Wednesday, July 18, 2007

Just a job?

A couple of interesting posts in DB Rants and Panda Bear recently regarding the nature of what it means to be a doctor. Specifically in the DB piece, I was surprised by the vehement responses from medical students and residents defending lifestyle and monetary compensation as legitimate guides to specialty choice. Now mind you, most of these posts were well written and carefully thought out. Diminishing reimbursement, long hours, and lack of respect were all cited as sources of disillusionment and justification for younger physicians to pursue opportunities in fields more conducive to a) better earning power and b) more flexible hours and improved lifestyle. Applications to primary care and internal medicine have tailed off. General surgery became a much less competitive field over the past ten years as numbers of interested fourth year students decreased (attenuated somewhat by the recent implementation of work hour reform). The best and brightest of our medical students, the AOA bunch, are gravitating toward specialties like dermatology and radiology and I wonder if this is something to be concerned about. There is a sense of entitlement found in recent medical graduates that I find a little shocking. The thinking goes, "I busted my ass, got the top grades, made AOA, racked up $150,000 in debt, now it's time for a little retribution. Why should I slave away as a 'provider' for some mega-corporation HMO that seemingly randomly denies payment for this or that procedure/admission/test?" Compelling argument indeed. But an important detail is conveniently omitted; no one forces anyone to be a doctor. There's plenty of ways to make a bundle of money and have weekends off. Manage a fund. Become a broker. Run a 4.2 40 meter dash. I don't think medicine is supposed to necessarily be a default pathway for "really smart" kids who happen get high scores on MCAT's. We live in a meritocratic society, I understand that. But I think you compromise a core principle of medicine when practitioners see the job more as a reward for high achievement, rather than a privilege to be treated with humility and respect. A classic quote that killed me: "Ultimately, medicine is a job." If medicine is simply a job, a way to kill some time between the hours of 8 and 5, then I think we're all in trouble.

The whole concept of "just a job" fascinates me. It used to be, man's identity was intimately tied up in his caste or profession. Warrior classes, the clergy, the nobility, merchants, even the peasant classes. As a surgeon who trained just before the era of work hour reform, I'm a little biased, but truly, how can I honestly separate what I do every day, all day, the rest of my life, from who I am? I am a surgeon. It's a big part of who I am. I spent almost twenty years in school training for this. I spend the bulk of my waking hours thinking and doing surgery, taking care of patients. Not that I'm a one dimensional automaton. I have a wife. I read voraciously. I watch too much sports. I work out. I mean, I live a pretty regular life. But if one's self identity isn't dependent to some extent on what one does for a living, I don't know what else is left. Are you "that guy who's married and has two kids"? Or the woman who "likes to paint reprints of Cezanne on the weekends"? I think a cursory review of human history demonstrates that only recently have we considered those who "define themselves by the work they do" as somehow pathologic and subhuman. "It's just a job" denigrates all those conscious hours one expends during the day as mere frippery, an unessential, meaningless experience. One reason for this may be the way the workforce has changed. Factory jobs are gone. Agriculture long ago ceased to be a viable occupation for the average person. Most people are employed in the service industry, or involved in sales/marketing of mass-produced merchandise that they really could care less about. Is it any surprise that someone who sits in a halogen soaked cubicle all day hawking widgets would rather define his or herself by something other than "paeon of giant corporate conglomeration"? As a surgeon, as any physician, that isn't an issue. I'm lucky enough to be involved in an occupation that allows me to help people directly, every single day. It isn't "just a job". To consider it as such would be disrespectful to all the patients who come to me seeking to be made well again.


Bongi said...

spoken like a true surgeon. i agree.

yet i don't think one can view our job as just a job. it simply is not. to get there takes too much and somehow changes you. sounds very melodramatic, but unfortunately it simply is true. if i had an office job i think i would also view it as just a job though.

when i see the super achiever school students of today applying to medicine, just because their marks are good, i sometimes shudder. some of them should become cutthroat lawyers and mass murderers and the like. yet they go into medicine because of school marks? doesn't make sense.

Sid Schwab said...

Many guys I trained with are in academic surgery, and for a few years now they've been decrying the change in the commitment they see. On the one hand, I look back and wish I'd been at least a little less insane in my prioritizing of work over everything else. On the other hand, I'd rather have me operate on me than some young guys I know. My hope -- our hope -- is that there will always be some who see it as a calling no matter what. There will, I think. But probably not enough of them.

Anonymous said...

As a pre-med who has agonized over the decision to attend med school, I happen to agree with your post 100%. In fact, although I feel I was born to practice medicine (surgery in particular), I feel I have spent most of my adult (read:post 18) life running from it, because of te lifestyle, the time commitments, and the divorce rate among physicians, UNTIL I realized that it was a part of me I couldn't deny. It is who I am. Sure, I could be a successful realtor, or mortgage broker, or even a nurse (which incidentally I considered for a long while), but the practice of medicine is inside of me, and is as much a part of me as any other tangible part. I knew it the first time I observed a surgery, I tried to ignore it until it became so impossible that I sat my husband down, and told him that if he loves me, he has to love all of me.

I certainly hope that when I take my own son to the pediatrician, that he has that same love, that same dedication, and that same level of intimacy with his profession, so that he's focused on my child's rising temperature instead of on the fact that he's missing the game on TV that night.

Anonymous said...

Spoken like a true surgeon. It's no surprise that you happen to be a glutton for punishment and a martyr. It's any wonder most MS-3s hate surgeons.A person who defines himself by his job has a psychopathology going on and it isn't healthy.

Your type of attitude is the exact reason why third party payers, hospitals, and the govt. think it's perfectly acceptable to decrease or deny reimbursement bc doctors are willing to be martyrs for "the good of patients" at the expense of everything else. Top students, get top grades, and get top specialties. Corporatism infiltrating medicine is what is destroying it, not high achieving students who aren't stupid enough to fall for the chorus refrain.