Medicine: Trade or Calling

At its heart, medicine is a moral enterprise and I want to believe that the majority of medical students still enter medicine to make a difference. But, my faith in that belief is eroding over time. I know that, along the way, many students and residents grapple with fundamental beliefs about what it means to be a doctor and how we will live up to our own high expectations.  Some others, under the guise of “work –life balance”, grapple with more self serving beliefs such as maximizing income, access to the mountains during an elective, or what do I say to ensure a positive review even if its not true.

How did I come to this state?  A historical perspective dating back over decades may shed some light. There was a time when doctors considered their needs, as well as what was needed by the community when they chose to set up practice.  Clinics, indeed communities, would not support physicians starting a practice that did not meet their societal needs.  We were secure in the certainly of a reasonable income, and chose to consider the community’s needs. This supported and promoted the generalist model of care with less need for sub-specialization within the individual practitioner. It meant that doctors had to consider the needs of their community, and balance that perspective with their own needs.  It meant that work and life were integrated and not mutually exclusive.

Having come from a very defined patient centered care model, which by all accounts could be exhausting for us… 24/7 call for obstetrics, shift work in the E.R., in-patient care, medical examining and office work…. a shift in the position of the pendulum began.  The proliferation of specialists eroded the generalist model of care.  Not only did I observe the unilateral removal of privileges from family doctors by specialist groups, the generalist orthopedic surgeon who would come in to take over care of the hand trauma or the facial trauma, had their skill sets changed as increasingly sub-specialized physicians were perceived to provide improved care. Unfortunately, the Starfield data, that demonstrates that the number of specialists involved in care is not linked with improved outcomes, was not available.  In fact, the converse seems supported.

In Alberta, we then experienced in regionalization which continued the push away from the patients’ perspective and desire for relational continuity. Regionalization, an interesting misnomer for centralization and rationalization, placed the relationship between the care giver and patient as a lower priority to budget management. The large data suggested centralizing services was more fiscally responsible, and the move away from the patient perspective continued. Relational continuity started to dissolve.

So, as the system grew and became more focused on dollars and cents, what was the response of the doctors, medical students and residents? Naturally, they felt a loss of control and therefore began to consider their own health in this transition. The idea of “Work: Life Balance” was born… and the pendulum shifted still further.

So how far has the pendulum shifted?

We now have doctors that practice one day a week in one location, a few days at another clinic, then two shifts as a hospitalist followed by a number of days off for “life balance”.  The continuity of relationship with the patient has disappeared…except for the ten minutes in the room. Whereas there was formerly such a focus on the patient relationship as to potentially erode the well-being of the physician, now it seems there is relational continuity only at the times the physician wishes it to be present. 

Are we now a trade?  Do we contract for specific services in specific hours and negotiate for benefits?  Do we leave at the end of the shift before the O.R. is completed while others carry on the work?  Do we neglect to call the anxious parent back after our shift is done when you wonder what might have happened to their child? 

We do, for the moment, continue to exercise self regulation.  Is that all that is left of the calling of medicine?  Are we being pushed into a trade and contract mentality? Or are we walking there ourselves?