you should absolutely read those threads because among the forest of hyperbole and hysteria there are kernels of truth. I will simply offer a counterpoint, which is that I love my job and my career and I would make the same decisions if I had to do it all over again. I did not always feel that way, and training was hard. But, at the end of the day, I have no regrets and don't think that I could find the same combination of intrinsic satisfaction or financial rewards doing anything else. I did not feel this way as a medical student or for the first half of residency, but it has become increasingly true as I finished up my training and especially as an attending.

Again, I think many of OP's points are valid and true, and there are many critiques of being a physician posted on other threads on SDN that I also think are true. But I would push back on what I perceive to be the implication that being a physician is simply dooming you to a career/life of dissatisfaction, resentment, and anger. You may feel that way at times - I certainly did. And the path isn't always lovely, satisfying, and fulfilling - there were many times in medical school that I seriously considered quitting because I got zero satisfaction out of what I was doing (and if you dig deeply enough in my post history, you will see these posts when I made them at the time). But with the benefit of a more complete view, I can say with complete candor that I would do this whole crazy thing again. I love my job. For anyone wondering if a career as a physician is "worth it," I would simply respond with a very cautious and guarded "maybe." If you investigate the career and the very real benefits and downsides and, with eyes wide open, you think you are likely to enjoy the work, then I would answer with a resounding "yes." If you are approaching this work with the expectation that you are going to make some fat stacks and be at the top of the social hierarchy but don't find the work intrinsically fascinating or enjoyable, then look elsewhere because you are likely going to be miserable.

My brother is an academic doc. He is much more shielded from the troubles of the average doc in a corporate environment

 

[PikminOC]

The OP or Nick? I assumed the OP was FM/IM. I asked a local FM physician about encroachment and he just said to have a skill set that no one else can offer, like OMT. He didn't really say it doesn't exist though.

Does any specialist besides anesthesia deal with encroachment?



I also have friends who went into CS and they've said that the culture (FAANG and non-FAANG) can be pretty toxic. For example, SWEs trying to out-work each other by staying later and later and establishing a norm of 12-hour workdays. It also doesn't help with the companies giving you no reason to leave work with in-house gyms and cafes.

So how's the knifing in medicine? Non-existent?

 

[PikminOC]

The physicians of today need to stand up for themselves and the physicians of tomorrow. Fingers crossed!!

It's not about the Physicians. It's about the corporation.

I challenge the rest of you to post in ten or fifteen years.

This mid-levels garbage is something no one saw coming. And it's horrible. At least you premeds know about it. You're not going in blind

 

[Osminog]

I’ve talked to a lot of doctors. Some of them loved their jobs and were planning on working as long as possible, while others told me that medicine is a crumbling, miserable profession and that they wish they had pursued something else.

There are obviously some major social and economic trends in medicine right now that are significant and worth talking about—but I think that overall job satisfaction (in any field) at least partly stems from one’s personality and general outlook. Many of the physicians who harbor overwhelmingly pessimistic views about the medical profession would likely be just as unhappy in any other career, and the optimistic physicians would likely be just as satisfied if they had chosen another path.

 

[PikminOC]

I’ve talked to a lot of doctors. Some of them loved their jobs and were planning on working as long as possible, while others told me that medicine is a crumbling, miserable profession and that they wish they had pursued something else.

There are obviously some major social and economic trends in medicine right now that are significant and worth talking about—but I think that overall job satisfaction (in any field) at least partly stems from one’s personality and general outlook. Many of the physicians who harbor overwhelmingly pessimistic views about the medical profession would likely be just as unhappy in any other career, and the optimistic physicians would likely be just as satisfied if they had chosen another path.

Pollyanna

 

[EdgeTrimmer]

He also has parents that may insulate him from the loan burden or he can ask for money. Not everyone has that

True, there won't be a loan burden for him. I was talking about going into tech (He has lot of interest in tech) and making money instead of getting into medicine.

 

[Damson]

The OP or Nick? I assumed the OP was FM/IM. I asked a local FM physician about encroachment and he just said to have a skill set that no one else can offer, like OMT. He didn't really say it doesn't exist though.

Does any specialist besides anesthesia deal with encroachment?



I also have friends who went into CS and they've said that the culture (FAANG and non-FAANG) can be pretty toxic. For example, SWEs trying to out-work each other by staying later and later and establishing a norm of 12-hour workdays. It also doesn't help with the companies giving you no reason to leave work with in-house gyms and cafes.

Nick is psych.

 

[Angler]

I think this is my first post on SDN. I've lurked here off/on, and recently signed on to help my daughter (more about this later). I graduated from a six year med program in 1981. I've been a primary care doc for over 34 years. I just retired this year (I had retirement planned before Covid; I just have great timing). I retired because there were a lot of things I wanted to do (like travel, go figure). I started practicing telemedicine urgent care part time after retiring, and I love it.

There have been numerous times in my career that I hated Medicine. Just hated it. Wanted to get home from a difficult day ASAP. A crappy patient, a bad interaction with a colleague, etc.

Also, numerous times that I loved it. Just loved it. Didn't mind spending a couple of hours late in the evening to catch up on work that I felt was very worthwhile. A patient who simply says thanks is often all that is needed to make me smile.

I believe Osminog has it nailed. There will be people who are unhappy and won't be happy until they get out of their profession (hopefully on good terms). But there truly are also docs who love and live their work.

Me? I have the benefit of a retroflexed view now! I can't see myself being satisfied in any other profession. Life isn't meant to be easy. I love problem solving, which is basically all that Medicine is. Hence my username, I love the challenge of fly fishing, which is pure problem solving. Medicine isn't easy; if so, then docs wouldn't be needed. You need to have a basic fund of knowledge; you need the experience to know a horse from a zebra; you need to read personalities and adjust your approach accordingly. This all doesn't come easily.

It is very true; the administrative hassles of the practice of medicine have become onerous. I was in a solo private practice before moving to a large multispecialty group early in my career. I think solo practice (especially primary care) is very challenging, and those administrative hassles which need to be handled alone aren't worth it (but there are those who thrive in such a situation). Remuneration is a huge deal too; I get it, especially for those "cognitive" fields. But I think that physicians, no matter the specialty, will never be poor.

My daughter is now applying to Medical School. She's seen the good and bad in me over many years -- does this count as "shadowing?" I've never encouraged her to apply; she's too stubborn to listen to me anyway. But I am beyond ecstatic. She has the personality that will do well. She's a people person; she loves a challenge, the harder the better. Since I've got some free time, I enthusiastically read SDN posts to help her. If I thought Medicine were a lousy field to enter, I would actively steer her away.

 

[HuskyMD Emeritus]

I think this is my first post on SDN. I've lurked here off/on, and recently signed on to help my daughter (more about this later). I graduated from a six year med program in 1981. I've been a primary care doc for over 34 years. I just retired this year (I had retirement planned before Covid; I just have great timing). I retired because there were a lot of things I wanted to do (like travel, go figure). I started practicing telemedicine urgent care part time after retiring, and I love it.

There have been numerous times in my career that I hated Medicine. Just hated it. Wanted to get home from a difficult day ASAP. A crappy patient, a bad interaction with a colleague, etc.

Also, numerous times that I loved it. Just loved it. Didn't mind spending a couple of hours late in the evening to catch up on work that I felt was very worthwhile. A patient who simply says thanks is often all that is needed to make me smile.

I believe Osminog has it nailed. There will be people who are unhappy and won't be happy until they get out of their profession (hopefully on good terms). But there truly are also docs who love and live their work.

Me? I have the benefit of a retroflexed view now! I can't see myself being satisfied in any other profession. Life isn't meant to be easy. I love problem solving, which is basically all that Medicine is. Hence my username, I love the challenge of fly fishing, which is pure problem solving. Medicine isn't easy; if so, then docs wouldn't be needed. You need to have a basic fund of knowledge; you need the experience to know a horse from a zebra; you need to read personalities and adjust your approach accordingly. This all doesn't come easily.

It is very true; the administrative hassles of the practice of medicine have become onerous. I was in a solo private practice before moving to a large multispecialty group early in my career. I think solo practice (especially primary care) is very challenging, and those administrative hassles which need to be handled alone aren't worth it (but there are those who thrive in such a situation). Remuneration is a huge deal too; I get it, especially for those "cognitive" fields. But I think that physicians, no matter the specialty, will never be poor.

My daughter is now applying to Medical School. She's seen the good and bad in me over many years -- does this count as "shadowing?" I've never encouraged her to apply; she's too stubborn to listen to me anyway. But I am beyond ecstatic. She has the personality that will do well. She's a people person; she loves a challenge, the harder the better. Since I've got some free time, I enthusiastically read SDN posts to help her. If I thought Medicine were a lousy field to enter, I would actively steer her away.

I am just slightly behind @Angler in years of practice and close to but not quite retired yet. I agree with you. My undergrad major was EE, it was interesting and challenging but not what I imagined I would be doing. Medicine was always my 1st choice and I actually thought medical school was easier than undergrad. After so many years and looking back even without rose colored lenses, I have no regrets. I think medicine has gotten much much more difficult (from getting into medical school, then residency and fellowship, to actual practice as an attending) for all the reasons everyone has stated, and the patients are really sicker. Yet at the end of the day (or career), I still think this was the best career choice. The majority of my practice has been patient care, but along the way, lots of teaching and administration. Medicine definitely provides opportunities to advance in multiple directions, but you have to put in the hours and weekends. Yes there are definitely lots of maddening frustrations especially if you're in administration, but like @Angler said, when a patient says thank you, it makes a huge difference. Recently a patient who was critically ill from COVID-19, on ventilator, the works, was about to be discharged. I went to decannulate his trach. He cried and kept on saying thank you over and over. It definitely made all the bad days worthwhile.
By the way, my daughter just graduated from medical school. I did not do anything to encourage or dissuade her either but medicine is also her passion even after seeing my long hours and haggard look after work.

 

[NickNaylor]

The OP or Nick? I assumed the OP was FM/IM. I asked a local FM physician about encroachment and he just said to have a skill set that no one else can offer, like OMT. He didn't really say it doesn't exist though.

Does any specialist besides anesthesia deal with encroachment?



I also have friends who went into CS and they've said that the culture (FAANG and non-FAANG) can be pretty toxic. For example, SWEs trying to out-work each other by staying later and later and establishing a norm of 12-hour workdays. It also doesn't help with the companies giving you no reason to leave work with in-house gyms and cafes.

Most fields of medicine are going to have some degree of "encroachment" going on. This is true in psychiatry as well. At my institution, it seems like there are endless hiring of midlevels but not too much hiring of physicians. I primarily work on an inpatient unit, and if I put in a consult, no matter what the service it's more likely that a midlevel is going to see a patient. When I occasionally work on our consult service on the weekend, I rarely deal directly with a physician as midlevels function more or less like residents and do all of the scut work. In our own clinic, we have expanded the number of midlevels working in the clinic dramatically while the number of physicians has been relatively stagnant.

I can't speak to other fields though I imagine what I'm about to say is generally true. In psychiatry, most patients - at least the ones I deal with - know the difference between a midlevel and a physician, and most prefer to see a physician, given a choice. For basic, run-of-the-mill issues, the truth of the matter is that a midlevel is just as capable of managing a problem as a physician. While there are some great midlevels - I work with a few in our ED and on our ECT service, they are truly on their game and are great clinicians - there is a clear difference in quality, and most patients are aware of it. On the flip side, there are some physicians that are terrible and I wouldn't refer anyone to them, and I have little doubt that a midlevel can provide better care to a patient than them. You distinguish yourself as a MD from midlevels not because of your title but because of your expertise (particularly for more challenging cases) and how you interact with patients. If you don't make this value add known, then a patient should very rightfully wonder why they are seeing you rather than a cheaper midlevel (and an employer should have similar concerns on the hiring side). Especially in psychiatry, many midlevels have a superficial understanding of the pharmacology and certainly can't do psychotherapy to any meaningful degree. They aren't able to work down a treatment algorithm and seem to lack the ability to reconsider diagnoses despite their treatment plans clearly not succeeding. They are excellent at referring out when they run into roadblocks rather than trying to problem solve and rethink their approach. I used to be extremely worried about midlevels - and to some degree, I still am - but the more that I work with them, the more I feel comfortable with my own job security and the role of physicians generally.

Again, you must make your value as a physician known when dealing with patients if you expect them to see your unique training as valuable. This is a service industry. If you went to two restaurants, one run by a Michelin star chef that trained at a prestigious culinary school and another run by some guy who taught himself how to cook at home, does paying more for food at the former make sense if you don't like what's being served or the experience sucks? Of course not, and you should feel like you're getting ripped off. Medicine is no different. As @Angler said, doing this is hard work and it is tiring, but that's what is necessary. If you offer nothing special as a physician that can't be obtained from a midlevel and simply expect that people will see you as special because you have MD/DO at the end of your name, then you should be worried about encroachment.

 

[deleted804295]

Here I am on a Sunday morning and curiosity got the best of me: I wonder if that old account I had in med school still works? Sure enough, it does, and here I am. I started reading SDN in 2003 and posted intermittently from 2004~2008. I lurk occasionally still under a different name.

But man, I've aged. Reading through my old posts I was probably like you all are now: full of energy and youth and a laser-like focus on getting into and succeeding in med school. And I did that. And then I did residency. And then I've... worked. Worked as a doctor for about 9 years now.

I'm inspired to write this because I regularly work with pre-health students, specifically scribes, who are applying to health programs often including medical school. For many, I've written letters of recommendation. Undoubtedly, pre-med students can often be the brightest, most passionate, driven people I know. I'm genuinely impressed by the amazing, well-rounded folks that medicine draws in.

Here's the thing. Medicine, real-world medicine, is not great and it's getting worse.

As much as I'm tempted to say, "just don't do it," I think that would be hyperbolic. On its surface, what I do is actually pretty good. I enjoy taking care of patients in the field I work in. I take pride in the expertise I've gained over the years, knowing that I'm making a difference in people's lives. The pay is good (some would argue great); I easily support my family, and really want for nothing.

But there's the bad, and there's a lot of it. Don't get me wrong - when I was pre-med, I didn't have the ability to look 15 years down the line. All I knew was that I needed to get into med school, future be damned. I'd let future me figure that out. Well, here is future me reflecting.

Corporations have taken over healthcare: hospital systems, staffing companies, insurance companies. This isn't meant to advocate for government healthcare; I'm just letting you know the current reality. It is unlikely you will open up your own private practice. It is very likely you will be hired by a massive, national corporation who will directly dictate how you practice medicine. They will tell you how many hours to work, how many patients to see in those hours, demand that you oversee undertrained PAs/NPs who you may not trust, and possibly overwhelm you to the point of patient harm. Your practice of medicine will not be doing what is best for the patient, but rather, what is best for your corporation's bottom line. You will constantly be bombarded (daily/weekly) with emails about meeting arbitrary metrics. These metrics frequently harm patients, but they make the company more money. You will struggle with your conscience: do I do what's right for this patient, or do I follow what the company tells me to keep my job?

Tied to the above is the mass proliferation of mid-levels, particularly nurse practitioners. I'm not telling you anything new, but I'm not sure if pre-meds really "get it." Doctors are being replaced by NPs. This isn't scare-mongering, this is what's happening. Five years ago, where I work, we'd have say 50 hours of doctors per day and 30 hours of mid-levels. Today, it's 40 hours of doctors and 40 hours of mid-levels. They are cheaper, and easily make corporations money (see above). Not to beat a dead horse, but NPs are not doctors. They cause harm, real patient harm, and it's only getting worse. I don't need to tell you this - you're applying to med school. But patients think they're doctors. And hospitals prefer them due to economics.

Continuing on this thought, part of the allure of going to med school is to be a doctor, to obtain that title. There's nothing wrong with that. There is no shame in recognizing that you excelled academically, you worked hard, you sacrificed, and you achieved what most others couldn't. Most people have an idea of what pre-meds/med students go through. I know it personally and damn if I'm not proud of each and every person who puts themselves through that journey. And not only that, after you become a doctor, you have to go through residency, an unrivaled training experience that few humans on this planet will ever endure.

Why do I bring that up? There's an active dismantling of respect and reverence toward physicians. Again, this is not exaggeration. Open any medical journal today. They don't say "doctor" or "physician." They say provider, practitioner, clinician. Medical journals, hospitals, insurance companies... you are not a physician. You are now a provider and are no different than NPs or PAs. A small example: where I work, NPs and PAs park in "physician parking." Residents (physicians) do not. This is the world you're entering and it will only get worse.

I didn't even touch on student debt, but please read this: Maximum Student Loan Debt to Salary Ratio | White Coat Investor

Predicting the future is hard, and I admit enough humility to know that I probably can't guess what medicine (or the world) will be like in 15 years. That said, medicine is currently getting worse and my salary is decreasing. I'm actively living below my means and saving money for a future in which I make half of what I do now. I don't know if alternative careers are better, but consider all your options long and hard before jumping into this one...

Maybe I'll log on in 2035 for an update.

You sound miserable. Maybe you should open up a private practice and go rural so you don't have to deal with all the bureaucratic stuff.

 

[deleted804295]

Out of curiosity, why is it less and less feasible for one to start a private practice? I hear this frequently but don't know the logistics.

In terms of midlevel encroachment, I agree it is a pretty pressing issue but also it doesn't seem sustainable. Like you say, unsupervised NPs are actively causing harm to patients. There are multiple studies that show this. This will only increase with increasing independent NP practice rights and after a certain point, the system will implode. Of course, by that point the damage to the patients will be done, but to me it seems like a very fragile bubble.

In any case, thanks for the insights. I could be totally wrong about midlevels but that's just my 2 cents.

It's hard to open up private practice in inflated suburbs/cities due to difficulty getting patient base, malpratice and overhead costs.

Many of these issues can be circumvented by having a PP friendly specialty ie psych or going rural.

In the past all doctors weren't concentrated heavily in one area so this is part of the problem.