by Curt Graham, MD
Never in the history of medicine have doctors faced such a ruthless gauntlet of threats, financial debts, and practice restrictions than they do today.  These factors, among others just as crucial, don’t begin to tell the story about why 40% of medical doctors readily admit to intense frustration in their practices, in addition to the percentage of doctors quitting medical practice completely.  They’re not retiring.  They’re adapting.  Extended hours to see more patients to make enough income to stay financially solvent is just one highly stressful necessity causing eventual burnout.  Coupled with the recognition that private medical office practice for most doctors is not lucrative enough to reach their original goals and dreams for their careers, reasonable satisfaction with medical practice becomes a moot point.

Profound disappointment increases as they realize it will take them a couple decades to pay off their education debts (avg. $150,000 plus), let alone make enough revenue to support a family and cover office overhead.  If you have missed the obvious, doctors the day they graduate, are financially hamstrung right from the start.  The roots of this dilemma are found in the medical education program itself.
Discouragement intensifies dramatically when they are faced with malpractice litigation.  You know…it’s the penalty for using all their best medical knowledge, skills, and judgments to prevent and to treat illness, yet isn’t enough.  The most well trained and experienced doctors are subject to malpractice lawsuits, even when they haven’t done anything wrong in their medical practice treatment of patients.
Governmental fee restrictions and intrusions are constantly increasing, which is firm validation that it will be harder to financially survive in practice.   Their future practice income for the majority of physicians will barely keep them in the middle class of Americans.  For those minority of physicians in the highly profitable surgical specialties such as plastic surgery, orthopedics, cardiac surgery, and anesthesiology, most do quite well in their practices.

The easy solution for most medical school graduates is to join a managed care group as an employee where they at least can earn some money right away.  Once they become aware that they aren’t able to practice medicine the way they intended to, they try private practice.

The path into a medical practice career has other unexpected potholes.  Upon entering college and into their pre-med curriculum the idea of becoming a doctor is challenged repeatedly.  The high competition for getting into medical school is strongly influenced by their grades.  The hard studies and required courses weeds out many pre-meds.  Of the one’s who make the grade after four years, there is no guarantee they will even be accepted by a medical school.  Who wants to academically struggle for four years only to discover your dreams have just been squashed on the rocks?  Individuals not accepted to a medical school may keep re-applying yearly with the expectation of being accepted later.  Rather than wait and hope, pre-med students can apply to dental schools where the competition is considerably less, with the idea they can get into medical school later.  The way things are today, they’d be a lot better off being a dentist for many reasons.  So, here’s a student who wanted to become a medical doctor and is often left stranded without a backup career in mind—didn’t think he needed one.

Once accepted to medical school, a student is expected to graduate in four years.  In days past some medical schools apparently had programs for planned attrition the first year—like the bottom 10% of the class would be dropped from the school.  I’m not aware of any of the 142 medical schools in the USA doing that today.  Medical students eventually choose the area of medicine they want to practice.  Some choose a surgical specialty and discover they don’t have a surgical talent or skill. Others, for the first time, begin to understand what they are talented to do, as opposed to what they think they want to do.  This tendency may lead a student to becoming a specialist in something they are not skilled to do, but manage to practice in a career in that medical category anyway.  It’s not a rare circumstance.

After all of these hurdles have been accomplished, the new set of hurdles comes into view—specialty training and/or medical practice.  Let me paint a mental picture of this new doctor’s situation at this time in his/her medical career path:

1.  The average new doctor now has an educational debt to pay around $150,000 or more.
2.  The new doctor does not have a job, but may have some connections.
3.  To open a private practice requires either family money or bank loans — estimated to be around $50,000 at the very least.  Debt is now $200,000 plus.  How long would it take you to pay that debt off?
4.  Common practice choices are:
A. Private solo practice if the money is available to get started.
B. HMO managed care organization if spots are open.
C. Group practice if one is available.
D. Contract partner with another physician already in practice.
E. Hospitalist (employee)
F. Join the military, get further training there.
G. Concierge practice (Cash only).
5.  Often, they are supporting a spouse and children.
6.  The geographical area where they will practice, and the situation they will practice in often is not even close to what they intended or wanted.
7.  Surveys by the AMA indicate that about 14% of doctors move their practice, or move to another area to practice each year.  It means their first choice was not good enough—but who can predict outcomes?

The tragedy is in having no reliable options that guarantee any degree of medical practice success.
Like all professionals starting in any business, there are no guarantees.  The hope is that with one’s passion, entrepreneurial attitude, and persistence will inspire the survival of their medical career.  Those aspirations at their most earthshaking levels must not only be maintained for the duration of a medical practice career, but also must be fortified intermittently with signs of professional progress and practice profitability for those inspirational drivers to continue to exist.

Unfortunately, passion dissipates with time; hope falls short of the mark and medical professional careers relapse into mediocrity because of a doctor’s expectations for their highest career potential turns to, “I’ll just have to settle for what I can get from my practice.”

At this point in their practice, usually about 5 to 7 years after starting medical practice, 95% of physicians have absolutely no idea how to go about improving their practice income.  That’s because they have never been educated in successful business management and the business knowledge required to reach their full potential.  Without it they simply limp along doing the best they know how—they don’t know what they don’t know.

The highly regarded business expert, Michael Gerber, describes the realistic dynamics of this in his book, The E-Myth: Physician.  It should be required reading for every pre-med student.
WAIT—There may be a couple secrets that can salvage the medical careers of the majority of the medical professionals in trouble.

First, for any health care provider in June 2011 and disregarding the ominous December 21, 2012 prophecies, understanding that medical practice is a business, provides a proven foundation for success.  The most profound whitewashing of that one fact by the medical schools today should be punishable by law.  It should also be extended to all pre-med programs across this nation.  Every successful small business owner in the world understands that their business profitability and survival depends on the foundational business principles and time validated concepts that must, not should, be followed.  It’s rare to find a doctor who has been educated in business strategies and the more complex issues of how to use them profitably and efficiently.  Can you rationalize with any degree of intellectual logic why there is such a widespread neglect by the medical academicians to institute business education as a primary curriculum element for all physicians?  There isn’t any today!  If medical practice is a business, then why should anyone expect a doctor to survive in medical practice with no academic knowledge about business?  It defies logic and common sense.

Second, why should any physician or other health care professional expect to do well, earn a good income, have a successful business from medical practice, or even survive financially without any, even basic,  business knowledge?  The traditional belief, “if you hang up your shingle, patients will come,”  is the greatest mental deterrent to successful medical practice that exists.  You might wonder why so many medical practices today are failing because of financial deficiencies.  What could possibly be the cause of that?

Third, considering the tsunami of attrition of medical doctors and their medical practices happening today, you must be aware of the causes.  If we were able to eliminate the many current devouring parasites destroying medical practice today and deal with the one issue of physicians lacking even basic business knowledge, practices would continue to fail.  Doctors would be exactly in the same situation as they are now in—living with mediocre, or just plain lousy, medical practice profits and unable to fund a retirement plan.  It’s an acceptable fact that the parasites of malpractice, law tort reform, litigious patients, and governmental control of health care will not change from how they are today or in the foreseeable future.  It seems quite obvious that I will find rare supporters who believe as I do.

Time to eliminate private practice altogether?

A tour spent on an HMO medical staff will convince any doctor that private practitioners should hang around a while longer.  Concierge medical practice does seem the safest of all the private medical practice models for a doctor to use in the present medical political environment.
With the increasing pressure and restrictions by our government on private practice doctors, even the smartest business and marketing experts such as Dan Kennedy are forecasting the quick rise in numbers of the cash-only models of medical practices.

Comparisons with other professional career choices show a significant difference in profits and satisfaction between a medical career and almost all others.  For the time spent in academic education, cost of education, the skills, talent and intelligence required, the stress of long hours and critical actions, among others, doctors are at the ultimate bottom of the income and lifestyle list. The reasons for that are many.  The solutions to that dilemma are unresolved—just floating along with the current.
And, now I’m back full circle to my original premise, what idiot would ever consider a career in medical practice?  If they would take the time to investigate what’s in front of them, it would be a blessing to them.
Winston Churchill made a point about a crisis during WWII, which seems appropriate here—“It’s not enough that we do our best; sometimes we have to do what’s required.” Private medical practice is increasingly required to bend to the external forces that make the rules, but that doesn’t mean there aren’t other alternatives.

Alternatives more enticing are those in other businesses separate from medical office practice.  This is especially disheartening when physicians discover that most successful business owners earn much more income than physicians.  And, they need much less education and spend much less on education than medical doctors.  More disturbing than that are the thousands upon thousands of people who barely made it through high school or dropped out of college who now earn three times the income of doctors, and work much less.

The question really is, why are there still college students who will continue on into the medical profession knowing all these drawbacks of the profession?  Would you judge them dedicated, just masochistic, or plain ignorant of the issues?

The practice of medicine is a highly honorable profession to be a part of.  No question about that.  However, honor attained at the detriment of so many sacrifices being made, may not be a virtue, but an illusion.

These health care warriors seem undeniably capable of withstanding the perpetual onslaught of our society, which dwells on them as prey.  One has to wonder what it is that makes them think it’s worth compromising most everything in their lives, from family to free time, just to continue a struggle against everything that can destroy them and their private medical practice at any point in time.
Next time around, I’m going to select a different career.

Curt Graham is a physician, author, marketer and expert in medical practice business and marketing strategies. He can be reached at Marketing Your Medical Practice Today.

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