How important is it for a doctor to want to be a doctor?

At first glance, that question is ludicrous. The path to becoming a practicing physician is so long and tortuous that no one would do it if they didn’t want to. Right? First, there’s the four years of undergraduate education, then four years of medical school, then at least three years of residency. No one has ever suggested that becoming a doctor is easy.

Here’s a scenario: A bright, promising young student decides on pre-med for whatever reason. Maybe they’ve known doctors they admire. Maybe they want to help in third-world countries or underserved populations here in the U.S. They have good reasons or OK reasons. Maybe they don’t have a service mission, but they want an economically stable future and intellectually challenging work. They volunteer at a hospital to get their hours in so their application to medical school will be strong; they end up mostly escorting patients, and they like the chit-chat. They shadow a specialist who’s a friend of a parent. It isn’t the most interesting work they’ve ever seen, but then, that specialty isn’t really what they had in mind — it’s just a way to get the hours in so they can apply to medical school.

They apply. In their interview, they’re poised, confident without being arrogant and have well-thought-out opinions on the state of health care today. They’re accepted.

The first two years of medical school are classroom learning. Brutal, but they’ve developed the study skills to handle it. Besides, this isn’t really what they want to be doing. Things will be different when they’re a doctor.

Third year hits. (In newer curriculum programs, this may happen on a different timeline, but the transition — from classroom to hospital — is the same.) For the first time, they are directly responsible for patient care. It is their job to come in, as early as 4:00 a.m., to pre-round on patients, present care plans, navigate the environment of the hospital, round with their team, suppress all bodily functions as much as possible to prevent the appearance of weakness and leave the hospital anywhere from twelve to thirty-six hours later.

This is a dramatic shift. It is impossible to fully prepare for. And this is where many medical trainees discover that they don’t want to be a doctor after all. They don’t like the hospital or the clinic; they don’t enjoy talking to patients; they’re frustrated by the enormous demands on their time and the lack of respect from superiors, colleagues, and patients alike. Being a third-year medical student is not quite like being a doctor, but by the end of the year, students have a pretty good handle on what they do and don’t like, and if they didn’t like anything … well, that’s going to present a problem.

If they didn’t like anything that they did in third year, what residency programs do they try to match into? Some students aim for programs with good work-life balance — radiology, dermatology, anesthesiology. But going into a field, you’re not passionate about will haunt you for the rest of your career.

So why would they do it? Why do students who realize once they start clinical medicine that they hate it continue on in training, match and end up providing patient care despite their dissatisfaction and burnout?

Money. It’s a very simple, very painful answer. There are other factors — the feelings of guilt and shame; you wasted all that training time that could have gone to someone else, you aren’t living up to your potential — but the biggest single reason people don’t quit medical training is that they can’t afford to.

My tuition has been climbing every year. This is normal; both inflation and the general trend of skyrocketing tuition everywhere are at play. Yearly tuition varies by school, but it’s common to be paying between $35,000 and $50,000. If a student decides in third year that they hate medicine, they would already be more than $70,000 to $100,000 in debt just for tuition, not even factoring in living costs and undergraduate student loan debt. What about students with professional spouses who also picked up a ton of debt (asked the med student who married a law student)? You can easily be looking at a moderately nice home’s worth of debt. If you go into practice, you can deal with that debt — on average over the course of 5 years after becoming an attending.

The question becomes: who could leave medicine? Very few students have families rich enough to absorb that kind of debt. If you go into any other field, with your background, as a failed medical student, how are you ever going to make enough money to pay it off? Leaving medical school is a recipe for lifelong financial insecurity.

What that ends up meaning for patients is that there are plenty of doctors out there in practice who would quit if they could.

Doctors who wish they could quit are more likely to be bitter, terse, short with patients, less interested in developing therapeutic relationships, less invested in diagnosing and treating correctly and less engaged with keeping up on the newest recommendations and research. In short, they are going to provide worse care than doctors who want to be there.

This is not a blame game. I don’t think all students should be able to see into the future to determine whether medicine is going to be a good fit for them. I don’t think doctors who were financially coerced into continuing are bad people, or weak because this field wasn’t a good fit for them.

I think the system has a problem. Medical trainees need off-ramps in our education so that people who are genuinely not suited to working with patients don’t have to. Let people who don’t want to be physicians leave the field without facing poverty.

Let patients have doctors who want to be doctors.

Kristin Puhl is a medical student and can be reached on Twitter @kristinpuhl.

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