Junior Doctors

The financial and emotional costs of becoming a surgeon

I have been thinking a lot about the blood, sweat, and tears I put into my surgical career cut short. There is a huge burden on junior doctors who wish to pursue a career in surgery, and we accept the costs because we have to in order to progress. As well as the emotional costs of looking after patients who may be extremely unwell or injured, there are huge financial costs to the training surgeon.

To begin with, I want to compare the medical and corporate worlds. When I speak to my friends in the corporate world, they are absolutely disgusted when they hear about how doctors are treated. Let’s call my corporate friend “Anna”, who is the same age as me and has the equivalent level of education and training.

When Anna works until late at night, her office provides food and gives her a cab voucher or reimburses her for the Uber ride home. When I stay until work late, I either miss out on dinner, or if any food outlets are still open, I pay for some takeaway. Then, I either drive myself home, or if I’m too tired to drive I sleep at the hospital. Not all hospitals provide on call rooms, so I sleep in a chair or spare hospital bed.

Anna gets an allowance from work to cover her rent. She also gets a “lifestyle allowance”, which she uses towards a gym membership. I’ve received neither benefit.

Here is where I see the biggest difference: courses and conferences. Anna gets paid to attend courses and conferences that will increase her knowledge, thus making her a more valuable and experienced member of her company. Flights and accommodation are also covered if the course or conference is interstate or international. Doctors have to pay for compulsory courses and the associated costs of attending them.

For surgical training, here are the compulsory courses, examinations and application fees I have had to pay in order to progress:

  • Critical Literature Evaluation and Research (CLEAR)
  • Care of the Critically Ill Surgical Patient (CCrISP)
  • Australia & New Zealand Surgical Skills Education and Training (ASSET)
  • Emergency Management of Severe Trauma (EMST plus its refresher)
  • Annual “expression of interest” fee to the Royal Australasian College of Surgeons (RACS) to indicate my intention to apply for the training program
  • The actual application fee to RACS
  • The surgical sciences examination (which has become a pre-requisite to apply for the training program)

In addition, there are ‘optional’ courses and conferences that are highly recommended to strengthen your CV and therefore make you a stronger candidate (that they may as well be compulsory). For example, it is desirable for any candidate applying for the Plastic and Reconstructive Surgery program to have taken the ‘Emergency Management of Severe Burns’ course.

We also have equipment that we are expected to own in order to learn surgery. All Plastic Surgery registrars own a pair of loupes, which are magnifying glasses (2.5-3.5x magnification) that allow us to see small or thin structures such as blood vessels and nerves during hand surgery. Most of us also invest in a pair of surgical clogs, which make a difference when you are standing for long surgeries.

These costs add up to about $30,000. This is a huge monetary investment, especially for those registrars who may still be paying off any student loans, or may have young families to support. It might be worth it if doing all of these compulsory and suggested courses actually grants you a spot on the training program, but some registrars spend several years as a “service” or unaccredited registrar without any guarantee that they will ever “get onto the program”. Some never do.

Add to this the invisible costs of the stress, long hours, and abuse that many registrars experience and you can see why many become jaded or disenchanted by “the system”. When surgical registrars finally give up, as some do, they come to the realisation that RACS and their specialty society (such as the Australian Society of Plastic Surgeons) has not only taken their dream from them, but also their money, energy, passion, and time away from loved ones, hobbies, and other important life activities. What are we left with?

So, is it worth it? Many of us keep going because we think that it is. We think that eventually we will be accepted onto the training program, which will give us the external validation we have waited years for, and once we finish that program we will be independent, qualified consultant surgeons. By that time, most of us will be in our late thirties or early forties. Perhaps even older depending on when the surgical journey started.

I started medical school aged seventeen. I know that I spent most of my twenties studying and working. Do I want to turn forty and have the same sentiment towards my thirties? That is the question I have asked myself many a time.

My abrupt career road block has forced myself to ask these existential questions. Was what happened to me a blessing in disguise? It is certainly confronting to start a new career from scratch, but maybe the Universe has something more suitable for me, which will give me a greater sense of purpose than surgery has.

I will be following up this post on starting something else from scratch: my fitness.

Until then, take care.

Miko xx

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  1. Anonymous complainer says:

    I wholeheartedly agree. After 6-7 years of unaccredited training I eventually got into a surgical training program. During this time of trying, I got dumped three times, got cheated on twice, and spent a whopping sum of $60k-75k as investment into surgical training, course, more and more exams, obligatory conference fees totalling up to 25k including travels in order to present my research only so that I can add more point to my CV, obligatory publication fees and so on.. I have spent a lot of money into repairing my car at times when I accidentally bump it on the parking pole from fatigue post-night shifts or microsleep on the road, that alone costed me 11K across these years. Do I have a mortgage? No, I can’t afford to. Nor do I have any investment property.

    In fact, disgustingly, I am not even allowed to buy food in my own hospital unless I have the time to “change into normal clothes”. I am getting UTIs constantly because I don’t even have time to pee sometimes. As if I will have any time to change and go wait in a fking line with all other patients chatting away. Really disgusting.

    What is the worst thing? It’s not like nurses make it easy for us either. When we are running to attend sick patients having a critical review, nurses stop us in hospital to yell at how we did not “change into outside theatre appropriate attire”. Sometimes I am tempted to tell them that I wish it’s their loved ones who will suffer the consequences of my time they are wasting.

    Overall I agree, it is a sick system. But recently I have come to realise one thing: doctors don’t actually have the time to properly complain about anything. We don’t even have time to eat or see loved ones why would we waste any energy or time into trying to change our workplace into a better environment? Subsequently all other professionals in hospital who have time to discuss admin things will make us follow their rule. Not that anyone’s actually thinking about doctors themselves.

    Excuse my extreme viewpoint.. but that’s what I feel everyday, when patients get cancelled for theatre, and they make ME apologize and be yelled at. Not like the team leader who’s not allowing us to operate to save their overtime cost of scrub nurses will want to tell my patient why we are cancelling them. And these patients don’t understand – to them, doctors are the most powerful and nurses or scrub or admins are supposed to listen to whatever we want to do to our patients. Argh! I do love surgery but I hate everything in hospital admin and system. Even in the US doctors get a better treatment.

    1. Miko says:

      I hear everything that you’re saying! You’re right, those who make decisions or write clinical protocols are often not even on the frontline of clinical care so how would they know how to make the rules? It is very frustrating for both parties.. I’m sure that they would invite input from clinicians, but clinicians are too busy doing clinical work to dedicate to administrative duties and writing protocols etc. etc… It’s only now that I have resigned from the public health system that I can actually reflect and see what was happening. At the time, I was just constantly under pressure to do the next thing that there was no time to stop and think about anything!

  2. Francesca says:

    I have noticed that many of the aspiring surgeons who take a year off often never actually get back into surgical training. I cannot speak too much because I went the straight through the system (physician), but perhaps it’s a chance to properly respect and identify how much of your soul you are willing to cut up. There are so many life journeys open to us. I think it’s right to expect that in any path you do take that you are valued and made to feel supported. The consequences of being so vulnerable and not belonging to yourself or others just seems too cruel.

    1. Miko says:

      You’re right, it’s very rare for anyone who takes a year off to go back to what they were doing (especially if that was surgery). I think it’s because during that time off you realise that life is actually pretty amazing, the world is a beautiful place with so many places to explore. You see what you were missing out on, and you don’t want to go back… that’s how I feel at the moment! It’s nice to finally have time to be with the people I love and do creative things.

  3. Angie says:

    Does your friend work at a law firm? Or a top tier accounting practice? Those kinds of benefits are standard in those industries because they are based on professional services revenue streams which are usually highly profitable and low cost. Essentially that means that the people costs are the highest direct cost the organisation has. Also, there is lot of competition in the market for skilled professionals because they can really work anywhere locally (and many places overseas as well) once they reach a certain level. I’m not sure if that is true for doctors/surgeons/nurses as government seems to be to major employer and moving internationally may require re-qualification before you are able to work. These are significant barriers that leave medical professionals at the mercy of their employers in the way that other types of professionals are not.

    That doesn’t make it right that surgeons/doctors/nurses are treated so badly, but it is a partial explanation. As the government is tasked with providing the majority of medical services, which are very high cost, it would need to make a policy decision that supporting the health and wellbeing of the professionals who perform those services is a financially worthwhile endeavour. This is most likely to happen when there is a severe shortage of medical professionals available in the market. Until then, there probably won’t be enough pressure to cause a change. Add that to the lack of employment options in the market and it is even more difficult. Industrial actions, such as strikes, would probably be an effective tool in this situation to improve conditions, as well as educating the public about what it’s really like for medical professionals. Either way, it will take a social and political movement to shift the status quo. In the meantime, keep looking after yourself and taking about your experiences. That has power in itself.

    1. Miko says:

      Hi Angie,
      Thank you so much for your thoughtful comment and great points. Yes my friend happens to be a lawyer, but I’ve seen those perks in people who work in other industries as well (finance, IT, etc). I think that we are lucky to have a system like Medicare in Australia where the public can receive free health care… but as a mentor once told me, people don’t value your services if you provide them for free. I think (some) patients take free health care for granted, and become more like consumers or clients rather than patients. You’re absolutely right in that there are more doctors than there are training positions, which means doctors are willing to put up with more to attain these lucrative spots. This will only get worse as we see the student tsunami come through the workforce. In the meantime, there is still a lack of doctors in rural and remote areas.

  4. Ping says:

    Well written. To much money is required for all these courses to pad up the CV.
    And too much weight is given to referee reports for selection – it then end , those selected to enter the training program ends up scoring nearly 100%.
    There should be an easier, simple, less costly way to select surgical trainees without making every potential trainee go through all these stress – it may mean resorting to some sort of surgical/anatomical GAMSAT. And reduce percentage of CV and referee report scores. Interviews too need to be fairer and not give advantage to those being interviewed later on.

    And I hope whoever did and condoned your unfair roster in your last job is shamed and punished ! That is outright bullying if you are forced to do way more oncalls than the accredited plastic surgical registrar.

    1. Miko says:

      Hi Ping, thanks so much for your comment. It really is a flawed system, and I will write another blog post on the problems with the referee system as well. I really don’t know how my roster was approved for such a long time. I believe that the hospital is being investigated, because I’m not sure that some of their practices (including the roster) were meeting the standards of accreditation.

  5. It’s like that around the world. It’s like the people who have the most impact, like teachers and doctors, aren’t cared for in the little ways that have a huge impact.

    1. Miko says:

      Thanks for your comment Sarah. Yes, so true. We need got look after the people who are looking after others!

  6. Anonymous says:

    The surgical training system is corrupt. Unaccredited registrars are made the point of blame unreasonably so. They are afraid of complaining due to lack of consultant support for training opportunities. They are the most vulnerable cohort of doctors in the medical system which make them an easy target for abuse.

    1. Miko says:

      I totally agree with you. I really do believe that unaccredited registrars are the most voiceless and vulnerable. I hope that it changes to a more humane system for them.

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