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Monthly Archives: August 2006

How do we describe doctors? Smart. Talented. Respectable. Rich. Well-educated. Maybe influential. Can a doctor be missing any of these traits and still be professionally successful (i.e. securing respect, steady advancement, economic gains, and achieving personal aims)? In particular, can a doctor ever have been poor and still achieve all his or her professional goals? Doctors fill many positions in a very broad field, each appealing to different career motivations and affording varying profiles of prestige. Everyone, no matter what they do in life, want at least three things out of a job:

1. Satisfaction

2. Appreciation

3. Making an appreciable difference or contributing something permanent

Doctors are lucky to always have the third: no matter what they do, they will be making visible differences in the lives of their patients, their students, and their colleagues. However, the first two may vary considerably in magnitude and nature between disciplines and professional roles.

Satisfaction is subjective. Some doctors find the greatest amount of happiness dedicating all of their time to clinical care, particularly that involving direct interaction with patients. Others prefer contributing new knowledge to the field through clinical, basic science, or “translational” research. Some enjoy teaching medical students and residents the science or the art of medicine. (There are many other interests that I don’t have the time to mention here, but I recommend exploring the “Pathways through Medicine” series of The Next Generation to learn more about various professional roles and settings.)

Appreciation, on the other hand, is less subjective and often succumbs to conventional forms due to its nature requiring the input of many: leadership roles, academic titles and credentials, prestigious ranks and positions, and also something as simple as salary. There is a surprisingly vast differential in the salary gap between doctors in various disciplines, and those who make more generally gain more respect from their peers as well as their patients and society as a whole. Furthermore, though doctors already gain respect just from being doctors, they can also gain much more respect if they are part of “academic medicine,” more freedom as researchers bringing in grant money to their institutions, and more power and influence as chairmen, chairs, editors-in-chief, federal officials, and more. Doctors who spend all their time doing clinical work often have to work long and hard, sometimes with little control over their schedules or salaries, while doctors who perform other academic or administrative functions may gain more flexibility and financial security.

Interestingly, although the vast majority of medical students are extremely talented, smart, and motivated, it would appear that only a relatively small portion would dare to aim for lofty pies-in-the-sky: being a doctor is ambitious enough. And truthfully, it is: it takes a lot of time, extremely hard work, and a lot of money just to become a doctor. Most doctors are like anyone else: they want to have satisfying careers, get married, have kids, live comfortably, and see their life’s work be meaningful in all of these areas. This should be enough for most people to deal with. But a lot of doctors aren’t “most people” – we want that larger professional appreciation, and we want to make a big, positive, lasting difference. What do we need to get it? More time and money? It would seem that those who enter into large amounts of debt need spend their time paying off their debt and supporting their young families (and possibly parents, relatives, etc.).

What bothers me is that medical training is so exorbitantly expensive. Why is this so? Won’t the rigorousness and difficulty of the medical training be enough to show whether we, as students, have the mettle, skills, and character to be good physicians? Do medical schools really need $45,000 or more from each of their students to generate and run a strong educational program?

Ultimately, I think this is not the case: my guess is that the high cost serves to weed out financially disadvantaged applicants. I don’t think that this is because medical schools or the professional hate poor people: instead, I think this is representative of a fundamental set of assumptions about the structure of American society. Incorrect assumptions, maybe, but then are these incorrect on an individual level or a broader level? A medical school admissions committee might wonder: has this applicant had a good enough education (because the best he/she could acquire is not necessarily good enough)? Has the applicant grown up in and been refined by an environment engendering positive, respected societal norms and ideals? Americans, outside the popular media and on a daily basis, associate wealth (in moderation) with sophistication and education (or at least the opportunity to acquire them). Medicine is, at its heart, still an “old boy’s club”: an elite club, a society with limited admission, and when the gates are opened, distinct lines to distinguish the truly blue-blooded from those who are let in because of the need for more doctors.

Being in the unique position of having traversed multiple socioeconomic strata during the first twenty-two years of my life, I feel acutely tuned the kinetics of social mobility, and I’m finding that it is at once remarkably easy in some cases and remarkably limited and difficult in others. I had the privilege of spending my junior high and high school years at a relatively good, private school, shoulder-to-shoulder with children of New Orleans high society and successful professionals. From this experience and from my later experiences at Harvard and in Boston, I gained much sophistication and refinement of skills. Perhaps more importantly, I gained the motivation and ambition to go higher and do more. But, is this possible? After all, I’m a first generation immigrant. My parents came to the U.S. with a hundred dollars in their pockets and were derailed from otherwise fast-tracks (based on their own talent and merit) to academic and financial success by immigration law, terminal sickness, and most recently, a perfect storm called Katrina. With my own strength of character and perhaps some smart-genes, I made it to the best college in the world. I feel like I’ve come a long way already, but now, I’m acutely aware of how unsteady one’s footing can be. What if my parents hadn’t moved to the U.S.? What if my parents hadn’t sent me to private school but instead sent me to one of the notoriously abysmal public schools in New Orleans? (It hasn’t escaped my notice that most of my classmates whom I’ve met in medical school in New Orleans come from private or parochial schools.) What if, instead of going to an expensive private college, I chose instead to be less of a strain on my family’s finances by going to a public university? Now, though it would be insulting to poor people for me to call myself poor, I am in no good condition to be placing myself $250,000 in debt (after four years in medical school, for which tuition is increasing $2000-3000 per year). I wondered for a long while why the “average” debt for private medical schools is approximately $130,000 to $150,000, until I realized that so many students have their educations partly subsidized by their parents. This obviously is no mark of shame, but it reminds me that, no matter how bad my situation may be, it can always be a lot worse.

I sometimes wonder why our society tolerates unnecessary hardship that many suffer, despite their good intentions. But is that hardship unnecessary? Does that hardship, that exorbitant cost, make the select few who step within the threshold and feel that burn stronger and better or does it simply kill the flame? Our society is propped up by the “American Dream” and the myth of the “self-made man” – is it just a myth? It seems to me that no man is truly self-made: he’s helped by those along the way, above, below, and at his level, who see his worth. I guess I’m lucky, then, to have received that help already, so it’s up to me to do what all in this position must do – stick with it and see this through. And, in some ways, this is analogous to the nature of sickness: we are most encouraged and inspired by the cases of those who stand at the edge of life and death and come back from it. But they never come back from the edge on their own. They need help. Enter the doctor.

The Oath of Hippocrates is referenced a lot in popular culture (i.e. medical TV shows, books, magazines, etc.), but most people don’t know what it states. Here is what it really says (at least, the version I will be taking):

I swear by Apollo, the physician, and Aesculapius, and Health and All-Heal, and by God and By whatever I hold most sacred, that according to my ability and judgement, I will keep this Oath and this stipulation—I will look upon those who shall have taught me this Art even as one of my parents. I will share my substance with them, and I will supply their necessities if they be in need. I will regard their offspring in the same footing as my own brethren and I will teach them this Art by precept, by lecture and by every mode of teaching not only to my own children but to the children of those who have taught me, and to disciples bound by covenant and oath, according to the Law of Medicine, but to none other.

The regimen I adopt shall be for the benefit of my patients to my ability and judgement and I will abstain from whatever is deleterious and mischievous. I will seek to inform my patients fully about their illness and prognosis, and will always remember that the final decision regarding their own life rests with the patient. I will regard my patients always as fellow human beings and will do everything possible to preserve their dignity. With purity and with holiness I will pass my life and practice my Art. Whatsoever things I see or hear concerning the life of men in my attendance, on the sick or even apart therefrom, which ought not to be noised abroad, I will keep silence thereon, counting such things to be sacred secrets. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respect by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot.

There are a few noticeable lines:

1. “I swear by… God and By whatever I hold most sacred… With purity and with holiness I will pass my life and practice my Art.”

2. “I will teach them this Art by precept… according to the Law of Medicine, but to none other.”

To me, this immediately sets up a contradiction, but the wording escapes the conflict with a very fine distinction. The Oath states that physicians must teach their students according to the Law of Medicine and none other, but physicians must practice according to their own individual codes of ethics as well (e.g. purity and holiness). Hopefully, the profession would train physicians to share a common code of ethics, but this isn’t always the case, especially in the case of abortion and teenage pregnancy. Allegedly, New York Medical College, a Catholic medical school, doesn’t teach its medical students about abortion (this notion needs to be verified, but two students from NYMC have made this allegation). Is this a breach of the Oath of Hippocrates (by using a religious “Law” to infringe on teaching that should only be guided by the “Law of Medicine” which undoubtedly seeks the best health outcome for the patient)? Those who support this measure might view abortion, in all situations, as an improper practice for physicians or any moral being, but should this moral judgement typically based on a religious belief be integrated into the physician’s code of ethics in the case of teaching or should it be overrided by the need to teach medicine that can save lives or prevent suffering (leaving the decision to engage in abortion practices to the individual physician)?

3. “I will keep silence thereon, counting such things to be sacred secrets.”

Ancient HIPAA! This seems to be a fundamental principle in the practice of medicine, but one that a lot of people forget: physicians, nurses, physician-assistants, and other care providers talk about their patients all the time (sometimes abstractly, sometimes more identifiably). In many cases, they want to share their daily life experiences with their spouses, families, and friends (afterall, doctors aren’t spies or secret agents). On the other hand, patients seem to want privacy, so physicians should be respectful and only talk about patients in discrete manner in ways that won’t substantially affect the lives of the patients (in other arenas).

4. “I swear by Apollo…”

Awesome.

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