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.
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.
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.
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?