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.
This presumes that everyone is going to be able to get their financial houses and personal lives in order in that 7 years which the average even well educated person does not. So now they’ve waited are still single had undergrad science degrees that’s aren’t super helpful for a well paying job (you need an advanced degree and if your going to be in school anyway might as well make grad school medicine). so maybe they worked at the Apple store and have a decent 401k and a spouse now what they have to make some notable sacrifices to go to little to no income and big school bill while navigating family. If you could go to McDonald’s and order your life this is a great plan but too much is unpredictable to prescribe this.
First, your medical school training will take four years formal education, 3 to 5 years of specialty training, if you choose to go that route, plus an additional two to three years of fellowship training. On top of that, I took three years out for research work at the NIH. And now you are positing it’s a good idea to delay that another eight years?
I am the same age as OJ Simpson and Kareem Abdul-Jabbar. Just as I was starting to finish my training, the media were saying how my age equivalent colleagues had lost a step and were beyond their prime…I was just starting out on my professional career. I think if you delay medical school to pursue other endeavors, you will lose a lot of talented individuals because they will be established in a career and making money which they will not be squirreling away to pay for medical school, but instead saving to take care of their young families. The endurance and focus required to complete your medical training is something that would be hard to ask your family to endure while you were studying, getting trained and appropriately being abused during that time.
If you’re concerned about the financial burdens induced by medical education, you are entirely correct. But if you take the position of the Kaiser Permanente School of Medicine and NYU, you could make medical school free. I think the payback, however, should be a period of service of perhaps five years in providing healthcare to underserved populations and clinics. My bet is that the satisfaction of serving needy patient populations in those areas would likely create many young doctors establishing a permanent practice in that area. Even if not, that population would be well served by bright young physicians, and the benefit to the physicians is they would be free of debt and thus be able to pick specialties of their choice, not out of financial necessity.
If you know healthcare is the profession you want, and you realistically know how long it will take, get started as soon as you can and be the best that you can be.
No thanks. I went to med school after a year between college and med school to work. During med school, my parents helped me purchase a house, which I then used my time not studying and summers to fix up. Once I got to residency, I found the woman to be my wife, married, and had my first daughter just before I graduated.
I now have three children, aged six, four, and eighteen months. As hectic as it was trying to repair a house while going to medical school, I could start and stop the process as school demanded. I cannot start and stop when I care for my family. I give all the credit in the world to those who go through such rigorous schooling with a family, but I could not have done it.
Delaying medical school for everyone will only serve increase burnout and stress as the demands of family are far greater than one living on their own, with ample time to focus and study.
Very interesting and eye opening to what medical students face.
Being at the tail end of medical school after starting right out of undergrad, I agree that I would have possibly appreciated maybe a year or two of “real life” experience to prepare me skill-wise for managing finances.
However, I certainly would never consider delaying medical school for 8 years. Nor would I commit to having a child, which is at least a $250,000 investment to make by lax figures—especially not if I consciously made the decision to delay earning the already abyssmal salary of a resident.
Your article provides good thoughts. However, your evidence is consistently contradictory to your main point, that delaying medical school would be financially beneficial.
Fantastic article and is spot on!
Spoiled milennial drivel – that’s what this is ! And it sure sparked many similar reactions i.e.” stop whining and grow up !” It is far better to enjoy hyper-productive studying with no strings attached like partners, babies, real estate, savings, etc. This article does not show any understanding of the joys of being a rightfully selfish hard-going student. Best time of my life (from 18 to 24).
I did just that- went to Med school after working 7 years at IBM so I had a highly paid skill to work during summers and holidays of med school. I however felt like an indentured servant in residency and thought the system needed vast improvements in how it treated house staff (cannot speak to how it treats residents today). It was legal to discriminate on the basis of age at the time so most schools discouraged older applicants. Luckily NYU was progressive and had almost a dozen more mature students. Apply there – tuition now Is FREE and I am very proud of my alma mater for being a pioneer again fostering medical students’ wellbeing. In my internal medicine practice I was also lucky to eventually work “part time” for childcare purposes, clocking in less than the 60-80 hours a week that many endure. Now fertility can and was a major issue. We cannot plan our lives to mesh perfectly with our biological clocks but I ended up with one terrific child and husband. All in all not an easy ride but patient care, fellow practitioners and satisfying my own mental curiosity made up for most of difficulties. I retired early when my husband started his own company but still am involved with doing online research in a very rare disease. I think this route is still harder for women as we often shoulder the lion’s share of house and family needs but I applaud the younger generations where the men help out more and thank my medical director at NY Presbyterian who agreed to a part- time position. We need empathetic doctors at the top. Thanks for reading.
I started Medical School at age 29. I worked as a PhD Chemist in industrial Research prior to that. One problem: Once I started Med School, the Chemical Industry considered that I was no longer a chemist. So I would have to sell insurance or be a Greeter at Walmart.
The best strategy is to live on 1/3 of your income. Put 2/3 of your income in a Spyder on the Stock Market. Then when you can tolerate Medicine no longer, give them the finger and head to Costa Rica or the Philippines and live out your life. (Or at least that is what I wish I had done.)
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