18 June 2011
Practice Medicine, Not Martyrdom
There is no one in the practice of medicine today who has not walked the corridors of their hospital, ankles swollen from thirty consecutive hours of standing, and wished they had chosen a different profession. When this happens there is usually someone older, wiser, and with far more experience lurking close by, ready to tell you that they had it worse. In fact, I have found this a much more reliable constant during my years of training and now practice in Pediatrics than the basic tenet that kids in daycare always seem to be sick and parents are harder to care for than the patients themselves.
This is why, disappointing though I found Karen S. Sibert’s recent Op-Ed bemoaning the gap between the healthcare needs of this country and the physician work force’s ability (or willingness) to provide them, its message was not surprising. Dr. Sibert, physician and mother of four works full time, which is by implication the right thing to do, and so everyone else should strive to as well.
As much as I find fault with her conclusions, there is much in the piece she has written that is unassailably true. The medical school and residency training slots in the U.S. are limited, yes. An increasing percent of the physician work force are female – hurray. Women doctors are more likely than their male counterparts to work only part-time, perhaps. The conclusion, however, that the lost physician work hours that result from part-time positions is bankrupting the system and denying the poor people of Noxubee County, Mississippi (and other heavily underserved areas) the access to medical care they need and deserve is shaky at best.
The most glaring omission to her reasoning is the assumption that if all female physicians did work full time, as she does, these very real issues of access to care would be righted. But even if I, a female physician and also a mother, were to pick up an extra shift in the ER each week, it would not be in Noxubee. I did just buy a hybrid, but even so the commute is too long. Instead, I live and work (as Dr. Sibert does) in a metropolitan area where it is impossible to run out for a Starbucks without tripping over a nephrologist or interventional radiologist, so high is the physician to patient ratio in these cities. Luckily, there is sure to be an orthopedist nearby, to make sure nothing is broken after your fall.
Scott Shipman and colleagues wrote about just this problem of geographic disparities in the availability of healthcare providers for children in the January issue of Pediatrics and though the data is compelling, there are no easy solutions. As much as I, like Dr. Sibert, would like to see patients have greater ease in accessing care, I have a husband, a generously sized mortgage, and a hyperactive Labrador, the result of which is that I won’t be moving to Mississippi anytime soon.
So I am not as good a person as I, or Dr. Sibert, would like me to be. Despite working full time and trying my very best to give good patient care, there are deficits in our nation’s health care that I am not willing (or able) to fully address. The question now is, do I care? Do I owe more, by virtue of my partially taxpayer funded medical education and training, that I am not repaying in full? More than the myriad of academics who spend more time in the lab than they do seeing patients? More than the nearly two-hundred-thousand dollars in student loans (plus interest) I will undoubtedly have to delay retirement in order to pay back? More than the engineers and other scientists who also rely on the government to subsidize their higher education and who often graduate with PhDs and no student loans at all? More than the lost years of income incurred during my seven years of medical school and residency that Dr. Benjamin Brown suggests in his book, The Deceptive Income of Physicians, is impossible to regain?
Do I owe, in addition to these very real financial debts, a promise that I will never, not ever, curtail my work schedule to care for a sick parent, teach my daughter to read, write a book, take an art class, travel to another country to provide medical care in a place with even fewer physicians than Noxubee County, Mississippi?
I think not. But I do know, without a doubt, that if this is the manner of promise physicians are expected to make, neither I nor Dr. Sibert will be happy with the sort of physicians we get when we find ourselves not in the role of doctor but patient, as we all eventually must. In fact, we may find ourselves without physicians at all.
After all, medicine is not necessarily a calling. It is also a job. I happen to think it is a wonderful job, a complex and rewarding field, but it is not a job that any one person can do on their own, whether or not they are working full time. It requires, as Atul Gawande suggested at this year’s Harvard Medical School commencement, communication and teamwork. And although he did not point this out explicitly, I would venture to say that the best thing about teamwork, about having supportive colleagues who are not only kind to their patients but also to each other, is that they get each other out the doors of the hospital at day’s end and back to our families. Without teammates like these, I fear medicine will be a job the next generation decides to forego, increasing the shortages of physicians Dr. Sibert so rightly highlights.