Thus spoke Confucius.
Below is a letter written by gastroenterologist Matthew Moeller and posted on
CaduceusBlog. It was reposted on LinkedIn as a topic for discussion in a managed care forum. Below the rather lengthy letter is my response, also posted on LinkedIn.
DEAR LAWMAKERS: THIS IS WHAT IT’S LIKE TO BE A DOCTOR TODAY
Matthew Moeller, MD | Physician | March 20, 2013
I am writing this letter because I feel that our leaders and lawmakers do not have an accurate picture of what it actually entails to become a physician today; specifically, the financial, intellectual, social, mental, and physical demands of the profession. This is an opinion that is shared amongst many of my colleagues. Because of these concerns, I would like to personally relate my own story. My story discusses what it took to mold, educate, and train a young Midwestern boy from modest roots to become an outstanding physician, who is capable of taking care of any medical issues that may plague your own family, friends, or colleagues.
I grew up in the suburbs of southeast Michigan in a middle class family. My father is an engineer at General Motors and my mother is a Catholic school administrator in my hometown. My family worked hard and sacrificed much to enroll me in a private Catholic elementary school in a small town in Michigan. I thought I wanted to be a doctor in 5th grade based on my love of science and the idea of wanting to help others despite no extended family members involved in medicine. Winning a science fair project about the circulatory system in 6th grade really piqued my interest in the field. Throughout high school, I took several science courses that again reinforced my interest and enthusiasm towards the field of medicine. I then enrolled at Saint Louis University to advance my training for a total of eight years of intense education, including undergraduate and medical school. The goal was to prepare myself to take care of sick patients and to save the lives of others (four years of undergraduate premedical studies and four years of medical school). After graduation from medical school at age 26, I then pursued training in Internal Medicine at the University of Michigan, which was a three year program where I learned to manage complex problems associated with internal organs, including the heart, lungs, gastrointestinal tract, kidneys and others. I then went on to pursue an additional 3 years of specialty medical training (fellowship) in the field of gastroenterology. The completion of that program culminated 14 years of post-high school education. It was as that point, at the tender age of 32 and searching for my first job, that I could say that my career in medicine began.
Over that 14 year time period of training, I, and many others like me, made tremendous sacrifices. Only now as I sit with my laptop in the dead of night, with the sounds of my children sleeping, can I look back and see where my journey began.
For me, it began in college, taking rigorous pre-medical courses against a large yearly burden of tuition: $27,000 of debt yearly for 4 years. I was one of the fortunate ones. Because I excelled in a competitive academic environment in high school and was able to maintain a position in the top tier of my class, I obtained an academic scholarship, covering 70% of this tuition. I was fortunate to have graduated from college with “only” $25,000 in student debt. Two weeks after finishing my undergraduate education, I began medical school. After including books, various exams that would typically cost $1000-$3000 per test, and medical school tuition, my yearly education costs amounted to $45,000 per year. Unlike most other fields of study, the demands of medical school education, with daytime classes and night time studying, make it nearly impossible to hold down an extra source of income. I spent an additional $5000 in my final year for application fees and interview travel as I sought a residency position in Internal Medicine. After being “matched” into a residency position in Michigan, I took out yet another $10,000 loan to relocate and pay for my final expenses in medical school, as moving expenses are not paid for by training programs.
At that point, with medical school completed, I was only halfway through my journey to becoming a doctor. I recall a moment then, sitting with a group of students in a room with a financial advisor who was saying something about how to consolidate loans. I stared meekly at numbers on a piece of paper listing what I owed for the 2 degrees that I had earned , knowing full well that I didn’t yet have the ability to earn a dime. I didn’t know whether to cry at the number or be happy that mine was lower than most of my friends. My number was $196,000.
$196,000. That was the bill, for the tuition, the tests, the books, the late night pizza. $196,000 financed through a combination of student loans, personal loans, and high interest credit cards, now consolidated, amalgamated, homogenized into one life defining number for my personal convenience.
I then relocated to Michigan and moved into a small condo in Ann Arbor, where I started my residency. As a resident in Internal Medicine, I earned a salary of $39,000. All the while, interest continued to accrue on my mother-lode of debt at the rate of $6000 per year due to the high debt burden. Paying down this debt was not possible while raising two children. My wife began working, but her meager salary as a teacher was barely enough to cover day care costs. During residency, my costs for taking licensing examinations, interviewing for specialty training positions, and interest on the large loan ballooned my debt further, now exceeding $230,000, all before I began my career as a “real doctor”.
Relatives and friends often ask me, “now that you are a ‘real’ doctor, aren’t you making the big bucks?” While I am fortunate to now be making a higher salary, some basics of finance make my salary significantly less than meets the eye (very in-depth article on how this is so). First, I was 32 years old as I began training and I now had over $230,000 in debt. Had I invested my talents in other pursuits such as law school, I would not have built up this level of debt. Also, as I did not start saving when I was younger, financially speaking, I have lost the past 10 years without the ability to save and invest to earn compounding interest. In addition, as physicians, though we make more money than many others, we are not reimbursed for many of the services that we provide.
We do not “clock” the number of minutes as attorneys do when we talk with patients. We do not hang up the phone as attorneys may do if they are not going to get paid. No, we listen to patients and answer their questions, however long it may take. Even if it is the thirty-second straight hour of work, which happens very often, we listen, respond, and formulate a logical plan. If it involves calling a patient at home after I just worked 30 hours in a row and just walked in the door to see my family, I do it. I never come “home” from work. As physicians, we are always available, and have to respond in an intellectual way using the $230,000 rigorous education that we received. And if we don’t do our work well, we don’t just lose business, but we can lose our livelihood through lawsuits.
You may ask why do we do all of this? It’s because we have pride in what we do. We truly care for the well-being of the human race. We have been conditioned to think, act, talk, and work as a very efficient machine, able to handle emotions, different cultures, different ranges of intellect, all to promote the health of America. We are doctors.
In reading this letter, one may think that one has to sacrifice a significant amount to become a great physician. You may think we face physical and mental stress that is unparalleled. You may begin to think that doctors not only have to be smart, but they have to know how to communicate with others during very emotional times. You may think that we must face adversity well and must develop very rough skin to handle all walks of life, especially when dealing with sickness and death on a daily basis.
Now that you see this additional aspect to our career, you may think that we have a tough job to tackle several tasks at once, demanding much versatility. You may think someone needs a great work ethic to do what we do. You must think that not only do we have to know science extremely well, we also have to know other areas such as writing, history, math, even law given the multiple calculations we go through in our heads on a daily basis and conversations we have with families. And finally, you must think we know finance, as we have to try balance a $230,000 loan while making $50,000 at age 30.
Now imagine, if you would, having $230,000 dollars in debt with two young children at age 30 and listening to the news with lawmakers saying that doctors are “rich” and should have their pay cut. Or that “studies show that doctors lack empathy”.
Unfortunately, we physicians do not have much of a voice on Capitol Hill. There are not enough doctors in Washington D.C. who can give the insight of this letter while you in Washington, D.C. discuss health care reform. You may hear from leaders of the American Medical Association, but these are not the doctors on the front lines. These are the older political voices who were physicians when the times were different, when doctors did get reimbursed fairly for their work, when student loan debt was not this high, and when lawsuits were less prevalent. Many of the loudest voices in the healthcare debate are those of lawyers and lobbyists for special interests. They do not care about the well being of patients; that is what doctors do.
I want to make it clear that this letter is not just another story about the difficulties of becoming a doctor and being successful in medicine. I do not want you to think I am complaining about how hard my life is and used to be. In fact, I love my job and there is no other field I would ever imagine myself doing. My true wish is to illustrate the sacrifices doctors do make because I feel we are not represented when laws are made. These sacrifices include a lack of quality family time, our large student loan debt, the age at which we can practically start saving for retirement, and the pressure we face with lawyers watching every move we make. Yet we make these sacrifices gladly for the good of our patients.
I want to challenge our leaders to address the points I have made in this letter, keeping in mind that this is an honest firsthand account of the personal life of a newly practicing physician. It is a letter that speaks for almost all physicians in America and our struggles on our arduous yet personally rewarding life. It is not just a letter of my own journey, but one that represents most physicians’ path on our way to caring for America’s sick.
You may ask how I had the time to write this letter? As I’m sure many of you do, I made time. It is now 3:00 am on my only day off this month. I considered this a priority. I hope you feel the same. I just finished my 87 hour week. Time for a short rest.
Matthew Moeller is a gastroenterologist. This article originally appeared on CaduceusBlog and was reprinted on LinkedIn as a topic for discussion in an managed care forum.
I am a physician in private practice, and read Dr. Moeller’s letter with interest. With respect to the summary of his training, the consequent late start as an earner, the debt incurred along the way, and the demands of the profession among other things, my own experience is mirrored. However, the letter has a grandiose and entitled tone that I found off-putting. Dr. Moeller is going a bit far in stating that his opinions represent those of a majority of physicians. The use of the royal “we” only underscores the fact that he does not represent me.
Physicians had been glorified for so many years in this country as the “I play one on TV”, Marcus Welby types that the current trend towards doctor-bashing is jarring, especially to older doctors.
One problem is that, at least when I was in medical school in the 70′s, we were not taught a single thing about the economics of medicine, how to set up a practice, etc. Doctors were not questioned, they could keep patients waiting forever. The average patient was passive, and many physicians did not deign to discuss their fees, leaving that chore to their billing person.
With the advent of managed care, physicians’ practices came under greater scrutiny and insurer’s gained power. The nation’s health care expenditures grew and grew, to the point that it is projected that by 2021, they will approach 20% of GDP. There are many reasons for this. Time and space do not permit me to address them.
Physicians are “supposed” or expected to hold to a higher moral standard than other professions, such as the law. Yet medicine is a business in a capitalist economy. U.S. physicians, even under the current circumstances and constraints, earn far more than their counterparts in the rest of the world. Nobody is entitled to anything in this world. If Dr. Moeller wishes to get the attention of “leaders and lawmakers”, he would have been well-served by elaborating just a bit, in his letter, on what the problems are on a national level, and what these people should be doing about it. Mostly, what he plans to do to solve the problems, other than throw himself a bang-up pity party.
The noted philosopher Albert Camus wrote that man takes control of reality through action. Complaining is not action. It’s just complaining.