Going to med school and becoming a surgeon when you're older

A 34-year-old attorney writes I have a good salary, am married, and have two children. My whole life I've been drawn to medicine (I'm an EMT, have experience on the job with trauma related injuries, etc.) and have always enjoyed it. However, I have a Bachelor's in English literature, so I've always put it as unattainable to become a doctor. Now, once again, I'm considering doing one of the post bac premed programs out there and going for it.

Am I insane? At my age, I'll likely be 41-42 by the time I'd complete medical school, then residency. I'd love your opinion.

Let's do some math. You are 34. Most post bac premed programs take at least a year if you go to school full-time. Assuming you can get into a program this summer, you will be applying to medical school for a class starting in the fall of 2017. You will be 36 years old when you start.

Four years of medical school plus five years of general surgery residency and you will be 45 years old. If you want to take a fellowship in something for a year or two, add those years on.

What are you going to do for income while you are pursuing your medical degree? And let's not forget the tuition cost of the post bac program and medical school, living expenses, and your paltry salary for the 5 years of your residency.

I wrote a post about this four years ago. It was about a then 30-year-old man did not get into medical school until 2014 which means he is now in the middle of his first year at the age of 34.

My discussion of the "cons" of doing this is much more expansive in that post. Just remember that tuition costs have risen much faster than inflation and will continue to do so in the foreseeable future.

I can't tell you not to do it and it certainly has been done by others, but I strongly advise you to give it a lot of thought.

He replies Thanks for the response. Unfortunately, you paint the bleak reality I was afraid of. As I likely won't make cutoffs for the good post bac programs this year, you'd have to add another year to the equation.

What if I went for a less rigorous residency like emergency medicine? Or what if I consider having the military pay for medical school?

Does this change anything? Your post is so bleak, it definitely gives pause.

The family issue is a tough one. I'm fortunate to have about $200k in liquid assets, but it's still a big financial hardship.

$200K might just about cover your tuition for the post bac year and 4 years of med school.

Yes, emergency medicine will save you a couple of years, but it is very competitive.

Remember one thing about the military. Once you are in, they own you. They can send you to remote bases in the states, Afghanistan, or wherever they want. You cannot believe anything they tell about your ability to choose an assignment.

Readers, please comment if you agree or disagree.

Applicant worries about the future of surgery

A medical student writes:

I am a few weeks away from applying for residency training in general surgery. Lately I've been lamenting that I was not born in the 1950s. I worry that the physician that I became enamored with so early in life is looking more and more like the surgeon I may never become.

Increasing enthusiasm for innovation in surgical technology is subtly paving a road toward a time in which a surgeon may be rendered obsolete. The rise of the two M's—machines and mid-levels—may herald a very different future from that which I ever imagined.

I love to solve problems and stand (not sit!) above an anesthetized patient making use of my hands and tools directly. There has never been a higher challenge than surgery which involves clinical skills in diagnosis, peri- and intraoperative disease management, and a sense of duty, service, and sacrifice. And now, robotics calls into question why hands might ever need to be laid on patients, and time-honored sutures are replaced with Silicon Valley-prescribed tinker toys.

Many articles call into question the relevance of physicians, particularly surgeons, in the not-too-distant future.

Will mid-level providers take away many general surgery cases? Will opportunities to function as a surgeon be threatened by the relentless emergence of technological or perhaps financial pressures? Are surgical societies actively confronting these issues?

I see you have thought about this in depth.

The PAs I have worked with did a lot of rounding, H&Ps, clinic work, and discharge summaries. In the OR, they assisted and closed skin. In some specialties, they do more such as harvesting vein grafts and closing fascia.

Here's an interesting anecdote about a PA who excised a neck mass by himself. He smelled it, said it was a benign sebaceous cyst, and threw it away. When the mass recurred, a surgeon biopsied it and found squamous cell carcinoma.

I don't see robots operating independently for quite a while, if ever, although NASA apparently has a robot that can be inserted into the abdomen and perform an appendectomy while being controlled remotely.

There is much variability in the location of the appendix, the inflammatory response, and the location of surrounding structures. How can a robot can ever be programmed to do this supposedly simple operation without human guidance?

If NASA has a miniature robot, it may be possible to control it while standing next to the patient. Having never seen it, I just don't know.

Surgery will undoubtedly change a lot in the next 40 or 50 years. As I wrote here, it certainly has since the 1970s. It might change at a faster rate too. But surgeons have adapted well, and they will continue to do so.

Surgical societies have not exactly shined during all of these changes. When laparoscopic general surgery was introduced in about 1990, mainstream surgical leaders called it heresy and were slow to catch up. Conversely, few said anything about the introduction and widespread acceptance of the da Vinci robot, which has not been shown to improve outcomes despite all the fanfare and expense.

Someone (the feds?) will have to put the brakes on unproven technologies or the country will go broke.

So if you want to be a surgeon, go for it, but be prepared for change.

A college junior wonders if she will get into med school

[Email abridged and edited.] A 21-year-old married woman, who is a junior at a large public university, has always wanted to be a doctor. She had some family and mental health problems (panic attacks, depression) which have affected her grades. She has a current GPA of 2.8, but when recalculated by including grades in repeated courses and deleting the poorer grades as her college allows, her GPA is 3.3. She and her husband have a combined $24K of student loan debt.

She feels very strongly that her family and mental health are no longer issues and is getting A's in science courses that she previously did poorly in. She says, "I seriously feel like a completely different person. I feel capable of getting good grades. However, people keep telling me that I might not even make it into med school because of my low GPA. The thing is though I don't care what I have to do. I am so passionate about learning and helping people. My dream has been to work and eventually have a free clinic on the side to help people who can't afford healthcare. That's why I'm in this. But is there a chance I can even get in? I know that's what I want, but people (peers, degree advisors, and my anatomy professor) keep bringing me down."

This is a very difficult question to answer definitively. I really can't speculate on your chances of being accepted to medical school. Your level of commitment is outstanding.

There is one missing variable—your MCAT scores.

You may want to take the MCAT at the next available opportunity. Great scores would be encouraging. Poor scores would seal the deal. You would have to move on to something else.

Your combined debt is low and you are young, both of which will allow you to spend a little extra time beefing up your GPA.

If you are thinking about applying to offshore medical schools, please do some research. As US medical schools expand their classes and new schools open, there will be fewer residency positions for offshore graduates. If you look at Table 1 on page 2 of the 2013 match data for International Medical Graduates (IMGs), you will see that 2420 US citizen IMGs failed to match to a residency position. It's only going to get worse as I noted here.

Have you considered another option such as becoming a physician assistant? The path is shorter, and PAs are becoming more and more autonomous. It might help you to look at a post of mine from a couple of months ago on "Ask Skepticalscalpel" called "Should I be a nurse practitioneror a doctor?" Read the many comments because they are pertinent.

I hope this is helpful to you. Check back here for comments as they are often more useful than what I write.

A woman asks, "Should I be a nurse practitioner or a doctor?"

She writes [email edited for length]:

 

I don’t ever do this sort of thing, but your blog seems to be pretty legit, so I guess I’ll go ahead this once.[Quite a testimonial for my blog, don't you think?] I’m a post-undergraduate student seeking to become either a nurse (with likely continuation to a nurse practitioner [NP] degree) or a doctor.  The problem is I don’t know which way I should go.

I know I have the ability to get through medical school, but I’m not sure if it is worth it as far as cost and benefit is concerned.  I do, however, like the idea of the autonomy that comes with being a doctor rather than a nurse.  I have a very analytical mind, and would enjoy the diagnosing and problem-solving that comes with being a doctor.  In fact, I’m not sure I would be happy without the authority to determine and pursue treatment I had researched myself.

On the other hand, I really like interacting with patients and getting to know them personally. Ideally, I want a job where I help people solve their medical issues, diagnose, have autonomy, and interact regularly with patients.  My main question is, does this happen more as a nurse practitioner or doctor?

I’d also like to know if you think medical school is worth it with the rising cost of education and likely fall in salary (at least in the US with Obamacare). I’m practical and even if medical school is really what I want, I cannot justify going after a degree that won’t be worth the cost. On the same note, if there is a great shortage of doctors, will NPs be stepping up into doctors’ roles more often? Is such a role assumption legitimate? And what will this mean for the medical community and individuals going into medicine?

[Note: She is in her early 20s with very little debt right now, will finance future education with loans, is not married, but eventually wants to have a family.]

Thanks for the kind words about the blog. 

Here's what I think. It sounds like you want to do primary care. If that is so, why go to medical school? You might want to consider becoming a physician assistant (PA) too. The NP or PA route will be far less expensive. You will be able to start practicing sooner, which means earning real money and paying off any debts instead of deferring. 

Future doctor shortage or not, I think nurse practitioners and PAs will dominate primary care and also be given more autonomy. It is inevitable. The truth is, many PAs and NPs are not very closely supervised even now.

I hope that others will comment.

A UK Med Student Discovers Surgery, Has Questions

Gareth (not his real name) writes

I came across your blog a few days ago and I have been reading it since. I am a third year medical student studying in the UK. I am writing to you because I would be grateful if I could get some advice. I have always wanted to become a doctor, since I was veryyyyy young, but I never ever considered a career in surgery. Before medical school, I believed that surgeons were like butchers, not capable of any human attachment for the patient etc etc. I believed I would not be able to bear the responsibility to cut someone open given the fact that I am a very emotional person. However, my perspective changed when I was in the OR and saw my first surgery. It was a coronary bypass surgery and I loved it, I loved the idea of making the patient better in such short time and the fact that the surgeon was the one responsible for it, I suppose it must be very satisfying. Therefore, I have started to consider a career in surgery, however, I am still very unsure of whether I have the right personality type and skills to become a surgeon. I still tend to get very attached and moved by patients' stories and experiences and I don't know whether that would help me detach myself from the patient whilst operating. Also, most surgeons seem to be extremely confident and outgoing whereas I tend to be shy and not confident, even though I'm quite good academically. So I am really confused right now. Also, I have never had great hand skills, even though I took some introductory surgical skills courses and they went quite well. I seem to get a bit of tremor when I do practical stuff though, I guess that's because I get nervous. 

I'd like to ask you one more thing. If I do decide to go for a career in surgery, is there any point for me to try and take the USMLE and apply for a US residency after graduation? I heard surgery it's really competitive, I guess many schools don't even accept international applicants?

Thank you very much for your time and dedication. I admire the passion that you show.

Thank you for reading my blog and for writing. I am glad that you have realized what a rewarding career surgery can be.

First let's talk about the "surgical personality." There was a time when most surgeons could have been categorized into a couple of personality types. Those days are gone. Now that 40% of all surgical residents are women it is no longer necessary to be a certain type of individual. I know many surgeons who are quiet, thoughtful and introspective. You need to dismiss any thoughts about your personality type being incompatible with a career in surgery. Also it is not a bad thing for a surgeon to identify with and become attached to his patients.

The next myth is that one must have great dexterity to become a surgeon. In the old days some residency programs use to screen applicants by making them build model airplanes. I don't believe anyone still does that. Now it seems that video game skills are much more important since so many procedures are done laparoscopically. I believe that anyone can become a more than decent technical surgeon through practice. We all get nervous. This is a real person you are operating on. I have written that there is more to surgery than manual skills. It is very important to know who to operate on and when to operate on them as well as who not to operate on.

I have written before about the decreasing chances of graduates from non-US medical schools obtaining residencies in the United States. US medical schools are expanding their class sizes and a new schools are opening. It is not even clear that all us graduates will be able to obtain residency positions in the future. The most recent statistics from the match show that only about 5% of non-US citizen graduates of foreign schools matched into categorical general surgery positions. However, I do not believe you have anything to lose by trying. You will need to get an excellent score on the USMLE and of course, have good grades and recommendations. Although it is difficult, some trainees from the UK have been able to find fellowships in the US. I do not know how easy that will be in the next few years.

Good luck

A pre-med student asks some probing questions

Here are some questions from Lionel, a pre-med student.

What is something you wish you had known before entering medical school?

It would have been nice to have known what changes were going to occur over the 40+ years since I graduated.

If you had the opportunity to choose a specialty all over again, would you do surgery again?

Yes. While I have often envied the controlled lifestyles and flexibility of radiologists and anesthesiologists, I don't think I could have stood the sitting in the dark all day (radiology) or utter boredom 95% of the time (anesthesia).

If not medicine, what other healthcare occupation would you consider to be more rewarding?

It depends on how you define rewarding. It seems to me that being CEO of a hospital is more rewarding financially these days. I have blogged about that. Is it more satisfying on any other level? I don't think so.

Is it possible to carry a healthy relationship where the significant other is not a medical student? Would it be more/less difficult in residency compared to medical school? [this is one I'm mostly interested in especially since you are a surgeon]

I am living proof that it is possible to have a healthy relationship with someone who is not a med student or physician. I met my wife, who is a nurse, when I was an intern. We were married when I was a third-year resident and still going strong at 39 years.

What implications have enduring medical school/residency had on your personality?

I was always kind of a pessimist, but med school and beyond amplified that trait a lot. As some people have written about lately, med school and residency can induce cynicism, and I'm afraid I am a classic example of that.

Does every single day of the year feel stressful or are there days where you feel in control and free to relax?

Since I retired late last year, the days are not particularly stressful right now. When I was an active surgeon, just about every day was very stressful. It took at least the first five days of every vacation to unwind, longer if I had gone away and left a sick patient to be managed by someone else. Here's a link to a post I wrote about "collateral damage," which is about how complications affect surgeons.

I have always dreamed that being a physician would help me feel more connected spiritually to god/universe by seeing all the unfortunate people and being able to lend compassion. However, does being under constant stress distract a physicians focus from that feeling and does it make you just want to finish the job and go home?

There were many days when I just wanted to finish the job and go home. I would like to think though that I was able to get past that and offer my patients the compassion and support they needed.

What do you like/dislike the most about your journey thus far?

I liked the challenge of figuring out what was wrong with a patient and having the ability to fix it. I liked the feeling of satisfaction after helping someone who was really sick get better. Today I got an email from a former patient who is 10 years postop from breast cancer surgery and disease free. Hearing that is hard to beat.

I took every complication, whether it was my fault or not, very personally. That can wear you down. I didn't like the empty feeling that I got when I operated on a patient and found something like incurable cancer. It was frustrating not to be able to do anything about it. It is very hard to look someone in the eye and tell him that the surgery did not solve the problem.

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.