You Can't Eat Prestige

Even the NEJM is talking about it

Everyone in my residency was confused when I said I was going into private practice.

"Aren't you like, the surgical education person? Don't you want to be a program director or something?"

I did, at first. But I'm not convinced the kind of education job I was imagining exists anymore.

Don't just take my word for it. It's in the New England Journal of Medicine. Jatin Vyas — former program director at MGH, now at Columbia — is in those hallowed pages this month putting some extra-crispy euphemisms on what's rotten at the core of academic medicine:

"The shift from viewing our trainees as future colleagues and problem solvers to seeing them as a workforce whose primary purpose is to serve as the effector arm of the patient care engine devalues them."

From mission, he says, to margin. What was once a values-based system has become a system for extracting value.

And yes, of course it comes down to money…but not in the way you might think.

You should know that our great-great-grand mentors fought hard against exactly this world. For most of the 20th century, American medicine resisted corporatization by promoting itself as a calling that was above commerce. Think of the white coat, the Hippocratic Oath: these are closer to the trappings of clergy than capitalists. Paul Starr won the Pulitzer Prize for telling this story in The Social Transformation of American Medicine.

That paradigm worked for decades. But the cultural authority doctors once had? It's fading fast. And this is America; you can't keep money out of anything.

Our profession got corporatized, it just wasn’t for the benefit of doctors. Payment flows to insurance companies, administrative bureaucracy, hospital systems, and private equity: a set of faceless intermediaries who seized the financial gears, leaving doctors to look the patient in the face and say, “Sorry, we can't tell you if this will be free or will cost more than your car.”

The changes to medical education have been slower, but the result is a similar feeling of helplessness in the face of that not-so-invisible hand of the market. Anything that doesn't generate margin gets minimized: Teaching. Mentorship. Research. Intellectual community. You can still have all those things! But your compensation is based on your clinical productivity and you’ve got specific targets to hit, so maybe move that research meeting to the weekend.

When I told one of my mentors I was joining the "dark side" (aka private practice) he launched into an impassioned defense of academic medicine. What about your commitment to mentorship? What about tackling complex cases within an intellectual community? Don't you want the chance to teach the next generation?

The problem is, I know exactly what his job is like day-to-day because I’ve been cutting and sewing alongside him for 6 years now. This is the same surgeon who told me he stopped giving med students constructive feedback because "I need to feed my kids," and his promotion is in part based on med student evals. He's the same person who taught me that "protected academic time" is fictional in an RVU model. I think he knows, on some level, how hollow the academic mission has become. But I don't think he's ready to face it.

I still, deep down, believe in the mission of academic medicine. But I've had enough jobs at this point to recognize how an industry shows you its true values: ignore what you’ve been told, and look at where the money is flowing.

Caring for patients the way I want to care for them is my number one priority, and when I look at all of the complexity and inertia and obfuscation of these big academic bureaucracies, I know I can take better care of patients with more independence. That's how I ended up choosing private practice.

The academic title, at this point, is mostly just a title. And while my number two priority is education, I believe I can find a way to scratch that itch from outside the system. 

You can't eat prestige. If that's the main course, decide–eyes open–if that’s what you’re hungry for.