The Crumbling Bedrock of the Medical Profession
A respected medical colleague who recently retired offered to buy me a cup of coffee to talk about some “issues.” I was uncertain about the topic, but we met at a local coffee shop where he started with the comment, “Wow, I never really thought about that.”
He was referring to the transition from being a visible, respected doctor who now has the label of emeritus—retiree. He was uncertain who exactly he was and how to deal with becoming obsolete and irrelevant. I’ve been a student of this topic, so let me share with you what I have learned from fellow travelers.
Medical training is much like a merry-go-round. It takes a driven, focused individual who must be obsessive and compulsive to go through this training ordeal. There is typically the four-year college experience in a premed program with an enormous dropout rate. In many medical schools 500 applicants compete for one seat so those students are carefully selected and obviously are driven and focused almost to the point of obsessive pathology.
Following medical school comes an arms race for top residency programs. These might range from two or three years for specialties like dermatology or pediatrics up to eight or nine years for some surgical specialties. Now let’s look at my area of medical oncology.
And following medical school I had an internal medicine internship at the University Michigan followed by two additional years of internal medicine training. Following those three years I had a two-year medical oncology program, and within five years I was board eligible in medical oncology.
There were also two additional years at the National Cancer Institute. Today, those five years are eight or nine. The oncology program is combined with hematology for a four-year program, and almost all graduates of those programs take an additional year or two of subspecialty training in a specific tumor such as lung cancer or breast cancer.
But no one on this treadmill asks this question: What happens when the merry-go-round stops and we have to get off?
With physicians leaving practice at a rate greater than at any time in history and with those remaining in practice decreasing their clinical responsibilities, this question about “what’s next” has become a daily issue of discussion in the doctors’ lounge.
Let me share some reflections and observations from those of us who have been creative and those who been somewhat indifferent to this major life-altering transition.
In my own neighborhood we have a medical petri dish. Here in Rochester, Minn., home of the Mayo Clinic, I am surrounded by nationally recognized professionals in orthopedic surgery, neurosurgery, cardiology, dermatology, and gastroenterology as well as in public policy and technical administration. We are all about the same age although most left practice somewhat younger than I.
Each was convinced and shared with me at the annual neighborhood barbeque or Christmas gathering that they expected they would be asked back for some sort of consulting contract, where their gifts and skills would be shared with the rank and file. Almost to a person, this did not happen. Many had planned their post-retirement years to continue to participate, but their medical talents and drive, which once brought them to the Mount Rushmore of medicine, were now faded and not marketable. In general, they had not anticipated the emotional fallout from becoming irrelevant.
Another story. A major healthcare system outsourced some services. Custodial activities, security, and tech support were outsourced so the health system was not responsible for benefits and vacations, and this arrangement work very well. They also outsourced anesthesia support. Arrangements were made with a 40-person anesthesia group to provide anesthesia in their hospitals. The group was an independent contractor and under the umbrella of a national organization, which handled the administrative activities of the medical staff.
This was an effective arrangement because the physicians could practice anesthesia and did not have to expend energy dealing with legislative, compliance, and regulatory issues. But then the wheels came off. The hospital system told the anesthesia group they were going in another direction. A different group of docs was contracted to provide more efficient and less expensive anesthesia services. Oh, and when the contract with the first group expired, there was a three-year noncompete clause within a 25-mile radius.
The physicians were devastated, disenfranchised, and bitter, but one colleague took advantage of this predicament.
He was in his mid-50s and had always been intrigued by hospice and palliative medicine. The fellowship for that specialty was one year so he sent out a resume and applied for and was accepted in a fellowship. Obviously, cash flow will take a hit, he will cut back on some expenses, but he felt good about this decision, which would not have been possible under most circumstances.
When you wonder where all the doctors went, now you know. They are timed-out by age and not replaced. They are replaced with other contract workers and have had their hands tied. For some, the merry-go-round stops mid-career.
In the iconic novel Death of a Salesman by Arthur Miller, Willy Loman is the tragic salesman. Early in his career he got by with a “shoeshine and a smile,” meaning the power of his personality sealed the deal and brought home the big contract. However, Willie did not look down the road. He did not anticipate the role of technology such as the telephone and ended his own life.
We in medicine need to recognize that the changing medical landscape—the long-term relationships with patients, which have been the bedrock of the profession—are now being challenged, and we need to recognize the importance of being proactive, preemptive, and anticipating what we might do when the merry-go-round is no longer moving.
For my colleagues still in practice, now is the time to plan, to anticipate since none of us are fortune tellers. We cannot predict what may happen, but we can plan for our own career after medicine, as teachers, authors, or something completely different. Is now the time to pursue the elusive dream of travel or teaching? Of mentoring? Of changing medical specialties?
Where does that leave our patients? Most of us care about that a lot.
Edward T. Creagan, MD, FAAHPM, a cancer specialist, is the first Mayo Clinic doctor board certified in hospice and palliative medicine. His new book, Farewell: Vital End-of-Life Questions with Candid Answers, is about navigating those precious last days, at the bedside, and saying farewell with hope, love, and compassion.