[arkades]

The thing is, the salient bits of being a doctor have to do with the thought process going on in their head, the stresses of responsibility and decision-making, and all the considerations they weigh with each patient. It's just not an "observable" thing. Docs don't really start sharing their internal processes with you until you're in the second half of med school, and even then not commonly. From the outside, it just looks like... guy in a white coat, often at a computer, making pronouncements. And then doing paperwork, which largely consists of documentation to prove to the government and insurers you did everything they decided should have been done for that patient and if not, why not. The combination of accountability and lack of autonomy is a leading cause of physician burnout and, again, is all internal.

The other part it leaves out is the hours. "What do I do with this patient?" is a very different thought process at hours one, eleven, and eighteen respectively, of what should have been a twelve hour shift. One hospital I know of has its trauma/SICU surgeons do 5 days on and 5 days off where they pull 12 hour shifts daily, and they're on call every night. But trauma/SICU doesn't really sleep, so these folks are making critical care decisions at hour one-hundred-and-twenty, of which maybe eight hours involved sleep.

All of these things occur in the internal landscape. Shadowing is ... not effective.

Most med students have done clinical research, shadowed doctors, volunteered in hospitals, etc. Back in the day, I did hospital volunteerism, clinical research, hospital QI, and I worked in health insurance. I'd seen medicine from pretty much every vantage point before I second-careered into being a physician. And every senior med student and resident and physician will tell you, "holy shit, I had absolutely no idea what it would be like." Even the occasional nurse that decides to go to med school, who most commonly think they're halfway to being docs already, will say "omg, I had no idea how much I didn't know, and how much you guys have to do." We had two in my med school class back in the day. When we were in didactics, they were shocked by how much docs had to know. When we got to clerkships (the second half of med school, where you work in hospitals) they were floored by how much was involved in being a physician that simply wasn't visible to nurses. And that's... you know, nurses. Folks who work in our vicinity on a daily basis.

[sizzle]

Thank you for the eye opening insight, my significant other was accepted to med school in the states and she/we are double minded on her pursuing the field of medicine due to the dismal work life balance you mentioned, considering she has a science masters and works a 9-5 in medical research. She didn't have the undergraduate grades and did masters + high MCAT score to finally get in at 30 years old.

Given the current state of medicine in the states, you touched upon the topic of insurance companies. The endless paperwork seems to be a side effect of physicians being beholden to insurance companies to supply a steady stream of patients that afford an income that will offset the steep debt and decades of opportunity cost spent in school. This seems unique to America from what I can tell and is only getting worse, along with what I'm told regarding physicians (MD/DO) competing with nurse practioners and physician assistant, government oversight, etc over area of practice.

Finally, the topic of burnout and physician abuse (lack of sleep, working overtime and being on call), is truly disgusting. This was a tough read, previously posted on HN: https://ericlevi.com/2017/05/13/the-dark-side-of-doctoring/

I sincerely hope you and all overworked physicians take care of mental health and avoid burnout. I think private practice and limited hours for certain lower specialties might be the answer for my significant other if we plan on starting a family anytime soon.

[arkades]

> Finally, the topic of burnout and physician abuse (lack of sleep, working overtime and being on call), is truly disgusting.

The simple truth is this: pay has been dropping like a rock, every public mention of doctors is about how much we suck, regulators and bureaucrats are telling us how to practice medicine (but we continue to carry the liability), we're given 5 minutes to see patients when we should be given 20 (and when we rush out the door, patients think it's because we don't give a shit), and and and. .

The worst of it is: everyone else has a "career" - they're allowed to worry about work/life balance, about trying to get paid for their time, about trying to build a nest egg. When physicians do that, well, medicine is a /calling/. You're not allowed to worry about paying for your kids' schooling, or paying off your debts, or etc. That stuff is for programmers and accountants; you're just working with "sick people in their worst moments," so you're not allowed to be anything but self-destructively selfless. No one is allowed to discuss physician misery (I hate the word "burnout" - those docs aren't a resource that came to the end of its useful lifespan, they're human beings in desperate misery) except when residents are throwing themselves off the roofs of hospitals. I've lost -two- friends in the last year. TWO in the last YEAR.

And the only people that pay attention to that are the residents who have to carry on and the attendings that go, "well, it was still better in my day, when residents didn't expect to sleep or ever go home. It was better for patient care continuity if their doc never went home."

Private practice is dead or dying for most specialties as well. The healthcare field is heavily concentrating into large regional networks.

I knew this all going in. So I can say to your wife what I said to myself: The only reason to become a doc is if you cannot, for the life of you, force yourself to become anything else. It has to be a fire in your goddamn marrow.

And for all that, I recommend choosing a residency in psych. They work 9-5 even in residency - call tends to be 9a-8p or 9a-11p (rather than 24-hour shifts like the rest of us) and every other weekend they tend to work 9-9 Sat and Sun. It's the lightest residency on the planet, and they still make - per hour - the same money as IM and FM. It's the best thing I've ever heard of for people that want to have work/life balance and a family. Unsurprising, as they're the ones who spend every day seeing stressors break people's minds in half.

[1123581321]

Your comments have been interesting; thank you.

It remains that there are young people who understand this and still long to study arduously to be doctors, and then put in the work. It seems there is something appealing about the work that can be done, even if it’s imperfect. Is there any kind of enthusiasm you could accept as beneficial?

[arkades]

I don't think I said that enthusiasm was harmful, or non-beneficial.

So I want to clarify: what I said was that people who aim at medical school because "they're passionate about medicine" are mistaken. They're passionate about a fantasy of what medicine is, because you don't really know what it's like until it's there (and popular depictions of it are as unrelated to actual medicine as 1980s hackers movies are unrelated to actual programming.)

Many people are deeply hurt by the gap between fantasy and reality. They don't complain about it openly, but inside the doctor's lounge... oh yeah.

Some find a new passion, for what medicine actually is. Sometimes this is closely related to their original ideas, more often, it's only tangential. But they're on fire, and that's great.

Most just grow up, and find that they do a difficult but worthwhile job. They don't necessarily have a "passion" for it, but they appreciate the importance of what they do, and concentrate on doing it well. They work to take care of their patients, but also to avoid liability, and to earn their colleague's esteem. They're normal physicians.

I'm discussing the fact that what people think medicine is vs. what medicine is has a huuuuge gap. You can't be passionate for a thing when you've only seen its mirage. That doesn't mean enthusiasm is inherently bad. It's misplaced.

>it remains that there are young people that understand this

No, there pretty much aren't. That's rather the key point. I've never met a student, resident, or practicing doc that said, in retrospect, yeah, they had anything resembling an accurate clue about what medicine would actually be like.

[1123581321]

“Many people are deeply hurt by the gap between fantasy and reality.” This is another expression of the harm or non-benefit I was referring to you having said.

I agree public perception of a field lags behind reality, but it’s only a lag. Medicine has been a tough job for awhile. There are students who understand this well enough to handle the adjustment (since they don’t have first-hand experience yet.) It’s not a failure of “passion” if it’s crystalized into tangible goals, and better developed motivations and principles, as the student matures. It’s also not fair to equate surprise at some of the reality of a job with regret.

Finally, I know people who pursued medicine from childhood and are doing well in it. Granted, most of them had doctors for parents, but they were still quite excited.