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April 7, 1999

An Apology for Those Who Leave Medicine

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JAMA. 1999;281(13):1230. doi:10.1001/jama.281.13.1230-JMS0407-5-1

Within the ranks of internship classes across the country are a number of fledgling physicians who will be retiring from medicine long before they ever set up a practice. One colleague of mine is starting a computer software company. Others are dazzled by the 6-figure salaries and glamorous travel afforded by many consulting firms.

The reasons for this exodus are not difficult to understand. Frustrated by the diminished social standing, stagnant salaries, and loss of autonomy suffered by physicians, smart, hard-working young people fail to see the point of sacrificing years for little return. In Britain, many house officers must worry that they will not have jobs once they finish their training.1 The level of unhappiness among their practicing physician role models may be at an all-time high.2 There exist rewarding jobs for doctors, but with many opportunities being taken up by less costly and less well-trained physician assistants and nurse practitioners, those left are often geographically or professionally undesirable.

The phenomenon of young physicians leaving medicine begs a philosophical question medical educators and policymakers will be forced to grapple with if current trends continue. In its simplest form, the question becomes: What do we owe to those patients who have volunteered their stories and bodies to provide our training?

When we enter medical school, we enter a tacit, contractual agreement between ourselves and our patients. In exchange for the future privilege of being called "doctor," of commanding some degree of social prestige, and of earning relative financial stability, we agree to provide medical care to those who need it, in exchange for being permitted to "practice" on our teaching hospitals' patients, who might suffer an extra IV stick, a longer than usual history-taking, or even a misstep in the middle of the night.

One might argue, then, that those physicians who leave medicine during or soon after their training are violating this contract. An analogy is the National Health Service Corps, a more direct way that the government has seen fit to ensure that patient populations especially in need of health care receive it. This year the federal government will spend $302 million on this project.3 In this case, the contractual agreement is much clearer: in exchange for debt forgiveness, young physicians will practice in underserved areas of the country. A more subtle form of this contract could be said to be in operation at state-financed medical schools, many of which display a strong preference for in-state medical school and residency applicants. In this way, state governments are ensuring health care for the taxpayers who subsidize medical education. There is a choice; those who do not wish to practice where the government wishes may pay for medical school themselves.

Are those who leave medicine after enjoying this bounty then reneging on their part of the bargain and taking advantage of others' beneficence? Similarly, are those patients who refuse to give of themselves for the good of medical education being selfish and sacrificing the health care of those who come after them?

Neither of these questions has a clear answer. Society has always tolerated the knowledge that a certain percentage of those entering medical school will not practice as physicians in the usual sense. Given the tremendous debt burden incurred by these medical school graduates, some might argue that they have already paid their societal dues. Of the 83.2% of graduating medical students in 1997 who incurred educational debt, the mean debt is $80,"MSJAMA462 compared with $75,"MSJAMA103 for 1996 graduates.4 A significant proportion of those physicians who do not go on to practice are MD-PhD graduates, many of whose training is subsidized by government funds, and who are responsible for many life-saving advances. Society also values some of those who leave medicine and pursue entirely different careers. Would writers and politicians who trained as physicians be able to offer the same insights without having graduated from medical school or completed residencies?

Similarly, society should not ignore the individual in its quest for health care. Young physicians whose minds are occupied with pursuits other than medicine should not be forced to remain in the field. Patients and established doctors should ferret out the reasons why medicine seems so unattractive to younger members of the profession. Medical students and residents, however, should not take lightly the sacrifices made for them by their patients. The trickle of young physicians leaving medicine should make us come up with better guidelines and understood agreements, however, lest the trickle become a flood.

Galasko  CSBJackson  B Insecurity about progression is an added stress for senior house officers (letter).  BMJ. 1999;318534Google ScholarCrossref
Kassirer  JP Doctor discontent.  N Engl J Med. 1998;3391543- 1545Google ScholarCrossref
Not Available, Not Available http://www.hrsa.dhhs.gov/newsroom/NewsBriefs/final/20budget/2099.htm. Accessed January 17, 1999.
Beran  RLLawson  GE Medical student financial assistance, 1996-1997.  JAMA. 1998;280819- 820Google ScholarCrossref