Monday, August 16, 2010

"If you are a physician, much has been given to you. What are you going to do with it?"

I am going to do something unusual today - reprint in its entirety, below, a commentary from a 4th year medical student, Jonathan. He posted it in response to comments from other readers to my blog about Dr. Berwick's commencement address to his daughter's med school class.

Just a few minutes ago, I tweeted about Jonathan's post, calling it a needed voice of idealism at a cynical time. This is what Jonathan had to say to his physician-colleagues:

"To begin, I am a fourth year medical student going into primary care and this directly applies to me ...

We have two options when reading this [Dr. Berwick's] address:

We can take, in my opinion, the weak road or the strong road. Our new generation, as well as the one that raised us, is one of apathy and selfishness. We are only concerned about how changes affect us. We have lost the sacrifice and the consideration of our patients and fellow staff. This address, no matter how hard your heart may be, springs up a humanism in you that is undeniable. You can choose to brush it off and make excuses about policies and money, or you can stand up and be the physician that is described. I agree that there are a lot of issues in medicine today (billing, paperwork, bureaucracy to name only a few). However, if those issues render you cold and uncaring, my friend, I strongly suggest you find another profession. This profession is one of nobility. It is one of selfLESSness. This is a high calling. A good book states, 'To whom much has been given; much will be expected.' Well, if you are a physician, much has been given to you. What are you going to do with it?"

Today's question: How would you answer Jonathan?


Harrison said...

Bob, I don't think any physician who writes in response to your blog posts is apathetic, or selfish, or uncaring or cold.
You are running a political risk by using this post to label opponents with such strong words. Maybe you did not intend that, but that is the way it reads.
I think physicians who see patients or who otherwise serve the public with their work unselfishly answer the question that Jonathan poses every day.
I am usually someone who agrees with what you write.
I don't think you are going to like many of the comments that you get in response to this post.


ryanjo said...

As I recall from being one, a 4th year medical student is idealistic to the extreme. Very necessary for the hard road that lies ahead.

But the discussion isn't about whether physicians need to be reminded to be unselfish. It's about physicians resisting a cruel government bureaucracy and its corporate partners. It is about fighting for patients, and the patient-doctor relationship, that is being manipulated and exploited for money. It is about resisting intrusion by government wags who can't get anything right, telling our most highly held profession (in the public's eye) about quality.

Some of us haven't lost our ideals at all, Jonathan. And if we have our way, there may actually be a medical profession for you to enter a few years from now.

BDoherty said...


I am not trying to label anyone, nor do I view those who post comments that disagree with me, or with ACP, or both, as opponents. I blog because I believe we all benefit from hearing a range of views including ones that don't comport with our own personal views, or the organizational views of ACP. In the case of Jonathan's post, I believe that he has something important to say, even though (like many young people) he may have generalized about the attitudes of his peers and the generations before him, in a way that I understand could be offensive to internists who toil every day to provide excellent and compassionate care to their patients, even as the "system" seems stacked against them. I find Jonathan's idealism to be refreshing, though, and the heart of his message as I read it is that physicians have an obligation to heed Dr. Berwick's call to put patients first despite the problems (which he acknowledges) about reimbursement, coding etc). Jonathan is one of those who is choosing the path of primary care, when so many of his peers have not, for all of the right reasons. He deserves our respect, as do those of you who practice medicine every day. And although I think he might have made his points in a less offensive way, I think he deserves a considered response from his colleagues in practice to his challenge to you. And I do believe that an unfortunate degree of cynicism has crept into medicine that makes some physicians view Dr. Berwick's call with a jaundiced eye, when I believe Dr. Berwick is challenging all of us to do the right thing by patients despite the "system" and the "rules" set by others.

Finally, writing a blog like this is a political risk, because I have made a commitment to readers to seek out and publish provocative commentary, even commentary that will rub some (maybe many) ACP members the wrong way and that I don't always agree with. But in my view, a blog that just tells the readers what they want to hear is not an interesting blog, although there certainly are blogs like that. All of us need to get out of our comfort zone, it seems to me, and hear and comment on alternative, but well considered perspectives, like Jonathan's. So let the dialogue continue, and if readers believe that Jonathan has it wrong, use this forum to explain why.

And, Harrison, as always I appreciate your willingness to use this forum to express your views, as I appreciate all of those who take the time to comment and challenge me.


Mt Doc said...

Clearly Jonathan has a point about physicians placing the patient first. It is however offensive to stereotype 2 generations as being apathetic and selfish and to imply that many physicians are uncaring. I am 60 years old and frequently hear the complaint that the younger generation lacks qualities evident in previous generations, but most young people whom I know personally are bright, enthusiastic, energetic and far more advanced intellectually than I or my cohorts were at a similar age. I have also not seen a lack of dedication or compassion in the recent medical school graduates that I have known. I would say that the younger physicians are placing more importance on acheiving a proper balance between work and personal/family life. I think this is a good thing, especially since the working environment for many physicians is so much more toxic than it was 30 years ago. Finally, I am a general internist but realize that I am psychologically not cut out to be a surgeon, obstetrician, or even an oncologist. Many people are not suited to be primary care docs, and it may not only be about lifestyle.

Arvind said...

There are several factual problems with this student's immature "advice" to those of us that have actually worked in the trenches. I wonder if you would have cared to publish a comment if it was denouncing Dr. Berwick's speech.

First, I think this young man has a long way to go before he earns the respect to comment on his senior colleagues.

Second, it fully exposes his lack of understanding of this profession (as expected).

Third, we all know how easy it is to make lofty speeches like Dr. Berwick did. Did any one of us actually ask to see if Dr. Berwick ever follow the same principles that he spoke of? And correct me if I am wrong, but doesn't Dr. Berwick make close to $ 9 Million at his most recent position. Which practicing Pediatrician can boast of such a salary? Perhaps its easy to preach when you don't have worry about meeting payroll or tax deadlines or loan obligations or trying to meet stringent government mandates while still trying to practice medicine. How would a medical student know all this?

Finally, I would call into question your definition of "idealism". What you ascribe to Jonathan is simply ignorance and arrogance, exactly what he is trying to label others with. In real life, idealism would that physician who manages to run a successful practice that benefits the community, while allowing the practice to grow and builds an organization that can carry on the founder's mission.

And, where did you get the idea that billing, paper work and bureaucracy were the main problems in medicine today? Does anybody still remember the old notion of physician-patient relationship? Or perhaps it is irrelevant in your eyes, Bob, as long as we all agree with Dr. Berwick.

This was one of your worst posts, Bob. I hope you don't make such a mistake again!

Jay Larson MD said...

There is no easy road in medicine. All students sacrifice to become physicians. 4 years of college, 4 years of medical school, and 3+ years of residency requires dedication and for most, giving up their 20’s to education.

There are 2 things that I encourage Jonathan to read as he continues on his endeavors to become a primary care physician. The first is a book available through the ACP called “The Quotable Osler” and the second is a commentary called "Medical Professionalism in a Commercialized Health Care Market" by Arnold Relman found in JAMA, December 12, 2007, volume 298, #22, page 2668.

“The Quotable Osler” will inspire Jonathan to be the professional physician we hope to become. The commentary by Arnold Relman will help Jonathan understand what went terribly wrong in medicine over the past century.

PCP said...

Ironically neither Jonathan nor the Blogger who pontificate about the need for idealism in medicine, have ever held the responsibility of a patient in their hands. Yet they feel eminently qualified to lecture those of us who have been fighting this tireless battle for the past decade and more.
As pointed out, Dr Berwick, like many others in the profession, have made their fortunes by moving on into the pontification/administration/policy/corporatization of medicine role..............shall we call it "consulting" for lack of a better word.
Basically anything but direct patent care and Doctoring.

The sheer arrogance of it all could be dismissed if it was not so permeating of the entire developing elite class within Medicine.
Jonathan has a far way to go before he is qualified to speak, and along the way he will learn. He will profess his idealism in a thousand ways now, but alas like the rest of us, this too will be crushed by the reality and the bureaucrasy that has come to metastasize within Medicine today.

I have come to one realization over the past few months.
Medicare must collapse under its own weight. Until that point we will not see meaningful change.
That collapse will take with it all the actors in the current system, the Men in Suits, the organisations that pretend to represent Doctors yet only protect their hegemony. The full line up of Corporate welfare seeking Corporation types and on and on.
Only with this eventual outcome, will we see the reemergence of the actors at the center of it all. Doctors and Patients.
That is my new idealism. You Bob perhaps call that cynicism.
I do not think I am as far off as you might think. The system is teetering on the brink and it is only the monopolistic hold that Medicare and the Oligopolictic Insurance Complex has developed through its strategic M&A activity for the past 2 decades that has prevented it from happening already. The outcome may be delayed but it will arrive.
Our lives may not be the same again, we may earn less, but it will be with our heads held high and it will be an honest living and it will be back to basics. Sanity will return to the practice of medicine.

Emily Lu said...

First of all, I strongly disagree with the contention that our current generation is selfish and apathetic. Where is Jonathan getting that idea? According to a 2008-2009 study, 86% of Generation Y want to work to make a positive impact on our society.

Alternatively, his contention might be that physicians or prospective physicians, for whatever reason, fall into the remaining 14%. But that's a pretty strange assumption to make, unless his contention is with the medical school selection process, which is a different animal entirely.

Instead, it may be that the effect of the desire to do good that motivates people (in this generation and previously) is hidden by the many barriers to humanism set up by the current system, which he acknowledges in his comment. But if that is the case, now is not the time to blame your own generation for not caring but to celebrate the fact that they DO care. To recognize that across generations, we physicians and prospective physicians have a lot of work to do. To extend an open hand to speak of real and tangible ways to make things better for all humanistically-minded physicians and their patients.

Just my two cents,
A first year medical student

Megabrain said...

The medical student, Jonathan, is obviously a product of his left wing nut medical school professors or been hanging around with the local socialist clubs. He has not tasted the real world of private medical practice. He will be someones little automaton, a good little Nazi youth. He will not suffer the difficulties of residency like previous physicians, his will be a watered down version resulting in him being a poorer quality physician. He does not understand the economics or politics of current healthcare concerns, he should read the entire Obamacare bill in it's entirety then realize it's real impact to his future income, patient-physician relationships, independence and growth in practice skills. Dr.Berwick's nine million per year income is NOT the common physician's income. I am terribly disappointed in the ACP's decision to run these biased interviews and for their cheesy support of the Obamacare law.