Are student loans being exploited to limit physicians’ practice choices?

We are in the thick of the job hunt, and it seems like every time I feel like we are inching closer to having a couple of jobs locked down, some new variable comes up. We’ve interviewed at small private practice groups, large private practice groups, academic and “priva-demic” groups located in the southeast and midwest.  The more I learn about these different job configurations, the more I realize I don’t know. However, along the way we have discovered a few morsels of information, and I’ve been struck by some aspects of the evolving healthcare climate that I wanted to share.

First, there is a noticeable migration of surgical practices toward hospital-employed rather than private practice. In my limited sampling on the interview trail, the practices have either just become hospital-employed, or are doggedly fighting to resist the gravitational pull of becoming hospital employed (and discussing this situation openly). Coming from my academic institution, at first this did not strike me as noteworthy, and I felt like the physician-employed model was essentially more convenient and equitable.

I was pretty close-minded regarded going into private practice, and definitely didn’t  consider full-time locums as a viable option until I started listening to Nii Darko’s podcast Docs Outside the Box. I’m sure it was somewhere in the dozen episodes I’ve listened to where I first heard the phrase, “No one will pay you more than you will pay yourself.” Such a simple statement, but it got me thinking about this situation with physicians voluntarily giving up control of their practices, and to a large extent, their paychecks. My experience matches the published statistics on the AMA website that as of 2016, less then half of physicians own their own practices, and the statistics are more dramatic for younger physicians, with 59% of physicians under 40-years being employed.

The second issue that has come up more and more frequently is that of the federal program for Public Service Loan Forgiveness. I first heard of this program in med school, roughly ten years ago, and at the time it was described as a program that may or may not ever come to fruition but has the potential to wipe out your loans after ten years. I was quite skeptical at the description, and honestly I assumed that it would never work out. I kept my loans on the standard repayment plan, even though it was a bit difficult at times to keep paying them on that schedule through residency. Then I refinanced near the end of residency (I should have done this sooner) with SoFi. However, I have many friends and colleagues who bought into the program, made the minimum payments to stay eligible (opting for the income-driven repayment plan), and consequently ran up piles of interest, graduating with larger balances than they entered residency with. THEN, they are limited in choice of employer to these “not for profit” entities, and now are facing the frightening possibility that they still won’t ever see the loans forgiven. (Note: I don’t mean to incite panic or add to any melodrama. The White Coat Investor has some good advice for anyone worried about this issue). Whether or not this program was written with the intention of limiting physicians’ practice options in order to encourage the employed model is questionable, but it has certainly had this effect. (Here’s link to .gov site for direct info).

Taking into account the principle that “No one will pay you more than you will pay yourself,” these physicians have:  #1. Taken out massive amounts of loans, #2. Had interest payments balloon through residency thanks to income-driven repayment plans that don’t touch the principle, #3 signed up for jobs that will likely pay less and prevent them from taking control over their practices. This situation seems like an ideal formula to take a tremendous amount of power and earning potential away from physicians and transfer it to administrators.

Now, I’m personally not against taking an employed position. As a trauma + critical care surgeon, I think this is probably a much more common scenario for my field considering many tasks we are responsible for are non-RVU based and located in larger hospital trauma centers. Nevertheless, I’ve been amazed at how many neurosurgery practices have been bought by hospital systems, and the main reason cited is complexities of billing.

At the risk of sounding glib, I’d like to point out that this same evolution happened in the record industry, did it not? We ended up with a bunch of simple, formulaic, boring bands and cheesy music genres. Same thing happened with beer; remember before craft brewing was a thing and all that was on the shelves was weak, smelly water with clever ad campaigns?  Fortunately, these two industries, among many others, have benefited from an awakening of independent artists and craftsman, and there is now a flourishing variety of creative music and micro-brews for us to enjoy. Maybe the same thing can happen with healthcare, but that there are much stronger influencers including lobbyists, politicians, and that infamous army-of-middle-men standing in the way. However, if it’s best for patients and best for physicians, we can keep the indie spirit alive in healthcare as well. The Frugal Physician has just written an excellent post about this very idea, expanding on the idea that in order to take back control of medical practices we have to control the finances, starting with our personal finances (i.e. student loans).

This idea of finances being the key to engineering the practices, and lives, that we want has been coming up again and again lately. Personally, we have little choice but to pay off our debts and achieve some measure of financial independence if we really want to pursue careers in humanitarian medicine. But for those outside of this field, ignoring finances has the analogous consequence of limiting the type of practice, and ultimately life, that one can have. It’s likely no coincidence that these changes are correlating with the burnout epidemic. I’m not the expert, and I don’t have the answers. I’m merely the naive young doctor observing and asking the question: Is it too late for physicians to take their practices back? Who is really benefiting by keeping us out of practice ownership?

Guest Post: A Day-in-the-Life of a Surgeon Mom

I am pleased to share this post detailing a day in Dr. Jessica Schnur’s life. She is a general surgeon with a subspecialty in minimally invasive surgery at Stony Brook University Hospital. Despite her humor and talent for writing, I’m sure it will be quite apparent that her job and career require astounding commitment and sacrifice. While I have heard it said that the average person underestimates his/her free time, this statement couldn’t be further from the truth for dedicated physicians like Dr. Schnur. We are all searching for the balance that will allow us to do the jobs we love and use our talents to help our patients while loving our families the best way we can.

The last 6 weeks for me has been complete madness, between work and family I feel I have barely been able to stay afloat. I wrote this as a compilation of the combination of things that happen simultaneously every day. The amount of emotional and intellectual energy one must dedicate to taking care of your patients, your family and your friends is at times exhausting. We all became physicians because we want to help people, but the risk of burnout is real and while I have read many articles advocating for remedies to it I have yet to see anything significant be done about it. Dr. Jessica Schnur

My alarm goes off, it’s 4:40am. I flail around trying to turn it off so I don’t wake up my husband. Find it! I close my eyes for a second and pass out instantly, open my eyes to find that 15 precious minutes have passed. I debate whether I have enough time to exercise and still leave for work on time. I have an hour and 15 minutes. I can do it. It’s never happened before, but today it’s going to. I go downstairs, take my coffee and sit on the couch in the dark to enjoy my few minutes of peace for the day. My mind wanders until my phone goes off. Ping ping! I look over, my junior colleague was on call last night, he is letting me know there are a few new patients for today, two gallbladders. Maybe three.  Also a patient with a decubitus ulcer.  He is leaving town now for a “conference,” would I mind taking care of all that? Of course, I write, my freakin pleasure. I start to feel some unrest in my bowels, a combination of the rocket-fuel grade coffee I made and rage against my lazy co-worker. It’s been ten minutes and I need to get ready to work out. I go back into the kitchen to wash the dishes from dinner last night. I didn’t cook, so I do the dishes. Can I do this in 30 seconds? 100% More unrest from my bowels, I abandon my dishwashing and run to the bathroom. I finally get my workout in, inhale breakfast and jump in the shower. When I get out I see I have 11 minutes before I have to leave the house. Plenty of time. I look in the mirror at the pale bloated face looking back at me, pimples and wrinkles that need covering, significantly greying hair that needs to be blow-dried so I don’t look like Albert Einstein. Various creams, concealers, highlighters, blush… check the clock again. One minute left. Mascara flies on, blow dry my hair for 60 seconds, good enough. Compression stockings, scrubs, find a sweatshirt that doesn’t have too much dog drool and marker on it. Ready to go! Should have left the house 15 minutes ago but what else is new.

I arrive at work, tires squealing in the parking lot like I’m running from the cops. My phone rings, it’s my chief resident.  We have an intraoperative consult from GYN, they have run into some difficult adhesions and are requesting help, can I meet her there?  Ummmm, I’m not even in the building yet but sure.  Run up to my office and try to find somewhere to throw my stuff. It looks like a tornado hit, papers everywhere, dirty scrubs in piles on the chairs, multiple empty water bottles. I sort through the madness and am about to head down to the Operating Room when I realize I am wearing slippers. This is disappointing, but there is nothing to be done.

About an hour later we are finishing up the first case and my phone starts going off again. Ping Ping! Ping! Ping Ping Ping! It’s my husband, my little one peed all over her bed. He’s annoyed. The text message is multiple screens long and involves some talk about how we are going to sleep train her. After a few paragraphs, “Where are you?” I write back a frowny face. I have to round, still have four cases to do. I come out of the OR and find my intern and PA to start rounding. My intern is pale, sweating, looks like he might be in heart failure. I try to console him, it’s ok buddy, we will get through this day. He actually might not, but we must move on.

We go see a patient I operated on a few days ago, “Hello, sir! How are you feeling?” He’s a very nice elderly man, looks like he’s doing well. “I want to eat!” Fantastic! “That’s great! You can eat!” He looks thrilled, asks me if I can tell his doctor he can eat. I debate whether to point out to him that I am his doctor, decide to go for it. This may have been a mistake, he stares at me wide eyed, speechless. Was it the slippers? It is best to leave at this point. “See you later!” I say cheerily.

I battle my way through the rest of rounds, some more consults and admissions, a few cases. I get my phone to dictate my last case and there are multiple missed text messages and a missed call from my daughter’s school. I panic momentarily about the school phone call but it is just a robot announcement. We have told the school as well as any other place our children or dog goes to call my husband with issues because he stays at home but they still call me. Every. Single. Time. The texts are from two of my friends and my husband again. One friend wants to know if we can get together for a playdate tomorrow afternoon at 3, which is Friday. I say I will ask my husband if he can bring the kids over and then lose the motivation to relay this information to him. The next is from another friend who is seeing the latest greatest nutritionist among the other moms who magically helps you become thin and fit and full of energy. He had sent off a panel of blood work and told her she may have a gallbladder issue. She sends me three pages of lab results and asks me what I think. I think I really can’t look at this right now. Finally my husband. He is unhappy with the light fixture in our younger daughter’s room, it is apparently flickering, which may or may not be true. He is debating on how to rewire the fixture and switch to fix this. He is not an electrician and refuses to call one. I only ask that he not burn the house down while the kids are home.

At some point I realize I’m starving. It’s 5pm and I forgot to eat lunch. Or drink water. I don’t think I’ve peed since I left the house this morning. I go to the recovery room to get some water and graham crackers, but there are no cups. Or crackers. I ask one of the staff for a cup, he points out the cups really are supposed to be for the patients, reluctantly shows me where they are hidden. I apologize profusely for being a human being and take my water.

One more consult to see. Ping Ping! Husband again, apparently my younger daughter is “very angry” at me because she misses me and wants to know when I’m coming home. I’m on till 6, but things are looking good. Just one more patient to see, I tell him. We go to the ED to see a middle aged man that was suspected of having a bowel obstruction. He is there with his wife and mother, all look extremely concerned. He has been constipated for a week, very bloated. I listen intently to the tale of his failed attempts to poop this week. We look at his labs, imaging, he has no bowel obstruction, he is simply constipated. We recommend some laxatives and stool softeners, fiber, etc but his family catches us as we are leaving and wants to talk more about constipation. It is now well after 6. I have received a video from my husband of my four year old angrily telling me I have to come home and she is very mad. I extract myself from the ED and head back to my office to gather my things to leave.

I get home around 7:30, dinner has been had, my husband tells me he gave the kids a bath, but they washed themselves. He is proud of them. I’m concerned about their hygiene but too tired to look into it. He tells me to eat dinner quickly before we put the kids to bed but at this point my priority is the glass of wine that I am going to pound before story time. Teeth get brushed, stories read, I lie down next to my 4 year old to rub her head while she goes to sleep and pass out before she does. I wake up because she is kicking me in the face. I get up and look at my watch, 12:30 am. I crawl into my own bed and prepare for another day of complete insanity.

Being true to our younger selves

My alarm beeped at 5:00 a.m., and I was instantly awake. I roused my sister, and we donned our jeans and rubber boots before heading outside in the dark. Gravel from our driveway crunched underfoot as we hurried to the barn, banged on the wall to encourage the rats to hide, and flung open the wooden door to retrieve the feed and hay for our mares. We sat on the steps waiting for them to finish their breakfast, anticipating the joys of our daily trail ride. The air was already warm and thick with humidity in the Mississippi summer, and if we didn’t get the horses on the trail with the sunrise, it would be too hot. Tack on, we mounted and sauntered down the road, taking an easy pace for the first hour through Mr. Buddy Crawford’s pastures to the beautiful old pine forrest trails. The mystical beauty of the morning and perfect harmony with my horse, Naomi, filled me with joy every day of the summer. As we emerged from the woods, a long straight stretch of unused cornfield made for the perfect runway, and my sister and I raced our horses across. Naomi responded to my voice command, “GO!” with unbridled enthusiasm, and the thrill of galloping across the flat grass course was like no other. At the end of the ride, I could tell she was just as happy as I was. This horse was my soul-mate; she came when I called, sensed my moods, and would follow me anywhere. She was easily spooked, but I knew all of her quirks. We returned to the barn and went about our day, watching the antics of our goats, dogs, and cats, and always looking for more adventure.

At this phase of life, around age 8-10 years old, I simply knew who I was, what I wanted, and what I liked. Shortly thereafter, around middle-school, my self-consciousness soared while I became thoroughly confused about what I liked and wanted. Unfortunately, that “phase” of life continued through high school and in some form through college, and young adult life. I made decent decisions for majors, friends, career, life-partner (ok an astonishingly fantastic decision on that one!), but I didn’t have that effortlessly pure, distilled sense of who I was. I also didn’t realize that this was the case, until I faced my own big monstrous burn-out during residency. This topic deserves it’s own post, which I will eventually write, but for now suffice it to say that it took months for me to work through the challenges associated with it, and when I was finally emerging from those doldrums I had a burning question constantly on my mind: What would my 10-year old self think of me now?

It was hardly a rhetorical question, and I had lots of answers. First of all, I would have been appalled at the lack of book-reading happening. As a child, I devoured stacks of fiction-book series. I read in my room, in the car, in the yard, in trees, at night, first thing in the morning, on the bus…I was a bookaholic. If I recall correctly, I was into several equestrian stories, maybe had just finished all the Boxcar Children, Baby-sitters Club, Chronicles of Narnia, and Saddle Club books. Anyway, at the point of my burn-out recovery in residency, i hadn’t read a novel since 4th year of medical school, when I read one chapter each night of War and Peace to help me fall asleep; it took me about a year to finish (short chapters) but I loved the ritual.

I also would have been perplexed as to why I didn’t write more. I always enjoyed journaling and writing stories, and even through high-school and college I nurtured the interest and skill in writing. I took AP English and was an English major in college; I wrote all the time. Even as a math (double) major, I wrote an honors thesis (on Non-Euclidean Geometry), which is just to say, I worked in writing at every opportunity. As a med student and resident, I never wrote anything except daily notes and H&Ps.

The next one was even more painful to admit to that little girl of my past…I had grown up into a woman who was too busy for a dog. This was a profoundly sad realization, and was decidedly the catalyst for springing me free of the burnout and depression because I made his resolution: “If I’m too busy for a dog, I’m just too damn busy and something has to give.” I decided then that this would be one of the barometers of my life to keep things in balance. And I adopted, and got adopted by, my soul-mate dog Ramble. (If you want some insight into how low I felt at this point in life, listen to the song, “Too weak to Ramble,” by Dr. Dog, which inspired his name.)

My first hike with Ramble, when the sun literally and figuratively came out for me.

Maybe one last big one would have been participating in humanitarian work and travel, essentially being connected to current events. I had picked cardiac surgery as a specialty and was pretty determined to not fall back on what I felt was a commitment to that field, but increasingly I felt that trauma surgery was so much more intricately connected to the community and current affairs, which I was very interested in. I did go on a trip with a cardiac surgery group (Novick Cardiac Alliance, which is a fantastic organization I will write more about in future posts) to Ukraine, and learned a lot there about delivering superb quality, highly advanced surgical care in a developing country, but I was much more interested in what was going on with the folks being bombed at the border than with the cardiac stuff. I hadn’t really made being an activitist in global health topics a priority with my time and efforts to that point; I was just trying to “get through” training.

Me in Kharkov, Ukraine, with a tiny patient in the ICU awaiting her procedure. We had to hold/bounce/jiggle her to keep sats up before surgery.

Ramble and I went for hikes every weekend that I was free from work that spring, summer, and fall. His influence on my life was profound, and taught me to be open to sharing my time and energy with the right people (and creatures). I also wrote a couple of articles for a local independent journalism group. I picked up some good books to read. I started the first Global Surgery Journal Club at Mayo Clinic in Rochester, and networked with some awesome surgeons and residents who had similar interests. I’ve never had a recurrence of burnout or depression. 

So many people go through similar growing pains in their early 30s, it’s almost a cliché. But the transformation was real, and was about taking back my life in small ways, and stopping that utter neglect of all the things that made me “Me.” But where am I going with this long,  long post? What’s it got to do with Indie Docs, or Global Medicine?

Learning about myself, what I genuinely like, how I truly want to spend my time, has been a challenge and has developed some skills of insight. It almost feels like a muscle that started out pretty weak those few years ago. It can be quite stressful to trust myself to step off the prescribed path of daily routine or academic medicine, and even more-so for choosing a really unusual career narrative.

Josh and I have discussed the subject, “What do we want our lives to look like in 5 years,” countless times, and we are still discovering the answer.

Fortunately, through her interview on the ChooseFI podcast, I discovered Jillian from Montana Money Adventures. I started working through her mentoring worksheets, and I was blown away by the insight they provided me. I asked her permission to use the worksheets as topics for discussion here, to which she has graciously agreed. So in upcoming posts and maybe on some podcast episodes, Josh and I will use her mentoring worksheets to answer the questions of how we are purposely designing our lives, engineering our time and finances, and thinking about the future in order to be true to our most quintessential goals (doing humanitarian medicine!)

I gave birth to a beautiful baby girl this past week. I’ve designed my year so that I get lots of time at home by taking a research position rather than an attending job. I’ll be doing some locums assignments as well to keep my skills sharp and gain experience, but doing this “off-year” was one decision I made that may have been different than what most surgeons would think is the right way to spend my first year out of training. With our unique circumstances, and how much fun I am having with my girls AND with stretching my skills as a researcher, and I’m secure in knowing that I made the best decision for us.

The ability to answer these simple questions of what we really want in life will be central to making sure we make the right decisions about what jobs to take this year, particularly in order to facilitate our bigger goals of making humanitarian medicine a major part of our lives. The decision could enable us to have the freedom to pursue many global surgery projects, or strap us to confining responsibilities.

There are trade-offs to every scenario, pros and cons to weigh, futures to consider (the girls’ in addition to ours), and plain old money questions. But all of those specifics take a back-seat to the simply being able to know and do what will make us happiest and give us the deepest sense of purpose.

With the help of some great mentors this year (stay tuned for that!), I am certain that we will find the right path.

Announcement: Humanitarian Travel Scholarships through Doximity

Many physicians reading this are familiar with Doximity, a professional social media site that publishes articles ranging from scientific papers to editorials. Most of us are also keenly aware that finding funding for humanitarian medical travel can be very difficult and time consuming.

I’m very happy to share that Doximity is now sponsoring travel scholarships for humanitarian projects. The process is a simple application, and currently 80% of projects are approved! To check out their website and apply, follow the link.

 

How to start a global health interest group at your institution

Despite having a huge campus, state of the art healthcare, and an amazingly diverse group of employees, my hospital did not have a Global Surgery “group.” There were surgeons, nurses, scrub technicians, and even pharmacist going on medical and surgery missions projects and lots of individual efforts going on. We have a fund available to us as residents for competitive scholarships to various locations for humanitarian health endeavors. But no one was getting together to have discussions and provide wisdom and support to the group. No one was addressing the enthusiasm of our medical students for this field. And no one was promoting education of the larger group of employees regarding all the potential benefits of participating in humanitarian projects. I could imagine an amazing Global Surgery department at our hospital, much like what I explored via the internet sites from Harvard and Stanford.

I tried to think of the most basic first step. What was the move that would be completely without controversy, free, and easy for this one person to pull off? The answer: Organize a journal club. Journal clubs are ubiquitous, 100% educational and therefore in line with the mission of my program, and flexible. I could design it to meet when and where was convenient for me (I hosted the first few), and also drum up enthusiasm and support from others that might want to participate.

So that’s what I did, and we just decided to see what might happen next…

We had a small group of highly enthusiastic participants, including medical students. We met at the homes of group members and enjoyed very wonderful home made food. I was thrilled that some of our attending physicians agreed to host!

I was committed to meeting monthly with the exception of December and selected articles that tried to set the groundwork for understand the current state of the Global Surgery arena. We started with the Lancet publications (see http://www.lancetglobalsurgery.org/) and ended up talking through various publications from this series for the first 3 meetings. We branched out to publications featured on the Lifebox website (see http://www.lifebox.org/professional/publications/).

Group members started to undertake fantastic research projects and promotion of humanitarian missions. As a group, we brainstormed about how to establish a Global Surgery center, which is our current active goal.

Perhaps most importantly, we became a close-knit and defined group of Global Surgery enthusiasts, and there is tremendous motivation in having this support from peers and mentors.

Starting a Global Surgery, or medicine, or pharmacy, or simply global health, journal club, is a quick and easy first step for starting the fire at your institution. With consistency, you can build an alliance of folks looking for camaraderie and practical advice. There are no downsides!

Let me know if you’ve had a successful strategy for starting a humanitarian medicine group of any subspecialty at your institution in the comments below. It would be great to share strategies for success!