Saturday, April 2, 2011

Doctors Want a Life: A GOOD THING

The New York Times has an article up titled “More Physicians Say No To Endless Workdays” (April 2 2011), which features an emergency room physician, the daughter and granddaughter of long-time practicing family physicians. She had originally planned to go into practice with her father in her small hometown, but for several reasons decided to go into ER instead, and after she had twins, she took a salaried position as a part-time ER doc.
Basically, the author explores this cultural shift in medicine: more and more, doctors are turning away from regular practice and more towards part-time or shift work. More and more, doctors want to be able to go home at night, with no risk of being called in, or called, at all. Doctors want a family life, and this may be linked to the fact that more doctors than ever before are women, and moms.
The article is interesting and timely- but what is more interesting to me, and sometimes, frankly, disturbing, are the comments.
The comments attached to an article like this are a window into the room where our patients are talking.
Some comments were supportive of the trend, and they say things like “I say YAY! Good for docs, good for us! I'd rather be seen, whether in an ER or a clinic, by someone who is not overwhelmed, not heading towards burnout, someone who can still love their job because they have time to have a life.” But others says things like, “If an individual who has chosen a medical career as a physician is unhappy with the number of hours s/he must work, I would suggest changing to a position where family time is valued, say as a greeter at a Walmart”.
The opinions range from positive to brutal. One person described the young woman in the article as belonging to “a cadre of physicians who have little interest in putting patients needs before their own.”
Ouch, THAT stung. If I’m a primary care doc and I work part- time, and I value my family and my baby, does that somehow signify that I don’t care about my patients, that I don’t belong in medicine? Could it possibly mean that medicine needs me, needs moms and our viewpoints and experiences? Could it signify that I provide better care, because I have balance and can be present with my patients?
I wanted so much to grab a sympathetic doc and discuss this article, and the way these comments made me feel. And I realized, that’s Mothers in Medicine.
Here is the link to the article and the 51 comments. I want to read YOUR comments!

22 comments:

  1. I saw the article and I was encouraged by the fact that the majority of comments were supportive of doctors being rested and having lives outside the hospital.

    I found it interesting, and disheartening, but perhaps not surprising that the NYT editorial staff chose to highlight the most incendiary of the comments. In particular these included the comments you mentioned in which readers said that doctors who wanted to work fields that had reasonable hours were lazy and selfish.

    I really do feel that I am able to do a better job with my patients when I am well rested and have something to look forward to in addition to more time spent in the hospital.

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  2. I saw the article but haven't had time to read the comments yet. I think this is a good trend- I think that it's important for everyone, physician or not, to have a work-life balance. I'm considering pediatrics and once I have kids, would definitely want a half time position- especially since my future husband wants to be a surgeon.
    As for people who think the woman in the article is selfish for her decision, well, those are probably the same people who think all physicians are rich as well.
    Thanks for posting on this!

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  3. Oh, for pity's sake. If they want dedicated folks who will work all the time they'd have to PAY for somebody to do that. I fully expect in my lifetime that there will be no more primary care doctors and everyone will have to see mid-levels unless they need a specialist, and even then they'll have to see the specialist's mid-level before they see the doctor--oh, wait, that's already true in a lot of communities...

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  4. I also read this article and felt the need to share it with other physicians, particularly other mothers in medicine. The comments reflect just what the article suggests: a shift in the attitudes between physicians and patients. That necessarily means that not everyone is on the more modern side of things, like the commenters you highlighted. These comments aren't surprising; we hear them all the time from the "old school" docs who think that things should never change, but it doesn't make it sting any less.

    These shifts are undoubtedly for the better of both physicians and patients. It will just take a while for popular culture to catch up with common sense.

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  5. I saw the article this morning and I'm glad you put up the link. I didn't think the comments were THAT bad... some were kind of brutal, but those people were clearly kind of dumb. (I liked the guy who said that women worked less, then said that as a result "5 men are the equivalent of 4 women". Hmmm.) Most of the comments were pretty supportive, I thought. And I don't think they should have highlighted Dr. Dewar saying that primary care was boring, because really, that has nothing to do with anything. Different people find different fields boring. I hated working in the ER.

    It's nice that there are people out there who work 24/7 and love every minute of it, but there aren't a lot of people like that. I think most commenters seem to understand that an overworked physician is not a good thing. Moreover, the separation of PCPs and hospitalists is beneficial in a world where inpatients are sicker and sicker, and care is more complicated. Would the Dr. Dewar from 60 years ago be able to manage ICU patients now? Probably not. The amount of medical information available now dwarfs what it used to be and that's another reason for the change. You can't know "everything" anymore.

    All in all, I do think people in general are more supportive of physicians having lives.

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  6. I read this article and was kind of surprised that anyone still thinks that doctors SHOULDN'T have lives outside of medicine. I wouldn't want to go to a burnt-out, overwhelmed physician and I don't want to be one either--that's why I work 3/4 time. It's not selfish to want to have a normal, balanced life where you have time to enjoy and nurture your family.

    I think the outdated way that a lot of people in the US think that every doctor must a be a self-sacrificing Marcus Welby is just one more way our health care system is broken.

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  7. I'm not a doctor yet - but that is what I plan on doing with my life. But while I've always wanted to work in medicine, I've also always had the strong desire to be a mother. I love this blog because it's helped me see how it's possible to fulfill both of those roles at once, and I'm no longer afraid of pursuing the career I've been dreaming of :) And this article was also inspiring to me for the same reason. I want to be a mother when I have children, and this shift towards more part time work would allow me to do just that. Thanks for sharing :)

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  8. I think Dr. Dewar was unfairly skewered in some of the comments as being lazy and selfish for what I clearly see as a lifestyle/personality choice. Reimbursement in primary care these days is abysmal, and it is tough to blame her for not being able to assume a legacy that doesn't exist, in our current ways of practicing medicine.

    In my medical school, certain individuals entered into primary care contracts - they got their tuition paid and were bumped up on the waiting list because the agreed to do primary care and serve. Most of the people I know that signed these contracts ended up hiring fancy lawyers to get them out so they could pursue the subspecialty they fell in love with during their medical training. I'm not sure if these contracts, which seemed sketchy to me at the time, are still allowed.

    Lifestyle choices, such as ED and anesthesia, where you can hang your hat up at the end of the day are alluring. In pathology, we are expected to come in and finish our cases even if we are on vacation, as long as we are in town. Luckily for me - this can often be done during the daylight hours and not in the middle of the night - part of the reason why I chose this field.

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  9. When I left my full-time, community-based family medicine practice just over 5 years ago, because I was nearing burnout and realized if we ever wanted to have a child I'd have to make changes (kind of hard to get pregnant when you're home late and exhausted every night, and when you're 35 already you get stressed that there isn't much time left), my patients had a variety of responses (probably similar to the article and comments, which I was afraid to read). Probably most patients were supportive, but some were adamantly negative with comments like "how dare you do this to me? this is so inconvenient for me". I heard from a colleague that when one of her co-workers cut down his patient load (by random draw actually, which is another story), he asked an angry patient whether she would rather he continue to work at his unreasonable pace until he died from a heart attack or similar, and the answer was "yes, because at least then you'd be my doctor for a while longer first". (at which point he apparently felt no guilt whatsoever about letting that patient go ;-) ). My impression overall has been that society in general is very much self-centered, and if you dare do anything for yourself (even just for sheer survival) that might inconvenience someone else then *you* are the really selfish one, not the person who expects you to perform superhuman feats/work unreasonable hours/etc.

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  10. I am so grateful to the thoughtful, wise, reasonable group that has posted these positive and reaffirming comments to my post! I wanted to get on here sooner, but my husband and I were up much later than usual with Babyboy, who we think is cutting his molars, seeing as every chance he got he would grab our fingers and gnaw on them. Small protruding baby teeth are sharp! Ouch. But now I am reading these and I thank everyone.

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  11. I didn't read the article, but here's my two cents. I cannot get in to see my family physician. I think she's great, but what good is a physician who's unavailable?

    I often wonder who she sees, because she is clearly not seeing sick patients. Yearly checkups? Acute illnesses that require monthly rechecks? I'm really not sure. All I know is, my family has to see the nurse practioner when we are sick.

    My opinion? I really don't care how much you choose to work, as long as your patients get seen by a doctor. Go ahead and work part-time, but hire other physicians in your office to cover for your absence. When my child is sick and has a fever of 104, I don't want to see the nurse practioner...I want to see YOU or someone with your credentials. So hire enough physicians so I don't have to wait a month to see you.

    Also, I have to comment about the excessive wealth of specialists. One commenter said that medical students hired lawyers to get out of their primary care contracts to pursue the subspecialty they fell in love with. If primary care physicians made as much as the specialists, they wouldn't have to find that second love... would they? Greed has a way of rearing it's ugly head no matter what your profession is (ie. Charlie Sheen requesting 2.2 million per episode so he can provide for his family).

    Primary physicians are under paid, end of story. Specialists? You'll never convince me (or most of the general public) that medical students specialize because of their love for the human urinary tract or bone structure. Their 'strong like' is for something green...and it's not phlegm.

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  12. Dr. Dewar's qualification of primary care rubbed me the wrong way, and I am not going into primary care. I've wanted to be a surgeon since before I started kindergarten (long story). If primary care paid a million dollars a year and surgery paid $100K, I would still choose surgery.

    Color me cynical... but if primary care started paying $400K a year from July of this year, legions of medical students, residents, and even practicing physicians would suddenly begin waxing poetic about the incredible amount of gratification they would derive from the deep, meaningful relationships they develop with patients in primary care, and how ensuring a hypertensive diabetic patient is well-controlled and has high quality of life for decades would make them feel professionally "complete", and how they cannot imagine doing anything else in their professional lives.

    I am not at all saying that all physicians who opt into other specialties would have this attitude, but not a small number would.

    As far as the work-life balance - doctors need to have a life outside their jobs, without equivocation. Thankfully, this is being accepted by most sensible people and the culture is definitely shifting. However, what does make me sad, (and I'm not some grumpy 90-year-old man who longs for "the way things were" by any stretch of the imagination), is the fact that not only have medical students and hordes of doctors stopped seeing medicine as a calling, and a noble one at that, but they actively dissuade, belittle, mock, berate and bully those who still see it as such.

    I am significantly older than the vast majority of my classmates and have life experience in spades, so it is not naivete or young idealism that makes me feel that medicine is a calling for me. I dare not express this around classmates, residents or attendings for fear of becoming the subject of intense ridicule and derision. I have never felt that others must share my views or passions and would never dream of demanding that, but I fear the pendulum is swinging too far in the other direction. In my experience, more and more, if you don't agree that medicine is just a job and you should be able to work as few hours as you'd like so you can get to the more important things in your life, then you are seen as the enemy. I can’t tell you how many times I have had this “JUST A JOB” phrase practically spat in my face.

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  13. White Coat Dreamer- I am with you. I wanted the high stress low remuneration job of academic oncologist since college. Could I have chosen private practice particularly part time? Of course. This is a regular ongoing conversation with my business man husband. "Why are you not valued enough to be paid more." But I love it, in spite of the hours away from my kids and the school plays and field trips missed. But you are right, it is an anathema to say you have an avocation.

    While I completely agree that we should be able to work and have lives, no one seems to acknowledge that patients come to us in need. And sometimes, that need might need to come before our own.

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  14. Ack. I was worried I would inflame, with that comment. PB - I realize that there are doctors out there who get sucked into drug companies and over-utilize procedures and medication for $ - reading about this makes me sick.

    But I also think it is wrong to lock someone into a specialty before they are exposed to everything. You laugh at urinary tract and bone loves, but as a general pathologist (good at everything, great at nothing) who is often overwhelmed by the amount of knowledge I need to function on a daily basis, I can see the appeal of subspecialization.

    Don't we all get jazzed about using our knowledge to help patients? We would not be human if we didn't. I can't tell you the number of times, since I've been in practice, that I have called in sitters/missed soccer games for emergency apheresis procedures/helping to get a diagnosis on someone in SVC Syndrome/dealing with time limited important specimens to triage for flow and genetics/I could go on and on.

    Is it so wrong for people that give up a large chunk of their adult lives incurring massive debt and neglecting friends/family to want to have a little compensation? Most doctors do not live in mansions anymore. We just want to pay our bills/student loans, have some time with our families, save up for a nice vacation, and eat out every once in a while. Not so different from the rest of the world. And that doesn't mean that we don't love to help our patients, whose needs often get placed before our own and our families.

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  15. On another note... As a board-certified emergency physician, I do sometimes wonder about all the promotion of ED as a "lifestyle" specialty. Granted, I'm in academic EM, where my weekly workload almost doubles the 32 hrs/wk quote in the article; but even as a resident, when I would work 45 hrs in a bad week during my PGY4 year, the constant changes in circadian rhythm were TOUGH. And that was pre-kid, in my early 30s.

    I think that as (a) ED docs get older (and less able to change with the overnight and evening shifts), and (b) ED docs' kids get older (and more likely to have athletics, concerts, and school, making evening and weekend shifts even less desirable than they already are), many many people who come to the specialty for the "lifestyle" will start looking for something else. Indeed, I know of many ED docs in their 40s-50s who are moving to urgent care, or getting trained in "chronic pain" and occupational medicine, in order to have a more predictable 9-5 schedule. Honestly, it's part of my calculus, too; the desire for a more regular schedule is part (though far from the major) reason I pursue research.

    So... Although I 100% back the idea that physicians have a right to a life/family, I am scared about people choosing a specialty *purely* for the lifestyle. They will often be disappointed in the long run. You have to choose it because you love what you do. And you have to recognize that even the most apparently cushy specialty will have drawbacks.

    (That said, I will be the first to admit that it is easier to go part-time in EM than in many specialties, assuming you have a practice group that is supportive!)

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  16. I am a part-time family physician with a 2yr old and another one on the way. I took a salaried position as well and work at a low income clinic with mostly illegals and uninsured patients. During the 3 days I work per week I feel completely burned out and exhausted, and I'm so thankful for the 4 days I have off with my family. I am happy that I spend more time with my son than with my career as that is what he needs most from me right now. My 'job' with my family is indispensible, unlike my job at the clinic.

    I'm actually one of those people who naturally has an easy time balancing without feeling guilt or caring at all what other people think. I am happy I can both do what I love (medicine) and have a family. Whenever I feel a pull towards the unbalanced side (like opportunities to teach and take courses) I just feel sick to my stomach. I feel perfectly balanced right now and that is how I am able to help my patients best. I have a lot of female patients whom I counsel, the majority of whom are mothers...I say this ability to balance helps me help them better.
    I say BOO to all those negative comments!

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  17. There are so many patients who whine about doctors who can't empathize with them, that their doctors aren't caring people. But then when that doctors wants to cut back on hours so they don't get burnt out, so they can have the emotional reserve to be empathetic, and so they can be a person not a medicinal robot, the same people start complaining. Some people will just complain about everything, they're not worth listening too. I say hurrah for doctors who want to take on fewer patients, and less hours.

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  18. MLR thank you for your comments. From the perspective of a resident who (even in the era of 80 hour work weeks) in many ways still lives in the hospital, the life of an EM doc seems attractive and easier in many ways. From my perspective, only in my 5th year - post training - of emergency medicine with 2 little kids, it's not exactly an easy lifestyle choice. 2 weekends per month indefinitely is a tough thing to ask your family to swallow, in addition to all the nights. Certainly other aspects of emergency medicine make balancing family easier, in that I can switch shifts etc which my husband who is also in medicine can't do, there is a major sacrifice. Burn out worries me.

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  19. I thought the vast majority of the comments were positive, understanding and suppostive. It seems to me that the shift in attitudes has already happened for the vast majority of doctors, patients, and general population.

    There will always be a few that cling to a romanticised version of the past. But mostly, the debate seems like much ado about nothing...

    I personally never got how it supposedly makes you a better doctor if you suffer. That's just BS, in my opinion. I trained in another country where this mentality does not exist. This country's health care system has an excellent reputation. It pays doctors considerably less than here, yet enough enter the profession to export doctors to other countries. Because medicine is an incredibly rewarding profession.

    And don't tell me I can't relate to or empathize with my patients because I work 9-5. Of course I can! I can empathize BECAUSE I have the time to listen.

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  20. I won't quote the "good old days" when 100-120 hour work week was the norm for my residency. But I do think the pendulum has swung a little too far in the opposite direction. I was precepting a first year med student in my office recently, and a patient called at 4:45pm for a severely painful rash on her forehead. Question - was it only on half? Yes. So I suggested she rush in and she said she could be to the office by 5:15. I told the med student she had a chance to see her first Zoster, a rash she'll never forget. Student said - "I don't think I'll stay after 5. I got up early this morning (maybe as opposed to the rest of us who sleep late???); I had an exam. Then I came to your office. So, I'm tired and I think I'll go home. Hard to imagine she'll survive even the clinical years.

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  21. I liked the article. (I couldn't access the comments though - not sure what I did wrong.) I think it did a good job of showing the generational differences. Like it or not, these changes are here to stay, and certainly I know that I'm part of that trend.

    I specifically looked for jobs without inpatient call, because I found it to be too much of a burden in terms of family life. I do primary care and enjoy it, although for me I think it's more of a job and less of a calling. Nevertheless, I really do find satisfaction in helping people manage their diabetes, blood pressure, giving children their vaccines, etc etc. At some point in the future I may get bored and want to switch, but for right now, I'm paying back debts, live pretty comfortably, and enjoy developing relationships with patients and their families.

    The cultural change really is interesting. The older doctors definitely think that us younger doctors are wimps, but I think for the most part they accept this cultural change in medicine.

    To give you a perfect example, my residency program had always been really old school. We had the traditional overnight call, q3 in the ICUs, and interns even wore short white coats because finishing internship was a badge of honor that meant you could switch to the longer white coat. The issue of interns wearing short white coats had been debated again and again, and was never changed. Lo and behold, a few years ago, the program did not fill and they had to scramble to fill the rest of the spots. The program directors/leadership were shocked. That was a difficult year of a lot of "soul searching" and changes. Finally the program reinstituted night float, did away with traditional overnight call on the wards, got rid of the short white coats, etc. So like it or not, they had to get on the bandwagon and make changes in order to attract top doctors to the residency program.

    There are still a lot of gung ho students and residents though, who will go the extra mile to show you their enthusiasm in learning. I'm sorry to hear about Dr. Nana's medical student experience, but it's probably not all that uncommon. Certainly the decrease in work hours means residency may have to be lengthened, but that may be the price we pay to continue training competent doctors.

    Thanks genmedmom for an interesting post!!

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  22. @ Anonymous 12:26am: In many ways EM is awesome - it is indeed flexible, and to my mind there is nothing as stimulating. But one has to choose it with one's eyes open to the drawbacks. Just as derm, surgery, & peds (to list a few!) have their drawbacks. There is no "perfect" specialty -- just the one that fits you (your nature, your interests, your lifestyle needs) best.

    For me, I chose - and still love - EM for a number of reasons. It has incomparable variety, a huge public health potential (we are the only people who see everyone, regardless of ability to pay), and pre-kid it fit my night-owl tendencies. I love the people I work with; there is much less mean-ness and pimping than in some other specialties. And best of all, if I'm ever on an airplane I won't hesitate to admit that I am a doctor ;). Of course, others may hate EM for some of the same reasons! The lack of call is nice but it is attainable in other specialties, with the right negotiation.

    .... But to go back to the original topic, I am so glad that this article was published and is now an acceptable, discussable topic. I think we are all better physicians for being aware of our needs as human beings.

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