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Do physicians owe society a longer practice lifetime?

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  • Do physicians owe society a longer practice lifetime?

    Enjoyed the latest podcast with PhysicianOnFire.  I was intrigued by the question he was asked by WCI about whether he might feel guilty about retiring early after all the training he received and if he "owed" society something by practicing longer.  I thought his answer regarding the amount of taxes he has paid was valid.  I also thought about how many physicians are retiring early because the practice of medicine has changed a lot during the last few decades.  Many of us did not sign up for the current practice model.  If "society" feels we owe them something and should be practicing longer, maybe "they" should be looking at fixing the problems that exist that are making physicians leave the workforce.  You can't change the rules of the game and expect everyone to keep playing.

  • #2
    Unless society is paying for someone's medical education, owing something back isn't much of a question to me.

    The more common comment I hear is that doctor's who have trained forever want a chance to actually practice for a long time BECAUSE of how long they trained.  That keeps people working in bad situations out of a sense of obligation, not to society, but to their past selves.

    The concept of a sunk-cost isn't something most doctor's learn about, which is why that feeling is so pervasive.

    However since most doctor's who hate medicine as a whole do not have an alternative way to make a six-figure income and aren't able to achieve FIRE at a young age, they aren't going to leave medicine regardless of their happiness.

    Then the key is bending the curve so you enjoy your job, not quitting your job or saying you have to stick around because you owe it to society.
    An alt-brown look at medicine, money, faith, & family


    • #3
      Short answer for me is yes. I recognize that this is an unpopular opinion in a free society.

      Society has a need for good doctors to keep practicing.
      I want someone around to take care of me when I'm older. As to whether society contributes to a physician education, most residency salaries come from Medicare funds. Education occurs at universities that generally receive public funds. I would argue they at least contribute something.

      But rather than frame it as a debt, it is more of a shared responsibility in my view. I am greatly saddened when I see so many who appear greatly disillusioned and want to get out as soon as possible. Certainly the expectations these days are daunting.

      Note that I don't include PoF or WCI as I read that they intend to practice at least part time for a significant amount of time yet. I think that is very reasonable. Cut back hours, enjoy other hobbies. Remain engaged rather than resentful.

      Life is long, if you are lucky.
      If you are a physician, you have been blessed with intelligence, focus, work ethic, reasonable health. You delayed gratification for a long time.
      If you hate your job, at least be sure it's not just the specific job you have that is the problem. Move to a different environment. Retrain yourself. Work part time.

      I don't think we necessarily owe it to society. But you owe it to yourself. And society loses if too many physicians retire completely at too early an age.

      It's interesting to me because we have a couple older surgeons in our multi specialty group who can no longer operate. They are financially independent and choose to work every day in the clinic. I couldn't imagine doing that. When I ask them, they say their identity is in being a physician. They couldn't imagine not doing it. We have retired physicians volunteering as guides to wheelchair people out of the hospital.

      There is certainly a generational shift in how physicians perceive themselves. I think I'm in the middle, but I see evidence of continued shift away from people viewing medicine as a calling.


      • #4
        I never really thought of this but I don't think I'll "quit" when I am able to.

        FWIW, there is a dearth of derms who can and want to practice medical dermatology. In that sense, I do feel my services are "needed." However, I am looking forward to when I can work as much or as little as I want and not be "told' I need to see X amount of patients per week to keep the dept afloat. I'd love to be able to spend more time with patients and not care so much about the bottom line. Not too too far off.



        • #5
          No, its ridiculous as a concept. You dont owe anyone anything. As long as I have to pay for the schooling, the upkeep, and be liable for its practice its 100% up to me.

          If society wants to start protecting their supply of physicians maybe they should stop treating them as enemies and ways to a insurers pocketbook. I agree its an important issue, but as usual too many docs take the ephemeral, stoic, and "calling" type road to the overall detriment of everyone involved, phsyicians and patients. Things have to be more collaborative and collegial if it is expected to go on.

          Its totally ridiculous to have someone be on the hook for the bill and at risk for others bad choices and then tell they have to stay in said position due to duty. Thats nuts.

          If anyone wants to start paying my bills, etc...I will gleefully consider your opinion on a great many ways of how I comport myself, until then....


          • #6
            How long is enough? What if PSLF does work and I get 300k forgiven by the taxpayer, does that mean I need to work x number of years (other than the 10 years for PSLF) to pay back my share and not feel guilty anymore? What about the doctors that had a career before medicine and are starting out in their 40's or even 50's, are they supposed to put in 30-40 years to repay society?

            I just don't see it as being a valid question. Most of us got into medicine to help people, realizing that we would have to go through many years of education beforehand. Once we're practicing and haved helped people our mission has been accomplished, regardless of how many years we continue to do it. At that point it just becomes a job. Hopefully its a job that you enjoy, brings you fulfilment, and allows you to be the patient's best advocate to recieve the highest standards of care while providing excelent bedside manner, but still a job, and once you no longer feel called to perform that job, and have the means to move on to other commitments that make your life feel complete, then do it.


            • #7
              I love caring for my patients. And it is a privilege to provide them my expertise.

              But I have no loyalty to the "Big brothers" that now shadow each encounter.

              1) EMRs that blanket the screen with suggestions and distract your thought process

              2) Coding to benefit the hospital or the corporation to maximize reimbursement and ignoring the harm of coding bloat

              3) Early AM Phone calls by hospital case managers to change "observation" to "inpatient" regardless of the diagnosis since we are at 48 hours.

              4) Variable hoops and hurdles for pre authorization when there is always a easy way around but no one wants to tell you about it

              5) Clinical Review Units that focuses on denials and not the image they present nor the extra days wasted.

              6) Hospitalist medicine (I am a hospitalist and guilty) has in some ways ruined it

              Be nice just to be able to treat the patient and the extra "mirror patients"

              Thus difficult to continue when you use to know what was comprehensive and satisfying medicine in the early years.

              Ready to give it up to the new doctors.



              • #8
                On the owing it to yourself front, why would staying in medicine be the only way to satisfy that? I feel like I owe it to myself to at some point pursue something else intellectually at some point. I dont "hate" medicine, but I also dont find it particularly interesting either. Maybe I chose the wrong field, but its just not that difficult or challenging from a medicine standpoint.

                Lots of other things that seem more challenging and worthy of my time.


                • #9
                  That was an interesting question, and both WCI and I will have a lot more to say on the topic in an upcoming post on this site.

                  I'm sure some of you have read it already, but Dr. Segan wrote a guest post "Confessions From a Physician Who Failed Early Retirement" that was published on my site yesterday. He suggested that early retirement is ethically a questionable move, which generated quite a few comments. Most rejected the idea, some more strongly than others.

                  From EnjoyIt (EM physician):

                  "As for the ethical question regarding physicians retiring early is a load of rubbish. We have no ethical obligation to society. If society wants to have physicians work more, then society needs to make it easier to practice medicine. Currently our system is making the job progressively more difficult. I have been an attending for less than a decade and my workload has changed dramatically is such a short time. My biggest reason for FI is not to be forced into relying on a paycheck from a system that appears to be getting worse on a yearly basis. As one of the posters above wrote, if the physician lounge was giving away retirement vouchers, half the hospital would be empty the next day. If so much change happened in the last 10 years, I can’t fathom what it will look like a decade from now. I truly feel bad for the up and coming physicians who have no idea what they are getting into with their $350k debt."

                  From The Happy Philosopher (radiologist):

                  "There are certainly many reasons to not retire early and you make many valid points (3-7), however I will turn my full fury on your assertion that retiring early is ethically questionable.

                  “Your behavior for about a decade in medical school and residency implied to others that you were in medicine for the long term. While you did not formally sign a contract to practice medicine for 30-40 years your behavior certainly implied that that was your plan. “

                  This statement uses guilt and shame to make people feel bad about leaving medicine. I strongly believe attitudes like this do great harm to people who want to leave medicine for many reasons that you or I may not fully understand.

                  No one goes into medicine thinking they will retire early unless they are insane. When people decide to retire early it is because medicine is not for them. They are not happy. No one should feel any guilt or shame for leaving the profession.

                  As you may have guessed, this attitude is a pet peeve of mine. We do not have an obligation to work a single day as a doctor. We do have an obligation to ourselves to be happy, and to be the best version of ourselves that we can. I pose the following questions:

                  Is it ethical for someone to go part time or quit because they are burned out or suicidal?
                  Is it ethical for a woman to quit medicine to be a SAHM?
                  It is ethical to retire at 50? 55? 60? What age it is “ethically appropriate” to retire?
                  Is it ethical to change your mind if you don’t like being a doctor and think you can contribute to society in another way?

                  There are many problems that arise when we start questioning the ethics of people wanting to quit a job."


                  • #10
                    EMTALA says that I need to see anyone who comes in the door.  State says that I should (possibly MUST, depending on current bill in legislature) accept a payment that will not reflect fair market rates.  I guess the next step will be a law that physicians can't stop working...wouldn't that be the icing on the cake.


                    • #11
                      A resounding NO.  People keep forgetting (and need to be reminded from time to time) that this is a free market, we have free choice, and we all make decisions that optimize our own/family's utility.  If that means to continue to practice medicine, then so be it.  But if one is miserable, or finds that they want to leave medicine early to be with their family more (for medical reasons or otherwise) how is it remotely reasonable to question their ethics?

                      And why physicians?  Because they received a government subsidy for their residency?  Are they not paying this back in spades to the government and its coffers on the back end?  Do they not suffer under the 6.8% loan regime set up by our government?  Is the reason for high tuition and the needs for loans not the government itself?  Spare me the "you didn't build it or get there on your own" crap.  If we're going to take that approach then every person getting tax credits should be obligated to keep working to support our government with tax revenue.  Every person joining the military who had their tuition paid for should not be allowed to get out before the 20 year mark.  Let's not stop there.  Let's obligate any NIH researcher to keep working until they die.  Or better yet, since people would die in waves if we didn't have angiocaths, let's make any person working for a company that produces angiocaths not be able to retire early.

                      Physicians provide a service - an important one.  But to assume that we are up on the mountain top while everyone else in our daily lives is somehow less important to the general function of all is ludicrous on many levels.  We don't function without the maker of the CT scanner, the janitor who cleans up the hospital, the makers of brick that built the building, the nurses around us, the makers of communication devices, the pharmaceutical industry, and so on.  On net, the sum of individual choices will signal something to the marketplace - a need or lack thereof.  And the market will respond appropriately.


                      • #12
                        No. You only get one life to live. Doing something only out of obligation and using up the best parts of your life is ridiculous. If being a doctor becomes such a burden that no one does it anymore, then the free market will react to either make it better or replace us. Where is that robot Doctor anyway?


                        • #13
                          Of course not.

                          Now if "society" wants to make a better offer, we are all ears.

                          I always thought it would be an excellent idea to allow physicians a student loan tax credit. Let's say Dr. Jones finishes medical school with $450,000 in debt. For every year of post-training work, Dr. Jones could claim 1/30 of his original debt ($15,000) as a tax credit, up until the $450,000 cap.

                          Or perhaps for every year worked after age 50, the government/"society" would contribute $10,000 into an HSA or IRA to make up for the decade of lost income and retirement savings of physicians during their training years.


                          • #14
                            You might argue that Dr. Segan is already an outlier as he obtained a law degree after his medical degree.

                            Perhaps his journey involved some early question of whether medicine was his calling, and only later in life did he come to acknowledge or accept it.

                            Regardless, his experience in retirement is his own and no less valid than anyone else's.

                            As to the question posed of longer practice lifetime, I took that to mean around regarding retirement around age 45ish, where I think WCI and POF roughly are.  Obviously it somewhat depends on what age you start.

                            Totally agree that society and corportization of medicine and commoditization of physicians is ruining the actual practice of medicine and making it harder to be excited to get to work every day.  Hopefully the pendulum will start to swing the other way soon.  We already can't recruit physicians to our local area, and it will only get worse as time passes, if nothing else changes.





                            • #15
                              If the forces that be stopped treating docs like piñatas, we would likely not be having this is discussion.

                              I was in the doctors' lounge yesterday, and I heard a "Joe*, I heard you were retiring..." I and the other Joe at the salad bar both wheeled around simultaneously. I asked, somewhat tongue-in-cheek, "which Joe?", and then promptly explained that, no, I was just unloading some duties, narrowing my practice, and going part time. The other Joe, unbeknownst to me, a surgeon is his mid-late 50's, surprised us with the news that, yes, he was retiring from his practice, moving to his dream location, and teaching anatomy part time to DO students. How would the ethics police handle that?

                              It seems like I am involved almost daily in early retirement conversations with docs in the lounge, and I am not starting these conversations. My favorite was when a brilliant and totally engaged oncologist in his early 60's was asked by another when he was retiring and he replied, "Ninety days or five years from now, I am not sure which." People are just fed up with the BS.

                              I am the one who said that if a genie were handing out magic retirement checks to docs in the lounge in the morning the hospital would be a ghost town by the end of the day.


                              (*My name is not "Joe" but it reads better that way. )