AMA Journal of Ethics^®

In 1950, a boy named Mark (now Mark Shulkin, MD) was thinking about going to medical school. Fast forward 25 years to 1976 and meet his son, David (now David Shulkin, MD) who was graduating from college and about to enter medical school. Fast forward again to 2013 and meet David’s son, Daniel, recent university graduate beginning work in the health services sector.

Mark had a competing passion for theatre, David dreamed of winning the lottery, and Daniel has an interest in public policy and economic development. Their stories of the range of factors that affect choice of a career in health care in an unpredictable and rapidly changing environment are their own, yet representative.

For Mark, the choice of medical school was most obvious. In June 1950, when the Korean War began, he was an undergraduate. For the first time in our country’s history, deferments from military conscription were awarded for education in occupational specialties needed to support the war effort. Mark opted for medical school rather than for combat.

David’s initial motivation was a frequently heard one—to follow in his father’s footsteps. But a love story altered that direction. David’s wife-to-be was a dermatology resident at the University of Pittsburgh, where he was a resident in internal medicine. When it came time for David to finish his residency, his fianc�e had another year to go. He could stay in Pittsburgh with the love of his life or leave to take a job elsewhere. David spent that year studying business administration in Pittsburgh, a divergence that sent him down the road to health care management, a road that will branch again and again as Obamacare takes effect.

As for Daniel, interest in the quality of medical care and in its distribution goes back to his undergraduate studies. It was a time of public alarm about shortcomings of many hospitals after Hurricane Sandy, the absence of an established mental health policy following the Newtown shooting tragedy, and of course the advent of Obamacare. The need for change in the structure of the health care system piqued Daniel’s interest in public health and public policy.

A Bit of Background

In the 1950s, specialization did not yet dominate the profession of medicine. Medicare had not been established, and the concept of managed care was in its infancy [1]. By the mid-’60s, the effects of the Hill-Burton Act [2] and the establishment of Medicare had accelerated the development of hospitals and research universities. And today, advances in technology and changes in health policy have completely transformed the health care delivery system [3]. Mark’s career took place largely during the era of explosive growth in the capabilities of medicine. David’s road to managing health care has focused chiefly on responding to the resulting problems of cost control and quality of care that have plagued the system over the past several decades. And Daniel’s path to health care will help medicine fulfill the provisions of Obamacare, creating greater access to health services.

Why Choose Health Care?

What do we make of these choices during the past 50 years? The tri-generational Shulkin story points to larger truths about motivations for choosing a career in health care.

For Mark, whose father was a pharmacist, fascination with scientific subjects—while Mark may have had a passion for the arts, the mystery of the brain and the intricacies of DNA replication superseded his desire to become an artist—and a promise of the recognition and status that doctors commanded confirmed his choice of medicine. It is likely that Mark’s rush to medical school was also a result of the U.S. army recruitment efforts to send young people overseas. Mark chose to specialize in psychiatry as result of experiences during adolescence and because the field offered more opportunities in academics and research than other specialties.

Without his father’s strong interest in science and little motivation for other pursuits, it was most likely the desire for recognition that brought David to his career, but his path led toward the current medical culture’s focus on care quality and improving health care delivery—he chose to study systems of care and why doctors make certain decisions and to apply that research to helping improve outcomes and efficiency in large health care systems.

Daniel attributes his first interest in social and health problems to Children of the River [4]—a book he read in middle school about a 13-year-old Cambodian girl who escaped the Khmer Rouge, leaving her family behind—for wanting to help families in poverty get access to the goods they needed to be healthy and survive. Daniel’s interest—and that of many in his generation—in eradicating poverty in developing counties contrasts sharply with his grandfather’s reluctance to deploy to Korea; thinking about health care has now gone global.

The opportunity for advancement, recognition and fame that comes with a medical degree has diminished over time, with new efforts focusing on international development and social change. Despite this, of course, financial gain remains an undeniable motivator for choosing a career in medicine.

Why Choose Not to Become a Doctor?

Would-be doctors appear to be concerned that the years of training and the expense of a medical education may not yield an adequate return on the investment. Research by Gail Morrison at the University of Pennsylvania School of Medicine found that many students are discouraged from applying to medical school because of rising tuition rates, and that, of those who do attend medical school, more choose higher-paid specialties to compensate for their educational debt [5]. David’s 1989 article in the Journal of the American Medical Association showed that medical student interest in primary care was diminishing and that specialty choice was directly related to the expected size of the physician’s average income [6]. Only 51 percent of today’s physicians would choose medicine again as a career, 42 percent would choose the same specialty, and only 19 percent would choose the same practice setting. Among various specialists, dermatologists lead the pack on satisfaction with their choice, with 74 percent stating that they would choose the same specialty, while just 19 percent of internists expressed that opinion [7].

We hear that, among today’s up-and-coming doctors, part of the “millennial” generation, life balance is gaining ground, not only against the self-sacrifice of idealism, but also against the self-interest of purely financial goals. Nowadays, when students are exposed to attending physicians during their clinical rotations, they learn the realities of practice. Physician office expenses, costs of medical equipment, salaries of personnel, malpractice and disability insurance, and continuing education, as well as the loss of autonomy imposed by third-party payers have pushed many graduating medical students into nonclinical careers. Medicine has changed since the 1950s and 1980s, and it is no longer a secret that treatment choices can be based on reimbursement rather than solely medical indications. As Daniel learned, it may have become easier to make a difference in health care by not practicing medicine—not going to medical school and preparing instead for a career in health policy or international development.

So what’s the student to do when his or her youthful idealism is overshadowed by the practical facts of twenty-first-century life and the inevitable cost-cutting that sustainable medical care delivery and payment will require? We firmly believe that in today’s political, economic, and social environment students are not wrong to shy away from medical school to enter careers in other health professions, public health, or administration. Perhaps some will look to careers in nursing, the allied health professions, public health, research, and health care administration—careers that will gain increased status as they become more essential to securing access to whole health for greater numbers of people. If they were starting their careers today, David and Mark might not be doctors!