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December 1, 2018

Medicine, Work-Life Balance, Money, and Time

Andrew G. Alexander, M.D.
Associate Dean of Clinical Medical Education
University of California School of Medicine
Riverside, California

Work-life balance was first described in England during the 1970’s. By the early 1980’s it had made its way to the U.S. The term was meant to describe the need for individuals to allocate time for events, other than work, within their lives. In the years since the turn of the century, the term has been more widely used and studied. A work-life “imbalance” has been reported by 9% of loggers and agricultural workers, and 36% of people in the legal profession. It is clearly no longer only associated with physical work.1

During the 1990’s, physicians began to rethink how they selected their specialties. This occurred at a moment in medical history when income separation between diagnostic and procedural specialties began to widen, and when insurance companies and HMOs began to exert influences. Insurance companies were newly empowered to select, or de-select panels of doctors for their medical policy holders. To insure adequate money, and time to spend it, the popular sanctities among newly minted physicians became Radiology, Anesthesiology, Pathology, and Emergency Medicine. These so-called “RAPE” specialties all had in common that patients and insurers could not avoid them. No patient or insurance company could predict who would read a hospital’s X-rays, who would perform the pathology report on a surgeon’s specimen from the operating room, who would administer the anesthesia necessary for their surgery, or who would be available in the E.R for unforeseen trauma. This did indeed help further widen the income gap, but we had no idea at the time how that would work out for happiness.

Burnout and work-life balance are close cousins. Studies of burnout disclose the highest rates in urology and neurology: two specialties that defy comparisons. One is a relatively high fiscal earner and the other a relatively low earner. If more money made happiness, one would expect orthopedics, neurosurgery, and ophthalmology to be areas of respite. In fact, their burnout rates all exceed 49%.2 Money has no relationship to physician happiness. Time off, a commodity available to shift-workers such as anesthesiology and emergency medicine, is still associated with burnout rates of 42 and 54%, respectively. It is clear that time away from the office is not associated with physician happiness. It was predicted that making more money would bring more job satisfaction, when in fact the evidence shows otherwise. Clearly, money is not a factor.

In the following decade, a new generation of medical students drank the Kool-Aide and strove to enter the higher paying procedural fields of Radiology, Ophthalmology, and Dermatology. It was again based upon a belief that more money and more time to spend it would bring happiness and balance. Each of these specialty fields has 50% greater “career regret,” about selecting their specialty than do members of the specialties of family and internal medicine.2 Clearly, time to spend the money is not a factor.

Applicants to today’s medical schools overwhelmingly profess to admission committees their eternal desires to practice primary care. By the time medical school is underway, however, they have succumbed to the glitter of higher income and time to spend it. They are re-drinking the Kool-Aide in a manner that would make Einstein ponder a popular theory regarding insanity. The medical student expectation is driven by the hope that work-life balance can be predicted by the formula of: Money earned, divided by Time to spend it will provide work-life balance. In short, Happiness = Money/Time.

This theory, in its 3rd decade of deceit, sounds intuitive to the newest generation of medical students. It is supported by the companies who sell USMLE testing materials that are guaranteed to raise USMLE scores. This support uses marketing to reflect upon the elephant in the room: money. For every additional point scored on the USMLE Part 1 exam, a doctor’s lifetime income can go up $120,000 (Figure 1).

Comment: USMLE Step-1 scores are graphed together with income, by specialty. The slope of the graph averages $4000.00 U.S. per year, or $120,000.00 for a 30-year career (AAMC.org/FIRST, Oct 2017; Medscape Physicians Compensation Report 2018).

Students do their part and study these USMLE testing materials at home in lieu of attending classroom lectures. The AAMC has become an unwitting enabler by proposing that students think about work-life balance when they select their specialty. It is unfortunate that the AAMC has not defined the term, but rather left it open for others to define. Regardless, the glitter of gold and the taste of purple Kool-Aide are so inuring that young medical students have inserted their own definition. The formula of Happiness = Money/Time has been re-run like a bad movie.

Work-life balance cannot be obtained by making more money, or by having more time to spend it. It is found, like all human goodness, in meaningful relationships. Time with people, and the opportunity to impact their lives is what doctors strive for. The thought of the healing profession, and the interpersonal relationships that abound within it is what brought our students into the medical field. Continuity of care is a curative and soothing ointment for the burnout that will surely plaque those who desire the insane Einsteinian chase of a repeatedly failed fiscal formula. Happiness will never be obtained by altering either money or time.

The first years of medical school are a time to explore science and humanity. The combination of studies is nearly unique to medicine, and can result in true happiness: true work-life balance. Our students should pursue good grades, learn to provide good patient care, and good test scores because their future patients deserve it. Patients also provide satisfaction if only the doctor will take the opportunity to know the person within. Sometimes this requires a rethinking of which specialty is actually best. Even the highest USMLE scoring student deserves to be happy with good life balance. Whether or not the lips are covered with Kool-Aide, the expectations that more money and more time away from work will guarantee work-life balance will never materialize. It doesn’t take Einstein to know that H ≠ M/T

Funding: None.
Conflict of Interest: None.
Authorship: Author is entirely responsible for the content of this manuscript.
Requests for reprint should be addressed to Andrew G. Alexander, M.D., University of California School of Medicine, 900 University Ave., Riverside, CA 92507 Email: editor@socaljmed.org

1. Alterman T, Luckhaupt S, Dahlhamer J, et al. Job insecurity, work-family imbalance, and hostile work environment: prevalence data from the 2010 National Health Interview Survey. Am J Ind Med. 56(6): 660-669.

2. Dyrbye L, Burke S, Hardeman R, et al. Association of clinical specialty with symptoms of burnout and career choice regret among U.S. resident physicians. JAMA 2018; 320(11): 1114-1130.

3. Results and Data 2018 Main Residency Match. The MATCH National Residency Matching Program.http://www.nrmp.org/wp-content/uploads/2018/04/Main-Match-Result-and-Data-2018.pdf . Page 3. Accessed September 12, 2018.

4. Results of the 2018 NRMP Program Directors Survey. The MATCH National Residency Matching Program. http://www.nrmp.org/wp-content/uploads/2018/07/NRMP-2018-Program-Director-Survey-for-WWW.pdf . Page 3. Accessed September 12, 2018.