My colleague Sean (who asked to be identified only by his first name) is like many medical residents I know. He cares deeply about his education. He wants to pursue the best opportunities available to him. But for him, medical training continues to stretch on and on. After completing an undergraduate degree, medical degree, and PhD in Iowa, he was finally ready for residency. But he was also ready to start a family with his wife. She was finishing her PhD, also in Iowa, so the timing seemed right. "We thought she would be done by the time I started residency," Sean said. "We were sort of applying everywhere and weren't really limited geographically." Unfortunately, his wife wasn't able to complete her degree as quickly as anticipated. "Anything in science and medicine is unpredictable," he said. This placed his family in a situation that I see often among my generation of medical trainees: Sean had to endure a long-distance relationship with his wife and newborn son. "It's really difficult to have a relationship with your son through Skype or FaceTime," he said. "There are limitations to how many vacation days [I can take]. We can't just fly back." Even attending his son's birth proved too challenging during his first year of residency. He planned his vacation schedule carefully, but his son was born a week early. A generous medical student willing to hold up a cell phone allowed him to virtually participate in the birth. Luckily, after about a year, his wife was able to move to Connecticut, reuniting their family. However, the transition has also been challenging. "Even after my wife and son came here, my son didn't really recognize me for the first couple weeks," Sean said. "He wouldn't let me hold him at all. He just thought I was a stranger." The Unspoken Assumption: A Nomadic Lifestyle Every doctor's story is unique, but we should consider the larger implications of these individual decisions. The constant moving that medical training often demands has far-reaching effects on the physician workforce. It influences our most personal life choices, reduces access, and hinders diversity. There is more discussion than ever about physician burnout. I believe itinerancy is one driving force. A nomadic lifestyle is essentially inherent to the process of becoming a doctor. Geographic flexibility is required to overcome the tough competition for medical school admission. About 40% of medical students now matriculate out of state. The social disruption is probably worse than even these numbers suggest. My classmates who came from New York City to attend my upstate New York medical school 6 hours away may as well have moved to a different planet. It's an unspoken assumption that you will have to move around. Displacement continues into postgraduate residency and fellowship training. Matching US medical students now rank an average of almost 13 residency programs. This is a more than 50% increase since 2002. In the top 5 most competitive specialties, students now routinely apply to more than 60 residency programs. Such extensive rank lists mean students are forced to look far and wide for an opportunity to learn. "Everybody encourages you to apply broadly at every stage of this process. We have so little control that it's an unspoken assumption for most people that you will have to move around," said Grace Oliver, MD, a family medicine resident in Kansas. "I knew my life would be completely different, and that I would be moving alone, probably to a city where I didn't know anyone." Most of the medical couples I know have sacrificed time, place, and family for their careers. I've watched my friends and colleagues select partners who can accommodate and understand these requirements. Often, that means marrying other doctors. Around 40% of physicians marry another physician or healthcare professional. Although this trend may improve interpersonal understanding, it also increases the complexity of training decisions. One partner completes an unnecessary master's degree so that graduation dates align for a couples Match. A resident plans her pregnancy around two competing rotation schedules. In order for both to obtain fellowships, one spouse takes a spot in California while the other heads to New York. Effect on Patient Access, Physician Diversity Mobility has its advantages. It opens trainees up to new opportunities and provides experiences that we might not otherwise seek out. But it is also worsening the problem of inequality in patients' access to care. Residents are not distributed in a way that matches the patient population. There were 77 trainees per 100,000 people in New York State, compared with fewer than 2 trainees per 100,000 in Montana, according to a study in Health Affairs. Trainees are moving away from those who need more healthcare, rather than toward them. The opportunity to train as a physician is a rare privilege. A lucrative, fulfilling career sits at the other end of the journey. Although most who take advantage of this opportunity were already born into economic advantage, learning to practice medicine is never an easy road. The constant moving inherent in today's medical education alienates young doctors from their families, patients, and communities. But transiency and expense mean a less diverse physician pipeline. There is evidence that despite rising average debt levels, medicine is being pursued by an ever wealthier subset of people, leaving the nonwealthy minority burdened by most of the debt. Those without family support often take out private loans to afford residency interviews and relocation. "A lot of people just went without things like a couch, took out additional loans at very high interest rates, or maxed out credit cards to get through the eternity between their last [student] loan disbursement in January of their final semester and that first residency paycheck in June or July," Dr Oliver said. For competitive specialties, the growing number of applications required, as well as costly "audition" rotations, further increase financial barriers. Easing the Burden I don't mean to imply that medical training is unique in requiring an itinerant lifestyle. From rookie journalists to assistant football coaches, many jobs demand that those early in their career move around. As physicians become older and more independent, they usually develop roots in one place. But we can't simply dismiss the challenges of a decade or more of education and training. There is probably no way to completely eliminate the itinerancy that medical training demands. But there are smaller ways to ease the travel burden and its associated costs. As a start, we can stop relying on away rotations to select residents, especially for the most competitive specialties. Medical schools can provide more flexibility for those in challenging financial or personal situations to minimize far-flung rotations. Residency programs in the same region could coordinate interview schedules to allow students to attend multiple interviews during the same trip. Hospitals could issue their first paychecks before graduating medical students have to pay for moving expenses, reducing reliance on high-interest private "relocation" loans. We can improve family leave policies, which modern physician families find lacking. The constant moving inherent in today's medical education alienates young doctors from their families, patients, and communities. It acts as an unnecessary barrier to the profession. We can find practical ways to reduce travel requirements and expenses. By doing so, we will better enable students from less privileged backgrounds to pursue medicine and improve the mental and social health of young physicians. Benjamin Mazer, MD, MBA, is an anatomical and clinical pathology resident at Yale School of Medicine, with interests in diagnostic surgical pathology, laboratory management, and evidence-based medicine. Source
