Is medical school worth it?

A woman writes

I came across your blog as I was looking for "doctors with good hours." Here's my situation:

I'm a female currently applying to medical school. Besides the question of "Can I get in?" (which is haunting me right now since my MCAT score of 31 is scaring me...all my friends have gotten interviews but I still haven't heard a thing), I'm wondering if it's even worth it to go to med school.

The biggest things concerning me:

1) The money. I have no idea how I'm going to pay that all back. If I get into my state med school, my estimated cost for tuition is $120,000. If I get into an out of state school, I'm looking at minimum $200,000 for tuition alone. I didn't calculate school fees, test fees, books, transportation, or car payment (I'll probably have to buy a car) into either my state or out of state costs.

2) The inflexibility. I have a boyfriend, we're planning on getting married, and he has his career too. It seems like the next four years + 3 years + ? = uncertainty since I don't know where I'm going to med school, where I'd match, etc, and where he'd work in that meantime.

3) The time. I'd also like a family. I don't know how fair it is to get through med school and residency and then do a part time physician thing. Doesn't seem very smart to me.

My question is, Is there light at the end of the tunnel? Am I just imagining trouble, or is medical life as a physician not worth it? My alternate career is to become a nurse--get my master's in about two years (through an accelerated program), work, and advance upward, maybe to a Nurse Practitioner level.

Thanks for writing.

You have nicely listed some of the major challenges facing most women who are considering medicine as a career.

You are the only person who can decide if medical school is worth it for you, but let's see if we can think it through.

My first instinct is to tell you to carefully reread your email as if it had been written by someone else. After doing so, what is your reaction? After you do that, resume reading my reply.

Not being a woman, I decided to outsource this. One of my daughters who is not a doctor, but has a master's degree in a science, is married and has two children said,

"It sounds like she doesn't really want to be a doctor..."

My wife, who is a nurse, agreed and said nursing is a career that allows you to do the things you wrote about.

Here are three posts I have written about this subject.

Choosing a medical specialty is difficult. And note the comments.

Surgery and work-home conflict.

A college student has second thoughts about medical school.

I will also ask my Twitter followers to read this and comment. I hope they do.

Is it possible to live a full life as a surgeon‏?

Neymar (not his real name) writes

Dear (Dr.) Skeptical Scalpel:

I'm writing this evening as a fourth year medical student wholly committed to pursuing a long and fulfilling life as a general surgeon. It's what I got into medicine for, and my love for the profession has only heightened in the arduous years of preparation and (nascent) training I've undergone thus far. I have had the fortune of living a very full life—travel, adventure, and a broad milieu of individuals have all shaped the form of the man I am now, and greatly influence the man—and surgeon—I hope to be in time.

Like many people in and outside of medicine, I reflect on what has been lost or what might have been lost along the path. At present, the balance sheet reflects a clear net gain. The opportunity cost, however, can be measured in the loss of time in wilderness, love and relationships and socializing that adds richness to my life. How do you advise young physicians pursuing such an ambitious and all encompassing professional course to maintain richness and fullness in their lives? How do you reconcile the personal forfeitures with the professional gains? And, most importantly, if one hopes to be a surgeon, are these questions worth considering or best left in the recesses of the mind?

Thanks for being a mentor to an entire generation of aspiring surgeons.

Thank you for writing and for the kind words.

The questions are definitely worth considering. I am not sure that my response will be applicable to your situation or anyone else's.

I chose surgery because it appealed to me more than any other specialty. Like most others of my era, I was young and had gone the traditional route—four years of college followed immediately by med school. I had experienced few adventures [in fact, none] and had not yet met my wife-to-be.

I never even considered what impact my choice would have on my personal life. The subject simply did not come up. I worked hard in medical school but had a great time. I think I had more fun in med school than I did in college.

My residency prepared me well for the rigors of a surgical career. I spent the first four years of my training taking call about half every other night and half every third night. As a chief resident, I was in call every night. Somehow I found the time to have a relationship and got married at the end of my third year.

My wife of 39 years is a saint. I have wonderful children and now grandchildren too.

I was fortunate in my career to have had the opportunity to supervise the training a number of surgeons who are helping people every day.

Although I'll never climb Everest, go an African safari, ski the Swiss Alps or do many other things that might be important to others, I've had an interesting and fulfilling life. Wilderness? Not so much. But love and relationships? I got 'em.

But it is different for the millennial generation. What I consider interesting and fulfilling might not be to you.

Surgery continues to evolve. I think it may be possible in the near future to have a career as a general surgeon and also have a manageable lifestyle. By the time you finish training, everyone will be in group or hospital-based practices. Or you could be an acute care surgeon with fixed hours.

You will have to decide what compromises to make such as deciding if leaving work at 5 pm is more important than staying late to operate on your patient who has a complication you created.

No one talks about this part—you will have to find partners you can trust with the lives of your patients. The roadside is littered with the corpses of group practices that didn't last because of productivity issues, attitudinal and/or philosophical differences among the surgeons.

For many surgeons, fulfillment is measured by the satisfaction of knowing you made a difference in someone's life.

Can you be a surgeon and have a rich and fulfilling life? You can, but it depends on how you define rich and fulfilling.

If you haven't read this post, you should.

Are program directors the reason that surgical residency training is a mess?

A resident writes: "You have been a program director (PD). I read your article about residents not being confident about surgical skills and you conveniently blamed resident work hours limits/resident work ethic for this. I ask you how come PDs are not responsible for the training they provide? How can they get away with telling residents/fellows on what the residents/fellows can say/write on evaluations that accredit the program? How can they get away without providing adequate training/exposure in lap/robotic surgery? How come we don't teach surgeons how to teach surgical skills? Just because one is a good surgeon does not mean they can teach surgical skills to others. After all Michael Jordan was a great basketball player, but that does not necessarily imply he would make a good coach. In fact I would argue that average basketball players make better coaches."

 

Great questions. Let's see what I can do to answer them.

I "conveniently blamed resident work hours limits/resident work ethic" for the lack of confidence in their skills that >25% of general surgery residents have. That problem was not created by program directors. Most PDs hate it. It certainly is a contributing factor to the lack of resident confidence.
We are responsible for the training we provide. We must sign a form attesting to the competence of our graduating residents. I cannot speak for current PDs, but I felt very responsible for the residents when I was a PD.

I never told a resident what to write on an evaluation. I understand that may happen, but the evaluations are submitted on line anonymously to the accrediting body, the Residency Review Committee for Surgery. The residents are free to say whatever they want and no one will be able to trace it back to an individual. In my experience, the residents did not hold back on their complaints.

I agree with you that we are obviously not training residents well enough in some areas such as advanced laparoscopic surgery. That is difficult to understand and explain. It must be true because so many graduates of five-year programs feel the need to take extra training. I think it is somewhat harder to teach minimally invasive surgery. I always felt I could control what the resident was doing during open operations; for laparoscopic procedures, not so much. But we should be doing a better job in that area.

And it's not just laparoscopy or the American College of Surgeons wouldn't have established "Transition to Practice" fellowships. See my previous blog about this. There is also the problem of too much supervision which I mention in that blog.

I have news for you. In most cases, surgeons are not taught how to teach anything, let alone surgical skills. For many years, it has just been assumed that any surgeon (or any doctor in any specialty) is an excellent teacher. Of course, this is not so.

However, teaching is not particularly valued or rewarded an academic medicine. On the other hand research is, especially research that brings in grant money.

Teaching is also a problem in community hospital programs because attending surgeons are busy trying to stay afloat financially.

I agree with you that Michael Jordan and most other superstars of sport would not make good coaches. It may be similar in surgery. I don't think that has been investigated, nor is such a study likely.

In case you haven't read any of my previous posts (search "surgical education" on the Skeptical Scalpel blog) on this subject, I am pessimistic about the future of surgical education.

Why I left academic medicine

A medical student who thinks he wants a career in academic surgery asks, “You were deep into academic medicine and walked away from chairman, program director, etc. Why?"

[Background: For over 23 years, I was a full time surgical chairman and residency program director in three different community hospitals affiliated with medical schools.]

Good question. For many years I had always said something like, “No matter what crisis happens with the residents or the chairman’s job, it pales in comparison to having a patient with a complication.” In other words, non-clinical problems were annoying but manageable.

Then one day I realized that was no longer so. Patients with complications still caused me many sleepless nights and that hadn’t changed. What had changed was that resident issues and administrative hassles finally became intolerable.

The rules set by the accrediting bodies, the ACGME and the Residency Review Committee [RRC] for Surgery, had always been difficult to comply with, especially for a small program. They became more onerous every year or two until it reached the point where I can’t imagine how anyone can stand it. Residents can complain to the RRC anonymously and no matter how factually you refute the complaint, the RRC always believes the disgruntled resident. Add in the work hours rules and the lack of motivation of some of today’s med school graduates and I had had enough.

The position of surgical chairman in a community teaching hospital is like that of a football referee. At any given time, half your constituency is not happy with you. The administration pays your salary and expects you to spout the party line. But you need your attending surgeons to treat the residents well and support the program. Many times you have to make decisions that are guaranteed to alienate many people.

A lot of energy was spent investigating complaints. Families were unhappy with the residents; attending surgeons were unhappy with the residents and conversely; nurses were unhappy with the residents and/or the attendings; someone was rude to someone else; someone shouted; someone cried and on and on.

And the site visits. Drop everything; the state is here to investigate a case or the state is here to interview the residents about their work hours. The Joint Commission is coming in six months. We need to meet twice a week to make up for all the unnecessary but JC-mandated stuff we haven’t been doing for the last two-and-a half years. Countless hours were spent buffing up the paperwork for an RRC site visit. I think that’s where I learned creative writing.

And the meetings. Risk management meetings could last three hours during which time you would have the opportunity to try to explain why a surgical complication occurred to a room full of non-surgeon MDs and non-physician administrators. We used to deal with this sort of thing quite effectively at morbidity and mortality conference.

Then there were the committees. At one of my former hospitals I was either chairman or a member of the following committees: Pharmacy, Critical Care, Infection, Medical Executive, Operating Room, Surgical Performance Improvement, Strategic Planning Work Group, Product Evaluation, Library, Clinical Leadership Group, Cancer, Trauma, Budget, Graduate Medical Education, and Risk Management. I’ll save you the trouble. That’s 15 committees.

For a long time, I enjoyed being a residency program director. I am proud of the more than 50 chief residents I helped train. I view them as my legacy. I regret that running a program and teaching residents stopped being fun a few years ago. I also liked being a chairman until medicine took a turn toward the dark side.

I could go on but this post would reach 20,000 words.

So my young friend, think long and hard about that decision to become an academic chair.