One of the greatest shortcomings of medical training is the lack of financial guidance for trainees. Too often students are told not to worry about compensation when choosing their specialty since they will be comfortable no matter what field they enter. However, I have come to realize that compensation and finances go far beyond just having a fancier house or car. In reality, they can have far deeper repercussions in how we care for our patients, including a loss of autonomy and being undervalued in the work we do. And all of this contributes to worsening physician burnout.
I chose pediatrics, which is traditionally one of the lowest-paying medical specialties. I knew I would not be driving a Lamborghini or living in a large mansion, but I was more than happy to give that up if it meant practicing in a specialty I love while still being financially comfortable. However, my intern year came with a hard reality check. I was considered one of the slower residents in our outpatient clinic. I started out being very thorough, going over small details and not skipping any anticipatory guidance, but it made my 10-minute visits 30 minutes and resulted in fewer patients seen. As a result, I was pulled aside and told that due to our low reimbursement in this field, I needed to learn to see a higher volume of patients to generate enough revenue to keep a practice running. That was simply the nature of our field. When reimbursement and compensation per visit is low, you must make up for that with a higher volume of visits or your practice closes. That meant either shorter visit times prioritizing speed over thoroughness with my patients or giving patients the time they needed but working later and longer hours to see that high volume.
In pediatrics, being more thorough meant you went over relevant anticipatory guidance with families in the room and had them repeat back instructions to confirm they understood what needed to be done for their child. It meant observing a child playing with things like blocks in the room to assess their developmental milestones in real time. It meant doing a thorough chart review and following up with patients to make sure they were following through on the treatment plans given.
Instead, we skip most of that anticipatory guidance and give parents a printout of bullet points on their after-visit summary at checkout to read on their own. Instead of observing the child, we run through a brief checklist of developmental milestones and rely solely on the parent to confirm if they are being met. Instead of following up on treatment plans, we just hope it’s being done and never get to check in.
Being more thorough meant I would run hours behind and work late into the evening. Being faster made me feel like I was cutting corners. Either way, I felt miserable and burned out. The love, passion, and joy I had for my chosen field had evaporated almost overnight. I found myself being timed when I was in the exam room, having to learn to do just the bare minimum so I could quickly move on to the next patient.
The happiest physicians in my field simply accept the low pay and see fewer patients while spending more time with them. However, accepting a pay cut is not an option for many of us with high loan burdens, private practices to maintain, or families to support. As a result, many of us in poorly compensated fields like primary care or pediatrics must accept the high-volume schedules put upon us or settle for less than ideal positions because good-paying jobs in our field are limited and we must take what we can get. The lower compensation also means more time needed to pay off loans, save for retirement, and achieve enough financial independence to be able to practice on our terms.
Beyond giving up autonomy in how we practice, I find lower-compensated fields are also far less valued in the healthcare system as a whole. Poorly compensated fields like pediatrics or primary care typically generate less revenue for hospital systems. As a result, when budgets are tight, it’s often pediatric floors and offices that get closed down first or get fewer resources and attention. A close friend who is a pediatric hospitalist almost saw their entire floor get shut down shortly after accepting the job, and a local hospital just recently lost its pediatric floor. In the outpatient setting, PCPs are often treated as expendable referral machines to send patients to specialists who generate the real revenue. This is obviously not ideal and a bitter pill to swallow after the time, stress, and debt many of us take on in training.
All of this is to say that medical students should be educated on finances and how it will impact not just their lifestyle but how they practice medicine itself. This could include honest discussions about insurance reimbursements and how that shapes the way practices are run. It would also help to go over not just the ideal way care is given but how that actually translates over in a real-world practice setting so students know what they will actually be doing.
What advice would you give medical students? Share in the comments.
