I will never be the physician that my father was

Let me start by saying that I love my father dearly. We have an excellent relationship, and talk regularly. So there’s no bitterness in this post, nor any desire to engage in armchair psychology.

My father, now retired, was a general and thoracic surgeon, who was triple-boarded in critical care, and ran a trauma unit in inner-city Philadelphia. He was in private solo practice for most of his career. He worked seven days a week for much of my childhood, and seemed to be on call all of the time. I can remember multiple Thanksgivings that were cut short or scrapped because someone needed him.

I’m the oldest of three children, and we were all born during his residency and fellowship. He spent pretty much every other night in the hospital. My memories of my father when I was little are of a man who came home every once in a while, sometimes yelled, and then fell asleep.

This is when you should remember how I began this post.

But my father was a phenomenal physician. He was immensely dedicated to his patients, who knew that he had – literally – saved their lives. He always seemed available, regardless of their ability to pay, regardless of how frustrated he might become. I worshiped him. He was awe inspiring, the reason I became a doctor was likely because at some level I wanted to be like him. But he was also demanding, sometimes short-tempered, and not always present. His career consumed so much of his life. He always so very tired.

In the mid 90′s, my father had a terrible ski accident. He needed to have complicated surgery, with bone grafts to repair his leg. He was off his feet for six months, and still can’t stand to do long procedures. He was forced to quit surgery, and to give up the career that he loved.

Personally, I think it’s the best thing that ever happened to him. For the first time in his adult life, he slept. And I mean slept. He also slowly became a different person. He became more interested in his hobbies, and became a pretty impressive woodworker. He read, not just journals, but fiction and non-medical non-fiction. He played golf. He made friends.

He became a better human being.

My wife only knows my father since his accident. She only knows this man who rolls around on the floor with my children, who has been known to cry easily, and who always seems to want to give you a hug. I have to explain to her often that this is not the man I grew up with. He celebrated his sixty-fifth birthday last year, and when I gave a toast at his party, I said that he was a man who was getting better with age. I meant every word.

When I entered medical school, I knew only what I didn’t want to do with my life. I knew I didn’t want to be a surgeon.

I love my father, but I want different things than he did when he was starting his career. I want to be present for my children when they are young. I want to make it to every Daddy’s Day at Sydney’s preschool. I want to be available to take Noah to football practice. I want to spend hours playing video games with Jacob. I want to be able to meet my wife for lunch every so often.

I know that this means I will never be the physician that my father was. I will never be as close to my patients, nor will I garner the respect for my clinical skills that he did. I can live with that. I absolutely love my job, but I want to have protected time to be with people I love. I want to read, and to write, and to grow. I want to try new things. I want to spend time working on being a better father, a better husband, and a better friend. I want to do that now, not just when I retire.

I was thinking about this just yesterday morning, as I was visiting someone I’m close to who was in the hospital. I was there not as a physician, but as a friend. I was grateful that I have a career, as a physician, which allows me the flexibility to be there for people I care about when they might need me. I think that makes me a better human being. I think that makes me a better doctor.

There are those who disagree with me:

It is one Sellers, a doctor for 37 years, hardly recognizes from the days not that long ago when physicians worked 20, 30, 40 hours in one place, on call at all hours, their social lives often non-existence. That isn’t the way of most of today’s young docs. Not when you get into the whole new issue of changes in physician productivity that are really generational, Sellers explained…

“The priorities in the profession have changed in the last 30 years dramatically from (days when) always before the profession came first. I’ve got to work 90 hours a week. I know that going into the profession, it’s a 24/7 profession. I’ll make arrangements for coverage if I need time off. But yeah, that’s what I do. the marriage relationship and so on suffers,” Sellers said. “But the priorities for younger physicians, generally speaking, place the profession below quality of life, below family, below concerns about lifestyle. So productivity-wise, the current estimate is that the new generation of physicians, in general, will be 50 percent as productive as the retiring generation.”

“They won’t be putting in the time.”

I’m sorry, but I have a really hard time identifying with this kind of thinking. It’s not uncommon these days, though, especially among older physicians. Me? I don’t know why doctors think it’s a good idea for them to martyr themselves on the altar of professional sacfirice.

When I was a medical student and resident, I worked with an untold number of attending physicians who were absolutely miserable. I don’t believe that made them better at dealing with patients. I knew many who left the house before their children got up and got home after they went to bed. I don’t think this made them better pediatricians. Did you know that physicians have the highest suicide rate of any profession?

I remember one of my medical school friends who interviewed at a top-tier surgical program where they bragged that over the seven year training  period the divorce rate of residents was more than 100%, because some of them divorced twice. They were bragging; I was horrified.

I think there’s room in medicine for all types of people. Some obviously enjoy working 90 hours a week. I do not. It turns out that most people don’t:

After Sellers joined a practice of seven internal medicine specialists in Sioux City, he gradually saw the practice depleted by retirement, departure and death, and the survivors quickly learned that they were not able to recruit internal medicine doctors willing to share equitably in on-call coverage for the group, which included covering the two hospital emergency rooms for unsassigned patients that might need their specialty. Even reducing the on-call coverage obligation from 90 to 60 hours a week failed to draw any new recruits.

Maybe I won’t be as famous as I would otherwise be if I worked that hard. Maybe I won’t be as rich. Maybe I won’t touch as many lives or be as beloved as those who came before me. But I believe I’m replacing a lot of that quantity with quality, and I’m investing in my family, my friends, and my community.

Someday my children will have to make similar choices. Maybe they’ll choose to be like me; maybe they’ll choose to be like my father. I’ll love them either way, just like I love my Dad. But this is my life, and it’s my decision, and I really wish doctors could stop judging each other for making different choices than they themselves made.

Aaron E. Carroll is an associate professor of Pediatrics at Indiana University School of Medicine who blogs at The Incidental Economist.

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  • http://twitter.com/MGastorf Melissa Gastorf

    My father was not a physician, but otherwise I fully understand what you are saying.  My husband and I met in medical school, and elected to not go that route.  He actually works more hours than I do, but if I took call, who would be there for our children if we were both called in.  Most of my patients understand this, and can even agree with it.  I don’t know that it hinders my skills any, I am still there throughout the week.  I can still treat diabetes, hypertension and pneumonia. I still do well child checks.  I made the choice not to do deliveries, so maybe I lose skills there, but how many OBs can manage all of the health conditions that I do.  It is a compromise, but I don’t know many people who regret going to their children’s school plays, but there are definitely those who regret missing them.

  • http://www.zdoggmd.com ZDoggMD

    As the physician son of two physicians, I find a lot of truth in your piece. It hits very close to home.

    My dad and I actually got together recently and filmed a couple of interviews, which to some extent hit on the differences between “then” and “now” in medical practice:

    http://zdoggmd.com/2011/07/meet-zdadd-m-d/
    http://zdoggmd.com/2011/07/zdaddmd-the-lost-scenes/

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I’m not sure what is wrong with the thinking of Dr. Sellers quoted above. He is just stating facts and it doesn’t seem to me like he is making any value judgements. And the facts are that the newer generations of workers, not just physicians, places higher value on aspects of life not related to work.
    So if each worker produces less work, either we as a society learn to do with less, or turn to substitute services, as he describes, or we educate and deploy more workers. For some reason, we seem reluctant to educate more physicians, and as Dr. Sellers estimates correctly in my opinion, we should graduate double or triple the number of physicians we used to. If we are not willing to do that, then we should contend ourselves with less medical care or medical care provided by non-physicians. It’s just simple math.

    • Jeremiah Pamer

      When Dr. Sellers says that the new generation will only be 50% as productive as the previous generation, there is, inherently, some value judgement implied. What I mean is that, why it may be true that there will be quantitatively 50% production, what Kevin is talking about is an increase in quality, overall, in a physician’s ability to treat patients. If we really could increase the quality, we could also decrease the necessary quantity needed (admittedly, this would not be a 1 to 1 relationship). I will concede that this may not be the case with surgeons, but when more face time/communication is needed with the patient, quality is something that, at times has been sacrificed by the previous generation in order to perform at 2X the pace.

      That being said, I agree with what you have to say. In my med school the faculty has told us they have been making a real effort to produce physicians who are willing to take care of themselves. There have been many frank, and at times scary and intimidating conversations about the suicide & divorce rate (among many other issues) among doctors.

      As a side note, as is evident with the latest scare from congress to slash GME funding, the problem lies not with schools producing more students, but with increased residency positions. And to think I used to see the real bottleneck existing at med school admissions process — little did I know that that pales in comparison to trying to get into the training program I desire.

  • Easton Jackson

    My father is a recently retired family physician. He and another doctor took all the ER and hospital call in their rural hospital for about 20 years. Each took call a week at a time. When my Dad’s partner had emergency spine surgery, he was out for 6 weeks. Dad worked every day for 6 weeks. 

    This story strikes a lot of chords with me. I remember not seeing Dad for 2-3 days at a time, or we’d take him dinner out at the hospital. Despite this, he still managed to be a Scoutmaster for several years, a little league coach, and a great Dad. During his last 10 years of practice, he got a 3rd partner, and had somewhat less call. 

    My dad retired earlier this year. He says he can’t believe how much better he feels now that he can sleep, uninterrupted, every night. His blood sugar and blood pressure have improved, he’s biking more now, and he goes scuba diving to exotic places. He always managed to maintain an upbeat outlook on life, but I could see the cynicism and frustration seep through now and then. Today, he visits with all of us kids regularly, gets to play with his grandkids, and does yardwork. He and my mother are planning a 2 year church mission next year.

    I did rural family medicine for 5 1/2 years in a very similar rural community. I had call every 3 days in the ER, delivered babies, did some surgery, and had a full clinic. I averaged 80-110 hours/week. I loved the work, but didn’t see my family much. My wife said I was more grouchy, and I didn’t feel like I knew my younger children very well. So, we moved to the city, and I took a job in an urgent care. Now, I do three 12-hour shifts each week and have no call. The work isn’t quite as enjoyable, I don’t have as close of a connection to my patients, and I make somewhat less money. But, I sleep every night, I’ve made it to my daughters’ ballet performance and school plays, and I go to my sons’ ballgames. 

    While I love medicine, it is just a job. It does not take priority over my family. What doctor, if they’re honest with themselves, looks back and says, “Wow. I’m sure glad I took all that call rather than spending time with my family when the kids were young.”

    I would’ve liked to have been a general surgeon. But the residencies still brag about their 100% divorce rate. No thanks.

  • http://twitter.com/PorterOnSurg Chris Porter

    My father is also the father/surgeon you describe. I decided to become a surgeon nevertheless, but with a modern sensibility. Being a good doctor is much more than logging hours, yet so much breathe is wasted on the topic. Men have greater responsibility in the lives of their families now, to say nothing of the women who make up half the graduating doc work force. Change happens. I embrace it and encourage young surgery residents to do the same. I think a generation whose mature priorities include time for family and outside interests is a generation I’d like taking care of me. You were up all night operating? Cut the machismo and send in your well-rested partner, thank you. 
    I’ve blogged on the generation gap here: http://porteronsurg.blogspot.com/2011_04_01_archive.html Several related posts in the archives.

  • Anonymous

    Physicians do not have the highest suicide rate of any profession.  It’s higher than that of most professions, for sure, but that dubious honor belongs to veterinarians, who have a suicide rate twice that of physicians.

  • PamelaWibleMD

    Aaron ~

    I grew up in Philly. My dad spent over fifty years as a doctor in Philadelphia. I share many of your views, but I disagree with you here:  “I know that this means I will never be the physician that my father was. I will never be as close to my patients, nor will I garner the respect for my clinical skills that he did.”

    You can be even closer to your patients than your dad. You can garner more respect for your clinical skills than your dad. And you do not have to martyr yourself to accomplish either.

    Like you I love my job and I still have time to read, write, and try new things. Heck, I am even making a documentary film on primary care right now: http://www.idealmedicalcare.org/docs/The-Documentary.pdf

    I want to be an ideal doctor and I discovered it’s easy to do when we jump out of the this-is-the-way-we’ve-always-done-things box and simply ask patients what they want and follow their advice. In 2005 I challenged my patients to design an ideal clinic. I hosted several town hall meetings, collected 100 pages of testimony, adopted 90%, and we opened the clinic one month later. My job description is now written by patients, not administrators. 

    Patients don’t want a martyr. They want (and I quote) “a relatively relaxed physician in a calm space, someone with plenty of time off.”  I am happy to be their doctor. 

    You can have it all Aaron.

    Pamela Wible, MD
    IdealMedicalCare.org

  • http://twitter.com/TPane1 Thomas Pane

    The generation gap arguments are false, as you point out.  Dr. Sellers and others with this view don’t seem to acknowledge that the major driver behind the behavior of the younger generation is that the realities of practice have changed.  This is in part because former generations of doctors did not do enough to protect the profession from external forces, which have transformed much of medicine into a mere job. 

    In fairness, even solid effort from prior generations might not have been successful, but that is where we are right now.  The current delivery system is adjusting to the new realities of contemporary clinical practice.

  • https://me.yahoo.com/a/8lPLyDsl3uS.LfDfaSVX3iw8FEhj7vq1#44b0c joe

    Sorry Dr Wible but as per your previous threads:
    1: Your panel is 25% of the average doc. You pretty much have a pseudoconcierge practice
    2: You don’t see any inpatients
    3: You don’t take unassigned hospital patients
    4: You don’t take self-pay/medicaid unless you specifically choose to do so.

    I don’t fault you on any of these issues for your mental health. However, to say your model is some new paradigm shift for medical practice is simply not true until we start producing four times the docs (and paying for the residency spots) that we are now in this country. That will never happen. That’s the fact.

    • Anonymous

      Joe ~ 
      My comment was to help Aaron realize that he could be closer to his patients than his father and he could garner more respect for his clinical skills than he dad – both without being a martyr. My dad was an amazing doctor, but I have no doubt that I am closer to my patients that he was (he totally burned out as a solo GP and went into pathology). His clinical skills in pathology obviously far exceed mine, but I’m respected for my clinical skills all the same. . .I’m not promoting any one model. I do believe in asking citizens what they want and designing clinics around their needs. It’s why I volunteer to help physicians lead town hall meetings to discover what patients really want before opening their practices. I’m hosting free retreats for physicians all winter long at a beautiful hot springs resort to teach the community building skills that (of course) we never learned in medical training. So much can be accomplished with collaboration and celebrating what works for people.

      When we listen to what patients want and need, we realize that maybe they can be better served by acupuncture or massage than simply producing more MDs. We realize that they value happy physicians who are not martyrs, doctors who take themselves off the medical pedestal and are not afraid to be real human beings. 

      • Erika Svenson

        And patients who were on Medicaid wanted you to stop taking their insurance and patients who needed to be hospitalized wanted to be seen by a hospitalist instead of their PCP?

        • Anonymous

          Patients did not specifically ask for those two things. People were less concerned about me taking their insurance than taking care of them. Many people with insurance wanted to pay direct. What seemed **most** important is a human encounter with a happy doctor. I fulfilled 90% of their testimony. I still took care of my hospitalized patients the first several years (which I loved) but then the hospital doubled the yearly dues for courtesy staff (<25 admits/yr) to $700 and kept active staff at $300. I loved seeing my 1-3 admits per year, but not be TAXED by the hospital just because I have lower volume!!!!  I still see my few admits socially. I never turn anyone away because of insurance so all-comers get care.

  • Anonymous

    Thanks, Dr. C for this comprehensive perspective.  But this reality is certainly not limited to medicine. Both of my parents were self-employed business owners – they literally
    left for work each morning before their five children woke up, and returned from work
    every night long after we were sound asleep. We were raised by live-in
    housekeepers.  We saw our parents on Sundays.

    Canadian researcher Dr. Linda Duxbury at Carleton University has spent decades looking at the issue of ‘work-life balance’ and has found clearly distinct priorities for each age-demographic studied during her 30 year study. (Her landmark 2009 report: “The National Study on Balancing Work, Family and Lifestyle” found that people who emphasize the importance of long work
    hours tend to report higher role-overload, more
    work-to-family interference, as well as more family-to-work
    interference).  This obsessive work ethic of my parents’ generation and to a great extent of their children (all of us Baby Boomers) simply assigns work a far higher priority in life than their families get. But you can tell what’s important to us by simply looking at how we spend our time.   Conversely, the reality of this new generation of doctors whose work-life balance priorities are pretty clearly different from past generations of the eternally-available doctor means that patient care will invariably suffer unless we start graduating more docs. How can it not?

    For example: when you describe problems hiring new doctors for “…on-call coverage which included covering the two hospital
    emergency rooms for unassigned patients that might need their
    specialty…”  this translates as: there were patients in those two hospital emergency rooms waiting in vain to be seen by specialists they needed to see.