Physicians

Why Become a Doctor?

Recently, I was having a discussion with a colleague about being a doctor. She confided in me that if someone asked her about becoming a doctor, she would tell him or her to become a nurse practitioner.   After reading the emotional open letter to our policymakers in Washington DC, it may sound like a reasonable suggestion.  After all, why go into this much debt and spend so much time in training if your prospects are not much better?    More recently, the New York Times article points out job prospects for radiology trainees are thinning, meaning the well known “ROAD” (Radiology, Ophthalmology, Anesthesiology, and Dermatology) to success may soon become a road to nowhere if there are no jobs.

There in lies the question, why become a doctor? If the answer is to make money or to have an easy life, then you probably need to look for a new profession.   With healthcare payment reform, doctors can expect lower salaries as bundled payment and cost cutting measures are instituted.  Moreover, the demand for healthcare will go up as more patients have insurance, leading to higher patient volumes and the expectation to see more patients with the same amount of time.

So, why become a “doctor”?  Simply put, the decision to become a doctor includes a sense of calling.   The decision to become a doctor means accepting your duty to at times sacrifice your holidays, weekends, nights and other personal time to help someone else.   This sentiment is best reflected by the motto of the coveted Alpha Omega Alpha medical student honors society, “worthy to serve the suffering.”   A recent New York Times Magazine article about giving reminds us, the joy in medicine needs to comes from the job itself, taking care of the most vulnerable people in our healthcare system, our patients. And as tough as being a doctor can be at times, it pales in comparison to the tough life of being a very sick or chronically ill patient.

Unfortunately, too many of us may forget this somewhere in training. Burnout is rampant among physicians, an epidemic that threatens the profession.   Faculty, who could be powerful role models, instead become too burned out to emphasize the positive of their profession.  Medical students who are thinking about going into primary care get burned out during their training, and decide to go into lifestyle oriented subspecialties.  Practicing physicians who are burned out decide to leave the profession altogether.  Not surprisingly, those with a stronger sense of calling are more resilient to burnout.

Given the long dwell time it takes to train a physician, creating systems that allow doctors to live up to their calling to serve while avoiding burnout is critical to ensuring a healthy workforce and safe care.   Unfortunately, the recent debates over new residency duty hour studies this week highlight our failures in this mission.   While resident work hour restrictions limit the number of hours worked, the lack of dramatic improvements does not come as a surprise to anyone in medical education.  Insiders know that the pace of work and intensity has gone up while many residents often care for similar numbers of patients, but in less time.   While some have proposed a controversial move to extend residency training, it is worth considering another solution before we tack on more debt to our graduates.  The solution sounds simple:  change the type of work residents do to align with meaningful doctoring.

A recent study led by one of my colleagues demonstrates virtually no difference in the types of resident activities have performed in 20 years!   A bevy of studies show that at least one third of resident time is spent doing something of “none or marginal educational value” that could be performed by someone else…and that someone else need not be a nurse practitioner or a hospitalist… it could be a clerical worker!   While technology could make things easier, adoption of electronic health records has added to the time charting, tying our physicians-in-training to the iPatient, and distancing them from their real patients who could remind them of their calling.  Just as there are serious discussions going on in the healthcare community about “working at the top of your license”, we need to critically examine what our residents are doing and when in training.  By redesigning the activities of residents to align with their “calling”, we can instill in today’s medical trainees the duty to doctor in the context of duty hours.

Vineet Arora, MD, MPP is an Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. She blogs regularly at FutureDocs.

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  21. Love this article! It’s so true, if you enhance an employee’s passion the quality of work will skyrocket! The thing I worry about in this day in age is that students are entering the medical field for the wrong reasons. So many watch these medical shows like House and want to be a doctor because of their false impressions of the medical field. Or, they could be driven by money. I hope we aren’t losing that passion across the board…

  22. The title “Doctor of Medicine” still carries weight in our society. With that respect, however, comes significant moral imperatives to maintain that respect.

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  24. Don’t.

    It no longer makes a difference.

    You will never be part of the community. You will have been commoditized. No longer are you a professional. You will be disillusioned, itinerant, unappreciated and underpaid. You are an idiot for spending that much time and money to start life so late and achieve so little.

  25. I think you’ve created a false dichotomy in this essay.
    Your physician friend says s/he recommends the NP path because studying medicine isn’t worth it, and you respond that the sense of mission/vocation makes it worth it. Does that mean that nurse practitioners do not have a vocation/mission/sense of responsibility for their patients?

    Whoever is caring for patients needs both the fund of knowledge and the professional ethic/vocation to be a great provider. We, collectively – with our NP, PA, and other colleagues – need to figure out a way to return the practice of caring for patients a fulfilling one, without eroding the quality of worklife with unsustainable volume or trivial tasks – and others have commented on how to do this.

  26. A good start is to have all those MD/MBA’s (hot trend = in the 80s and 90s) trade in their MBAs for MPHs

    Dr. Rick Lippin
    Southampton,Pa

  27. The article may be the culmination of arguments on why not to be come a physician. No wonder, we are so confused.

    Firstly, replace ‘healthcare’ with ‘hospital care’. Doctors don’t create health-public health professionals do that. Doctors cure diseases.

    Secondly, majority of economies dissociate value (e.g. health) creation from wealth (i.e. earnings) generation.

    So there isn’t a revenue model for ‘healthcare’-creation of health, a value!

    The Final question remains of Thoreau-If we don’t agree with the system, are we ready to build our Walden?

  28. Doctors have become window washers for the HIT vendors, insurance executives, and hospital CEOs. The intrusions and manipulation of medical care to enable the building of their fortunes and greed is despicable. The CPOE and CDS machines make life nasty for doctors and serve no meaningful beneficial purpose, except, perhaps, for a chimp.

  29. Very interesting comments from all. As a “seasoned” primary care internist, I suggest the following to deal with the issues noted above.

    Bolster primary care:
    1. eliminate “Pay for Documentation” so primary care docs can treat patients and not “treat the chart”. Benefit: improved efficiency, improved patient satisfaction, reduced medical error, reduced cost.
    2. pay PCPs 30% more than current. Benefit: more PCPs who spend more time with each patient.
    3. subsidize medical education costs for PCPs; for example, 10% reduction in med ed costs for each year spent in a primary care specialty.
    4. tort reform. Benefit: reduced cost through redduced defensive medicine.

    Being a clinical faculty member at U of Hawaii, I think medical education has changed tremendously in the past two decades. Here are a few of the changes that I see:
    1. Problem-based learning. Benefit: Structured problem solving is better than the rote memorization of the old school.
    2. Patient contact in the first year of med school. Benefit: emphasizes the fact that people should be the reason we go into medicine.
    3. Emphasis on self-learning techniques and use of electronic resources (med students care a whole library on their iPads and smart phones). Benefit: Life-long learners are more capable of using rapidly advancing medical science in daily practice.

    Patients often ask me how I am reacting to pressures in healthcare. I tell them:
    Every day the medical science gets better and better.
    Every day I can do something new and better for my patient.
    Every day someone makes me feel like a hero.
    Every day the business ethic of modern healthcare seems to eat away at my ability to maintain the professional ethic.
    But, for me, so far, better science, the ability to help, and personal reward overcome the negative commercialism in healthcare.

  30. Imagine that you tripled the cost of law school, designed an internship of many years, and the government set the prices that a lawyer could charge…you would laugh at anyone interested in practiing law. None of those things have occured, and you hear lawyers constantly complain about the value of their education.

    The cost of med school is obscene and forces $$ first thinking. A simple answer is to cut the cost of medical school – or – heavily subsidize tuition (not more loans). Rough numbers here, but 20k physicians graduating each year at 100k debt load is $2 Billion a year. I know that sounds like a lot, but the Feds pay $20 Billion in farm subsidies each year.

  31. I also differ, for the reasons that Mathieu pulls out, as well as one other: It’s still tremendously lucrative to be a physician. http://www.advisory.com/Daily-Briefing/2013/04/01/The-nine-highest-paid-jobs-in-America-are-in-health-care

    As Dr. Arora alludes to, the compensation isn’t what it once was — and new pressures will further tamp down income — but the average doctor’s income is still somewhere between the 98th and 99th percentile.

    Thankfully, most physicians enter the profession for nobler reasons. But the draw of dollars can’t be overlooked.

  32. I somewhat disagree.

    I think this is what we tell ourselves and this is what students say at interviews.

    However, I believe many students get into medical school because it is an accomplishment in itself. It’s about getting into the most competitive program, about the prestige of becoming a doctor, about the opportunity for a good career and so on.

    I would argue a lot of doctors develop a “sense of calling” during their training. We do long hours and are dedicated to our patients for many reasons. Some of it is because we like what we do, we care about being good at it, we care about our patients and so on. The “sense of calling” is part of this multifactorial puzzle.

    The fact that the hidden curriculum is able to transmit this culture however is a very positive thing.

    M

  33. The idea to shift the service-education balance in order to optimize residents learning is a great one. It faces a major problem however. From a system standpoint, residents are paid to provide service. Less service equals lower salary. Debt and finance are already one of the major stressor for residents. You need to optimize learning opportunity without cutting services. There is no easy solutions.

  34. Has medical education changed in any meaningful way since the turn of the last century? I wonder. Other than the number of women now in med schools (a welcome shift from the very XY days of Not So Long Ago), the education itself seems to have absorbed the tech and clinical advances without putting either in the hands of residents in meaningful ways – particularly if residents are still seen as great clerical options by those training them.

    I love your question. I worry that there’s still a noticeable percentage of med students who answer it with economic goals, not purpose-related ones. Is reducing the cost of a medical education an option? Perhaps by having interested docs-in-training provide primary care in underserved areas for 3-4 years?

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