“Verily the lust for comfort murders the passion of the soul, and then walks grinning at the funeral.”
Khalil Gibran, On Houses
In medical school, we were required to take a survey to help us decide which specialty was right for us. When I was done, a web page flashed a column of specialties and corresponding percentages. I had an 80% chance of matching into “family medicine,” a phrase I had never seen before. I looked it up and discovered that as a family doctor I could serve just about anyone: a child, a mother, the grandparents. I was hooked. I finally had an answer to that ubiquitous medical student question: “What specialty are you going into?”
The responses I received were complimentary. “I’m so glad you are doing it; the country needs good family doctors.” I knew that was the case from experience. My mother, Miriam, was diagnosed with diabetes while I was in college and in the same visit rebuked and condemned to dialysis and blindness if she did not lose weight. No one explained to her what diabetes even was. She wasn’t alone. My family had the pox of low-quality, inaccessible primary care; an uncle who died in front of his children at 45 from heart disease and another whose high blood pressure led to a subarachnoid hemorrhage; he was in his 50’s. My classmates all agreed family medicine was important, but just as important, evidently, was their stated reasons for not doing it. The short conversations were punctuated by empathetic gestures at continued uncertainty or elated remarks at the final decision. But, no one challenged the other’s decision.
The laissez-faire attitude was in stark contrast to most everything else in medical school. We were taught to cultivate compassion and respect, which necessarily led to specific ways of addressing our patients, even particular phrases to use. We were to choose our words carefully to meet the needs of the patient. The same was true, of course, of our medical care. Our clinical decisions affected our patients profoundly, so they had to be both evidence-based and patient-centered.
Outside clinical care the reigns were cut lose. Each of us was encouraged to choose the specialty that was best for him or her; daily schedule, types of patients, number and types of procedures, all were considered. We should also practice in the part of the country we liked best. Non-profit, for-profit, or public sector, it didn’t seem to matter in the eyes of our instructors. Health care was expansive and varied enough to fulfill any of our dreams; all we had to do was pick a corner of it and make our mark, at a top 20 medical school, and be leaders. What the nation might need — what patients might need — was never mentioned.
This is all, perhaps, as it should be, this is a free country. But I wonder what we have lost in exchange for all this freedom. As a profession, we vied for power over the health care system and, to a degree, won. Every order, every dollar goes through us. In response to increasing costs and poor outcomes regulations over the lone physician of yore increase dramatically. Burnout rates soar.
Meanwhile most Americans have seen real wages decline for decades as the proportion they spend on health care grows. We point to pharmaceutical companies, hospitals, insurance companies, and medical device maker’s feasting, as politicians continue to slash already meager social spending. But, uncomfortably, we have been receiving the dividends, as well. Unemployment among doctors is less common than pregnancy among women using long-acting reversible contraception. Even after accounting for student loans and malpractice, we are paid more than physicians in any other high-income nation. A medical degree is an automatic pass into the top 3% of income earners. A medical degree in America is a golden ticket.
In a 1966 American Medical Association Report, “Meeting the Challenge of Family Practice,” there is a sentence tucked away among critiques of the medical education of the day, which has stayed with me:
“The satisfactions available to students in the modern curriculum derive more from solving scientific and intellectual problems than from learning to meet the health care needs of the people.”
It made me think of all the iterations of personal statements I read, both mine and my colleagues, filled to the brim with contrasting experiences and resultant commitments to improving health and equity. During my college years, there was an ever-growing group of Paul Farmer fans and followers. No one seemed to choose medicine because it was a comfortable lifestyle. In fact, the more masochistic of us chose it, in part, because it would be challenging. Nobody I knew chose it for all the wealth they planned to accumulate. And yet, this fall, when Politico published a controversial article titled “The Problem of Doctor’s Salaries” arguing that physicians are paid too much, most doctors I knew disagreed vehemently. There are many reasons to.
But, I worried. If the health care system is producing $1 trillion of waste, a quarter of all health care spending, then, to get to the best health system for all Americans, perhaps by reallocating that trillion to education and housing, may require everyone to take a pay cut. I have heard many providers bemoaning the health care system ask, rhetorically, if it will ever change when so many people are making money off of it. The “people” always seem to be someone else, all those other industries that do not care about patients. But historically, there are too many examples of physicians also standing in the way of progress. Might we get in the way again? A cut in physicians’ income will not, on its own, fix the health care system, but it may be a necessary part of the solution. We must be ready to choose our patients over our wallet. Others in the industry are also receiving dividends and are responsible. But only we wear the white coat, only we took the oath, “first do no harm.”
Jonathan Jimenez is a third-year resident with the Duke Family Medicine Residency Program. Email jonathan.jimenez@duke.edu with questions.
Editor’s note: Duke Family Medicine residents guest blog every month. Blogs represent the opinion of the author, not the Duke Family Medicine Residency Program, the Department of Community and Family Medicine or Duke University.