This article appeared in NEJM Catalyst prior to the launch of the NEJM Catalyst Innovations in Care Delivery journal. Learn more.

An attending in mid-career and a fourth-year medical student discuss the emerging options for medical students in the new heath care marketplace — many of which did not exist even 10 years ago. Paul Rosen, MD, and Niko Kurtzman cover health care disruption, entrepreneurship, physician burnout, and what has changed about how medical school graduates approach their career post–medical school.

Figure 1 .

Niko Kurtzman: When you were in medical school, did anyone talk about not doing a residency?

Paul Rosen: When I was a fourth-year student, 20 years ago, the options were clinical care, research, or teaching. Almost everyone went into clinical care. The MD-PhD students were trying to figure out their balance of clinical care and research for their future. No one I can recall ever considered not doing a residency. The idea didn’t exist. I would estimate more than 80% of us came straight from undergraduate school and then I believe went straight into residency after medical school.

What was your education prior to medical school?

Kurtzman: My path toward medical school was a non-traditional one. Having majored in economics and computer science, I was destined to go into business or a tech start-up. After a year in consulting, I decided the life was not for me. I quit my job and began a post-baccalaureate program. While attending classes, I began working for a diagnostics start-up doing biomarker research. Working within a start-up offshoot from a university energized me to continue my non-traditional path and come up with my own start-up to work on.

Rosen: How have you managed to juggle medicine and entrepreneurship? Are you considering not doing a residency?

Kurtzman: Fast forward one failed start-up attempt and one year of medical school later, I began start-up attempt number two: an education tool for medical students and residents. The road has been challenging and has involved a lot of missed classes, rescheduled meetings, and pauses in my medical school activities to coordinate with practicing physicians and sign them up. It has definitely slowed progress on business outreach and made me choose between studying for school exams/boards versus mov[ing] the company forward.

I pursued medicine to create a better world on an individual as well as global scale for my patients, and I see completing a residency as necessary for me to accomplish that.

I’m still not sure it is entirely possible to succeed in both at once. When I spend time on one activity, I always feel like I’m neglecting the other. Start-ups, like medical school, require complete dedication to succeed, and I know that if I gave my start-ups the complete dedication they require they would succeed.

Unfortunately, the timing is off. Medical school is a once-in-a-lifetime opportunity that requires me to choose school over the company when it comes to that decision. Many in my position have made the opposite choice and have left medicine halfway through or allow their medical school performance to creep down to achieve success in another realm, but I feel this is counterproductive to my long-term goals.

If you could do it all over again, would you become a doctor, and why?

Rosen: If I had to do it all over again, I think I would have followed the same path. However, I wish I had learned some of the lessons I know now more upstream in my education. It was not until my medical education was completed that I learned about medical management by way of my graduate degree. I think it would have been better if I had learned some of this information (technology, strategy, negotiation, legal) at some point during medical school, residency, or fellowship. While I received amazing clinical training, I don’t think I was prepared to deal with the realities of health care.

Right now, I am in a good place, as I get to enjoy practice, administration, teaching, and do some research. I enjoy the interactions with my patients, my colleagues, our hospital leadership, and of course, the medical students. Also, I do some things that I never envisioned, like blogging, and being part of a local innovation and entrepreneurship club. I am trying to keep up with the changes in health care and learning about design thinking, innovation, and patient safety and quality.

I know some students are reticent to talk to their clinical mentors about not pursuing a residency so they can work for a start-up or go into consulting. I think we should embrace all of these alternative pathways for our young doctors.

Are you able to talk to your attendings about the possibility of not doing a residency?

Kurtzman: Despite my desires to start a company to change health care delivery, I have never once considered not doing a residency. I pursued medicine to create a better world on an individual as well as global scale for my patients, and I see completing a residency as necessary for me to accomplish that. Many of my attendings during my clerkship years feel otherwise. Almost every time I tell an attending about my extracurricular activities, they ask me why I actually want to practice medicine and try to push me to leave. Many of my fellow students assume that I am not doing a residency.

If I had to do it all over again, I think I would have followed the same path. However, I wish I had learned some of the lessons I know now more upstream in my education.

Hiding the fact that you are not planning on doing a residency is not as important as it once was. Some attendings will not teach you as much if you are not doing a residency (though they often do this anyway if you’re not specializing in their field) because they will assume it is a waste of their time. However, many will applaud you for making the “smart decision” to get out while you still can. There is a sense among many physicians, especially those not at academic centers, that the heyday of medicine is over and if they had to do it over again now, none of them would have chosen to enter medicine. I believe this is the reason for the high burnout rates among practicing physicians.

Rosen: It is true: one of the most concerning issues in medicine is the high levels of physician burnout. We need to redesign health care so physicians have joy from helping patients again. That’s what it is supposed to be all about, and that’s why we go to medical school. I think medical students come on rotations and see the inefficient workflows, the outdated technology, and the long hours and start weighing their options.

Kurtzman: This is partially why I plan on specializing in emergency medicine. While I love the fact that in emergency medicine I am constantly exposed to every specialty each shift and will always be learning, I also appreciate the relative freedom emergency medicine will afford me to focus on other career goals such as starting my own company or helping other start-ups grow.

I see myself practicing part-time and working with entrepreneurs to test their technology within the hospital and improve it. The current technology that hospitals use is abysmal. The computers frequently freeze; the programs are not user-friendly and are designed more for billing purposes than they are for medical purposes. Technology exists to improve patient care, but hospitals are slow to adopt and are often decades behind the tech sector.

Did you worry about being able to pay back your loans based on your specialty choice?

Rosen: My family situation was such that I was worried about financing my medical education. I had to take out loans for school and I was focused on getting accepted to public medical schools. At the time, the tuition at SUNY medical schools was $9,000. I remember my friends going to private school were paying $25,000 per year. Many of us were struggling with financial concerns at the time, but we all just took out our loans and assumed it would work itself out down the road. I don’t think any of us really understood the financial impact of all those loans at the time. However, I did not entertain attendance at any private medical schools due to the cost involved.

Medicine is a calling, but what was once an intrinsically rewarding career has lost its appeal, and until it can be rediscovered, medical students will continue to search for what else is out there.

I thought at the time I wanted to be a general pediatrician. I met some of the pediatric residents and I knew they were struggling with the decision of getting into the workforce to start paying back their loans or doing a fellowship. A fellowship meant another 3 years of low pay, deferred 401(k), and perhaps even a lower salary in some cases. In the end, I picked my specialty based on the love of the field, without doing any formal assessment of the financial impact.

What are some of the financial and career choices you and your classmates are thinking about?

Kurtzman: While I’m the type of student that may have seemed like an anomaly 20 years ago, more and more of us are coming out of the woodwork. At Sidney Kimmel Medical College, a group of students began to meet my first year to teach ourselves about innovation, leadership, and entrepreneurship because we saw interest to increase our education about the non-clinical aspects of health care. Many of us have begun to understand that we need to plan for alternative career options in case medicine is not for us long term.

The administration has since begun to support this movement, including enabling students to do a rotation with the CEO of the health system, but there is little in the way of mentorship easily available to the medical students. Other students consider work in pharmaceuticals, management consulting, hospital administration, public health, or entrepreneurship. There are a myriad of opportunities that sometimes have better benefits than working as a physician.

We need to redesign health care so physicians have joy from helping patients again. That’s what it is supposed to be all about, and that’s why we go to medical school.

What once seemed like a lifelong profession is now seemingly becoming more of a pit stop for many physicians in training. Medicine is a calling, but what was once an intrinsically rewarding career has lost its appeal, and until it can be rediscovered, medical students will continue to search for what else is out there.

How did society view being a doctor when you were graduating medical school?

Rosen: When I was a medical student in the mid-1990s, being a doctor was an esteemed profession.

Kurtzman: The physicians I talk to are currently practicing in the face of new metrics, regulations, documentation requirements, and a more demanding patient base. My impression from medical school is that the attendings are in a stressful nightmare where very little time is spent on actual patient care. The senior attending did not grow up in this era as I have. Knowing the little I’ve seen thus far, I don’t believe I will be satisfied working for the next 40 years as a clinician. I believe I will likely become frustrated with the increasingly regulated health care ecosystem. This includes how we treat patients. We often forget that patients are at their most vulnerable moments when they are with us.

Rosen: It seems like when I was graduating medical school, it was much simpler. I had few career options. Tuition was worrisome, but much less expensive than now. Physician burnout was not recognized as it is today. You have 300 career options, which sound great, but definitely makes choosing more challenging. It seems that you are engulfed by a lot more uncertainty. Your generation of students seems to be straddling the health care, business, technology, entrepreneurial sectors all at once without a clear roadmap.

Kurtzman: That’s true — making choices has become incredibly challenging. It has been made even worse due to the increasing number of specialties and subspecialties as well as the narrowing scope of practice. Due to the lack of experience we have in actually living the day-to-day life of residents in different specialties, we are often unprepared to make a lifelong decision in September of our fourth year. This contributes to the 4% average annual attrition rate among residents, most transitioning to another specialty, but some leaving medicine altogether.

The choice of what to do becomes even harder when you have options that will pay you a reasonable salary out of medical school without a residency, when you’re considering the 3–10 years of training/small salary you have ahead of you. My generation has a different mindset from 20 years ago. Medical school has room to improve on how it prepares you for the career choices you have to make. As a fourth-year student, the future is exciting, but murky at the same time.