AMA Journal of Ethics^®

Case

Dr. Bryant was nearing the end of his residency at City Hospital and starting to think in earnest about the next steps in his career. City Hospital was a teaching hospital for residents and medical students and affiliated with the state university’s academic health center. City had just offered him a position as an attending physician with an appointment as an assistant professor on the medical school’s clinical-educator track, but Dr. Bryant was debating a job offer from Horizons Clinic, a large, multispecialty clinic with an impressive reputation, working environment, and compensation package.

Unable to make a firm decision, Dr. Bryant turned to one of his closest mentors, Dr. Gabriel, for some career advice, telling him about his job offers and asking him for his perspective.

“Remember when you just started here and Mr. Johnson was your patient?” asked Dr. Gabriel.

Dr. Bryant smiled, “Ah yes, I learned a lot about myself because of him.”

“Yes, I remember it well too,” said Dr. Gabriel. “You never said anything, but your first impressions of Mr. Johnson were all too clear. You thought he was just another hopeless alcoholic indigent with TB, cruising through this hospital system. But I saw you develop a relationship with him, pushing him to stick with the alcohol addiction recovery program. As I watched you work with him over time, I knew you were beginning to understand what medicine was really all about. My point is that you can do whatever you want, but remember that encounter, and remember that there are more Mr. Johnsons out there.

“You’ll also have the opportunity to partner with the health department and community agencies to improve the health of this entire community. And with our long-term affiliations in Haiti you’d have the chance to help develop a sustainable system of health care in that impoverished country. These are benefits of a job that no amount of compensation or weeks of vacation can give you.”

Inspired by his conversation, Dr. Bryant leaned toward taking the City Hospital job. As he was leaving the hospital one evening, he ran into Dr. Patel, who had recruited him for the interview at Horizons Clinic.

“Decide to join us yet?” asked Dr. Patel.

“Honestly Dr. Patel, I am having second thoughts.”

“Everybody does; I did too,” Dr. Patel said. “Why don’t you tell me about your reservations?”

Dr. Bryant explained that he had been thinking about the mission of medicine and his role in fulfilling it, describing the insights Dr. Gabriel had provided him.

“Entirely understandable,” said Dr. Patel. “In fact, it is very mature of you to think about your obligations to patients of all incomes, and I am aware that our clinic’s clientele are mostly employed in well-paying jobs and have excellent health insurance. But, Dr. Gabriel left some important points out. First, our physicians are compensated well because they provide excellent care, far above average. Just think of the opportunities you will have working and learning with some of most respected physicians in the area and being able to tell your patients confidently that they are receiving the best care available.

“Horizons also has an active charity program in which you could participate, giving free or reduced-fee care on a case-by-case basis. Plus, our physicians can use their personal financial resources however they choose. For example, Dr. Smith has given thousands over his lifetime to various charities, and Dr. Anderson takes 2 weeks of his vacation every year to travel to Guatemala to help staff a clinic there.”

Dr. Bryant went home thinking that Dr. Patel had said a lot of things that made sense, and the allure of working at Horizons had returned. He fell asleep that night unsure about which job to accept.

Commentary

Wrestling with the decision about where to invest your professional career is never easy. The consequences of that choice will significantly impact your personal and professional future as well as the future of one’s family. One way to approach this decision is to employ a process of focused, active self-reflection. “Active reflection” refers to a formal process of critical thinking. Grenz and Olson describe it as:

using our minds to organize our thoughts and beliefs, bring them into coherence with one another by attempting to identify and expunge blatant contradictions, and make sure that there are good reasons (for believing and acting) in the way we do…. Reflection…involves…critical thinking…(that uses) logic...as well as some amount of objectivity toward one’s own assumed beliefs and life practices [1].

Remember Your Calling

In the first stage of active reflection Dr. Bryant may wish to pause and reconsider that point in time when he made his decision to enter the profession of medicine. It might be enlightening to reread the personal statements he prepared for his medical school and residency applications. Thinking about his commitment he can ask himself, what most attracted me to enter this vocation? To what was I most committed and have those commitments changed? To what, or to whom, am I now most dedicated? The answers to these questions can help clarify his professional motivation and rekindle his calling into medicine.

Those who enter religious vocations commonly speak of a calling. A calling is also important for those who enter the profession of medicine [2, 3]. As Dr. Bryant reexamines his calling to medicine, he may find it helpful to view it through the lens of professionalism and its core values [2-9].

Reynolds reminds us that professionalism is:

[a] set of values, attitudes and behaviors that results in serving the interests of patients and society before one’s own. Honesty and integrity are…essential to medical professionalism….Professional behaviors include a nonjudgmental and respectful approach to patients, the pursuit of specialized knowledge and skills with a commitment to life-long competency, and a collegial and cooperative approach to working with members of the health care team in the delivery of patient care. Lastly, community service and public leadership reinforce the responsibility of physicians to fulfill the goals set forth for the profession by the public. In exchange for putting the interests of the patient and public first, physicians earn trust, respect, and the confidentiality of (their) patients [10].

Define Your Professional Values and Priorities

After thoughtfully reflecting on his professional calling and on the core attributes of professionalism, Dr. Bryant should engage in active reflection again to delineate clearly the professional values and priorities he envisions for his life and commit them to writing. Within the context of professionalism, which principles hold the highest value for him? Which will govern his professional life and conduct? Which is he willing to share with others so they can help hold him accountable? How will he define himself as a professional?

Evaluate the Options

Having defined and listed his values and priorities, and with this “professionalism scorecard” in hand, Dr. Bryant is in a better position to evaluate his two employment options. Because of his intimate exposure to City Hospital, he is more capable of assessing the degree to which that vocational option fulfills his criteria.

Since his knowledge of Horizons Clinic is hearsay rather than experiential, Dr. Bryant will need to explore Horizons in greater depth, addressing probing questions to its physicians and staff and to other physicians and health care administrators in the community. For example, he will want to know more about how physicians are compensated. According to Dr. Patel,  “physicians are compensated well because they provide excellent care.” But how is excellence or quality assessed? And how is this tied to compensation? Compensation based on measured quality is not yet the current mode of compensation in the United States. Compensation currently depends more on patient volume, maximizing billing codes, performing higher-paying procedures, aggressive billing and collection practices, limiting or denying access to patients whose health care is reimbursed at low rates (e.g., Medicaid), and productive incentive plans.

In a similar vein, Dr. Patel indicated that Dr. Bryant would be able to tell his patients that they are receiving the best care available. On what basis is that comment supported? How is care measured to determine that it is the best? Furthermore, how is care at Horizons better than the care patients receive at City Hospital?

In terms of career development, Horizons Clinic’s focus was directed more on personal development and working and learning with some of the most respected physicians in the area—not on the generative process of helping develop the careers of others as a teacher and mentor for student and resident physicians.

Regarding the charity care program, Dr. Bryant may ask, how are case-by-case decisions made about who is eligible for charity care, and how does that determination relate to the professional’s responsibility to duty, service, compassion, ethics, and responsiveness to patients? To what degree is charity care integral to Horizons Clinic’s culture? Do all physicians participate? Is it voluntary? Are physicians limited in the extent to which they can participate? What are the financial consequences for participation, or for nonparticipation? How does Horizons Clinic assess and attempt to meet the health needs of the community as a whole?

In terms of the prospect for international health opportunities, Dr. Bryant might ask why one must take vacation to participate, if a commitment to global health is truly part of the organization’s culture. He may also wish to determine whether the global health options available to him are really making a significant difference or whether they are a type of medical tourism or a form of professional penance that some physicians feel they must pay to compensate for their high personal income.

Consider the Organizational Culture

In addition to assessing each vocational option in terms of the best possible match to his own professional values, Dr. Bryant will also want to think carefully about the respective cultures of the two organizations to determine which one best fits his personality, professional calling, and professional values. The organization he chooses to join will exert a profound long-term effect on shaping the rest of his professional life.

In Leading Change, J. P. Kotter defines culture simply as norms of behavior and shared values among a group of people [11]. Consistent with this definition, Dr. Bryant will need to compare and contrast the cultures of City Hospital and Horizons Clinic to identify those common and pervasive ways of acting within each organization that endure because its members teach them to new members, reward those who fit in, and sanction those who do not. He will also need to determine those unique concerns, goals, and ethical standards within each organization that shape group behavior, and that persist, even when group membership changes.

Organizational culture powerfully shapes human behavior. It is difficult to change, and, since it is nearly invisible, it is difficult to confront. Its power is vested in the fact that it selects and indoctrinates its inductees well, exerts itself through the actions of numerous influential people, and does so without much conscious intent, again, making it difficult to challenge or even discuss. When you have the option, choose your professional culture carefully.

Conclusion

How will Dr. Bryant decide between City Hospital and Horizons Clinic? Although no decision-making process is foolproof, the one I suggest follows a sequential, semianalytic, critical-thinking method that employs key personally defined standards to help Dr. Bryant arrive at the best possible choice. This method requires engaging in active reflection that takes him through a series of steps. He must:

• Bring to mind his initial calling and commitment to medicine, considering and prioritizing the attributes and values of professionalism to which he is most committed.
• Articulate, perhaps even in writing, his personal professional values and priorities.
• Evaluate his options on the basis of his professional values and priorities.
• Determine the organizational culture that best matches the norms of behavior and shared values of the professional environment in which he will thrive.

A final caveat: making decisions of this importance is rarely accomplished well in isolation. At every stage, Dr. Bryant should consult with trusted friends, professional peers, and mentors who know him well. They can help to validate his thinking and provide perspective that he may lose because of personal bias, persuasive marketing, or loss of objectivity.