Confusing Situations in Medical Specialty Job Markets

I've had a busy week, hence the low posting (more on that later, hopefully). However, I wanted to take a minute to discuss a phenomenon in the modern medicine job market that is endlessly baffling me: specialties with physicians who are simultaneously overworked and underemployed.

Underemployment in quite a few specialties has become an increasing concern. Resource-intensive specialties, especially surgical ones, are having the worst time. Neurosurgery, for example, has a notoriously terrible job market - across the country, positions are rare and demand ludicrously high qualifications. Yet in many of these specialties, practitioners are working insanely long hours, often have high stress levels, and in many cases, are rushing through patients at a rate that limits good patient care.

I can't help but see an obvious solution to this set of problems - let the overworked staff take on a little less responsibility, hire the desperate-for-work newly graduated physicians to take on some of the slack. Lower levels of stress for everyone involved, right?!

Yet, there are a lot of reasons this doesn't happen. Money is a big factor. Increasing the number of physicians working fully means higher health care costs. The physician's compensation is one part, but the support for these physicians is even more expensive, especially when it comes to surgeons. One figure I was quoted was that a new Cardiothoracic surgeon costs the health care system $1.5 million a year, but only a third of that or so goes to the surgeon. The rest goes to the administrative staff, the nursing staff, the research staff, and additional services needed to support that surgeon's work.

Now, if these new physicians were simply taking over work formerly done by other physicians, a good portion of the cost increase for additional physicians would be defrayed by lower costs of those other doctors. However, physicians generally don't want to work shorter hours - after all, many have the option, but choose not to. Each physician has their own reasons for the long hours, but here are the ones I've seen more-or-less directly.

1) Habit. Residents work insane hours. Consultant physicians are therefor used to these insane hours. They may be working 65 hours a week, but they're used to 80, so they think they're cutting back, even if they're still working rather long hours.

2) Career advancement. Physicians are, almost by definition, ambitious people. Being a fully trained doctor with employment is only the start in many fields. To move up means making an impact, which means more responsibilities, both in clinical and non-clinical settings. Those all take time. Even when the extra work is non-clinical, that crowds out the clinical time, leading to some jam-packed clinics.

3) Money. It matters for governments, but also for physicians. For everyone really, but there are some important financial factors specifically for physicians. Our careers start later with a substantial amount of debt. Most physicians are not salaried - they have to cover their own pensions, benefits, insurance, etc. Many also cover their own supplies, infrastructure, or support staff, meaning it costs a fair bit of money just to have the practice open.

Physicians are also notoriously poor money-managers. A good number of physicians don't save enough for their retirement and of those who do save enough, many invest poorly. High incomes but low wealth characterize many physicians' financial situations - they make a lot, but habitually spend most of it.

There's undoubtedly some greed in there as well. That's not meant to be a judgement, we all are greedy in our own ways and physicians are no different. Conspicuous consumption - buying expensive things to show you can buy expensive things - also seems to be a hallmark of a high-earning physicians.

Whatever the motivation, working less for physicians means earning less, so there's a strong incentive to keep hours up.

4) Preference. One thing I've noticed in my first bit of clerkship is that while long hours can be incredibly draining, I feel that drain mostly at home, not at the hospital.

At the hospital, while there's a lot of work, much of it quite stressful, there's also a lot of gratifying aspects. The work is intellectually stimulating, socially engaging, and can have some clear positive effects on others. There's a fair bit of direct, positive feedback - rarely from other physicians, mind you (unless you're a student!) - but certainly from patients. I said before that physicians are, almost to a person, ambitious. Most are also egotists. Getting thanked, being told that you're smart, or that you're a wonderful person simply for doing your job is like a drug. It's a drug that's very hard to give up.

At home, with rarely enough time to pull your share around the house, to be social with friends or family, to spend time with your partner, there's almost a recipe for failure. I'm incredibly lucky to have a supportive SO - which seems to be the major factor in keeping life together as a physician with long hours - but if there's a place I feel like I'm not quite living up to expectations, it's at home. This doesn't seem to be an uncommon sentiment among physicians and it creates a destructive cycle prone to workaholism. Physicians feel good at work, bad at home, so they spend more time at work. That makes work feel better and home feel worse, which in turn pushes these physicians to spend more time at work and so on.

The sum of all these effects is older physicians working longer than they need to, longer sometimes than they want to, all while younger physicians struggle to find enough work. While efforts are certainly underway to change this dynamic - financial counselling, more flexible work schedules, encouraging physicians to spend more time with their family - all of this does help to get physicians to take more time for themselves and in specialties with job shortages, frees up some work for new graduates. However, where these initiatives seem to be having the greatest effect are on those younger physicians looking for work, as well as on physicians in specialties that don't have shortages.

Point of this ramble (and wow, much longer post than I was expecting) is that while it's laudable to go the extra mile for your patients, long hours don't always equate to doing the best for your patients - or yourself.