Monday, May 16, 2011

What do we owe?

I recently had a discussion with fellow residents, their spouses and friends at a dinner party. We ended up discussing the difficulty of balancing family and a surgical career which brought us to a discussion about two recently graduated female residents who both have young children. They both started out residency very similarly. I had the pleasure of working with both of them and they were awesome leaders and had great technical skills. Both were ironically interested in the same very demanding subspecialty and had done everything necessary to secure top fellowships. Then they both had kids during residency. One went on to pursue her very demanding fellowship and is currently doing well and loving her job. The other finished residency and is now a stay at home mom and also very happy. When we brought up these very divergent career paths it started a discussion about what doctors owe society. One person commented that there is a significant societal costs of training a doctor. In addition, there is a surgeon shortage and therefore a responsibility of those trained as surgeons or any type of doctor, to actually practice medicine. I was surprised by the strong feelings about this issue and felt that personal and family decisions are based on more than these large scale societal issues. Yes - the resident that is not currently practicing as a physician represents some loss to the society. But, I didn’t feel she owed anything to society. She worked hard through medical school and 7 years of residency. She took care of many patients during that time and devoted much of her life to it. In my opinion we all have a right to choose.

What do you think?

33 comments:

  1. Great topic!

    I've heard a lot of people say that women who work parttime or not at all after their training are wasting their education and owe society or whatever. I find this attitude (usually from men) very irritating. First of all, med students pay up to a quarter of a million dollars for their education. Then we continue to work like slaves for YEARS at less than minimum wage. How could we possibly "owe" anything after all that? If anything, society owes us for our years of basically free service! I think women should work after training, if only to recoup some of the money they are owed. I mean, I hope we don't go to med school and do residency just for the fun of those wonderful training years.

    The other thing is that I suspect that SAHM will probably not be a SAHM the rest of her life. I'd guess that once her kids are all in school, she'll go back to work in some capacity. I don't think it's unreasonable to want to enjoy your kids' early childhood, or to not work when your motherhood responsibilities are so overwhelming that you might not be a good physician.

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  2. Hmph. If she went to medical school on a full scholarship, contingent on x years of service afterward, then of course -- she owes it to society to either practice for those x years, or pay back that money.

    But I'll give 10,000,000:1 odds that's not what happened! I love how people always think they're owed something -- if anyone tried to tell me I OWED them service after incurring tens of thousands of dollars of debt to put myself through school, I'd shove it down their throat.

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  3. Agree - we don't owe anything. If anything - I feel like someone owes me a part-time position after all of this so that I can STOP missing moments of my child's life. Furthermore, as a human being with choice of occupation and life decisions available to me in America - it is kind of up to me what I want to do with my life. If I finish med school, residency, and then want to spend my days picking daisies in a field - sorry, but that is entirely my choice. I don't demand that those spending years earning a Master's in Creative Writing churn out a poem personally written to me every month, so why would I owe anything to anyone as a doctor? It's still a choice to work in that profession despite the training.

    Anytime we start talking about owing things ...it just takes away this free will we have in our own life.

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  4. societal cost?

    if society is paying my med school bills -- as in NHSC, or somesuch -- well, sure. but there are legal ramifications from breaking contract there anyway.

    but really, societal cost?!? getting myself 200k in unsubsidized debt for an education is my own cost, and it *certainly* isn't being covered by anyone else.

    is there opportunity cost? sure. do i ought to have a darn good backup plan to pay off the ungodly amount of debt i've racked up in this training, if i decide to be a stay-at-home mum instead? absolutely. but do i owe anybody anything? outside of husband and kids -- no, not a thing, not even an explanation.

    whoever would dare assert otherwise should try to survive a year of medical school -- *while* fronting their own costs, of course, which are on the order of 50k and don't include rent, transportation, or any of that.

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  5. Very good topic. I am in agreement with those above. One of the other arguments I've heard, just to throw the thought into the ring, is that "society" in this country offers only a limited number of training spots available. So, the argument goes, those who don't continue to practice have wasted the opportunity whereas another might have improved our overall community health.
    Devil's advocate. I think it's bunk, personally -- when whoever in charge decides how many medical school slots to allot to each school/state, they should just factor in those who will go part time, stay home, change careers, or work for industry, and not assume we're all going to be primary care doctors in rural Oklahoma or whatever.

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  6. I'm glad to hear what you all think about this. I am starting medical school in the fall, and while I am pretty sure I will want to practice when I am done, I know I want to have children. I know this will be a lot of work, and sometimes I get a little panicky that I won't be able to do it all. To make myself feel better, I tell myself that I could always be a stay at home mom and go back to work later. This probably won't happen, but I think I would still be glad I had gone to medical school just for the sake of the knowledge I gained.

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  7. I don't think they owe anyone anything. I only think a person owes if they go to college on free federal financial aid with the premise that when they get their degree (whatever it may be in) they actually work. For people getting $250K in loans they don't owe anyone a damn thing.

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  8. The only reason that people think a person who chooses not to practice or leaves practice is "wasting their education" is because A) there is a huge doctor shortage and B) more than half the people that apply to medical school don't get in. But the issue isn't that those who are accepted and complete their training owe anything to anyone - it's that the supply of physicians is restricted by the AMA.

    No one complains about lawyers, accountants, or physicists (me) leaving their field to do something else - end the blockade on the supply of physicians in the US and the poor attitude about individual freedom to live as one chooses will evaporate.

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  9. Sounds like there is consensus here, at least among the MiM-population.

    On a related note, as a soon to be med student/parent, I get irritated at hearing (from men) that women should not go into medicine because they tend to work part-time and therefore aren't giving Society the return it deserves for training them. For one thing I myself prefer a female doctor, and imagine that at least a good portion of the population (i.e. women) do. It is equally true that women are more likely to go into primary care. And I would wager that a woman going into primary care and working 3/4 time is doing more for society than yet another specialist. (No offense - of course there is nothing wrong with specialists, but when we are looking at this from "Society's" perspective, there is more value in women working part-time in needed fields than a person of any gender working crazy hours in a less "needed" profession.

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  10. There are studies to indicate that the profession is losing esteem in the eyes of the public. I would argue that sentiment goes hand in hand with the feeling that many young docs have that "this is just a job"

    Now, before I get screamed at: you should have the choice to work as much or as little as you want. The disconnect here is between old perceptions of the societal role of the physician and the new realities of medicine.

    Speaking to how much you pay to be educated: yes the price is high. Just remember that the residency years are still training and the cost of that training is high, indirect and hidden. The money you are paid is low because it is a stipend while you finish your schooling. Not a perfect system but the one we have...

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  11. I decided to go back to med school/PhD because I felt like I had a good brain, and that my talents would be completely wasted in either business or as a mommy. I have no regrets (or children) at this point. But, if you want to be sahm after going through training, more power to you. I really couldn't care less. What about all those people who leave medicine to work for industry or an insurance company? Do people get all up in their grill about depriving society of their dr-ness?

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  12. It costs a heck of a lot to educate and train a doctor. This includes paying for the deficit between tuition and cost-per-student in medical school, as well as all of residency training the bulk of which is funded by the federal government. There are also intangibles costs: the privilege of dissecting a cadaver, access to the bodies and the most intimate secrets of real live people in their most vulnerable moments. That medical students and residents work very hard and make personal and financial sacrifices does not negate the investments, both financial and otherwise, made by society. And as I am starting M1 this fall, I am still idealistic enough to think that I am entering a profession where the public good is being served.

    That being said, I still think everyone has to live his/her own life because we only get one, and if that means quitting medicine to be a SAHM, then so be it. Who knows, that may be me some day. Blustery self-assured (mostly male) docs can talk till they are blue in the face but they never know what is going on for that person who chose to quit medicine, so they are in no position to judge. I also totally agree with Old MD Girl that it is of course the SAHMs who get judged in this way, and not MDs who work for industry or insurance companies. Just the same old double standard that denigrates traditional 'women's work' such as raising children.

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  13. Great topic.
    1) As several here have posted, society does invest heavily in medical students and residents. So do the medical students and residents, but it doesn’t’ cover the cost.
    2) Specialists are needed at least as much as primary care physicians (regardless of all the rhetoric). If you have an aortic aneurysm, you probably don’t want an internist fixing it. Hip and knee replacement surgery returns thousands of people to functional life every year. Primary care physicians are clearly valuable, but please don’t denigrate specialists.
    3) I agree that physicians should be free to decide what they want to do with their life just as much as someone in any other profession. On the other hand, I worry a lot about the SAHMs. Where is the safety net? How easy is it to get back into practice if your partner loses his/her job, leaves you, or dies? I’d much rather see us focus on ways to sustain women physicians in practice than on ways to facilitate their staying home with their children. And in terms of the kids, I think it’s at least as good for a child to have a physician in practice mom as a SAHM. Great role model, opportunity to develop independence and personal responsibility, opportunity to see work as a positive influence in life.

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  14. There are societal issues involved in ANYONE practicing less than full time after med school and training. "TAANSTAAFL and 'Mommy-Track' Docs"

    http://blog.skyvisioncenters.com/?p=428

    When a fully trained physician makes a decision to practice less than full-time, or indeed to not practice at all, someone somewhere always pays.

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  15. I come from a country where in my time in training all education (including med school) was free. Society expected all university graduates to work for 3 years in designated location as a pay-off. Now this was for a salary, but you would get sent to location in need. Not bad considering most such graduates in this country cannot pay off thier debt in 3 years. And I imagine many would agree to 3 years of service in exchange for free medical education/expences paid (as stipend was attached too). So, given this modest payback that existed once upon a time somwhere, I think it is inappropriate to expect US physicians to pay back with their entire life, and work full time till retirement.If society lacks doctors, it should prepare more doctors, and make their professional careers livible with variety of life style choices. You almost feel like you have to apologize if you do not take call, some peers look at you like you are not working. Sorry, guys, I still work longer hours than doctors in my former country, and I am not about to miss raising my kids. One of my great colleauges said :raising kids is your community service. And I regard it as such. We raise responsible citizens for our country.

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  16. I have a suspicion that if more women had opportunities to work part time without the associated stigma, there would be less women choosing to become SAHMs once finished with training. Medicine is still very all or nothing.

    Ladies, don't click the "mommy-track" link above like I did. Holy misogyny, Batman!

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  17. The interesting thing about a lot of the discussion is that it's based on amount of service to pay back society and not on quality of service. As a non-trad pre-med you see this same type of argument that older people won't contribute as long as younger ones so they shouldn't accept older people. But some people contribute more value in a smaller amount of time than other people do over a much longer period.

    That value to society isn't counted in terms of years or hours. It might be the perspective and life experience brought by non-trad or female doc who's had children to reassure a patient, or communicate better to catch a diagnosis. Maybe they have leadership or time management skills from other areas that make them more efficient than their colleagues. Plus, though, I'm not a parent and don't plan to be, I do think there's a societal value to raising kids well.

    While I do agree that the costs to train a physician are underestimated by a lot of people in training, it's also true that there are more ways physicians contribute to society than just seeing patients. Those ways are hard to quantify and there's no way that anyone can say that one deciding to stay home, or go part-time, or write a novel, or design a drug isn't paying society back with those other contributions.

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  18. I thought that Medicare pays about 100,000/ year per resident for training of residents. That is why it is hard to do two residencies, the second one won't get Medicare, ie tax payer dollars to support the training.

    I hate to be devil's advocate, especially since I'm a part time surgeon, but I believe that tax payers have invested in my training. I worked very very hard in med school and residency, but I don't think my hard work 'payed' for my training.

    To be sure, I also feel that I have a social responsibility to do the best I can to raise good children into good adults.

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  19. I don't think "society" gives any med student or resident enough so that the person owes society. I think they are probably robbing themselves, having wasted many years of their own. But I do agree with some posters above, there are very limited spots to get into medical school, and then to get into certain specialties. I don't think it's fair for someone to take that spot if they don't intend to practice. They are robbing the spot from someone else who very much wanted the training and wanted to practice.

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  20. I read that "mommy-track" link above. I didn't find it as horrifying as I thought I would, and I think the blogger makes some good points. The reality is that the number of physicians being trained is not keeping up with the aging and sicker population, and the fact that ALL physicians (male and female) want a better lifestyle. I think a different type of person goes to med school these days than fifty years ago. Maybe the work ethic isn't as good as it was and doctors don't want to be slaves to their work anymore. But I don't see the point of whining about something that nobody can change? What are they going to do... make prospective students sign a paper saying they will work 60+ hours a week for the rest of their lives? Sterilize women before starting med school? What needs to happen is we need to train more physicians (this is already in the works) and more midlevels need to be used to pick up the slack.

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  21. the minute "society" pays for all of my education, time, effort, and hours spent at the hospital, i'd be fine "owing" them something. until then, they should kiss my boots for putting myself through hell just to help them in the best way i know how.

    don't get me wrong, i wouldn't trade this for the world because this really is my vocation, but it just IRKS me when someone tells me that i owe something to society bc i chose to learn to save people's lives.

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  22. I think part of the difficulty of the debate here is the definition of "society." Do we mean the investment of tax dollars in our medical educations or do we mean a much more vaguely defined sense-of-duty type sentiment stemming from the fact we have gained access to a much-needed and respected profession when others haven't?

    I am getting a heavily subsidized education courtesy of state and federal taxpayers. I pay probably 10% of the tuition someone at a private school does. I have loved my education so far and I'm grateful to that I will be able to make a living with it someday. I do feel a sense of obligation to pay this back in some manner since I am gaining so extensively from it.

    As for the vaguely-defined sense-of-duty sentiment...that's harder to say. So few people in any field actually honor the social contracts that they should by being fair and not acting in a self-interested and ethical manner. Some people in medicine don't act honorably (like doctors who order unnecessary tests for patients for personal financial gain). I think the most important thing you can do to "pay your debt" to society is to be a kind, honest person and be good at whatever you do, be it a SAHM, doctor, lawyer, painter, store clerk, whatever.

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  23. Kellie (General surgeon)May 17, 2011 at 11:20 AM

    If and until society pays 100% of training and school (ie leaving physicians with NO debt) then there is, IMO, absolutely no requirement or societal obligation for someone who finishes residency to work as a physician.



    JMO.

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  24. Sunni- I may just be too young to understand, but why does "the public" associate a desire to work fewer hours with a "just a job" mentality? Cant someone be passionate about their patients and believe medicine is a calling without it being her entire life?
    Dr Darrell- the link was interesting, and from am economic standpoint, who'd argue w you? (also, I think you make a great case for why we need to train more drs and make sure said drs have good lifestyle balance.) I don't believe you've proven why I can't have everything, though.

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  25. I don't get what anon found misogynistic about the link either.

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  26. I think this is a tougher issue than most of the comments make it out to be. I was unprepared for how much I would not want to return to work after having my daughter and how fulfilling the SAHM role would be. I think it's rare for women to know exactly how they will feel years in the future about whether they want to be mothers and what kinds of mothering they will want to do. On the other hand, when patients allow us to practice on them, they are giving us quite a gift and they do so for a reason. When my daughter had jaundice and needed blood draws, I allowed a trainee to try (twice) because I felt some obligation to support trainees as I had been supported. I'd have been pretty annoyed if instead of finding him very competent three days later I had found that he had quit. I'm not sure there is a good, humane way to balance these things.

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  27. @barefootmoses- I know it is not fair but public perception of the role of the physician has not caught up with the desire of both male and female physicians desire to have a more balanced lifestyle. When I get asked by teenagers about medicine I tell them I love my job but that the career is not for everyone. Just because you love science and make good grades does not mean that you will love the hours and committment. We have it better in our training system in that we choose much later to go into medicine. We had a comment earlier from someone who trained in another country; they generally choose or are chosen for medicine out of high school. Talk about really not knowing what you are getting into! I don't think I necessarily owe the public my whole life, but we could not be fully trained without taxpayer money or without the patients who allow trainee participation. There is a reason it is called PRACTICE.

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  28. Wow. I'm glad I'm not currently on the admissions committee, because I think I would reject any female applicants except for post-menopausal sterilized nuns.
    Medicine is hard; it's time consuming. It means not only delayed gratification during training years but also some sacrifices during years of practice. This doesn't mean no children. It doesn't mean no vacations. It does mean however, that we cannot lead the life of a 9-5 worker. It's a life of sacrifice but also a life of privilege. Even the debts of a private med school don't completely cover the cost of our training. As others note, residency is largely supported through Medicare money to hospitals.
    I think it's profoundly selfish to occupy a medical school slot and then drop out completely. Certain residencies are more child friendly. Also, I would love to see shared residencies for mothers, which might take twice as long but with half time work commitment. Currently I have two young partners who "job-share" in a busy office while they raise their children. We're all happy with the arrangement, but it still involves night and weekend call, only at 50% of the usual amount. It involves the commitment to go to a child's game or concert, then return to work to finish the day. Hopefully, this sort of work environment will become more common, so that female graduates stay in medicine.

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  29. @Dr. Nana - I appreciate your thoughts, however I think the closing part of your argument shows why the overwhelming response has been in support of women who chose to do what is in their best interest. You describe a beautiful set-up of job sharing allowing for balancing the ability to raise children with the ability to practice this fulfilling career. I'm sure most people wouldn't have a problem if they had to work after going to a child's game or concert, but what we aren't ok with is always giving up the ability to even GO to the recital or concert, or SEE our children awake at least once a day. Job sharing opportunities are FEW and far between. Until we do address the need to 'remix' the system a little, women AND men will continue to leave this field for opportunities for better balance.

    This has really been a great discussion.

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  30. Rach (pre-med student/future mother)May 19, 2011 at 3:07 AM

    Wow - so grateful this topic came up!
    It's funny because I am a pre-med student seriously considering going into specialized surgery....and I also have the very strong desire to be a mother someday. So these situations sound eerily similar to my life. Haha.
    It's good to see all the different views on the subject - thanks for all the discussion and comments! It's so helpful!

    And I've said this before, but thank you for this blog in general. It is so uplifting to be able to see how motherhood and medical careers really can work together...it gives me the strength I need to keep pursuing the path I am on. Thank you :)

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  31. Furthermore, as a human being with choice of occupation and life decisions available to me in America - it is kind of up to me what I want to do with my life. If I finish med school, residency, and then want to spend my days picking daisies in a field - sorry, but that is entirely my choice. I don't demand that those spending years earning a Master's in Creative Writing churn out a poem personally written to me every month, so why would I owe anything to anyone as a doctor.alifula

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  32. @snoring solution: Of course this is a free country. If you so choose, leave the profession. I think it is far better to have people leave than be unhappily tied to the profession. But wrt to what is owed, remember that you were not the only one who paid for your education. You also may have taken an opportunity from someone who may have practiced 40 years. It is your right to choose, but accept that some may look at that decision askance.

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  33. I have been on maternity leave for six months, and when I see a fellow doctor, I get asked, "Are you coming back?"

    I'm still a doctor. I still plan to save lives. But I worked hard, banked up my money, and have a husband bringing home some bacon so I can raise my children and write and live a little instead of burn myself out. You can look askance and you can think I owe you, but I will basically ignore you.

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