Last week, the prolific Xrayvsn reached out to me on Twitter and asked if I would be willing to represent the Millennial generation in a 4 way cross-platform collaboration, looking at medicine through the eyes of different generations (click on the links to get to their posts):
- Baby Boomer via Hatton1
- Generation X à la Xrayvsn
- Millennial Doctor
- Resident Physician by way of Wall Street Physician
My first reaction was ,“This is an awesome idea!”, immediately followed by an Oh sh*t moment. Who am I to speak for an entire generation? And isn’t our Resident Physician also a millennial??
But, my enthusiasm got the best of me and I couldn’t back out, not when I have the word Millennial in my own name.
So who am I?
I am indeed a Millennial, born in 1985. I still remember tv’s where you had to physically get up to turn the knob and adjust the rabbit ears, telephones that had cords to tangle and life before the internet and social media. This makes me an old millennial, and I make this distinction because even over the course of my short lifetime, I have seen so many technological changes that impact my view of medicine.
In terms of my career path, I graduated med school in 2011, completed a Med/Peds residency in 2015 and due to my classic millennial idealism, I’ve been in primary care private practice ever since.
Over the years, I have watched more and more people choose to go into specialties over primary care. Some do it for the love of academia, love of the subject matter, or more prestige. Some do it for the increased earning potential to quickly attain financial independence. What has remained a consistent sentiment is best said by a friend of mine who chose to not go into primary care, more than he chose to go into his medical sub-specialty: “Primary care is the ultimate abyss where physicians go to die.”
But, I’m still here. Thus, I write from the perspective of experiencing the joy of having long term relationships and leaning on patients’ trust with each interaction. With that, however, comes the long list of labs and documents to be addressed, daily fights with insurance companies and the threat of Yelp/Google ratings that are causing many physicians to flee this calling, myself included.
These days, I no longer identify myself solely as a doctor but as a storyteller and as such, I’d like to couch my response to Xrayvsn’s request in:
A tale of 4 frogs
Once upon a time, there was a frog who happened upon a cauldron. The water looked refreshing, the fire cozy – this was a perfect spot to set up camp. She gingerly put a leg in to test the temperature and sighed a breath of relief. She had finally found nirvana. She hopped right in and started to swim around.
Her splashes and delighted laughter started to attract other frogs.
“Come on in! There’s plenty of room!” she said.
A second frog came up to the cauldron to see what all the commotion was about. The water looked a little bubbly to him, but she seemed to be enjoying herself just fine. He dipped a leg in and found that the water wasn’t really all that warm. All the other frogs seemed to be pretty miserable in the overcrowded pond he just left, so he too, jumped in.
As the two frogs started to joke and laugh with one another, a younger frog approached the cauldron. “Mind if I join you?” she asked cautiously, not wanting to fully interrupt their banter. The two frogs exchanged a look that said, I don’t know… three’s a crowd. They swam to the other side of the cauldron and nodded their assent.
As the younger frog looked around to determine where she should dive in, she noted some steam rising from the surface. She hesitated and looked up at the other two frogs. They seemed to be enjoying themselves just fine. How awkward would it be to make them move and not jump in? She chose not to test the water but launched into a full nosedive, shocked by the searing heat upon impact.
As she tried to collect herself while treading water, she saw her friend barreling in right behind her, straight into a boiling bubble. As he surfaced, she saw the panic in his eyes.
“Let’s get out of here!” she said, pulling him out with her.
As they assessed their collective partial and full thickness burns, they turned back to see the original 2 frogs almost comatose in the water, but hanging on the edge of the cauldron for dear life.
Welcome to Medicine
It is no secret medicine has changed significantly over the last 30-40 years.
As a self-described “realist” with a healthy dose of cynicism, I’m not one for nostalgia. There is no true “Golden Age” – history is written by the victors, and of course they will paint their deeds in a positive light while leaving out the not so wonderful details. Each generation thinks they’ve had it harder than the one before them. Since the beginning of time, every generation has thought the next is annoying, lazy and entitled, making it a universal truth that teenagers are seen as the absolute worst.
I’m not sure we are so drastically different among generations, but we certainly are coming in at different stages of the boiling frog tale, thus our responses have changed accordingly.
Three’s a crowd…
As I alluded to in my tale, there has been a palpable loss of community between the prior generations and Millennials. You can feel it in all of the physician community groups on Facebook. You can sense the disdain when other physicians refer to those Millennials in online articles or even in normal conversation.
I get it.
We are the new teenagers. We’re entitled, lazy and ungrateful toward our older colleagues who have forged a path through medicine for us. We harp on work/life balance, see the benefits of shift work and are even contemplating leaving medicine early because we don’t want to work anymore.
I propose, however, we are merely responding to the toxic environment in which we have found ourselves. While the Boomers and Gen X acclimated to this environment over time, Millennials have abruptly arrived and found it to be unacceptable to sit in for too long.
The cauldron takes a while to get to boiling but once we’ve reached that tipping point, it’s game over for all of us. Either you stay in and be cooked alive or you find your way out.
From the Boomers, Gen X to my generation: The Environment Heats Up
Hostile takeover by insurance:
In the last 30-40 years, the patient-physician relationship that was once very deeply personal and community-based has now shifted to a patient-insurance/healthcare system relationship, thanks to the rise of insurance companies and HMOs. I am told this was not the case in the 1980s to 1990s, but in my short career in medicine, I’ve come to understand much of what is done in medicine these days is dictated by what insurance will and will not allow. The increase in prior authorizations, peer-to-peers or just flat out stonewalling of reimbursement for services rendered several months ago has gone up exponentially in the 3 years I’ve been doing this.
Unfortunately, this was omitted from the Powerpoint presentation in pre-med, med school and much of residency. Upon surfacing out of training as a new attending, it was a shock to arrive in an entirely different type of medicine than I had anticipated – an arena of insurance games.
Now we are forced to decide – will we meet our metric goals, spending our office visits ticking off checkboxes for “meaningful use”, or will we do what our patient actually needs?
Technology:
Technological advances have changed the face of medicine in the same amount of time – some for the better, some for the worse. Advances in diagnostic techniques such as MRI, CT and mammography have all saved lives. We’re able to access an amazing amount of medical knowledge with a quick search, which is exceedingly important as the doubling time of medical knowledge is a mere 3 years.
Despite all this, most hospital systems still use pagers. Someone please explain this to me.
As an old millennial, I took part in the transition between paper charting and EHRs, and I must say – things are a lot better when notes are legible. However, I’ve seen the EHR change from being a tool to help increase efficiency and decrease medical errors to something that has been built as a vehicle to increase billing revenue.
Now we have loads of data and information that don’t add any value, other than to buffer our notes in order to “prove” we’re doing our jobs to the powers that be, charge the “best” billing code and exponentially increase charting time. This takes time and energy away from what I wanted to do in the first place: take care of patients.
Another layer of complexity facing our generation is the issue of social media and online ratings, something that didn’t really exist even 5 years ago. Doctors’ reputations can be torn apart in a matter of minutes, for simple things such as being pro-vaccine or even telling patients the labs they are requesting aren’t medically necessary. Extending physicians’ social capital into the online space is something the medical machine is ill-prepared to handle, and while we struggle to maintain a foothold there, other entities are more than happy to swoop in and take over.
Student loans:
After discovering I was $250,000+ deep in med school loans during residency, my baby boomer attending remarked , “When I was in med school, you could work a summer as a college student and pay for your tuition!”
This is something unique to the millennial generation – the amount of student indebtedness.
I was fortunate to have been inducted into the minimalist/financial independence community early on in life via my parents, but I see my cohort struggling to avoid the “keeping up with the Jones’” lifestyle that afflicts our predecessors. Profligate spending – on top of the huge loan burden – locks us into a career in medicine, an environment that has turned out to be more toxic than we anticipated.
Looking Forward…
How do we turn down the temperature to make this workable for the next generation?
Should we even try to make this specific environment workable, or do we find an entirely different cauldron to start fresh?
These are the questions my generation faces moving forward.
Perhaps they won’t be answered by us, but by future generations.
We could demand better transparency from insurance and healthcare companies, making them prove they are actually putting their pooled resources toward patient care instead of lining the pockets of their executives. Or, perhaps the answer will be found in joining other health care models such as Direct Primary Care or even the often maligned single payer system. What we are doing now is not sustainable.
We could design an EHR that would enhance efficiency and optimize the time a physician spends in the room with a patient, instead of discovering more new and interesting ways to shift our focus from the patient to our computer screen.
We could look into why the costs of medical education have skyrocketed over the last 20 years. The lack of transparency of where $50,000+/year per student actually goes is infuriating. Perhaps we don’t need another fancy medical building to impress people driving by, or have our medical tuition used to subsidize other university pet projects.
We could encourage more of our colleagues to discover the Financial Independence movement to create a more hospitable landscape and give ourselves more options. We unfortunately can no longer have all our eggs in this one basket of medicine, despite the fact that this basket took over a decade to build. Perhaps this will allow us to still wade into the steaming cauldron but enable us to exit and re-enter as we see fit.
As a current primary care physician, I am choosing to jump from this cauldron into another, hopefully one in which the temperature is not rising as quickly.
It is my hope this serves as a warning call – there are many more like me who are planning their exit strategy who are not as vocal.
And we’re taking friends with us.
So there you have it – the Millennial Doctor perspective.
Agree? Disagree?
Feel free to leave a comment below and also check out my colleagues’ posts to see where they stand on Medicine through the ages:
- Baby Boomer via Hatton1
- Generation X à la Xrayvsn
- Resident Physician by way of Wall Street Physician
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Photo taken of mountain goats grazing in the foothills of Mount Rainier, WA.
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Absolutely love the tale of the 4 frogs Millennial Doc! What a fitting comparison. Yeah Hatton1 and I are definitely the ones that have found themselves getting acclimated to a slow boil as the changes took years to slowly insinuate itself into the culture of medicine.
Thank you for participating in this 4 physician collaboration. It actually exceeded my expectations.
Thank you for including me! It was a really great experiment – I’m totally in for the next one!
Wait… are the 4 frogs in your story the same ones that XrayVsn’s father received as a gift from a patient? Either way, I’m not eating those frogs 😉
On a serious note. You are spot on from the millennial perspective. I am a fellow older millennial too since I’m born in 1983. I’m too young to be considered generation X. And frankly, I identify myself as a millennial personally.
Like you, I’m relatively frugal and sensibly minimalist to the point where I have paid off my student loans and on the fast track to financial freedom. My salary is likely higher though.
I have made the conscious decision to join a large group practice / medical organization where the insurance, the hospital, and the medical group work in concert within the same organization. No preauthorization or unnecessary paperwork for me. I may have less direct autonomy as someone in private practice, but I readily accept this for the convenience of not having to do paperwork and the flexibility of a large group practice.
At any rate, I’m setting myself up financially so that I can jump out of the cauldron anytime I want if it gets too hot.
Thanks again for your perspective.
Haha.. I think there was definitely some subliminal messaging on Xrayvsn’s part. Odd choice in frogs, but I totally fell for it 🙂
I’m glad you concur with my perspective, seeing that I boldly stated all of us millennials feel this way.. it was a gamble.
As for your comments about being in a large healthcare organization, from my perspective as a PCP in private practice, what I have in autonomy (which quite honestly seems to be lacking with the top-down edicts from the practice’s physician owners/office manager), I more than lose out in terms of support staff. We have a bare bones operation which leads to burnout and a constant revolving door of MA’s and now, providers.
Physicians in all of these Facebook groups keep talking about private practice as the end all/be all but I have not found this to be the case, especially when you’re an employed physician without a partnership track. That was a mea culpa on my part, and I’ve found I am being taken for a ride by my own private practice. Lesson learned, and now I’m jumping ship, or cauldrons in keeping with the theme of this post.
The one shining light in all this is there is more incentive for me to become financially independent so we can weather these ups and downs. I may be a little behind you but I should be done with my student loans by the end of next year!
Thanks for your comment!
Completely agree, millennial doc. Our environment is much more toxic. One of our older faculty members finally came around to realizing how much debt we have and how much it impacts our ability to be fully present… and it only took three people (two internal, and one from outside the organization) to convince him this stuff mattered.
I was born in 1985, too. We hike a different road with a different attitude. And a questioning attitude that the generations before us simply do not understand.
TPP
100%.
I find the lack of empathy/the inability for others to put themselves in another person’s shoes is so pervasive in medicine – it’s like we only reserve this for our patients, with nothing left to spare for our colleagues.
Perhaps that’s a self-preservation thing – there’s only so much emotional bandwidth to go around. The great thing about this online community though, is finding other millennial docs (or perhaps even Boomers and Gen-Xers) who feel the same way!
Thanks for reading!
student loans, the joneses, being preyed upon by unscrupulous financial advisors, EMRs designed to “optimize billing” at the expense of our time and energy, insurance companies and peer to peers, toxic work environments that burn people up, law suits lurking around every corner….
The powerpoint left out a lot more than just the insurance companies….
But we CAN rebel against this mess that we inherited from our “parents” and try to fix it. Our idealism isn’t dead and buried, we aren’t old enough for that.
Haha.. but aren’t we? I know I feel old 👵
Primary care has sucked the idealism out of me and all that’s left is cynicism as evidenced by this post – perhaps I just need to take a step back and regroup. Or maybe just siphon off some of your can-do attitude 🙂
Long-time lurker and fan of your writing. What a few from the older crowd call entitled, I’d describe as appropriately fed up.
When you have your, “This is not my beautiful wife, this is not my beautiful house?!” moment of reconciling the ideal with the reality, there’s a lot of understandable cynicism and resentment.
Having a sound exit strategy, ideally by reaching financial independence, is the superpower that gets you out of this untenable scenario.
Working less, more humanely, when you no longer do it for the money – this is what has the potential to make your actual career look more like the career you’d envisioned.
Working so that it no longer depletes you; so that the cost to your loved ones is manageable – that’s a job you can perform for a long time, as part of a glide path out of feeling stuck.
Thanks for writing from your wonderfully candid perspective – I’m grateful your voice is part of the chorus.
Fondly,
CD
CD, thank you for your comment! I am also a long-time lurker of your blog, so I appreciate knowing you’ve stopped by a moment or two!
I am on a quest to change from trying to make my life work around my job (which for most of us is how it’s set up in training) to now making my job work around my life.
Working less was the first step to realizing I didn’t really have a life outside of work for me to come home, and now I’m aiming to cultivate that.
I’m finding this is a common struggle for many of us who’ve built our lives around this achievement treadmill, so we stay stuck because this is what we know. I know I would enjoy my job a lot more if I knew I wasn’t doing this for what feels like the sole purpose of paying off my student loans and achieving FI, and ironically, even that goal is just another dangling carrot keeping me on this treadmill.
I’m waiting for the day I show up to work because I absolutely 100% want to, not because I have to – I hope that comes sooner rather than later.
Thank you for reading 🙂
M,
I hope that when you take a step back from the treadmill, you’ll have a chance for some idealism to return. Mine has started to seep back, slowly. It is a wiser, sharper, less naive idealism, though. Once bitten, twice shy as they say. I increasingly think each of us has a specific formula that is something like “X minus number of patient’s seen divided by time minus hours spent on paperwork plus days spent on vacation=days til burnout.” Gotta slow down if you’re gonna last.
At some point, the system can have intensely productive doctors or long-lived doctors, but not both. Not at this pace. I remember in my first practice seeing my partners making a ton of money and being absolutely miserable, I didn’t want their life in 10 years.
Agreed. It’s so fascinating to me – people who are miserable always seem to want to suck you into their scripts. I guess misery does love company 🙂
I hope some of my idealism will return, but at this point I am skeptical even of that. I’m trying to decide whether I’m going to burn out hot and fast and retire from medicine sooner, or live a slow paced life and doctor forever – the problem is, this profession tends to attract all or none personalities, so going slower has been against my nature. We’ll see how this upcoming change goes!
I loved everything about this collaborative series. You are 100% right about there being a palpable loss of community between millennials and older physicians. I think a lot of it stems from the tradition of older docs grinding it out for years until newer docs came in to replace them on the chain gang. All of a sudden new docs showed up and realized they didn’t have to wait to age 55 before contemplating work/life balance. A lot of what you perceive as disdain may actually be jealousy.
Thanks for being part of this unique collaboration.
Thank you for reading and being a fantastic cheerleader for our collaboration!
I love your insight of disdain = jealousy. The older I get, the more I see the truth in this, especially when I start saying things like, “Well, when I was your age…”
Nothing like realizing you’re being a hypocrite to shine light onto some hard truths.
When Boomers started, the enemy was Death, and everyone fought the same enemy. They knew their enemy well, and respected and feared it. This common cause united everyone, and they stood together.
Now, our old enemy is not as frightening any more. In my entire intern year I only lost three patients; many Boomers lost that many in a single night shift. Death is not the unifying foe it once was.
The result of our successes fighting Death is that we have now turned on each other. We are all meeting unrealistic long-term expectations in the short term, knowing we are overburdened personally, but like the drowning person we grasp and clutch and drag down anyone else in our reach. The elders blame the younger because they remember a time when elder doctors’ burdens were removed by those following. The younger blame the elders for creating this untenable system.
As for me: I’m going to go look at funny pictures of cats now, and I recommend you do as well, because this is a very dark topic in these times for medicine.
This is why I go on hikes, take pictures of pretty things and post them up on Instagram. It allows me to step back from this black hole and gain some clarity.
I still believe we can do something about this whole situation, but not until we stop the in-fighting among us. It’s really the system that needs to be torn down and started anew – refocusing efforts on that crusade would be much more productive. Still don’t know what that looks like though, so in the meantime I go on rants on the internet until my next moment of clarity 🙂
Thanks for reading and commenting!
Hey, M!
I’m new to your site, and just wanted to say how incredibly well written this is. You’ve managed to articulate a pain point for millennials and millennial doctors in a way that seems rational and completely justified, and not whiny. That’s hard.
Well done, and I look for to learning more from you soon 🙂
I’ll be honest – I sent a rough draft to a friend and point blank asked him, “Does this make me sound too whiny?”, resulting in so many iterations of this piece! It was a fine line to walk, and if not done in a mindful way would’ve absolutely corrupted my argument.
With that being said, thank you so much for your kind comment! I checked out some of your stuff and can’t wait to dig in more as well!
Haha, I’ve made my husband read through stuff too with the “Is this too whiny” prompt.
I think you did a wonderful job. Cheers!
Thanks for this. I think about the different generations and their practice experiences a lot. For me, as a boomer MD nearing retirement from primary care, it is clear that the current generation has more challenges on their hands than I did. Physically, training for and practicing medicine has gotten easier but in all other ways, intellectually, emotionally, financially, it is gotten much harder.
Consider my father, a retired pediatrician who trained in the early 1960’s. Internship consisted of 36 hours in the hospital, followed by 12 hours off, repeat ad nauseum, for an entire 12 months. Solo practice where he was on call for his patients every single night for many, many years until he finally started a group. No urgent cares, no peds ED’s. Exhausting. BUT, he controlled his own practice, mainly was paid in cash, no med school debt and the amount of knowledge, medications, treatments etc.was finite and manageable. He was generally happy, retired at 70 and was never sued.
Now me. Internship was 100-105 hours per week and the fund of knowledge and medications/treatments available was sizable. Med School debt was moderate for my colleagues (I was a military scholarship recipient) and HMO’s were just beginning. Little to no insurance issues, easy record keeping, could pretty much control my schedule etc. Shared call, Urgent cares and ED’s readily available for after hours care etc.
Current residents are (generally) limited to 80 hours per week. But the debt load, EMR’s, ridiculous amount of technology and medications, CPT and ICD-10 codes, demanding/unsatisfied patients, malpractice etc. etc. makes this current generation at increased risk for stress /burnout and generally at risk for unhappiness. I’m very concerned for these younger physicians going forward and I don’t know what will change to improve things. But overall, I would pick my era over my Dad’s or the current one, all things considered.
Thank you for your perspective! I find it interesting that despite the large time discrepancy spent in training/work between our generations, you would still say that you’d want your era over mine.
I am with you – I’m not sure what will change to improve things either. Perhaps we need to allow the system to implode on itself before something is actually done.