A lot has been said lately about the fact that many doctors are quitting medicine because it isn’t rewarding. With applications opening for entrance to the class of 2016 this week, it is a particularly important time to think about how our current system rewards seemingly selfish behaviors in the extremely long and harsh competition to rise through the ranks from premed to attending physician.
I am a patient, mentor, scientist, and health training innovator. Due to unique life circumstances I have trained and worked with hundreds of physicians in many different roles. They define “Rewards” in many ways. Clinical, research, financial and reputational success matter in varying degrees.
I agree with the Institute of Medicine’s July 29 report that says we aren’t using the $15 billion we spend each year on physician training to maximally benefit overall health. I am personally and professionally aware that our current system promotes physicians in training based on their capacity for selfishness, not selflessness. We therefore create health professionals neither experientially nor psychologically prepared to see the rewards in managing the 150 million Americans with chronic health concerns who need money, more than a $1 trillion a year in low-yield assistance more than brief, “interesting” interventions.
We therefore increase patient and family caregiver suffering, raise healthcare costs enormously and, almost certainly, add significantly to physician burn-out through poor selection and preparation.
Candidates for medical school admission are told a great “story” includes outstanding scores, grades, recommendations, extra-curriculars, and research. These demand lots of study time. Studying-while it can be done in groups-is usually done alone. Most pre-medical students say earning outstanding scores, grades, and recommendations rewards competitive behaviors, not teamwork skills.
Many pre-health advisors and most pre-medical students also say students are told admission to “dream” medical schools like Harvard, UCSF or Washington University requires lots of time doing laboratory research. This is supported by data from the American Association of Medical Colleges showing that “good” research is particularly attractive to these schools where students are prepared to be "academic" physicians even though most of their graduates will primarily work with patients.
Doing "good" research requires competition to get noticed by the "right" lab director. Once in lab, students often work with yeast, flies, mice or rats for at least fifteen hours a week during the year and fifty or sixty ours a week in summer. Students’ human co-workers in lab are socioeconomically similar to them; aka they are generally more educated, higher income, healthier, younger and less likely to be African American or Lattino than the typical patient will be. Lab work, therefore, doesn’t offer much interaction with patients whose life stresses and experience are very different than those of most medical students and young physicians.
Once in medical school, students keep competing. They need high grades in classes and clerkships along with high "board" scores to get into the "best" residencies. They learn and regurgitate 20,000 facts. They must put hundreds or thousands more hours into lab work in order to publish papers that are, again, necessary to get into competitive residencies and later, prestigious fellowships where strong pressure to publish still exists. Trainees may work outside the clinic, but there is relatively little time for this priceless, often voluntary, experience.
After fellowships often requiring trainees to spend 50% of their time in the lab, they become attending physicians. They have learned that behaviors leading to good grades, scores, research, and recommendations (often ignoring their interactions with co-workers or patients), will help them succeed in medicine.
At this point, Life suddenly changes. Self-focused behavior is still accepted, (after all, practicing physicians aren’t punished for refusing to take patients who can damage their outcome factors) but helping people very unlike themselves is now their full time job.
It therefore isn't surprising that our physicians are burning out when they must now focus on patients full time rather than on themselves. Too many aren't prepared to work with everyone in our healthcare environment. We now know this causes poor team and patient management leading to errors and suboptimal outcomes that cost hundreds of billions and kill many thousands annually.
How can this be changed? First, service is quantifiable just like scores and grades. The American Medical College Application Service which handles students’ applications currently classifieds service as "significant" or not. AMCAS members could demand a set number of direct patient care hours before applications are considered. Most physician assistant training programs require candidates to show 500 hours of direct patient contact before applying. MD applicants (who spend almost twice as much time in medical school), should have twice as many. Second, implementing the IOM report’s recommendations on putting training dollars into community medicine could be very beneficial. Medical school debt for community physicians can be fully waived or traded for service under any new rules. Further, Medicare—which funds most residencies-can choose to fund only residents with no more than 10% of their medical school time in research and require 90% time on direct patient care for Medicare funded residents and fellows .
Scores and grades will always reward selfishness, but these changes would quantify service time, reshape financial incentives for many specialties, add clinical service time and better prepare our future physicians who will mostly focus on patients, not research in their careers.