By: Arjun Byju, MD

In Act 1 Scene 1 of The Taming of the Shrew, Gremio offers a bit of timeless advice: “Think’st thou, Hortensio, though her father be very rich, any man is so very a fool to be married to hell?”1 Pre-meds are not usually known for the attention they paid in English class. But as we enter an unprecedented era of 21st century medicine, rapidly consolidated and corporatized, physicians would do well to return to the classics and recall the wisdom of the world’s most famous playwright. Shakespeare’s point: no amount of money is worth being miserable. But married to hell many physicians are today.

Locked into positions that limit their clinical decision making, forced to see more patients in less time, and chained to computers at work and at home, it’s no wonder that so many of America’s physicians are unhappy. In 2022, 63% of physicians met criteria for burnout.2 According to another statistic, only 6% of doctors were satisfied with their job.3 Doctors have the highest suicide rate among professionals, twice as high as the general population.4,5

At first glance it might be hard to sympathize, given that physicians earn on average five times the national income.6 But as Shakespeare astutely noted, “No profit grows where is no pleasure taken.”1 Behind the raw numbers lies the reality that though they command high salaries, many doctors feel trapped at their jobs. Straddled with hundreds of thousands in student loans, immense debt is the first obstacle keeping most doctors from financial independence.7 And, the longer and more comfortable we get with it, the harder it is to shake. As Falstaff says in Henry IV: “I can get no remedy against this consumption of the purse: borrowing only lingers and lingers it out, but the disease is incurable.”8

I will never forget Dr. L, a hospitalist I worked with during my med school sub-internship. He routinely managed more than 20 patients, his salary was being slashed, and he was forced to rely on non-physicians for clinical judgment and consultation, which led to frequent over-testing, missed diagnoses, and outright errors. He lived far from his family and in his off days moonlighted for extra cash. He had an app counting down the days until he could quit. Still, he had a tricky contract and loans to pay, so he had to stick around. He was, in effect, married to hell.

There was a time when physicians enjoyed considerable professional autonomy, but over the last several decades doctors have moved steadily away from self-employment; 2019 was the first year in which more doctors were employees than owners of their own practice.9 There are perks (at least in theory) to this model: none of the hassle of HR, quibbling about rent, or negotiating insurance. In other words, the option to offload the business side of medicine. Many millennials, myself included, are enticed by the thought of treating patients, accepting a paycheck, and then going home. We went to medical school because we enjoyed science and humanism—not the barren world of billing and coding.

But consider the alternative: practices bought out by private equity, then crunched to turn a quick profit;10,11 doctors systematically replaced with non-physicians in a myopic quest to save money;12 physicians fired for speaking up about PPE.13 One survey found that 62% of ED physicians could be laid off without due process.14 We thought we were trading independence for simplicity, but in truth lost both professional autonomy and financial security. We ought to have listened to Bolingbroke, who in Richard II warned to be content with autonomy. “Must I not serve a long apprenticehood…and in the end, having my freedom, boast of nothing else…?”15

Private practice has at times been maligned, if only for the rare and sensational story of a doctor overtesting patients or performing unnecessary procedures. But what makes us think that the corporate behemoths that have taken over healthcare—many of which are explicitly for-profit—are better? After all, the largest case of healthcare fraud in American history involved HCA, a for-profit organization.16 Healthcare executives infamously received bonuses during the height of the pandemic and hospitals continue to flout federal requirements for price transparency.17,18 As Danielle Ofri wrote in the New York Times, the business of healthcare relies on the infinite professionalism of caregivers; doctors take their work home with them, even if the MBA’s running the hospital don’t.19

Without independent financial stability, doctors are pushed to make decisions that benefit their employer, often to the detriment of patients. I am only a few months into residency, but have already become familiar with administrators badgering attendings about discharge and reprimanding residents for not crafting their notes to maximize billing potential. At one of my sites, hospitalists get bonuses for discharging patients before 9am. I don’t think any of them care for this arrangement, which is needlessly stressful and occasionally unsafe, but they seem to have few alternatives. With bills to pay and families to feed, this is their proverbial “pound of flesh.”20

Flexibility then might be the most vital element for a career in medicine. Being able to choose a practice that aligns with one’s values means having the financial security to walk away from a bad one—to have the confidence, in the words Dr. James Dahle, founder of the White Coat Investor, to say “shove it” to an administrator interfering with patient safety21. We might then agree with Brutus when he said, “I can raise no money by vile means. By heaven, I had rather coin my heart.”22

In the end, financial independence is healthy for patients and doctors. It makes for less compromised relationships, and allows more time for hobbies, friends, and family. “If money go before,” Ford says in The Merry Wives of Windsor, “all ways do lie open.”23 The Bard gave us the script. Now it’s time to act.

References

  1. Shakespeare, William. 2003. The Taming of the Shrew. Edited by Dr. Barbara A. Mowat and Paul Werstine. N.p.: Simon & Schuster.
  2. Berg, Sara. 2022. “Pandemic pushes U.S. doctor burnout to all-time high of 63%.” American Medical Association.

https://www.ama-assn.org/practice-management/physician-health/pandemic-pushes-us-do ctor-burnout-all-time-high-63.

  1. Kliff, Sarah. 2014. “Only 6 percent of doctors are happy with their jobs.” Vox. https://www.vox.com/2014/9/8/6110839/doctors-low-morale-doctored-sandeep-jauhar. 4. Wallace, Claire. 2023. “Physician suicide rate higher than any other profession.” Becker’s ASC.

https://www.beckersasc.com/asc-news/physician-suicide-rate-higher-than-any-other-profe ssion.html.

  1. Cohen, Marya J. 2020. “Perspective | Doctors die by suicide at twice the rate of everyone else. Here’s what we can do.” The Washington Post.

https://www.washingtonpost.com/lifestyle/2020/10/06/doctor-suicide-coronavirus-covid/.

6. Katzowitz, Josh. 2023. “How Much Do Doctors Make? [Salary by Specialty 2023] | White Coat Investor.” The White Coat Investor.

https://www.whitecoatinvestor.com/how-much-do-doctors-make/.

  1. Hanson, Melanie. 2022. “Average Medical School Debt [2023]: Student Loan Statistics.” Education Data Initiative. https://educationdata.org/average-medical-school-debt. 8. Shakespeare, William. 2020. Henry IV, Part 2. Edited by Dr. Barbara A. Mowat and Paul Werstine. N.p.: Simon & Schuster.
  2. Henry, Tanya A. 2019. “Employed physicians now exceed those who own their practices.” American Medical Association.

https://www.ama-assn.org/about/research/employed-physicians-now-exceed-those-who-o wn-their-practices.

  1. Sanger, Margot. 2023. “Who Employs Your Doctor? Increasingly, a Private Equity Firm.” The New York Times.

https://www.nytimes.com/2023/07/10/upshot/private-equity-doctors-offices.html.

11. Robeznieks, Andis. 2022. “Physicians warned of the pitfalls behind private equity promises.” American Medical Association.

https://www.ama-assn.org/practice-management/private-practices/physicians-warned-pitf alls-behind-private-equity-promises.

  1. Taylor, Mariah. 2023. “Why some hospitals are understaffing physicians.” Becker’s Hospital Review.

https://www.beckershospitalreview.com/hospital-physician-relationships/why-some-hospi tals-are-understaffing-physicians.html.

  1. Stone, Will. 2020. “Fired Doc Who Criticized ER During Pandemic Suing Old Hospital : Shots – Health News.” NPR.

https://www.npr.org/sections/health-shots/2020/05/29/865042307/an-er-doctor-lost-his-jo b-after-criticizing-his-hospital-on-covid-19-now-hes-sui.

  1. McNamara, Robert, Kevin Beier, Howard Blumstein, Larry D. Weiss, and Joseph Wood. 2018. “A survey of emergency physicians regarding due process, financial pressures, and the ability to advocate for patients.” The Journal of Emergency Medicine 45, no. 1 (April): 111-6. 10.1016/j.jemermed.2012.12.019.
  2. Shakespeare, William. 2016. Richard II. Edited by Dr. Barbara A. Mowat and Paul Werstine. N.p.: Simon & Schuster.
  3. Charatan, Fred. 2001. “US settles biggest ever healthcare fraud case.” British Medical Journal 322 (7277): 10.
  4. Robinson, David. 2022. “NY hospital executives pocketed $73M in bonuses as COVID raged.” Utica Observer Dispatch, September 14, 2022.

https://www.uticaod.com/in-depth/news/2022/09/14/ny-hospital-executives-paid-millions -in-bonuses-salary-as-covid-raged/65411150007/.

  1. Diamond, Dan. 2021. “Nearly all hospitals flout federal requirement to post prices, report finds.” Washington Post, July 16, 2021.

https://www.washingtonpost.com/health/2021/07/16/hospital-cost-transparency/.

19. Ofri, Danielle. 2019. “Opinion | The Business of Health Care Depends on Exploiting Doctors and Nurses (Published 2019).” The New York Times, June 8, 2019. https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.h tml.

  1. Shakespeare, William. 2004. The Merchant of Venice. Edited by Dr. Barbara A. Mowat and Paul Werstine. N.p.: Simon & Schuster.
  2. Dahle, James M. 2014. The White Coat Investor: A Doctor’s Guide to Personal Finance and Investing. N.p.: White Coat Investor, LLC.
  3. Shakespeare, William. 1991. Julius Caesar. N.p.: Dover Publications. 23. Shakespeare, William. 2020. The Merry Wives of Windsor. Edited by Dr. Barbara A. Mowat and Paul Werstine. N.p.: Simon & Schuster.