The Doctor Salary Is A Drug: Potential For Abuse

crispydoc Uncategorized 7 Comments

My sense of gallows humor, honed over decades of emergency medicine, is bound to infuse my writing. I hope it will not be mistaken for making light of substance abuse or the pain it causes individuals and families.

As a common final pathway for many in crisis, the ED at best serves as an inflection point and support for those seeking recovery; at worst, as a way-station that chronicles self-destruction.

Having explored the unique pharmacokinetics of the doctor salary, it's time to come to terms with the dark underbelly of a high income - the potential for abuse.

Narrow Therapeutic Window

By virtue of size alone, a physician salary is substantial enough to overcome many of the big rookie mistakes in personal finance (buying the doctor house or the doctor car) since it's far easier to carve brute savings from a big salary than a small one.

The flip side is that it's far easier to undergo lifestyle inflation with a big salary, opening a Pandora's box of cascading expenses that can be difficult (but, as my friend BC Krygowski has shown, not impossible) to recover from.

This suggests a narrow therapeutic window, and while I lack the data on number needed to treat vs. number needed to harm, I'd be curious (from a financial standpoint) if more physicians feel they benefit from the salary than feel constrained by golden handcuffs.

It's not uncommon to hear colleagues lament that they'd leave medicine in a heartbeat if only they could find a comparable paycheck in another field that would hire them.

Symptoms of Physician Salary Abuse

I used an entirely unscientific convenience sample of websites that popped up via google search to look for signs of substance abuse, and was surprised at how many describe either people I've known at various times during my medical career or people I used to be.

Loss Of Interest - Apathy - Complacency

Burnout, plain and simple.

Rapid Mood Swings

Thrown a scalpel lately?

Exploded when you were interrupted for the third time in three minutes by a lovely volunteer asking if the patient in bed ten can have some water?

Learning to walk on tenterhooks in order to play well with others is a major part of the job. We are routinely expected to navigate the emotional lability of colleagues whose tantrums are among the worst kept secrets in the hospital.

Many years ago I overheard a fellow emergency physician trying to extract from the angry phone tirade of a specialist he'd contacted to take a patient suffering a heart attack for an emergent angiogram. In as soothing a voice as he could muster, he said, "It seems unsafe to drive when you are feeling this angry. I'm going to hang up the phone now so you don't grow any angrier."

My wife similarly recalled a patient encounter where an adult son was subjected to the ever-productive, "Why didn't you bring mom in earlier before she got so sick?" line of questioning by the admitting physician.

If you are blaming the patient and their family for not having your level of medical education, or lashing out at the person on the phone for being asked to perform your job, you might have a physician salary dependence disorder. Marie Kondo, for one, would say this job no longer brings you joy.

Reclusive Behavior

Remember the fruit of your loins? Those little critters you like to announce are the reason for spending 12 hour days out of the house? They don't know you very well these days, and what they know they aren't terribly fond of.

Perhaps it's that by the time you get home, you have nothing left to offer them. So you offer them money instead of time, and you retreat to your escape: an office, a television, a drink, a country club.

Some time ago, work displaced the other elements of your life. Not knowing the people who lived in your house, it was awkward to spend time with them when you finally had a rare day off. It became easier simply to spend those days off working or escaping. Estrangement became a self-fulfilling prophecy.

Rapid Change In "Normal" Behavior

Friends have stopped calling because you are inevitably too busy to make time to see them. Frankly, you don't blame them. You've cancelled on enough dinners at the last minute that few are willing to book a sitter and take that chance again. Hose me once, shame on you. Hose me twice...

Formerly important routines are cut out. Fitness routines are cut out. Social outlets disappear.

Priorities shift such that time (formerly spent on relationships, reading, service to others) is sacrificed to make time for obtaining more of the drug.

I'll grant that over decades I've met a handful living saints whose essence resides in serving others via medicine.

The others? The dollars became the way to keep score, and they were winning. Since they were losing badly by so many other metrics of life, they diverted their energies to their greatest success.

Erratic Behavior

Underlying depression or anxiety can worsen dependence. Withdrawal when the drug is not available (job loss, inability to make a payment due to unplanned tax obligation or lack of emergency fund) can cause emotionally labile acting out.

Oversensitivity and defensiveness may result from attempting to hide dependence.

Why do you spend so much time at (the clinic/the office/the hospital)?

In order to (keep you in this beautiful house/pay for your private school/take you on this exotic vacation)!

Sometimes estrangement leads to the fear that a partner might leave if the money were not part of the relationship.

Financial Rehab

Those who provide treatment for substance abuse emphasize that it should be considered an experience and not a punishment.

A financial literacy conversion experience is an opportunity to alter your relationship with money, to recover from unhealthy habits and form new boundaries with debt.

It's a chance to assume responsibility for your future.

If the symptoms above describe you, or someone you care about, sit down and think about what a meaningful life would look like.

How would you spend your time if you lived this more meaningful life?

How can you reverse-engineer a work-life balance that supports this lifestyle?

Comments 7

  1. The first step is admitting you are out of control
    The second step is coming to believe there is a solution
    The third step is submitting to a fairly rigid set of boundaries, that are not self created
    The forth step is examining your life with with dead assed honesty
    The fifth step is admitting what an asshole you are and have been, the truth will set you free
    The sixth step is to become entirely ready to change and leave assholery 100% behind
    The seventh step is to allow the first six to work without sabotage and allow maturity to happen
    The eighth step is to make a list of people you have harmed without justification.
    The ninth step is to amend the relationships you have soiled, I mean soiled in it’s most blatant way
    The tenth is to reprocess the first nine in a do loop
    The eleventh is to actively seek truth order peace and love in your life eschewing politics and power plays
    The twelfth is once 11 are generally mastered, pass on the wealth

    The 12 steps came out of an 18th century Anglican group called the Oxford movement which had 6 steps and conjunctions between pairs like 1 and 2, 3 and 4, etc. The Oxford group took their lead from the writings of St Ignatius of Loyola a 15th century spiritual leader and thinker. Ignatius had been a mercenary aka a hired killer. He was wounded in battle and managed to survive but was severely incapacitated. He spent time living in a cave where he underwent a spiritual awakening and crafted a theology of service, not unlike military training and founded the Jesuits.

    Interesting the solution comes from a 15th century mystic. A better song for the addiction to medicine and money might be:

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      From Ignatius to Janis, that’s a truly visionary historical series of links.

      There’s no small amount of wonder and insight that develops from behind left behind or outside, in caves both literal and figurative. In fact, the often moving blogger behind Lacking Ambition spent nearly a year in a tent in the New Mexico desert. Although he hasn’t posted in a long time, I enjoy rereading his hermit’s reflections.

      Thought of you while visiting the Sagrada Familia in Barcelona, Gasem. The light and the space made it such a sacred space that you’d be hard pressed to leave the place without believing deeply in some force of good in the world, regardless of your prior cynicism or assholery.

      1. Never been to Spain but I kinda like the music. I did not know of Holy Family in Spain. Amazing place. If you become open to making the trip inward the reward can be breath taking. The humility sure is. I spent a secluded month in 1993 doing the spiritual exercises of St Ignatius in a guided retreat. Revolutionized my life. My wife did it a couple months before I did revolutionized her life as well.

  2. This post touches on a lot of points of medicine that have been kept under the rug.

    There are a few that have medicine as a true calling these days. Most of us now feel obligated to work because we need the income to pay for the debt and stuff we accumulated while trying to be come a doctor.

    And when we are obligated and thus do medicine because we have to and not because we want to, that’s when the personality changes happen.

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  3. Great analogy Crispy Doc.

    I would also say that money has a short half-life and is titratable. Like levophed in a septic shock patient. There are times where you need to turn it up to save a life and others where it can kill if you don’t dial it back. We need to constantly circle back and reflect/reassess our state of human and financial capital shock and course correct. Don’t turn your back on the pump too long.

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      I didn’t see it coming, but delight in the critical care analogy, Loonie Doc! I my ask you what the financial equivalent of the intra-aortic balloon pump would be…

      You remind me of the final test question in first year pharmacology, an extra credit question where we were asked to describe our favorite drug and explain your reasoning.

      A jaded Israeli friend who went into anesthesia revealed his answer:

      Used to treat erectile dysfunction.
      Side effect: impotence.

      It appears not just the patient but the pump is placed at risk with certain drugs…

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