Last week, I was called about triaging a patient to the intensive care unit. A 38-year-old woman had come to a rural Ohio hospital emergency department with sepsis and chest...
As an intern, the one specialty I was sure I did not want to go into was pulmonary. The inpatients all had either COPD or lung cancer brought on by the bad life choice of smoking, the sputum they brought up was gross, and there didn’t seem like there was anything we could do for them. So, back in 1987, I decided to do a critical care fellowship and pulmonary was just the necessary appendage to a critical care fellowship. I was a bit surprised when I read the 2018 Medscape Physician Compensation Report that reported that pulmonologists appear to be among the most satisfied of physicians. The report is the compilation of 20,239 physicians in 29 specialties who responded to the annual Medscape survey.
Although the main focus of the report is about monetary compensation, there are several other questions that to me are more interesting than salary One question asked is “If you were to do it all over, would you choose medicine again?” Pulmonologists were more likely than any other speciality to respond that yes, they would choose medicine again at 88% of respondents, with cardiologists a very close second. In a previous blog post, I have commented on the fact that fewer physicians are choosing infectious disease and nephrology and this is reflected by the the low percentage of nephrologists (66%) and infectious disease specialists (68%) who would choose medicine again.
So, could it be salary that makes pulmonologists so happy? Probably not. All physicians make an extraordinary income compare to the rest of Americans. But pulmonologists are in the middle of the pack when it comes to earnings and earnings do not correlate very well with whether or not a respondent would choose medicine again. In fact, physicians in the highest earning specialties were just about as likely as the lowest earning specialties to report that they would go into medicine again. Plastic surgeons at 80% choosing to go into medicine as a career and orthopedic surgeons at 75% are the highest earners (note that neurosurgeons were not reported in the Medscape survey) where as pediatricians (79%) and endocrinologists (78%) are the lowest earners. So, it does not appear that income determines career satisfaction. However, in the Medscape survey, a separate question asked “If you had to do it over again and went into medicine, would you pick the same specialty?” In this case, earnings correlated with whether the physician would choose the same specialty with 98% of orthopedic surgeons and 97% of plastic surgeons choosing the same specialty again.
What about how the physicians feel about their compensation? The pediatrician knows that he or she is going to make a lot less than an orthopedic surgeon before starting residency. But does career satisfaction correlate to how appropriately the doctor believes that he or she is compensated for the work he or she does? Maybe so. The Medscape survey indicated that 70% of pulmonologists reported that they felt fairly compensated. The only specialists who reported feeing more fairly compensated were emergency medicine physicians at 74%. Interestingly, some of the specialists who were least likely to feel that they were fairly compensated were also the specialists who had the highest incomes. Only 50% of plastic surgeons and 51% of orthopedic surgeons felt fairly compensated.
So why are pulmonologists so happy and willing to go into medicine again? No one knows for sure but I have my own opinions.
- Variation in practice location. It is said that variety is the spice of life and few other specialists practice in such a variety of locations. On any given week, a pulmonologist will see patients in the outpatient clinic, the intensive care unit, the bronchoscopy suite, a hospital nursing unit, or a long-term acute care hospital. It is hard to get bored when you have contact with so many other doctors, nurses, and respiratory therapists.
- Pulmonologists have a built-in mid-life crises solution. Very few physicians do a pure pulmonary or pure critical care medicine fellowship. Instead, most do a combined pulmonary-critical care fellowship. It takes about 14 years of college/medical school/residency/fellowship to finally become an attending pulmonary & critical care physician so most start their career about age 32 and then retire around age 66. Straight out of fellowship, most newly minted pulmonary/critical care physicians do mostly critical care. This is because in the ICU, the first day on the job, you have a full set of patients whereas it takes a few years to build up an outpatient pulmonary referral base. At the other end of one’s career, when a pulmonary/critical care physician gets closer to retirement, he or she has built up a nice outpatient practice and is tired of the emotional and physical demands of the ICU. For most, the pulmonary and the critical care curves cross at age 45; younger than that and they do mostly critical care, older than that and they do mostly pulmonary. So right when many professionals are getting tired of their job in their mid-40’s, the critical care physician is metamorphosing into a pulmonologist and gets to have a different job for the second half of his or her career. When I started my career, I identified mainly as a critical care physician. Now, I identify mainly as a pulmonologist. It was surprising to me that whereas 88% of pulmonologists would choose medicine again, only 75% of critical care physicians said they would choose medicine again as a career. This may relate more to age than career choice since self-identified pulmonologists are older than self-identified critical care physicians.
- They do procedures… in moderation. In the past month, I have done (or supervised fellows doing) central lines, arterial lines, chest tubes, bronchoscopies, thoracenteses, ventilator management, endotracheal intubations, pulmonary exercise tests, and PFT interpretations. But procedures are only a minor part of the pulmonologist’s workday. Nevertheless, that mix of both procedures and E/M (evaluation and management) services gives variety to the workday and keeps one from being stuck in a career rut.
- We are entering a golden era of pulmonary medicine. Pulmonary is about 20 years behind oncology and 30 years behind cardiology with regards to scientific breakthroughs. We as a society have invested enormous public and corporate research money into finding cures for cancer and cardiovascular disease in the past several decades and it has really paid off. Pulmonary diseases such as idiopathic pulmonary fibrosis, cystic fibrosis, and asthma are just now getting the major research breakthroughs that oncology and cardiology have already experienced and many of the previously untreatable pulmonary diseases are becoming not only treatable but sometimes even curable. That makes for it being a very exciting time to be a pulmonologist.
This is all just speculation of course. But it is comforting to know that the majority of doctors in all specialties would do it all over again if they could. Pulmonologists just want to do it all over again a little more.
April 28, 2019