Impressions From the Med Trip

I’m back from my medical interviews journey. This was in fact a multi-purpose trip, partly fact-finding, and also involved three other job interviews–two for medical scribing, and one for a potential post-doctoral position. This post will be a wide-ranging and detailed exploration of my impressions, a kind of self-debriefing. (I hope to write something much more focused next time.)

I’ve been reluctant about the idea of doing a post-doc since long before I finished with my PhD, mostly due to the combination of intense day-to-day frustration, diminishing returns for significant discoveries, and inept management that I’ve found goes with laboratory research. But it’s also that I have simply seen what the culmination of an academic career really looks like too many times, and too up-close. Even at the higher levels of success (which involve a great deal of luck), the typical academic scientist’s life has become almost purely bureaucratic in character; for me, it summons countless images of lonely graying figures sitting in office buildings writing grants 70% of the day, dealing with administrative intrigues for the rest, with an occasional conference thrown in. Tenure is nice, but given the drabness of the overall picture and the awful odds of achieving it, it has never seemed like much of a sweetener.

Nevertheless, the thought of discovering new provinces of knowledge or creating technologies that change the way we live does have a stubborn allure, and I have kept up the idea that there might be some place out there where the funding might be secure, the professors engaged and helpful, the subject matter itself exciting, new, and amenable to dreaming big (and the women strong, the men handsome, and all the children above average). Lake Wobegon notwithstanding, when I found a laboratory a few weeks ago that focused on tools for controlling protein interactions using light–a hot subject, and also tantalizingly complementary to my own research–it was enough to make me wonder if such a perfect place might exist after all. Choking down my potential hypocrisy, I contacted the professor about potential openings. To my happy surprise, I was promptly invited to an interview.

I spent almost two weeks reading the publications of the lab, thinking up experiments to propose, outlining the connections between my past work and that of the new lab, and preparing a presentation of my ideas and previous work in case I was asked to speak to the lab members.

There isn’t much to tell about how it went, except that it confirmed my native doubts about academia far more than it assuaged them. It was bad enough to find that this prof had not bothered to glance at my CV before inviting me to interview, nor apparently had done so up to my arrival. What was much more telling was that she did not seem to know the ideas and experiments in her own recent papers. Whenever I would ask about a detail of an experiment or a method developed by the lab, she would peer at me with a baffled or slightly panicked expression and ask me what I meant by that. I’d then refer back to the publication and get a sort of hasty nod: “oh, yes, that…”

In a nutshell, my preparations backfired. The more I referred to details of the professor’s own work, the more I exposed her ignorance. Oops. Later when I commented on this to a friend, she said, “well of course; that professor probably didn’t write any of those manuscripts, and probably hardly read them either.” What is unfortunate is that this is quite likely true, and not atypical. Absolute concentration on funding leads principal investigators to a kind of weary indifference–if not outright obliviousness–to the work being done in their name by an army of postdocs, grad students and technicians, the vast majority of whom will never find faculty positions themselves.

On to the next, the medical scribing interview. “Medical scribing” has existed for decades, but has sprouted into a big business only since the passage of the HITECH Act in 2009, which incentivizes nationwide adoption of electronic health records (EHRs). An EHR is an extremely complex document requiring deft handling of a myriad of abbreviations and terms, so a number of companies now offer scribing services to physicians, in order to spare the latter from having to navigate the maze of an EHR while trying to listen to a patient’s concerns and figure out a course of treatment. The scribe masters the structure of the EHR as well as medical terminology, and follows the doctor(s) throughout their rounds, taking down every germane piece of information.

Scribing has rapidly been positioned as a kind of rite-of-passage for would-be medical students, and a more intensive substitute for traditional physician shadowing. Although most companies stress the “opportunities for advancement” for their scribes within the company, in reality nearly all base their business model on hiring future med students for short periods at rock-bottom wages: typically just over $8/hour, moving up to $10/hour pending good behavior.

These interviews went extremely well; I joked a lot, talked about my passion for science and hopes for a medical career, and left everyone smiling. It was good to know I can still turn on the charm from time to time. I was even willing to accept the wage and hours–which include weekends, holidays, and overnight shifts. I became more reticent, though, to learn that these companies demand a one- or even two-year commitment as a condition of employment. It does seem like chutzpah to demand a contract for what is essentially a low-level clerical position with bad hours, almost no pay, and negligible chances of promotion. Yet this is a reality of the job market everywhere: maximize employee responsibility while minimizing employer risk.

My last day was the big kahuna–the med school interview. I wrote in an earlier post about my growing ambivalence about medical school, especially the serious problems of medical school financing and the bizarre and distorting financial and administrative pressures exerted by the profit motive on the whole healthcare system. I also noted the strange determination of growing numbers of people to pursue allopathic training, no matter the cost in terms of finance or mental health. But I put these heavies aside for the time being and instead enjoyed strolling around the campus.

The campus was extraordinarily large (almost a half mile long), and sparklingly new. Though impressive, it seemed almost excessive: located so far outside the center of its city, such a huge and lavish medical complex could hardly expect to be used to more than a fraction of its capacity. The grounds were carefully landscaped, with broad tree-lined walkways wending between the dozens of brick-and-glass research and clinical towers, yet they were almost completely empty of people, whereas I have usually known such medical complexes to be filled with busy crowds crisscrossing from one building to another even in the dead of winter. The effect was sort of Potemkin-like. I thought maybe the place was so new they hadn’t been able to move everyone in yet.

I was surprised at the size of our interview group: nearly 50 applicants. We all gathered in the auditorium in our suits and finery for orientation, which went smoothly–as did my first interview, with a kindly old general surgeon. There followed a series of nuts-and-bolts presentations to the group on various programs and deadlines, but it was the one on financial aid gave me the most pause: $90,000 a year, plus 6.2% interest (if you get the “good” kind of federal loan).

I zoned out and did a quick calculation. Including simple interest, four years of this would put me and my fellow applicants about $406,000 in debt. Nearly half a million bucks underwater from the moment you get out, before earning a cent–and it would keep growing. I wondered: had this huge campus become a boondoggle, which the staff now hoped to cover by shaking down the students in insane fees?

I looked at the presenters after that with new eyes. Before, they had seemed matter-of-fact, considered, kindly, interested in our success. But now it felt like there was something almost predatory afoot. The room was filled with anxious and eager youth–all stoked with the dream of one day practicing medicine, of gaining the noble power to liberate others from the slavery of suffering, illness, mortality. Yet we were surrounded by a system that, in exchange for a shot at that dream, proposed to enslave each of us with decades worth of massive debt–except those of us who were already millionaires, like one of the second-year students, a former hedge fund exec who in his 40s decided medicine would be a wonderful lark.

I kept waiting for one of the administrators to either say “gotcha, just kidding” or apologize shamefacedly for these outrageous prices, but in vain. Instead, faced with these mind-bending numbers, we got (unintentional?) irony in the form of a visit from a staff psychiatrist.

With a practiced pep-talk swagger and a strange blend of inspirational clichés, he dove headfirst into the dire facts facing today’s doctors-to-be. How many of you have been warned by a doctor not to go into medicine, he asked in a teasing tone. All hands in the room shot up, including mine. (The very person I was staying with, himself a doctor, had just a couple nights before regaled me with awful stories about the proliferation of administrators in his hospital, and the abandonment of the hospital’s founding mission under a new president devoted to increased profit-seeking. This doctor had eventually been forced into retirement. He recounted it all with a dazed look, gripping a glass of scotch.)

The shrink continued. “How many of you have been warned about skyrocketing rates of job dissatisfaction in the medical profession, crippling debt?” More hands. He promptly flashed slides of recent studies indicating that, uniquely among the professions, the more hours doctors work the more job dissatisfaction they report. (Usually the correlation is the reverse; if you like your job more, you spend more time doing it.) The story grew ever grimmer, the numbers more stark. We waited in hushed anticipation for the speaker’s wise advice for coping with this possible future. Finally it came: “I would like to encourage you not to ‘go’ to medical school”, he told us, then paused to let it sink in.

That was the pearl of wisdom: the whole problem centered our errant usage of the word “go”. Somehow, this “go” contained the kernel of a mindset that could explode into motivation-destroying depression, or cynicism, or any of the other negative feelings obviously so common among physicians and medical students these days. (Alas I still think “go” is a nice, positive-sounding word.)

The psychiatrist did say exactly one thing that rang true, and reminded me of why I was there in the first place. Physicians, he told us, are unique among today’s professionals in being able to be directly engaged in highly meaningful work. This is true: although appointment times have shortened in order to see as many patients as possible, and paperwork has come to take up half or more of physicians’ workday, there is still hardly any human connection more profound, or potentially more satisfying, than guiding someone in their first steps towards healing.

Our world is chockablock with wantonly meaningless work, almost as if meaning were a blight that must be artfully contrived out of existence by precision management. I thought of the professor in the cubicle office writing grant after grant, not knowing about the work coming out of her own lab and basically too tired to care. I thought of the medical scribe, filling out mostly gratuitous paperwork and earning next to nothing, following the doctor around on a ten-hour night shift just on a hope of one day being like him/her. I thought of my own experiences in research–the long stretches of frustration and emptiness, punctuated by moments where it all seemed to make sense.

  All in all, I don’t know whether to classify the psychiatrist’s strange interlude as brilliant marketing, blithe hand-waving, or an incredibly brazen exercise in reverse psychology. I do know that by the end I felt like my brain had been tied in a stevedore’s knot, and the feeling of vague mistrust I’d gotten after my little calculation had shifted to high gear. “Yes, you will end up catastrophically in debt”, seemed to be the message, “and yes, the system is broken and most of the people who have followed in this path have wound up miserable. But lighten up! There’s no substitute for being a doctor. You know you want it. And you’ll get paid in meaningfulness.” I thought of used car salesmen and subprime mortgages. You can pay it off later. Don’t be fooled by the naysayers. You know you want it.

It’s interesting how students get hooked on the dream. One of the first-years who was giving us a tour of the grounds began to discuss his reasons for choosing the school. He said, “the one piece of advice I can give you is, go where you love. Like me. I got other acceptances, but I absolutely loved this school and I still love it. Look, I’m probably going to be $300,000 in debt when I leave here. But that doesn’t matter because I am just having such a great time.” He laughed nervously, maybe realizing he had said something he ought not to. I couldn’t help wondering what he would say four years from now, about to enter residency, with that 300k no longer an abstraction but a reality bearing down on his life and plans with its full weight. Would he still be having a great time? Perhaps. As the psychiatrist said, there are things more important than money.

My last interview was with an extraordinarily voluble specialist in neuroinflammatory diseases. An unrepentant technocrat, he seemed far more interested in discussing the nitty-gritty of the Affordable Care Act than in my clinical experiences or general interests. After plowing through the required interview questions he quickly steered the conversation towards an obscure provision in the 1,500 page legislation that establishes a new research initiative, PCORI. Unlike all previous such initiatives, he avowed, PCORI will be truly indexed to patient-evaluated outcomes, ushering in a tectonic shift in medical practice. At the same time, new initiatives in telemedicine will soon bring specialist care to remote underserved areas. “It will revolutionize healthcare,” he declared roundly.

I listened to these pronouncements of impending revolution with my best poker face. For the research institute, I imagined another multi-billion dollar bureaucracy, filled with more people just like my professor. And while telemedicine can offer real benefits to the underserved, there is something disheartening about yet another initiative to reduce our already diminishing in-person contact with those supposed to be healing and caring for us to yet another interaction with digital screens.

He went on to discuss a model of human cells acting on mouse brains being investigated in one of his labs. When I asked whether modeling a human disease based on the behavior of isolated tissues from two different species might be rather unreliable, he doubled down, reassuring me that “B-cells don’t have MHC receptors, so that can’t be possible”. Winding from topic to topic, I also learned that populations in countries with single-payer health care systems actually hate them, but just haven’t realized it yet.

My head still whirling from the encounter with the technocrat, I headed back home in a state of total exhaustion, managing to get caught in a snowstorm along the way. The dark of the night, the whirlwind of icy crystals, and the slow erasure of the road under a slippery white crust was like a running allegory of my own stewing reactions to these experiences. I checked into a cheap hotel and slept the storm away, getting home the next afternoon.

So long story short, medicine is over. It might have been my path at a different time–but given all I have seen and heard, it’s hard for me to grasp how it could be the sincere choice of anyone who is not either a millionaire or gripped by a romanticized attraction to unalloyed misery. At the very least, that is a terrible frame of mind with which to begin medical school.

I’d more or less come to this point a few days after I got home, but wanted to go see the the doctor I’d been shadowing and thank him for his time. Instead there was another MD in his place, one who I’ve met a few times, subbing in for the usual guy. I began to tell him about my experiences interviewing and it was not long before he was pouring his heart out in frustration at everything from insurance costs to the new ICD-10 rules. All the nightmare tales of dysfunction, malpractice and venality, and all the glum faces and veiled warnings of doctors I had met over the past year, came back to mind. After a certain point I could not listen to any more. I thanked the doc and headed out of the hospital one last time, leaving in my ID badge and blazer at the volunteer desk.

A few days later I got a call from one of the scribing companies I’d interviewed with, offering me a job. For an instant I toyed with the idea, purely for the sake of random adventurousness, of moving to a strange city to take a low-paying job whose sole upside was an increased chance at a career in which I was no longer interested. It could have literary value, I imagined, living a bohemian lifestyle by day and scribing like a maniac by night, wooing women in exotic nightclubs with my wicked knowledge of medical terminology.

I politely declined the offer.

It’s been a fascinating several months, but not exactly productive. I’m nearly back where I started: all around I see professional careers whose packaging and general goals seem appealing, but whose daily reality seems void of meaning, if not soul-crushingly miserable.

Lately, as my med school application saga has been winding down, I worry when I look at these choices and judgments I’ve made that I am falling into the trap warned of in Candide: “those are not the best stomachs that reject, without distinction, all sorts of food.” Yet maybe it isn’t purely a my fault of my character that so many of the options these days seem truly lackluster.

I’ve also found myself haunted by a line in “Do Androids Dream of Electric Sheep?”, where the pseudo-messiah Mercer declares, “it is the basic condition of life, to be required to violate your own identity”. I wonder if is this simply a throwaway line, devised by a troubled science-fiction writer who wanted to depict a world where war and mass entertainment had turned all human hopes awry, or something that resonates more deeply with how we now live. Has violating one’s own identity always been a sad fact of life? Was I was just too green and too insulated to see it?

I tend to answer that no, that it need not be a fact of life. When I talk with people of older generations, I see a lot of them really did not have to violate their own identity in order to make a livelihood–or at least only had to do so a little bit. All the physicians who I have chatted with at one time clearly loved their work–stress, studying and all. They joined the profession with high hopes for a meaningful calling and a chance to make good on their potential, and for a long time, the profession requited those hopes in exchange for earnest work and a dollop of ambition.

The situation in the professions has since become qualitatively different from that, not just in medicine, and maybe not just in the U.S. There is a wider trend here–something to do with a change in the relationship between professional and profession, a move from respect to indentureship. We have a long ways to go to get back to the days where a quality education and a can-do spirit could assure a reasonable financial freedom, a respectable career, and a chance at the pursuit of happiness–and I cannot help but think it will require social struggle, above and beyond distinctions between public and private sector. There are now doctors’ strikes occurring in Britain’s NHS over wage cuts and increasing working hours, and speculation is growing that American doctors might not be long to follow suit–there is talk of a union. For all the attention given to technological novelties like IBM Watson, FitBit, telemedicine and personalized genetic counseling, pavement-pounding actions like this may have at least as big a part to play in deciding the state of medical practice in the years ahead.

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