Last week, I shared a guest post from an interventional radiologist who chose not to pursue a career in academic medicine.

Today we’re going to discuss life in academic medicine, aka The Ivory Tower.

The term “Ivory Tower” is not a compliment — it is meant to imply those inside the tower are insulated from reality, have an easier life, and/or believe their own pursuits are more pure or rewarding than those working elsewhere.

My Ivory Tower is a medical school, part of a private university.  I work for the university, and inside the emergency department of a children’s hospital.

In the first in a multi-part series (full length TBD) I am going to tear down some of the walls and discuss life inside The Ivory Tower.

Today, let’s talk about money.

Speaking of $, go vote for the Rogue Dad MD 2018 charitable contribution!

All entries in this series will be able to be found here.

It’s Not About The $

I recognize and understand that as a doctor I am paid well by most standards, certainly enough to provide a comfortable life for my family.  This is not a “cry for me” discussion or meant to engender pity or empathy.

Becoming a physician is supposed to be a noble pursuit.  It takes hard work and sacrifice.  Shoot, we even take an oath to dedicate ourselves to helping others (and of course, to doing no harm).

You aren’t supposed to become a doctor for the money.  Few things are a more piercing insult to a doctor than to accuse them of making medical decisions because it benefits them financially.

At least, that’s what some angry patients think, since that is a commonly used attack when not satisfied with their care (not that I ever see patients when they are upset.  Everyone in the ER is always happy to be there).

Making money is supposed to be a byproduct of being a doctor, not a feature.  This is what is taught to doctors in training, and it’s the aura that cloaks those working in the Ivory Tower.

Since doctors working inside the Tower are almost always paid less than those working elsewhere, it’s easier to “walk the walk” by not talking the money talk.

I’m paid less than I could make elsewhere.  I could make more at competing Towers, or even leave the Tower altogether and make even more.  Staying does not make me noble; to many others, it makes me quite dumb.

Despite this, or perhaps because of it, I spend time teaching trainees at my own Tower about personal finance.  Like a good Tower doctor, I even conducted a research study showing how little doctors in training know about personal finance.  I tell people about why I fired my own financial advisor, and try to teach them the basics.

Through this blog I direct people to classes where you can learn to do it on their own (I never make referrals during my lectures, to avoid a financial conflict of interest.  I actually do take my educational role in the Tower quite seriously).

Yes, some people do need to pay for advice.  I have a solitary financial advisor as a sponsor on this site, because I recognize that reality.  I just don’t want people to get duped if they do pay for advice.

In fact, when I give lectures on finance, I usually start them off by playing this song:

Because it’s not about the money.  Until it is.

In The Shadows

Doctor’s inside the Tower do think about money, and they most definitely talk about it with each other.  It’s just usually behind closed doors, and rarely with the doctors in training they are overseeing.

The more time you spend in The Tower after training, the more you realize that even if you aren’t talking about money, others most certainly are.

Hospital presidents, medical school deans, department chairs.  They are running organizations with large inflows and outflows of money.  They aren’t just helping those on the front-line provide care, they are managing budgets, the same as a Fortune 500 CEO or vice president in charge of operations at a widget maker.

In eons gone by, when healthcare was not a multi-trillion dollar industry and there was less competition to maintain and increase revenue, those on the frontline were perhaps more easily insulated from these discussions.

Now that healthcare is 18% of our national spending, there is no way to avoid it.  It doesn’t matter where in healthcare you work or who you work for, money is part of the discussion.

Even when it isn’t being discussed in front of you, it is most certainly being discussed.

Not-For-Profit

Going through medical school and residency, I didn’t really understand this term.  While I work for a not-for profit organization, it doesn’t mean what many people think it means.

“Not-for-profit” means the organization doesn’t give money back to owners (or shareholders) — it puts all profit back into the organization.

It does not mean the organization doesn’t care about their expenses, not does it mean they eschew making money.  Far from it.

This isn’t a secret.  Everyone has bills to pay, overhead to cover, and expenses to defray.  Hospitals face competition from other hospitals, from urgent cares, from clinics, from telemedicine organizations, and other places.

Everyone working on the front lines of the Tower is aware that Maesters at the top want to maximize revenue and minimize expenses.

When new buildings are erected or large and visible expenses show up, the doctors in the Tower certainly wonder why their salaries aren’t higher.  Sometimes they do so facetiously, and sometimes seriously.

Hospitals are run by individuals with MBAs.  Tim Cook, the successor to Steve Jobs at Apple, has expertise in supply chain management. So do many people in leadership at my healthcare system.

Lean, six-sigma, TQM — these are things that have been leveraged to produce Toyotas more efficiently, and now are used in healthcare for similar reasons: achieve the same or better quality but at a lower cost.

These discussions of revenues and expenses used to be something Tower doctors were insulated from, but RVUs are now part of the vernacular, and budgeting the name of the game.

This is reality for everyone now, not just those in private practice or for-profit groups.  Sometimes even doctors in the Tower want more of those expenses to be us.

Reality Bites

Unfortunately money is not given out willy-nilly because we Tower doctors pursue a more pure form of medicine that advances the human race.  Just as in any company, expenses have to be justified, time has to be earned, and increasingly productivity is being measured.

It may not be done as accurately as they do it at Google or Apple, but it is happening, and it is not a secret.

Does the creeping money discussion detract from the aura?

Well, those in charge of training medical students and residents at my Tower want the trainees to learn more about the business of medicine and the personal parts of finance.

I’ve been on a traveling road show. I started a curriculum at my Tower to teach finance to residents in medicine and pediatrics.  I’ve spoken to graduating medical students, general surgeons, and was just asked to speak to neurologists.  Next month I’ll be at colorectal surgery conference to discuss finance (first time for everything).

With median medical school debt approaching $200,000 (and some routinely having $300k-400k in debt), people are worrying about money before they even graduate medical school.

If doctors facing massive debt are going to stay at the Tower, the Tower has to adjust.  That means openly confronting the issue of lower salaries, and helping doctors deal with massive debt that would otherwise make them take the highest paying job possible.

Does facing this reality it make us less revered?  Do we seem less “special” to find out we do talk about money, and not just the latest research paper, grant submission, or visiting grand rounds speaker?

I don’t know what others think.  I can say that providing high-quality care, supporting research, and providing education are still at the forefront of the minds of most of us in the Tower.

Even me, the squeaky wheel that talks about money in lecture halls, spends far more time writing grants and papers than I do on Twitter (where apparently Rogue One, my 9 year old son, is a hit).

In the long-run, however, only by accepting and embracing the economic realities of healthcare and personal finance, can those in the Tower focus on the things they hold most dear.  Those in charge already accepted that reality, and it’s time the rest of us do as well.

But no, if you stop me in the hallway, I probably won’t tell you my salary.

For those in healthcare, what are your thoughts on how money motivates you?  For those not in healthcare, does any of this surprise you?