What's Your Favorite Sense??

This week in JAMA Ophthalmology, I came across an article that tried to value different senses. It was a small study, and there may be some bias as the authors themselves were part of an eye health department; however, it came to what I feel was the predictable conclusion: sight was the most valued sense.

The study surveyed 250 participants in the UK. The group comprised mostly of women (56.4%), and the average age was 50 years old, but included people 22 years and older. The vast majority of the study group did not have any family history of vision impairment. They included the following 8 senses in their questioning: sight, hearing, touch, smell, taste, balance, temperature, and pain. How would you rank these in order of most to least favorite? For me, the top choice is simple… My rankings would be as follows: Sight, Balance, Hearing, Taste, Touch, Smell, Pain, Temperature.

The study also looked at Time Tradeoff. Participants were essentially asked: How many years of perfect health would you give up in order to maintain your sight (or these other senses)? This could also be rephrased as: How many years of perfect health would you prefer compared to 10 years of life with complete vision loss (or other sense)? The results were quite astounding!

“ “The time tradeoff exercise indicated that, on average, participants preferred 4.6 years (95% CI, 4.2-5.0) of perfect health over 10 years without sight and 6.8 years (95% CI, 6.5-7.2) of perfect health over 10 years without hearing (mean difference between sight and hearing, 2.2 years; P < .001).””

On average, people chose 4.6 years of perfect health compared to 10 years of complete vision loss. The second most valued sense was hearing as people chose 6.8 years of perfect health compared to 10 years of complete hearing loss. Even more interesting, 15% of people chose death over living 10 years with complete vision loss (compared to just 6% choosing death over complete hearing loss). While it’s important to keep in mind that this is just one small study that may not reflect the general population, the findings here seem to be reinforced by a couple other studies out there.

“As physicians in this economically tightening environment, we have to demonstrate objectively our value to the population. It is no longer enough simply to have patients say they like us.”

So what does this all mean? To me, this reinforces the value that my field of Ophthalmology brings to people. We value our vision and the health of our eyes so much that we would give up a lot to preserve our sight. From a personal standpoint, I’m grateful to be in a field that helps make a significant difference. Nobody really understands what we do (either as Ophthalmologists or Oculoplastics experts) until they need us and by then, vision could already be damaged.

From business and healthcare policy standpoint, I see a significant disconnect. First of all, it seems a little ridiculous to me that eye health is not universally covered. Vision care, from eye glasses to cataracts to other complex surgeries, should be a basic covered service because it has such a profound impact on people’s lives. The US system right now has just a patchwork of insurance options to cover eye health with many gaps in care. Imperfect vision not only affects one’s quality of life, but there is also an economic impact with loss of productivity

Secondly, all physician specialties have generally seen a cut in their reimbursements, but as policymakers, we should ask ourselves, what does the public value, and how should limited resources be distributed? As physicians in this economically tightening environment, we have to demonstrate objectively our value to the population. It is no longer enough simply to have patients say they like us.

Although I’m biased, I think it’s clear what the public values. People are willing to give up nearly 5 years of their life over a 10-year period to have good vision. That’s pretty remarkable.

Free Tuition?! A step towards better medical education!

NYU recently joined the ranks of few other medical schools that offer their students reduced loan burdens and an even smaller, elite group of medical schools that offer completely free tuition. This is fantastic news for medical students, and we can only hope that other institutions begin to offer similar deals to their students!

Medical education is a huge business and is expensive. While I cannot comment on exactly the resources it takes to train a competent physician, I imagine it's a lot. Medical liability itself must be particularly expensive in our litigious society, but also the costs to hire lecturers and practicing physicians to teach must be significant. The large administrations, bureaucracy, and facilities at many training institutions also have significant costs that someone needs to pay. So to have NYU, in one of the most expensive cities in the world, take a bold step to free their students from the shackles of educational debt deserves tremendous credit!

“To not consider the financial or economic consequences of your career decisions is short-sighted.”

I had a wonderful experience in medical school at Case Western in Cleveland and wouldn't trade it for anything. I was taught by the best, had access to amazing faculty, unparalleled opportunities, and was able to work/learn along side the most wonderful and brightest people. Yet looking back, I do wonder if the debt was worth it. Over $200,000 in medical education debt, to which I have not made a dent being on a trainee's salary for the last 5+ years. In order to keep up with the interest rates and even touch the principal, I would have to make payments of more than ~$1,500-$2,000 per month in after-tax dollars... on an average pre-tax salary of ~$55,000-$65,000 per year. The math just doesn't add up. This also means I haven't been able to save for retirement (and thus have lost out on a decade of compounding interest growth), create a safety-net fund, save for a house, plan for future child expenses... all those things that one should really begin in their late 20's and early 30's. 

My mentors and faculty would say that you should choose a field solely based on interests, while ignoring the potential reimbursements as a specialist. This is foolish. To not consider the financial or economic consequences of your career decisions is short-sighted. It makes little financial sense to not be a specialist with potential for higher reimbursement when you have so much accumulated debt. And I wonder if this factored into my class' residency decisions, where a significant number chose specialties like radiology, orthopedics, etc. Even among those that chose internal medicine or pediatrics, anecdotally, it seems most continued to further specialize. I wonder how finances/economics played into our decision-making, even on a subconscious level. 

“A lower medical education cost gives you the freedom to truly make the decision based on your passion. ”

Healthcare Implications: By reducing the debt burden, more people will consider going into medicine in the first place. It removes a significant financial barrier in order to attract the brightest students, regardless of their ability to pay. This benefits everyone. More trainees may also consider primary care, which could certainly use more physicians. In the long-term, a stronger primary care force would help maintain a healthier population and reduce overall costs.  

“If you work hard and score well on standardized testing, you will still likely get the residency you want, regardless of how much tuition you paid.”

Student Implications: Students have a tough decision to make when it comes to where to go and what field to choose. I would argue that it's better to go to an institution that you feel is a good fit AND has the lowest costs. Accrediting organizations like the LCME, AAMC, and AOA have stringent requirements, so most medical schools are pretty good. If you work hard and score well on standardized testing, you will still likely get the residency you want, regardless of how much tuition you paid. A lower medical education cost gives you the freedom to truly make the decision based on your passion.

There's little I would change about my journey as that is what led me to this moment. It's important to remember: Fulfillment in medicine comes not from the remuneration, but instead the intellectual challenge and gratification of helping another human being. If you're solely interested in money, perhaps a career in finance or starting a business is better. But this debt is a real burden. Physicians are certainly well compensated once they finish all their training, but these salaries are deceiving when you take into account the opportunity costs, length of education, shortened careers, lack of retirement investments, and lack of general savings. Previous generations of physicians may have done extremely well financially, but the economic reality today is much different.

Medical education benefits greatly from reduced physician debt burdens. Students can focus on learning and practicing medicine, instead of worrying about crushing debt. The brightest, most talented students may also be more likely to consider academic careers, where reimbursements are lower. Having happier, financially secure physicians to teach and lead future generations of physicians creates a positive cycle that benefits not only future students, but also patients. 

Kudos to the likes of Cleveland Clinic, NYU, and the few other medical schools that have found a way to reduce this burden on their students! It's a HUGE upfront cost, but an investment that will lead to more competitive and diverse applicants, happier trainees, less burdened physicians, and ultimately better healthcare for everyone.

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Beyond Burnout and the Business of Medicine

This week in JAMA, Dr. Catherine Humikowski penned a wonderful article about physician burnout that I think is worth a read. Over the last few years, we've started to see research and personal exposés on physician burnout. We have seen in the news the tragic stories of suicides across all levels of training, from medical school to late career physicians. In response to these events, there have been more resources, usually in terms of counseling, available to trainees. There has also been a greater acknowledgement that mental health is critical to a physician's well-being, and therefore by extension, our patients' well-being. However, this hardly seems enough as we continue to hear what our colleagues and current trainees face.

We choose a medical career not because of a business decision, but rather we hope to make a difference in others' lives. We are, and hope to continue to be, intrigued by the science, restored by the humanity, enlightened and entertained by our patients, challenged in every aspect, and driven to perfection. Yet we cannot escape the reality that the system is broken. Bureaucracy and administrative requirements dictate our practice, and profits have become the underlying driver of the field. 

“Medicine could stand to drop the attitude that we are somehow immune to the same basic physiology we have devoted our lives to understand.”

— Catherine Humikowski, MD

One great point that Dr. Humikowski highlights is that, "Burnout infers insufficient energy from within, as if one's spiritual well were too shallow, or constitution too weak." Like most residents now, I sat through a lecture in my residency every year on burnout. The conclusion was that we need to be more resilient, that indeed the fault lies within us for these overwhelming feelings. It fails to acknowledge the systemic or institutional issues that drive physicians to burnout. Just as Dr. Humikowski discussed in her article, we too were lectured on the importance of self-care, yet we face the reality of actual institutional policies contradicting this very notion. I recall in my own residency the challenges and fear I had to request a few hours off to see a doctor or dentist for my own health. How many residents out there encounter this kind of anxiety? Do training programs have actual defined policies in place? As residents, we genuinely strive to provide the best care we can to best of our abilities, often to the detriment of our own health. Dr. Humikowski mentions, "If any industry should care for the caretaker, it's ours. But we have not done it well." I, and countless other physicians who leave the profession for other fields, couldn't agree more.

There is no simple solution to physician burnout, but progress needs to be made, and large healthcare institutions that train and hire physicians have an opportunity to be at the forefront. Taking cues from other large corporations that have improved productivity and employee satisfaction, residency programs and large hospitals can offer (as Dr. Humikowski mentions) paid sick leave, child care, and maternity/paternity leave. In addition, they should also provide great and affordable health insurance coverage (I've trained/worked at literally the best institutions in the country, that provided the worst, most complex health insurance), a competitive 401K (to help make up for a decade of lost earnings), and student loan relief (the average physician graduates with over $190K of debt). Although capped at 80-hour work-weeks due to ACGME requirements, the reality is that many residents continue to approach nearly 100-hour work-weeks. How about offering pay commensurate to hours worked?

It's important to acknowledge that medicine is a business. On the business side, this means more costs and lower short term profits, which is why there will be a reluctance to make substantial change. Instead, trainees and physicians will likely be offered more online modules, counseling, and seminars because talk is cheap. Real progress requires a strong will and upfront capital investments. Yet these investments will pay off in the long-term as more people choose the profession, become more productive, and opt to stay in it for as long as possible. I would anticipate with some common sense changes, burnout would be less. For substantial changes to be made, trainees and physicians need to understand how business decisions drive medicine.

At the end of the day, Dr. Humikowski says it best, "Medicine could stand to drop the attitude that we are somehow immune to the same basic physiology we have devoted our lives to understand. We must cultivate balance around us and among us, not just within us."