Hope for the Future of the Medical Profession

The American College of Emergency Physicians is holding its annual Scientific Assembly in San Francisco. Preceding the educational conference there was a two-day meeting of the organization's national, representative, deliberative body (called the Council). I had the opportunity to visit with the delegation from Texas. One of the topics of conversation was the future of the medical profession - specifically the attraction of the profession to young people.

I have worried about this for many years. I believe it is very important for the medical profession to attract the best and brightest of our nation's youth. I don't know about you, but I realize I'm getting older. I'm not old yet, but I can see it on the horizon. And while I hope to be old and healthy, I know I may not be so lucky. I may be old and sick some day. I may even have the misfortune to be afflicted with the medical equivalent of the ancient Chinese curse.

You know the oft-quoted ancient Chinese curse: "You should live in interesting (or exciting) times." The medical equivalent of this curse is, "You should be an interesting case." I guess for those of us in emergency medicine, "You should be an exciting case" would be an appropriate variation, but I've not heard that version.

If I am ever unlucky enough to be an interesting case, I know who I want to be my doctor. Gregory House, as portrayed on the television show by Hugh Laurie, is the guy. I don't care about bedside manner. I want a brilliant diagnostician. Emphasis on the word brilliant - which brings me back to wanting the best and brightest to choose medicine over the many other professional careers open to them.

Many factors enter into a young person's choice of a career. Medicine appeals to those with superior intellect and strong academic aptitude in the sciences and mathematics. It appeals to those who want to help their fellow man, who want to spend their days curing the sick, saving lives, comforting the afflicted. It attracts those who want to devote their professional lives to something the value of which to society is unquestioned.

Those it attracts must be willing to work hard. Entering the profession requires eight years of post-secondary education (college and medical school) followed by three to eight years (depending on specialty) of post-graduate training, for a total of 11-16 years after high school. And then there will be several decades of hard work. Yes, doctors in some medical specialties work harder than others, but there are few really easy ones, and even those are easy only by comparison with the others. Slackers need not apply.

What is the reward? Most of what's really important, I think, is knowing every day that one's work has helped others and made a difference in their lives. And there is a reward in being a member of a profession that is respected and admired by one's fellow citizens. Finally, the profession does provide a comfortable income, an enviable standard of living, an economic position in the top five percent or so of income earners in the US. That matters in an economic culture that typically rewards hard work with financial success, especially when you consider that most young physicians accumulate substantial educational debt from college and medical school.

If you spend a little time crunching the numbers, you see that physicians' incomes, in inflation-adjusted dollars, have been on a slow but steady decline over the last generation. That doesn't mean we really have anything to complain about, as we are still doing just fine, but the trend is worrisome. And, coupled with that, many physicians perceive a variety of other currents that make the practice of medicine less appealing. There is far more government regulation. There are far more outside entities telling us how to practice medicine and interfering with medical decisions that really should be made within the physician-patient relationship, based on the medical information provided by the doctor coupled with the patient's personal values. And we have an absurdly flawed system for addressing harms that come to patients as the result of medical error. I will write more about that in the future, but the system we have of litigating medical negligence claims does a terrible job of fairly compensating patients who are deserving and is poisonous to the doctor-patient relationship.

Surveys of physicians conducted in recent years reveal that more and more of us, severely frustrated by these trends, actively discourage our children from seriously considering following in our footsteps. So, if we want to make sure the medical profession continues to attract the best and the brightest of our nation's youth, we have our work cut out for us.

My own career in emergency medicine, after medical school and residency training, began in 1985. In those early years I had the privilege of working with a colleague named Ken, a warm and jovial Irishman, who taught me much about emergency medicine - and about life. Ken and I shared many of the same concerns about the future of the medical profession. If you had listened to some of our numerous conversations on the subject, you would have predicted that we would be among those who would steer our own children away from medicine.

Last night I attended a social event for registrants here at ACEP Scientific Assembly. Soon after my wife and I took our seats at one of the tables, the remaining seats were filled by a group of young doctors who are in training in the emergency medicine residency program at Wright State University in Dayton, Ohio. Not long into the conversation, I learned that one of them was Ken's daughter Brooke. You can imagine how delighted I was to meet her, after hearing so much about her from her dad when she was a little girl - and to realize that Ken had, after all, not steered her away from our profession.

My younger daughter is a freshman in college, and she aspires to enter the medical profession. She has the intellect and the drive to accomplish that goal. Equally important, she has the warm and caring personality her patients will need, because she wants to be an oncologist. And she has my full support and encouragement, because I know she is exactly the kind of person our nation needs to be choosing medicine over all the other things she could do with her life.

As a nation, we are struggling to make difficult decisions about reforming our health care system. We should be focused on what is best for patients. We must also keep in mind that the doctors trying to help those patients need health care reform to make their work easier rather than harder. At the same time, it will help if legislators, regulators, and policymakers understand that an inexorable trend of expecting doctors to work harder for less money, year after year, is undermining the cause.