The old joke in medicine goes, ‘don’t get sick on July 1st.’ That’s because it’s the day when new resident physicians, freshly graduated from medical schools across the land, begin their training programs. Although they have spent four years in undergraduate school and four years in medical school, it’s residency where physicians are made from the raw material of knowledge-rich, experience poor high achievers.

However, even in residency physicians are seldom told the entire story of how the practice of medicine, and their lives, will look and feel as their careers evolve and they enter the medical work-force.

Since our profession changes from year to year and administration to administration, it seems a good time to mention some of the things upcoming young physicians will face. Sadly, these are things seldom mentioned by pre-med advisors or academic medical educators.

You see, physicians are struggling. Due to falling reimbursements and the ongoing federal mandate to see non-paying patients on call, it is increasingly difficult for physicians to cover costs like malpractice insurance, licensure, professional memberships and office overhead. (Well, if they want to have a house, family and food, that is.)

Many physicians are either leaving their private practices in favor of employment, or are searching for non-clinical avenues like consulting or entrepreneurial opportunities.( Large numbers of physicians are hoping for early retirement. And those who do not are leaving call responsibilities in droves, to the extent that in many hospitals, critical specialty coverage is getting dangerously thin.  (

Physicians are also struggling under a regulatory burden unseen in the history of medicine. Our ancestral physicians, Hippocrates, Galen, Maimonides, Halstead and Osler wouldn’t recognize a practice in which practically every aspect of medical life was subject to someone who was not a physician, from nurses to administrators, from political appointees to stockholders and even presidents.

They would be dumbfounded that those who did not sit by the sick could yet direct the behaviors of those who did, at all hours of the day and night. The standard excuse is that the regulations are about safety, efficiency and fairness, but the hard reality is that our vast Alexandrian library of rules and regulations does little except slow down innovation, increase administrative costs (and thus the cost of care), demoralize otherwise talented practitioners and researchers and change our focus from patients to keyboards.

Which brings me to electronic medical records, or EMR. From the offices of my family’s physicians to my own practice, from readers of my regular column and blog to colleagues at conferences, the general experience is that electronic medical records kills productivity…and trees. Paperless systems seem ironically to generate far more paper than the old systems. And they generate pages on pages of ‘necessary’ and ‘required’ data fields over which nurses and physicians labor with the same intensity with which they once hovererd over the sick. In fact, many of us feel we are changing from doctors to data-entry clerks. As evidenced by the fact that physicians are hiring ‘scribes’ to do data entry so that they can actually touch, and talk to, their patients.

Because I enjoy my profession, I never discourage aspiring physicians. I believe it is a noble profession, a high calling and one essential to the success and prosperity of individual citizens and the nation as a whole. I applaud our incoming physicians in training, and wish them Godspeed and many blessings for long careers of healing.

But if medicine is to move forward, if we hope for it to continue to attract talented, motivated students, we need to address many of these issues which young physicians will first discover in residency, and meet with ferocity when they begin to practice. We cannot expect them to sacrifice over a decade of their lives in training, since residency can last from three to seven years…or more with fellowships. We cannot expect them to be available at all hours of the day and night, bear enormous educational debts, then complain that their future incomes are too high, that they don’t want to see the poor on state or federal assistance, or that they fail to give away enough care. And we cannot hope for them to continue to be available for the poor, the high risk, the non-compliant and the non-paying patients that will populate their futures, if we refuse to protect them from liability for doing their best work for those most likely to abuse their kindness and skill.

The beginning of residency is a thrilling and terrifying time for young physicians. Sadly, there will be more terrifying times to come, as they realize that their professions are slipping steadily out of control, and that they are expected by their patients and leaders (academic and political) to do more with less: less money, less control, less freedom, less protection from litigation and (if trends continue) fewer medications and diminished medical innovation.

The sooner my young colleagues begin preparing, the better off they’ll be. They’re bright and motivated. Maybe, if they start now, they can chart a better future for all of us, both patients and physicians alike. And there’s no better time to begin than the glorious, terrifying and thrilling month of July, when educational dreams and scientific learning meet the hard pavement of medical reality.

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