American medicine is at a crossroads as doctors begin to reject a cruel, exhausting educational model and a minefield-ridden practice landscape. Hands wring over the worsening physician shortage, yet little happens to ease physicians’ administrative workloads or student loan burdens.
These challenges have led to unacceptably high rates of work-related psychiatric illness and suicide, with “physician burnout” entering the national lexicon. At the root of some doctors’ anguish and despair has been a sense that medicine is their only option — because it is all they know how to do — rather than a fulfilling job they choose to do.
Indeed, discussing one’s early exit strategy, whether to retirement or to a completely different job, has become all the rage in private online physician communities like Sermo. And doctors in practice for as few as seven years are quitting at an alarming rate, even as baby boomers are filling clinics and hospitals with their complex arrays of medical problems.
While U.S. medicine is in need of immense reform, including intuitive electronic health records and higher pay for primary care, there is something physicians-to-be can do to protect themselves from some of the problems that plague doctors today: spend their formative years working at a first career and meeting their life partners, and wait to begin medical school until age 28.
Why 28? For starters, working for six or seven years after college at a nonmedical job would let doctors put crucial funds into retirement and real estate. For many physicians, part of their current collective disillusionment with medicine is financial. Instead of enjoying incomes proportional to their sacrifices, they tussle on the phone with professional payment deniers at insurance companies and watch as money slips away to paying off massive student loans, licensure fees, and malpractice insurance. Plastic surgeons may buy mansions, but geriatricians clip coupons. It is no wonder that a geriatrician shortage looms.
Unlike their nonphysician counterparts, who have been growing their nest eggs since their early-to-mid 20s, many physicians worry about having to work past retirement age due to foregoing buying that fixer-upper or missing the years of compounded investment gains accrued from putting money into retirement accounts before starting medical school. For students and medical residents with little to no disposable income, the cash flow just doesn’t permit it. But both adult goals can be achieved before starting medical school. The proceeds from selling or renting out that home or the dividends from early investments can help offset the costs of medical school, as can doing work on the side in one’s “twenties profession” during medical school.
Starting medical school later in life can prevent unrealized dreams and potential, which are sometimes a source of resentment in unhappy doctors who feel trapped. For some people, the 20s are a time of stunning creativity and productivity. Musicians, writers, artists, software engineers, and others must often shelve their obvious talents for the unrelenting timeline of medical education: completing onerous chemistry labs, volunteering in hospitals, studying for the United States Medical Licensing Examination, and the grind of residency. That talent must be allowed time to marry with the incredible energy and neurological magic of the early 20s.
One of my most successful medical school classmates enjoyed international fame with a Taiwanese pop group during his early 20s. Not only did he have money to pay for medical school, but having self-actualized without wondering “What if?” he was able to study and achieve the level of mastery needed to earn a residency position in orthopedic surgery at a top program that was typically out of reach for graduates of our school.
Students considering a career in medicine who, unlike my classmate, realize a wish to pursue their artistic careers for life will simply not apply to medical school, making way for another deserving student rather than dropping out with regrets midway through a medical career.
Starting medical school at 28 would also create a perfect situation for starting families. Students could take advantage of perks like on-campus child care and a more relaxed schedule with the ability to attend lectures via internet. Exams can be made up easily after a maternity or paternity leave in the first or second year. Employers may scrutinize time off to care for children during one’s working years, but time off during medical school typically does not attract the same questioning.
It’s a different story in residency. Hospitals are known for punishing trainees who take even legitimate time off, in part because that supposedly creates more work for others. Hospital residents who took as little as six weeks of maternity leave have reported to the American Medical Association that punitive actions were taken against them, including being forced to work as poorly paid residents for an extra year or having their residency positions given away. Medical residents and fellows should receive three months of paid maternity and paternity leave, of course, but the retaliation culture in teaching hospitals is so widespread that preempting that process entirely may be more workable.
Children would enter school age as their parents were entering residency, with parents able to claim dependent tax deductions on their meager salaries. Further, having children before residency generally means that grandparents would be younger, healthier, and better able to help care for their grandchildren. Right now, many physicians struggle with stressful jobs, the demands of young children, and sick, elderly parents — all at the same time. That contributes to doctors reducing their hours or leaving the profession.
It is common for physicians to defer having children until their mid-to-late 30s — after residency and fellowship — adding fertility problems to their burdens. Prioritizing childbearing during the younger years before residency would drastically reduce the numbers of miscarriages, birth defects, pregnancy complications in physician families. Importantly, all of these health concerns directly translate to a loss of clinical hours for which those physicians are available to take care of patients.
Starting medical school at age 28 would also help break the cycle of abuse endemic in medical education. Attending doctors — the ones who do most of the teaching — tend to be age 35 and older, while medical students can be as young as 23 when they enter the hospital setting, with no real-world work experience. The rampant bullying, intimidation, and harassment by attending physicians would diminish by their teaching older students who have worked in other fields. Over the years, this would ideally result in a more dignified and intellectual culture in medicine than exists today.
Having established a career before entering medical school can also be a hedge against the capricious nature of medical training. No medical student should begin such an expensive and stressful journey without the confidence that another job awaits should things go awry. Residency trainees can find their contracts not renewed with no way to obtain board certification — a necessity for obtaining a job in the overwhelming majority of hospitals and clinics. For example, more than 500 residents and fellows lost their jobs as a result of the closure of Hahnemann Hospital in 2019.
Every year, fourth-year medical students apply for slots in residency training programs. Not all of them get invited to one. Many join the pool of several thousand “unmatched” (read: unemployed) doctors mired in the American system that does not fund all medical students to work in residency programs and gives some of those funded positions to foreign medical graduates. In other words, going to medical school is no guarantee of working as a resident and becoming a doctor. Without winning the “Hunger Games” of residency selection, graduates of M.D. or D.O. programs are not even allowed to work as physician assistants.
For those left without a job after investing hundreds of thousands of dollars in medical school, having been an accountant, pilot, social worker, or dental hygienist before helps them walk into new jobs with the ability to pay student loans and start their lives. They can reapply to residencies while enjoying a salary, benefits, and advancement instead of working for little or no pay in an exploitative research lab — often the only job offered to these graduates. Similarly, a sudden illness, the need to care for a family member, or simply wanting to take a break from medicine should not lead to utter professional and financial derailment, the way it often does now.
In the past, many made the argument that it took so much work to train a physician that the most desirable candidates for medical school and residency programs were those who would see patients full time for the greatest number of years. A 35-year career in medicine was more desirable than a 25-year career. Postings for residency positions frequently cite a cutoff date for medical school graduation in the previous few years, despite the glaring age discrimination that implies, and allopathic medical schools discourage older students from applying.
Yet older, more mature students have the potential to be greater assets to the medical profession overall, and enough young physicians lose their medical licenses early in their careers due to foolhardy illegal activity that it may behoove medical schools to seek out applications from those who have functioned decently as adults in society for some time.
Every generation of physicians must be free to act for itself. Claims to a physician’s 20s have withered away. Corporate health care has deemed physicians replaceable, either by those who accept lower pay or by nonphysician practitioners. Doctors of medicine and osteopathy are starting side jobs, from selling stick-on nail colors to dog walking. Modern physicians see a second line of income as a necessity, a hedge against the new uncertainty in the formerly most-certain job of them all.
But those side jobs would be much better if they were based on established careers from physicians’ 20s. They can provide a financial safety net that can be turned on immediately, unlike a business that needs to be built up over time. There are simply too many factors today that can lead to physician dissatisfaction or job loss to not have an alternative.
I took a year after college to work and earn money before medical school, and the savings decisively cut down the loans I had to take out in my first year. The cost of medical school now is so great that one year is simply not enough.
The axe of autonomy must rip at the root of doctors’ dependence on the fickle medical profession for career and life satisfaction and financial security. Medicine should be an individual’s second profession.
Monya De, M.D., is a Los Angeles-based internist and journalist.