“I Like (Political) Science and I Want to Help People”

I thought I was an oddball in college. I’ve only recently learned that I was avant-garde.

Right before beginning college in 1975, I decided I wanted to be a doctor. Being the first-born son – with decent SATs – of an upwardly mobile Long Island Jewish family, I had relatively little choice in the matter. Notwithstanding this predestiny, I felt confident that medicine was a good fit for my interests and skills.

But on my med school interviews four years later, I stumbled when the time came to answer the ubiquitous, “Why do you want to be a doctor?” question. The correct (but hackneyed) response, of course, is “I like science and I want to help people.” You’ll be comforted to know that I had no problem with the helping people part. It was the science thing that threw me for a loop.

It wasn’t that I didn’t like science, mind you. I found biology interesting, and organic chem was kind of cool, in the same way that Scrabble is. But I barely tolerated Chem 101, and disliked physics.

In contrast, I was gaga over my political science and history courses. Watching the Watergate hearings in high school turned me into a politics junkie, and I found that my real talents were in thinking about systems, history, and how to understand and influence the behavior of people and their institutions. My social science professors were dynamic, the reading was fascinating, and I had a flair for the material.

Yet I remained certain that I wanted to be a doctor.

As a senior in high school, I found a “How to Get Into Medical School” book that simultaneously frightened and reassured me. The frightening part was the admission percentages and the required GPAs. I was a good, but not great, high school student and the numbers were wildly intimidating, particularly since, to me, college was a scary and foreign place. (I was the oldest kid in my family and my parents had completed a total of one semester of college.) However, I was reassured when I read something like, “Medical schools no longer automatically reject non-science majors.” A chart displayed acceptance percentages by major, and I recall that music and English majors were as likely to get in as biochem majors, perhaps slightly more so.

So the day before I left for Penn, I puffed out my chest and told my parents that I was going to be a doctor… and a political science major. And that was that.

I was lucky enough to get into medical school (also at Penn). When I began, my goal was to become a practicing physician, perhaps also a teacher. My interest in politics and policy would remain an avocation, like golf or gardening. But, as so often happens, the Gods of Serendipity thought otherwise. When I was a 3rd year student, I met John Eisenberg, who was then a young professor of medicine at Penn. John was astonishing: movie star-handsome, charming and funny, and scary smart. He was a terrific clinician and teacher. He had an MBA, which was exotic, and his research focused on the healthcare system. It was through meeting John – who would later become the founding director of the Agency for Healthcare Research and Quality (where he was promptly dubbed “John of AHRQ”) but tragically die of a brain tumor at age 55 – that I realized that I could combine my social science interests with a career in medicine. And that’s what I did.

There are several things that bring this to mind right now. I’m writing from Vancouver, the site of the annual ABIM Foundation Summer Forum, which brings together a remarkable number of healthcare’s movers and shakers. This year’s theme is the future of medical education, and much of the discussion has centered on how to build a workforce of physicians (and others) who understand quality, safety, financing, leadership – all topics I began to think about in college. More than one attendee has remarked that – in addition to transforming our medical schools and residencies – we should rethink our medical school prerequisites.

The second item that brings this to mind is the recent publication by three UCSF faculty (David Irby, Molly Cooke, and Bridget O’Brien) of a book entitledEducating Physicians, commissioned by the Carnegie Foundation on the occasion of the 100th anniversary of the Flexner Report. I’ll say more about this powerful document, which addresses how we should be training physicians in 2010, in a subsequent post, but one of its top recommendations is that we rethink pre-medical requirements.

A third reason is last week’s New York Times front page story describing Mt. Sinai’s Humanities and Medicine (HuMed) program, which accepts 35 students every year with liberal arts degrees – students who, unlike me, have not completed standard scientific premed requirements, including taking the MCATs. A recent study in Academic Medicine compared the medical school performance of 85 HuMed graduates with 606 traditional Sinai students, and found that the HuMed students match the traditional pre-meds on virtually every measure (honors grades, research distinction). While there are methodologic caveats, this finding raises real questions about the importance of a scientific background in preparing for medical school.

Finally, last Friday I had a chance to meet with nearly a dozen UCSF medicine residents who are enrolled in our Leadership Pathway. All our residents are now encouraged to select a pathway (which you might think of like a college minor), in areas ranging from global health to clinical/translational research. Leadership pathway residents participate in a core curriculum in leadership, change management, and quality and safety, and complete a mentored project. This year, they analyzed a variety of physician payment strategies and presented their findings to leaders of the Pacific Business Group on Health. Prior groups have analyzed and improved our anticoagulation practices and our methods of communicating with primary care physicians when their patients are hospitalized.

My interest in political science, a chance meeting with John Eisenberg, and a whole lot of happenstance led to my career in policy, quality, and safety. In contrast, for the residents in our Leadership Pathway, interest in quality and systems change is anything but accidental. They are completely intentional in their desire to improve the healthcare system. They are devouring a real curriculum that gives them a skill set that I didn’t pick up until 20 years after graduation. Finally, they have stellar mentors (led by Drs. Arpana Vidyarthi and Read Pierce) who help them on the journey toward productive and satisfying careers.

Here’s my hope and prediction: In the future, all our medical students and residents will be schooled in the core principles of systems improvement and leadership, and many will receive advanced training. Moreover, within 5 years, undergraduate pre-medical science requirements will be relaxed and modified, and new social science requirements will help ensure that students have the foundational knowledge essential to systems change.

Don’t get me wrong – we don’t need all physicians to be poets and pundits, any more than we need them all to be molecular biologists. Medicine needs its world class scientists, and the system must continue to attract such folks to medical school. Nor do I favor eliminating all undergraduate science requirements. I agree with Emanuel (Zeke, not his brother Rahm), who wrote:

Genetics, molecular biology, and biochemistry are much more essential to medicine than organic chemistry and physics…. Rather than debate what to reduce or eliminate, it might be more valuable to focus on what should be required as part of medical education: communication, bioethics, statistics, health care financing, health law, and management sciences.

Somewhere in an American college today is a student who wants to be a doctor but is passionate about policy, or management, or cognitive psychology, or ethics. My hope is that this student is encouraged to blend these interests, and that neither she – nor the members of medical school admissions committees – find anything odd about this combination.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

11 replies »

  1. “of an upwardly mobile Long Island Jewish family”
    A fascinating book that touches on this phenomenon as well as on many other related issues is The Jewish Century by a Russian-born, partially-Jewish scholar at UC-Berkeley named Yuri Slezkine. I highly recommend it to anyone.
    The book covers a range of topics including the experience of many, more or less recent Eastern European Jewish immigrants to the USA and the associated cultural, social and religious basis for the push into professions such as medicine, law, engineering, accounting, etc. whether in the USA or elsewhere.

  2. Perhaps what Dr. Watcher is discussing points to a pendulum effect of sorts. Prior to institutionally supported, “scientific” medicine; there existed the “saw bones” who often times doubled as a barber. Whether they really wanted to help someone or had other motivations, I don’t think is knowable. But if we consider medicine as both and art and a science, the “saw bones” were definitely the “artists” of the bunch.As the biological sciences discovered more about how the natural world can affect disease and people, we attempted to standardize our medical practices based upon that growing body of knowledge. Subsequently we began a process to license those individuals in their practice of medicine. It was at this time, the movement of medicine squarely into the tent of science, that medicine became less recognizable as an art.Medical doctors became less approachable than the barber who doubled as a “saw bones” I think. This trend has continued. There is a clear distinction drawn in the examination room between a patient and a doctor. Though not a bad thing by itself, how the distinction is drawn can determine a great deal about how a practitioner is perceived. The distinction shouldn’t be more than patient= “one who needs help” and doctor= “one who can provide help” (regardless of outcome, help doesn’t necessarily mean cure). When it becomes more than that the doctor can be perceived as “inaccessible” at best or “terrible” at worst. A doctor should never assume superiority because of position regarding a patient. They are already operating in a position of power, as perceived by the patient. An almost empathic sensitivity to this would go a long way in improving bedside manner.These distinctions, barring any malevolence or malpractice, are subjective to be sure. Perhaps that’s why there is a need for more “art” in medicine. Because “art”, as it were, deals solely in the realm of subjectivity. The realm where feeling and emotion are maneuvered best by those who understand their subtleties. You still need the science to provide a cure (if available), but the application and implementation of the cure doesn’t really require a scientist. Science has a more difficult time in that arena, I think. And so, the pendulum appears to be on the return from its swing away from medicine as “art”. At least that is what I believe Dr. Watcher is positing.

  3. Bob’s point about the irrelevance of a science major is well-taken and similar results exist outside medicine. The MBA is nearly irrelevant for success in business. In both cases, the material studied for the degree is too far removed from the knowledge base used on the job on a daily basis.
    David, it is hard to more completely miss the point than your response did. I suppose you could have answered, “Ham!”

  4. Bob- your bias blind spots are showing. You’re a die hard believer that big up front design by priveleged experts like yourself is infallible.But 70% of Americans believe the health care system you helped to create needs to be overhauled- in response you offer old wine in new casketts. Making doctors better will only aggravate their feudal mischief and they will grow further and further removed from the people that seek their assistance. Perhaps you should focus more on people and less on medicine

  5. As a history major in college when I was asked “Why do you want to be a medical student?” I too quickly answered, “I don’t want to be a medical student….I just need to be one before I can be a doctor.” Four out of five interviewers chuckled, and I got accepted. It probably didn’t hurt that i was just 6 hours short of a chemistry major as well.

  6. Dr. Wachter,
    I was intrigued by your enlightening tale of political science junkie gone med student. I find the idea of non-science majors becoming doctors to be incredibly interesting and much more common now than we have seen in the past. Working for a site devoted to healthcare education and career advice, it seems more people are becoming interested in the “reliable” healthcare field, but many enjoy other subjects and wish to study them in their post secondary education.

  7. Certainly organic chemistry and physics have little to do with medicine-
    But the one thing missing I see over and over is critical thinking -i am not sure it can be taught- but it seems to be a missing component in many medical school graduates- (especiialy ER docs!)