How medical training teaches doctors to be financially unhealthy [PODCAST]

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“We physicians must come to terms with the trauma caused by the financial insecurity built into our training and the ripple effect it has even after we finish training, both as a way to repair ourselves individually and as a way to assure that our profession survives.

The cost of medical education is high, but the cost of the financial lessons learned in the course of obtaining that education is even higher. It may be a price too high for future doctors to bear.”

Elizabeth Hughes is a dermatologist.

She shares her story and discusses her KevinMD article, “How medical training teaches doctors to be financially unhealthy.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Elizabeth Hughes. She’s a dermatologist, and she wrote the KevinMD article “How medical training teaches doctors to be financially unhealthy.” Elizabeth, welcome to the show.

Elizabeth Hughes: Thank you, thank you. It’s very good to be here.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Elizabeth Hughes: Yeah, absolutely. So I am a dermatologist by training and practiced clinically full time for about 22 years, but I got the seven-year itch about 14 years into it and realized I needed a change. I was held back by a lot of beliefs that I had about how medical practice is supposed to look, what’s appropriate for a doctor, and how you make money. And so that was a big struggle, me picking apart all of those things, and it led me to almost entirely leave medicine.

I still have a very part-time medical job, but I now have this creative outlet that I didn’t know was possible years ago. I have invented something that, you know, I’m not supposed to invent. I’m not supposed to be creative. I’m supposed to stay in the lines and not make something new. But I wanted to, so I did. I help other doctors and people with their health in a totally different way. I do writing. I’m going to tell you, it’s a far richer, more interesting career that I feel like touches more lives than I ever did in that one-on-one, person-to-person interaction. Not that I don’t love that or value it, but it was just time for a change.

You know, I think doctors are supposed to evolve, or at least I know that I was supposed to evolve. I can’t speak for everyone, but I was supposed to evolve into something different. And so that’s where I am today.

Kevin Pho: One of the things I stress on my blog and on this podcast is that physicians are more than their MDs. I think a lot of doctors were in a similar boat to what you were talking about seven, eight years ago, in terms of: Is there anything more to medicine? So when you’re talking about that struggle, that decision that you had to make whether to go outside of traditional practice, how did you break through, and what were some of the decision points that arose that helped you break out of a traditional practice?

Elizabeth Hughes: Well, I started seeing that external events were sort of forcing me out. I mean, it’s sort of funny to look at the administrator who comes in and says you’re not seeing enough patients as something that’s not “I’m wrong, I’m bad, I need to work harder,” but as that wake-up call that says, “You’re not supposed to be here. You’re supposed to stand up and say, ‘That pressure is not going to give the highest quality care. It’s time for me to go. It’s time for me to make a shift.'”

So I guess it was taking away all of those “You’re bad, you’re wrong, you’re wrong,” and looking at it like, “No, I’m the best I can be. I’m doing the best I can. The system is asking something of me that is unreasonable, unsafe, and not in integrity with what I want.” So I got to stick up for what is in my integrity.

Kevin Pho: A lot of doctors now are in the position that you were in back then. What kind of advice do you have for them?

Elizabeth Hughes: Oh, what you said: We physicians are way more than our MDs. There’s a system of both recognition we get from it, but also control that we buy into when we take on that MD mantle, let’s say, and you don’t even realize it. It’s become part of your bones. It’s become something that is so natural and normal, you don’t question it. But it’s eating away at you. It’s the thing that keeps you awake at night. Pay attention to it. There is something else. That’s what I’d say.

Kevin Pho: Let’s talk about the KevinMD article that you wrote. It’s titled “How medical training teaches doctors to be financially unhealthy.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Elizabeth Hughes: One of the things that held me back from branching out of conventional medicine was the idea that I was going to lose a paycheck. It took a long time for me to take that apart, and I thought it was totally and completely gone. I also thought that “money story,” I’ll put it in quotation marks, was something from my childhood about how money was supposed to come in.

But then I was cleaning out my house, getting ready to move, and I found all my paychecks from residency. I didn’t even realize that I had them. I found the first one, and my first paycheck was $89.14. I had forgotten everything that went into that: the fact that I was living in a motel on a credit card that I couldn’t afford, I was about to have my credit card expire, and I had all of my belongings in a car. I couldn’t afford, you know, a down payment. All of this worry came back to me like a flood.

I hadn’t realized, with all the work I’d done, how much of that medical training of “You are supposed to suffer financially as part of your journey to be a doctor,” like, that’s built in. Even people who have had their medical school paid for will still at some point realize they’re working 80 hours a week, or in my case, because I’m a dinosaur, a lot more than 80 hours a week, can’t make money anywhere else, and yet are living on peanuts. I was in the Bay Area at Stanford, and my housing took more than 50 percent of my income, and that was university housing. So that’s what inspired this idea.

The word “unhealthy” that I use doesn’t mean that you’ve got good fiscal policies. I mean it’s that subconscious belief of medicine equals financial struggle, and normalizing it, accepting it: “I’m supposed to feel overworked and underpaid.” So many people feel that way, and they don’t think there’s an out. So that’s why I wrote the article.

Kevin Pho: When physicians are financially struggling, especially during residency and early on in their careers, talk about the impact that has on the doctor. You mentioned some of the emotional impact in your article, but go into more detail. How does that emotionally impact physicians?

Elizabeth Hughes: Well, think about the insecurity of knowing whether or not you’re going to be able to afford rent, or you are making a choice: Do I afford rent or pay off my loans? It’s this simmering discomfort that you suppress because you have to. You have to go on, you have to soldier on. And you add to that the fact that you’re exhausted, maybe haven’t eaten, haven’t slept. There’s a whole bunch of little injuries that we take on during medical training, so that we then start to abandon our own personal needs and our own personal security.

When you think about Maslow’s hierarchy of needs, you know, we doctors sacrifice the first two layers of that pyramid that are supposed to be the foundation upon which a healthy, self-actualized life is built. We sacrifice all of that for purpose. But it does something to us internally. It gives us a sense of unsettledness, a deep unsettledness that people can’t even name, but it’s there. It’s there. And then, you know, you get burned out, and you don’t know, like, “Why, why have I felt like this for so long?”

Kevin Pho: So what are some of the answers? Certainly, I think that there are some policy answers in terms of the cost of medical education itself, but on an individual level, what’s your advice to those residents and early-career physicians who may be financially struggling?

Elizabeth Hughes: So, wow. You’re in a hard position, and I’m not going to lie about it. You’re in a difficult position. I believe that medical schools and residency programs should treat medical residents the way they would anyone else they might hire. You know, what about a moving allowance? What about a sign-on bonus? Something so that at the very beginning of training, you don’t feel like the bottom is falling out. How about looking, especially in a situation like mine: I was in university housing. Is that housing actually commensurate with what you’re making?

I have a lot of empathy and compassion for the people who are in this situation, who are being told, “Why don’t you, you know, drop your health,” like medical students, you know, “Don’t bother to get health insurance. Apply for Medicaid. Go on food stamps.”

You know what I would do, honestly? I would probably say you need to speak up to your residency director, to your medical school, and talk about money, talk about your struggles, because it’s an elephant in the room that none of us are acknowledging. You speak up, things happen.

Kevin Pho: Any resources that you recommend these early-career physicians read or watch to kind of help them through this difficult financial time?

Elizabeth Hughes: Wow. I don’t know that there are any out there. That’s a real gap in the market. You can read all sorts of money mindset things, but when it comes to what do you do if you have a family, you’re the sole breadwinner, and you’re making $89.14? No, you know, I don’t think that there is an answer other than find your voice. Don’t be afraid. Don’t get locked into the medical system that says you can’t speak up about money. Your personal health and well-being is the foundation upon which the entire medical system is built. Don’t lose sight of that. Don’t lose sight of that, and speak up for yourself.

Kevin Pho: And when you tell physicians to speak up for themselves, what are some of the ways that they can do that?

Elizabeth Hughes: Well, in the case of medical trainees, there are program directors and hospital administrators who oversee medical students and residents, and that would be one thing. Same thing for later-career physicians when it comes to administration. You should say no. There are a lot of people who are accepting the concept that they have to do uncompensated work or add administrative duties without appropriate compensation, and they ask and they doubt: “Can I do this? Can I ask for money? Can I ask for time off?” Yes, you can, and you should, absolutely.

And if the practice situation you’re in is not able to meet those fiscal needs, if they’re not going to have an obligation to you, don’t reciprocate that obligation to them. Don’t, don’t think that it’s all on you. It’s got to be a two-way street.

Kevin Pho: We’re talking to Elizabeth Hughes. She’s a dermatologist, and she wrote the KevinMD article “How medical training teaches doctors to be financially unhealthy.” Elizabeth, what is your biggest piece of advice to early-career physicians? And perhaps you could end with a few take-home messages to my clinician audience.

Elizabeth Hughes: Yeah. Well, first off, don’t expect that your entire career is going to be in conventional medicine. There may be a time when you want to leave, and it’s better to have that in mind up front, as difficult as it may sound, rather than being broadsided by it at, you know, 20 years in or 15 years in. And evolution is normal, and that’s OK. That would be my first piece of advice.

The second piece of advice is: Look at how money is motivating you, all the way through, whether you’re an early-career physician or a late-career physician. What are you sacrificing for money? What are you thinking that money is going to get you? What do you think the only way you can obtain money is? There are a lot of unspoken, unhealthy beliefs back there. They’re individual for each person, but I know there’s some junk in there that needs to come out.

Kevin Pho: Elizabeth, thank you so much for sharing your time and insight, and thanks again for being on the show.

Elizabeth Hughes: You’re welcome. Thank you.

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