Considering Medicine - Prestige

We focus a lot on how students can prove they're good enough for medicine. These posts are for students wondering if medicine is good enough for them.

Short Version: Medicine a well-regarded profession. Most people generally assume physicians are reasonably intelligent and high-achieving. Perceptions of the profession are slowly changing, however, and not necessarily for the better. More importantly, prestige essentially represents the opinions of others based on superficial qualities and only matter to the extent that those opinions are valued. Prestige in a career is often most meaningful to those who feel their job lacks prestige. As such, its main value is in assuaging personal insecurities, but it can only do so much on that front. Having a prestigious profession is no substitute for developing strong personal self-esteem.  At the end of the day, prestige is a hollow comfort if a physician does not find the actual work of their job satisfying.

Long Version: Humans are social beings. We intrinsically care about what others think of us, even when those opinions fail to represent reality. It is in this light that we should consider the prestige of going into medicine.

The majority of individuals have positive opinions about physicians. In multiple polls, medicine is still regarded as one of the more respected, ethical, and trustworthy professions. Physicians tend to be thought of as intelligent and hard-working. Becoming a physician is often thought of as an achievement in isolation. Being a physician has many of the trappings of prestige, of being though of positively by society - with the "Dr." title, high pay, often an office, many times physicians get additional awards, or honours, or academic appointments.

It is hard to deny that medicine is a prestigious profession. Yet their are some cracks in public perception of physicians. With high earnings, physicians' earnings are coming into question, with concerns about the value the profession places on money. As medical knowledge disseminates more broadly, the expertise of physicians is more frequently under scrutiny by patients. Moreover, physicians can be seen as cold or uncaring when failing to meet the typically high expectations of empathy. If physicians ever were implicitly trusted because of their profession alone, that time has long passed.

What often gets lost in conversations about professional prestige is that while professions may have general qualities, they're made up of individuals. Individuals have their own qualities which may adhere to or contrast with those of their profession. For example, a physician isn't intelligent because they're a physician - they're intelligent because what they have acquired a good base of knowledge and the problem-solving skills necessary to use that knowledge effectively. The vast majority of physicians are intelligent, having the mental faculties to make complex clinical decisions competently, but there are exceptions. Becoming a physician doesn't instill intelligence automatically and as a result, a small minority of physicians are not particularly bright. Likewise, choosing to not become a physician will not remove intellect from an already-intelligent person.

So why should prestige matter at all? Well, it gets back to that original question - we care what others think of us. Furthermore, we want those positive opinions of us even when we don't have the time or opportunity to demonstrate our true qualities. It's not feasible or socially acceptable to demonstrate your level of intelligence to every person we meet. Our careers provide a proxy for who we are as people, whether we think that proxy reflects who we are or not. Being a physician provides a benefit of the doubt other professions often don't.

That benefit of the doubt can be a small comfort, however, when knee-deep in the medical profession. If there's one group of people unimpressed by someone being a physician, it's other physicians. In medicine, particularly in the training phase, guess who you'll be spending most of your time with? Likewise, most of the non-physicians you work with won't be overly impressed by your job. Nurses, pharmacists, PSWs, RTs, and the gamut of other healthcare workers have been around physicians long enough not to be in awe of the title. They will generally like you as a physician if you work well with them and do a good job for your patients, but will never like you because you're a physician.

The bottom line is that a prestigious career provides some benefits in terms of how you're viewed by others, especially those who don't know you well. When choosing a career based on prestige alone, you could do much worse than medicine. Yet, prestige is a weak and inconsistent shield against the judgments of others. Not everyone views physicians in a positive light, particularly those in regular close proximity to physicians. Therefore, as with any career, having the self-esteem to recognize who you are as a person, independent of how your job is viewed, is vital. If you don't have the confidence in your own abilities or value, being a physician will not provide much help to assuage those feelings. Similarly, if you do have confidence in who you are, that will show through regardless of what your career happens to be.

In the end, I believe that the prestige of the career is a positive reason to become a physician, but an exceedingly minor one. If a physician enjoys their work and the other aspects of medicine, the prestige of medicine is a helpful perk. For those that aren't as thrilled by the job itself, prestige is a poor consolation prize.

CaRMS In

After much scrambling, managed to complete my CaRMS applications on time. Personal letters got done at the last minute and I submitted everything far later than I'd like, but it's all in. My letters of reference were received in good time and all assigned already, so I don't even have that second reference letter deadline to worry about. It's all in, complete and done.

Posting has been a little bit delayed and will likely stay that way as I catch up on missed sleep, but it feels great to have a bit of extra time to get back to blogging. Expect to have some meatier posts in the near future.

CaRMS - Deadlines Approach

Ok, so I have to finish my CaRMS applications by this Tuesday. I've picked my programs, my letters of reference are all arranged, and most of my documents are uploaded. I've still got quite a bit to do this weekend, however. I have one personal letter that still needs some final edits and another three that need to be written.

I'm starting to over-analyze those personal letters a bit, and it's getting to the point where I really wish my brain would shut up. I'd like to think my application is fairly strong, but this is when the uncertainty creeps in. So, I'm going over trivial differences in wording and obsessing over what content to emphasize. It's going to be an exciting weekend...

Nevertheless, it feels good to be at this stage and to have everything put in. I'm confident in my interviewing skills, and while I won't be leaving anything to chance their either, once my written applications are in, I'm over what I consider to be my last major hurdle in my residency applications. Well, assuming those go well and I get the interviews I'm hoping for - we'll find out in a month or two!

So, About Last Tuesday...

I'd feel almost neglectful if I didn't touch on the US election last week. This blog is primarily about medicine and healthcare, so my intention was to touch on the numerous effects a Trump presidency is likely to have on the health of people in America as well as those abroad. However, since starting this piece, both major media outlets and more healthcare-focused sites have provided analysis of this with various degrees of depth, and I'm not sure I have much to add. Fortunately, the effects are fairly easy to sum up without losing too much with the brevity - a large number of people, mostly poor or sick people, will lose their health insurance or will end up with less-comprehensive coverage.

Of course, health effects will depend on exactly what policies Trump choose to enact, whether unilaterally through executive action, or through legislation by working with Congress, so it's hard to say exactly what will happen. Nevertheless, the proposals presented thus far all lead to that somewhat over-simplistic conclusion above according to multiple independent analyses.

It's a striking reminder that health depends on so much more than medicine. The sum of medical knowledge and ability in the US is constantly increasing, but the health of its citizens is likely to worsen if Trump proceeds as promised during his campaign. Keeping engaged in the political process and involved in advocacy roles are both important ways for physicians to influence the wider society that has far greater effects on patient health than most physicians' direct actions.

Like many disappointed by Trump's victory, I take this result as a spur to action. No, I'm not American, but it's a reminder that undesirable outcomes are often the result of complacency and that to see sustained progress, sustained effort is required. While I do use this blog as a way to express my viewpoints openly and honestly, I would like to make a more concerted effort to be directly involved in how the world is run around me. That said, as we see protests spring up across America, I'm equally reminded that hate is not the answer to hate. Most of the protests are peaceful, but some are not, and violence cannot be the answer even when other viable options are available.

Lastly, I'm reminded that effective advocacy should be one of the final steps to enacting change, not one of the first. Before pushing for what we think is right, it's vitally important that we take the time to determine what right is. Too often, advocates assume their positions are correct without ever challenging their own viewpoints, and good intentions are no substitute for a considered, informed opinion. Reading, listening, and learning are essential before - and after - speaking out. That includes
paying attention to those viewpoints opposed to yours. Those opposing views don't need to be accepted, but they should at least be understood. Furthermore, when asking the world to change, we first should consider how we can change ourselves. No one's perfect and that's an unrealistic goal, but there is always something we can do to change our actions and behaviours to do further our own priorities for the world.

I do a lot of my advocacy through this blog and other online postings. It's not a particularly effective approach - those who come to the read the blog are typically sympathetic to my viewpoints already, so I'm largely preaching to the choir. So, I feel the need to take a few more direct steps. My first is by starting some regular charitable contributions to causes I care about, putting my (currently limited) money where my mouth is. My goal has always been to give a significant potion of my income to these or similar charities, so despite my growing debt, I might as well start now, as I'm finally on the verge of having a real income. While I've always been involved with school projects that I feel are meaningful, I'm going to try to spend my last year and hopefully my residency as well, with more direct involvement in the curricular side of medical education. Lastly, I'm looking into ways to be involved in the political process. I'm not sure what form that will take, as I'm not particularly partisan and not sure how I feel about joining any political party, but it's time I explore my options. Staying on the relative sidelines, where writing and voting are my only methods of influencing policy, just doesn't feel like enough at this stage.

Considering a Career in Medicine - Money

We focus a lot on how students can prove they're good enough for medicine. These posts are for students wondering if medicine is good enough for them.

Short Version: Once established, a physician in Canada can expect to make a solid six figure income, with significant variation based on specialty, location, and practice type. However, it takes quite a bit of time and debt to become established. As such, delays in financing typical life goals are common. Money management skills are necessary to financial security, particularly when considering retirement, as physicians face different financial considerations than most individuals. Physicians often find themselves in trouble when they fail to control their spending habits and adequately save for the future. The high income in medicine is often a result of long hours worked, not just high hourly wage. Lastly, any career path should be considered with alternatives in mind, as students may have other, equally lucrative options.

Long Version: A desire for money is often thought of as an unsatisfactory reason to get into medicine, but money matters and income is an important consideration when planning a career. In Canada, physicians' income is high relative to most other countries, with the notable exception of our neighbours in the United States. There is significant variation in incomes for physicians. Specialty is the greatest factor, with lower-earning specialties like Psychiatry, Family Medicine, and Pediatrics earning closer to $200,000 on average, while high-earning specialties like Radiology or many surgical specialties earning in the range of $400,000 or higher. These figures are after accounting for overhead, but before taxes. Within each specialty there is a range of incomes as well depending on location, type of practice, and commonly performed services. It is not uncommon for practitioners to earn more - sometimes significantly more - than the averages quoted above.

Put simply, physicians have very good incomes, reliably putting them in or near the top 1% of earners in Canada. This high floor on earnings does come with a relative ceiling on income, however. Whereas similarly high-earning professions like law or business see elite performers earn several times what the average person in their field makes, physicians do not see that degree of stratification. The public healthcare system rewards quantity and with limited numbers of hours in the day, there's only so much physicians can do to see more patients and thereby increase their income. As a result, it is quite rare for a physician, even one in a high-earning specialty, to net over $1 million per year. Physicians are high earners, but students should not be expecting obscene levels of wealth.

Timing is also important when it comes to income and overall wealth generation, as the financial benefits of being a physician are not realized until after completing a long period of training, typically while accruing a fair amount of debt. A 40 year old physician tends to have more financial freedom than their peers in other careers. A 30 year old physician usually doesn't. This can complicate the achievement of non-career life goals that tend to occur in a person's late 20's or early 30's, such as buying a house, getting married, or having children, all of which carry a significant expense. All of these milestones are achievable as a medical trainee or recent graduate, but compromises are typically necessary. Some events will be delayed. Others will be lessened in scope - a smaller house, or a more modest wedding ceremony. Still more may be achieved only through added debt. Early career aspirations may need to take a back seat to income-generation. Over their career, physicians earn plenty of money to justify the initial time and debt invested, but the payoff is later in life, not earlier.

Once established, physicians' finances get easier in theory, but in practice, many continue to struggle. Physicians are notoriously poor money-managers and it can get them into serious financial difficulty. A mid-career physician has an enviable income, but can often set themselves up to have equally high expenses. After years of hard work and sacrifice, many physicians fall into the trap of spending too much and saving too little. This is particularly important as the vast majority of doctors do not have an employer-provided pension, meaning significant personal savings are required for a comfortable retirement. Jobs in medicine do not tend to have benefits either, residency being the notable exception, so physicians must also manage that expense out of their income. Failure to properly prioritize expenses through careful budgeting can leave physicians with significant money-related stress, despite having ample resources.

It should be kept in mind that the high earnings in medicine tend to come with long hours. Overall income can seem a lot less impressive when put in terms of an equivalent hourly wage, particularly once taking account all the unpaid aspects to a career in medicine. I hope to expand on this more in future posts.

Ultimately, when considering a career from a monetary perspective, a comparison must be made to alternative pathways, which can vary wildly person-to-person. If a student leaves undergrad with strong career prospects outside of medicine, they'll likely get far less of an overall gain from going to medical school than someone graduating their undergrad with zero immediate job prospects. In rare cases, going into medicine can be a financial negative. All students considering medicine should be actively developing alternatives to becoming a physician and should make the decision whether or not to enter medical school in light of those alternatives. Medical students tend to be intelligent, hard-working, communicative individuals who could be successful in a number of careers aside from medicine - it shouldn't be assumed that becoming a physician is the optimal choice from a monetary point of view, though it is often the lowest-risk pathway to ensure a six-figure income.

To sum up, there are some strong financial incentives to consider medicine. A physician can expect to be well-off to outright wealthy, but there are some caveats and physicians do need to budget their expenses to maintain financial security. Proper planning, with realistic expectations, is critical.

OMA and Elections

The Ontario Medical Association is not popular. It hasn't been for quite some time - speaking with senior physicians, I seem to find no one who has nice things to say about the OMA as an organization - but the feelings towards the OMA seem to have declined even further since the tPSA debacle. It provided such a clear example of animosity between the OMA and its members.

The OMA has gone on a massive "reconciliation" drive, soliciting opinions from members and hosting meetings across the province. While welcome, these efforts seem to only underline that the OMA has no idea what matters to physicians, residents, and students, or what the situation is like on the ground for its members. There is continued skepticism that this effort will not lead to meaningful changes in how accessible the OMA is on a regular basis, how it operates, or how it makes important decisions such as negotiating with the province over physician funding. Frankly, much of the communications coming out of the OMA since the tPSA vote have been rather underwhelming, jumping between irrelevant to my situation, or well-intentioned but pushy (a recent advocacy drive fills my mailbox more than I'd like)

That's why I was pleasantly surprised to see a recent e-mail regarding OMA elections. I've now been an OMA member for 4 years. I have no idea how the OMA's leadership is chosen. I've voted in a district election a few times, but don't understand how the candidates I picked between were chosen, or what their responsibilities are. I've tried looking once or twice and came up short. I'm sure the information is somewhere and if I put in a concerted effort, I'd find an answer and ultimately, it is on me to be informed as to how the institutions I'm a part of run, but democracy - even in the confines of a private group like the OMA - shouldn't be that hard. Physicians are busy and can't devote endless time to wade through the intricacies of a group that is supposed to be representing their interests.

This lack of accessibility and transparency was certainly part of the frustration with the OMA in recent years. The OMA hasn't seemed accountable for its actions and the only way to get a say in the process seems to require significant individual effort, usually with little effect. One of the arguments from the OMA and OMA-supportive affiliated groups was that the tPSA had validity because it had been approved by democratically elected OMA representatives. When OMA members don't feel as though they had much say in any election, or that their representatives, well, represent them, it doesn't give much credence to the OMA's argument of legitimacy.

The election changes appear to move the OMA towards transparency and simplicity. Elections seem to be easier to participate in as a candidate and to vote in, with fewer barriers to being a nominated candidate, consolidated elections, and online voting. It's a small step. Probably not a big enough one. I'm skeptical this will provide enough benefit to truly reform the OMA's ability to engage with its members. Still, after a rash of empty promises or tone-deaf announcements, I'll consider this a positive change and leave it at that.

Advising Highschoolers and Undergrads on Medicine

If you're in high school or undergrad and interested in medicine, it's not hard to find opinions on whether you should pursue becoming a physician. Parents will weigh in, mentors will weigh in, classmates and friends will weigh in. Critically, physicians have their own views on whether prospective medical students should become doctors, and they tend to share those opinions, liberally. It is not difficult to find those viewpoints online or in print.

And those viewpoints are diverse. Very diverse. On one hand, which gets promoted by universities and physician organizations, you have the physicians who feel that medicine is a wonderfully unique career, that they derive immense satisfaction from, which is worth considering and striving for. On the other hand, which more frequently comes up in anecdotes of prospective medical students who have asked physicians they know about the field, is the notion that medicine will suck your life away with all its demands on your time and energy, and thus should be avoided like the plague.

So what's a potential future physician to think? Is medicine an incomparable opportunity for success, or a dangerous trap leading to unhappiness?

It'd like to come out and say the truth in somewhere in the middle, but I'd say it's more like it's both at once. It's undeniable that medicine provides many opportunities - both personal and professional - that are not easy to come by in other fields. Already, I've had the chance to see and to do and to experience more than I likely would had I stayed in my previous career. I have new perspectives I never would have experienced in any other profession. Yet, I've also had to give up a lot of things I care about to continue on in medicine, more than once going through long periods of exhaustion or being overwhelming, experiencing despair bordering on depression.

My expectations for life have been revised upwards in many ways, while being simultaneously revised down in many other aspects.

That may sound bleak, but I don't view it that way. Life is about making choices, and those choices come with consequences, both good and bad. We can't take advantage of every opportunity - our time and energy are limited. Going into medicine was a choice that has had some positives, some negatives. Some of these trade-offs I was aware of heading into medical school. Others I knew about, but failed to fully appreciate. Still others seemingly came out of nowhere.

When a physician gives a judgment on their satisfaction with their career, or their views on medicine as a vocation in general, they tend to be giving a summary opinion on those trade-offs, perhaps highlighting the good or bad aspects that matter to them the most in forming that opinion. Yet its digging into the trade-offs that the answer becomes clear and each person will place different value on the pros and cons of the profession. To make matters more confusing, as people grow over time and experience new elements of the profession, their viewpoints will change - my own verdict as to whether going into medicine was the right choice or not has jumped around multiple times and continues to do so, even after 4 years of medical school.

So, should a student considering medicine take the plunge? Maybe. It depends on a number of factors, including current situation in life, career alternatives, life goals or priorities, and personality. Making any career choice is too complex to put into a binary "yes-or-no" answer and apply it to everyone. That's doubly true for medicine, a field with significant sunk costs and limited opportunities to smoothly transfer to another career (especially early on). Sorting through the meaningful considerations is well beyond the scope of a single blog post, and should ideally involve an active conversation rather than passive reading.

However, recognizing that not everyone has a physician they can talk to in-depth about all aspects of medicine, I think it's worth having some general information available on what a student can expect from a career in medicine. Over the next little while in a series of posts, I would like to explore some of these factors in greater detail. I can't provide a full weighing of preferences, but perhaps I can provide some context.

Halloween

Today is Halloween! Well, when I wrote this it was Halloween, as of the posting time, yesterday was Halloween!

The hospital embraced the day, with so many employees dressed up. The pediatrics department, as usual, stole the show. Got to see a kid in a Minions costume! The facilities staff also stood out, a lot of very interesting (and surprisingly functional) costumes around.

I'm on a Psychiatry elective, which means dressing up is generally frowned upon. Tame costumes in appropriate circumstances only. Some of the patients got into the spirit though, which I just think is awesome. Definitely brightened up my day.

Anyway, here's hoping you're having (err... had) a good Halloween!