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November/December 2004

When Is Enough Enough?

By Richard P. Mills, MD, MPH

Lately, there’s been a lot to gripe about. Cut fees, the managed care hangover, the quality police bypassing physician input, HIPAA and other nasty governmental intrusions, the malpractice crisis, patients flush with misinformation after a soiree on the Internet. Worse yet, the marketplace seems to value ophthalmic service less than in bygone years. My generation of Eye M.D.s remember the “good old days” as days gone bye. In the three decades following World War II, physicians “were surrounded by admiring assistants, loyal patients and respectful colleagues and had full autonomy in their work, job security and a luxurious income,” observes Abigail Zuger, MD, in a January report.1 Recent inductees to the ophthalmic fraternity don’t recall the good old days, but even so, they find it difficult to find a good job fit, moving frequently in the first few years. Most don’t earn a salary sufficient to buy a practice, a house and a lifestyle that was promised to them (by themselves) when they finished their educational marathon. While the reasons for discontent may vary by demographic, the resulting malaise is cross-generational.

“Enough is enough!” is a common refrain, as though it were time to retire, to retrain or to regress to a fetal state. In 1973, fewer than 15 percent of practicing physicians thought they had made the wrong career choice.2 Recent surveys show 30 to 40 percent of physicians would not choose as they had, and even more would not recommend medicine to their children.1 “Wait a second,” you may say, “all of this applies to the primary care specialists, but not ophthalmologists.” Not so: According to data from the late 1990s, involving 12,474 physicians, job satisfaction of ophthalmologists was significantly less than that of family physicians, with an odds ratio of 0.75 (95 percent confidence limits 0.60 to 0.94).3 On the Academy’s 2003 member survey, while 75 percent found their career choice extremely or very satisfying, only 53 percent would recommend it to a relative or close friend.

Apart from feeling miserable, what are the consequences of professional discontent? The collateral damage to the physician’s family is obvious. Less publicized is the effect on patient care. Stated simply, a patient can be only as satisfied as the person taking care of him. No matter how clever we think we are at masking our feelings, patients are better at detecting them on a gut level than they are at discovering whether our medical knowledge is current. Malaise is contagious, and it affects the healing relationship.

So what can we do? Isn’t situational depression an appropriate response? I don’t know about you, but I’d rather not feel that way. We aren’t in control of our external environment, but we do get to choose how we react to it. We are in control of our attitudes. My personal technique is to think of one thing that went well, every single day, like a patient who thanked me or a committee meeting that got canceled. Others think of how much worse it could be. Unless you are immobilized by clinical depression, you have similar methods that work for you, to keep your mood upbeat, to keep enough from being too much.

1 New Engl J Med 2004;350:69–75.
2 Hadley, J. et al. Acad Med 1992;67:180–190.
3 Leigh, J. P. et al. Arch Intern Med 2002; 162:1577–1584.