Young Docs Who Want to Work Less Must Expect to Earn Less

Jillian Horton, MD


July 28, 2021

Like most practicing physicians, I have income security. Most of our salaries put us in the top 5% of earners in North America. I am squarely in the middle when it comes to how much I make relative to physicians in general. Various factors are at play when it comes to where I sit among my peers. Practice style, specialty, gender, mode of compensation, and how we define efficiency all play a role. I have also made academic and life choices that have resulted in me receiving substantially less compensation than some of my immediate counterparts.

When it comes to the latter, I'm okay with that.

I'm okay with it because it's part of a larger discussion we don't frequently have when we talk about physician burnout. It is an inherent truth almost taboo to mention: When we truly prioritize a work-life balance, we will almost certainly see a reduction in income.

This may come as a shock to younger generations — or even those who are thinking about the issue seriously for the first time. Residency programs are salaried. Discussions about reductions in work hours are typically — and rightly — disconnected from any reduction in compensation because residents are notoriously overworked and underpaid. Younger physicians may not realize that current median levels of compensation for practicing physicians have been determined by excessive and unsustainable workloads carried by previous generations. That's why income expectations and the desire for a healthy work-life balance are often in direct conflict, especially for those starting their career with an eye toward "having it all."

To be clear, physicians should be appropriately compensated for what we do. We sacrifice a lot to become doctors. We should be well compensated…in proportion to how often we do what we do. And some physicians remain undercompensated for their work, with fee-for-service models often muddling the problem, tapping into both the best and worst motivators of human performance. We work in systems that assign market values to procedures, consultations, and blocks of our time. This can make it hard to weigh those costs against the toll that medicine takes on our mental and physical health.

The bottom line is that defending a healthier work-life balance typically means a decision to sacrifice a bit of the bottom line. With that in mind, here is some advice I give to young doctors trying to find the right balance for themselves.

Know Your Price

Eighteen years ago, I was a resident on the front lines of the deadly SARS outbreak. After 3 months of unprecedented hell, I was approaching a sweet spot: an entire weekend off. I had a date with my pillow. I was determined to put the hospital and its stresses out of my mind. That Friday morning, I got a call. It was my program administrator. She wanted to know if I would cover Saturday call.

I almost laughed out loud.

I hadn't had a weekend off for almost a month. I was bone tired and exhausted beyond words. Patients wouldn't suffer if I said no; the programs often paid HMOs more than $100 an hour to cover whenever the cheap labor of residents was unavailable. I made it very clear: I was not available. She said quietly, "We can't find an HMO. So we'll pay you $2000."

I said I'd see her Saturday at 9 AM.

Some physicians insist that money should never factor into our decisions. They argue that if we are not driven to work tirelessly by altruism alone, we should be doing something else. They attempt to reduce conversations about workplace safety and human limitations into overly simplistic moral arguments.

But these reductive views have made our work culture damaging to practitioners, our organizations, and our patients. Most physicians still view medicine as a calling. However, understanding the ways in which compensation — not calling — can also influence our willingness to perpetuate this culture is an important step in reimagining a healthier, more sustainable profession.

As a resident, $2000 was a windfall to me. It was more than my biweekly paycheck at the time. Even more valuable than that payment was what I learned that day: I had a price. What's yours? What will you do for money, even in the face of total exhaustion? Where is your threshold to say yes or no? What other factors weigh into determining your price? I'm sure I know at least one big one…

The Undue Influence of Debt

I made choices — and had privilege — that kept my debt low. This would have been more difficult if I were launching my career today. Compared with 20 years ago, the cost of both tuition and a modest first home has risen by far more than inflation.

Today's young doctors are graduating with a median debt of $200,000. While some progressive medical schools have eliminated tuition, most have price tags that remain daunting to all but the independently wealthy. When you graduate with significant debt, you must reflect deeply on your future compensation. And you may understandably be motivated to make choices that help eliminate it more quickly.

Perhaps the best advice I've ever received was to continue to live like a medical resident for several years after I was done being one. This allowed me to pay down my debt somewhat more quickly. My lifestyle did not change much until my debt was taken care of; that's part of why I never worked more than I felt comfortable (and safe) with.

To be clear, many of today's graduates don't have the option of keeping debt loads low. Those with dependents probably struggle with the astronomical cost of childcare. Others also subsidize a partner's education. Many have the added financial burdens of caring for loved ones. Simply put, those are costs that can't be cut.

At the other end of the spectrum, as a former student affairs dean, I've seen students who borrowed money to drive better cars than mine. For the record, my husband and I still share a decidedly unglamorous minivan. I've seen new graduates obtain massive first mortgages to purchase fancy houses in "the right neighborhoods." I've counseled some who were addicted to online shopping as a means of "rewarding themselves" for the deprivations of residency. I get it. We all get it. Medical school and residency are long and brutal. When you can, you want to treat yourself. The problem is that you find yourself financing those "treats" long after they are over.

Many of our high expenses when we are in training are extremely difficult to control. Control the ones you can, as best you can, and your debt load won't force you to work more than you want to down the road. If you think you are spending now because you don't want to wait for someday, let me offer you a reframe there too.

Someday Never Comes

I recently visited a colleague who was diagnosed with a critical, life-altering illness. He isn't presently able to practice. He sent me an email a few months ago that included this line: "Have you ever really watched the sunrise? I missed it all because of work."

Many of us accept the brutal schedule of being a physician because we have an endgame in mind. Once we pay off our debt, buy a house, get a vacation property, celebrate key milestone anniversaries, get a nice car, and put our kids through school, life will be better. Then, we'll have arrived.

Guess what? If we're only ever living for the future, someday never comes. Borrowing excessively against the future means we are compromising that future. We are setting ourselves up to sell off more of our time in that future. We'll never be able to see that sunrise.

A wise mentor of mine often reminds me that for everything that I agree to do, I will be unable to do something else. What have you sold each day of your life for?

Many years ago, a moment in my own life brought this question into focus. My eldest son was 3. His middle brother was still an infant. We were at a splashpad in a city park at the peak of summer. I watched the baby squirm on the grass, while my other son chatted to himself and filled the same bucket for hours. What I remember most was how happy that ordinary day made me. I thought to myself, No one could ever pay me what this day is worth.

How much money did I "lose" over the course of that day spent with my children? It may well have been more than the $2000 that lured me to sell one of my days years before. How much did I "lose" over the course of my three maternity leaves? Hundreds of thousands of dollars. In the middle of all those years, I have the memory of that day and so many others like it. Of all the times medicine took me away from my children, mentally and physically, it did not do so when they were small and needed me the most. That is the difference between having a price and knowing that some things will always be priceless.

Be Okay With Making Less

I want to be very clear. The literature tells us, unequivocally, that organizational factors are the primary drivers of burnout. Not our financial motivations. Not our excessive spending when we are medical students. Not our personal flaws. Not a mother's desire to spend more time with her infant children. Not our lack of resilience.

Our systems have been built on the premise that we neither have nor are willing to set limits; it is a principle with disastrous consequences. Senior doctors have long railed against the desire of younger generations to set limits on work hours. Sometimes it isn't possible. The realities of work-life integration will look very different for a neurosurgeon or for a lone rural doctor on-call than they will for a community internist in a populous area. No one solution will fit every specialty. Burnout and its origins are a wicked problem with various forms.

However, if we can begin by acknowledging that our energies are not infinite, we can at least make our individual choices accordingly. This may allow us to have longer, more sustainable careers where we actually contribute more overall. We need to look at our careers in their entirety as a marathon and not a sprint, one where we pace ourselves for the various phases of our lives.

And we will also need to accept that, yes, less work means less compensation for doctors. Just as it does everywhere for everyone else.

Jillian Horton, MD, is associate professor of internal medicine at the University of Manitoba in Winnipeg, Canada. Her writing about medicine and related subjects appears regularly in the LA Times. She is the recipient of the prestigious 2020 Gold Humanism Award from the Arnold P. Gold Foundation and the Association of Faculties of Medicine Canada. Her first book, We Are All Perfectly Fine: A Memoir of Love, Medicine and Healing, is a national bestseller in Canada and is now available in the United States.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.