From the Editor
May 2009
This month’s Virtual Mentor examines factors that influence the decisions medical students and residents make about their careers in medicine. There is tension, some perceived, some real, between medicine as an altruistic and healing art and as a business venture. This tension is present as a subtext to virtually every contribution of this month’s issue.
This issue begins with the story of Dr. Bryant, a third-year resident, at a crucial point in his career as he confronts the business of medicine—idealizations of different careers, money, and how to go about making it. In his commentary on this case, John G. Halvorsen provides an excellent framework for identifying, committing to, and acting on personal values in choosing the most suitable position. He suggests that Dr. Bryant’s real dilemma may not be about his choice of a job, but rather the result of an incomplete examination of his personal goals and desires as a physician.
Perhaps Dr. Bryant was unprepared to make the business decision he confronted. This is the notion Allison Carmichael picks up in her medical humanities narrative. Armed with several perspectives from a diverse group of practicing physicians, Carmichael takes us on a personal journey through the struggles of specialty choice, reflecting on her perception of the good life as a physician and an environment that forces her to prioritize values in order to achieve that good life. As a preclinical medical student, she grapples with medical business concepts in attempting to make an informed choice about her specialty and, ultimately, her job.
A second clinical case focuses on a primary care physician, Dr. Anderson, who is unsure about endorsing a new medical business model in the area—a medical spa. In his commentary, Lionel Bercovitch explores the controversy surrounding medical spas, commenting on the consequences of this business model for dermatologists and the complex, yet disjointed, regulatory structure that may contribute to the perception of these spas as questionable medical enterprises. He proposes that Dr. Anderson’s doubts might be less about the nature of the medical spa and more about a business model that is in some respects more desirable than her own. Bercovitch speculates that systemic factors such as our current health care system might be causing Dr. Anderson to wonder about her practice and career choices.
The last clinical case introduces a medical student named Adam who is determined to secure a job that will bring him personal and financial satisfaction, so determined in fact, that he begins to jeopardize his relationships with other students to achieve this goal. In his commentary on this case, Jeffrey Reagan faults Adam’s overly competitive behavior, reminding us that the pursuit of greatness in medicine is through patient-centered care and, therefore, is inevitably team based. Laurel C. Blakemore’s commentary also centers on the primary goal of providing excellent patient care; she argues that some level of competition can be good for medicine, as long as patients’ interests remain foremost.
The clinical pearl picks up on an issue faced not only by Adam but by virtually all medical students, residents, and attending physicians: stress. In his effort to stand out among his colleagues, Adam demonstrated several classic characteristics of Type-A personality, and, in the pearl, Sundeep Jayaprabhu discusses evidence that links stress in so-called Type-A personalities with negative health outcomes. He acknowledges that the evidence is inconclusive, but does not dismiss the connections. A lack of ironclad evidence, he says, does not diminish the common observation that stress decreases our quality of life, and assures readers that, while attempting to analyze how we manage stress can increase discomfort in the short term, the analysis can lead to long-term benefit.
An undercurrent runs through these articles suggesting that career decisions are not based solely on personal choice. They are influenced by the nature of our medical system, which plays a role in who become physicians, what specialties they choose, and, to some extent, where and how they practice. Other pieces in this issue investigate what effect this system has on the business of medicine and choices in a medical career.
In the medicine and society section, Daniel N. Robinson presents a narrative about the balance of idealism and business throughout the history of Western medicine. He casts light on a central theme running through the many epochs he addresses, which is captured in his conclusion. “If we expect saintly and heroic conduct [from physicians],” he says, “we must be prepared to accord the highest respect, the deepest admiration, and, yes, the right to a rich life during the few hours that can be spared.” Robinson reminds us that medicine has worked very well in the past with physicians being highly compensated and that it can also work this way in the future, but he simultaneously warns that medicine should not be considered primarily a business.
In the op-ed section, E. Ray Dorsey et al. echo Robinson’s conclusion. The authors are concerned with ameliorating physician shortages, proposing that the best way to do this is by increasing funding for residency programs and for other primary care physicians. One of their most intriguing arguments states that paying residents more would encourage members of underrepresented minority groups to enter medicine. If true, this would accomplish two goals: increasing minority representation in medicine and reducing the comparative economic disadvantage of going into lower-paying specialties.
In their policy forum discussion, Keisa Bennett et al. address the related problem of recruitment, focusing on rural medicine. They note that rural areas have fewer doctors per capita than urban areas and that the relative paucity of medical students who choose to enter primary care exacerbates this problem. Recent and ongoing expansions of medical school class sizes provide an excellent opportunity for administration to think about what type of student to admit, because research suggests that many of the best indicators of eventual practice in a rural or underserved area can be known at the time of admission.
Though interesting in itself, the question of physician compensation is also relevant to health care reform. Some of the articles in this month’s Virtual Mentor hint at this relationship, contending that paying physicians more would correct some of the maldistribution and access problems in today’s health care delivery. This view dissents from policies that argue physician overpayment contributes to runaway costs in medicine. The opposing arguments presented here cannot be ignored in larger debates about health care reform and the place of physician compensation in the health care system.
In a 2008 JAMA article, Hauer et al. explored the multifactorial nature of specialty choice, focusing specifically on the decision to enter an internal medicine residency. David Y. Chen’s discussion of this article explores the effects of earning potential on specialty choice and straightforwardly asks if our health care training, funding, or whole system, should be changed to meet society’s needs for medical care. He illumines some of the ways in which choices that all medical students make are linked to the broader system in which we operate.
As some of the case commentaries reveal, primary care physicians find themselves caught between dwindling payments and rising stresses, an uncomfortable position that reduces their job satisfaction. One such stress could be the need to keep up with increasing legal intricacies that have become part of the business of medical practice. In the article on fee-splitting, Cheryl Miller describes a case arising from a relationship that might seem innocuous but, as she demonstrates, is actually fraught with legal difficulties. The complexities of the legal practice environment certainly play a role both in the specialty choices that medical students make and the practice decisions that physicians in established practices face.
The complexities of the legal world often seem incomprehensible to physicians. The fact that practice laws and regulations vary among states compounds the issue further. Physicians encounter—and medical students worry about—daunting legal issues, but education about the law and business practices can alleviate some of the perplexity. In the medical education section, James M. DuBois outlines the mission and activities of the Bander Center for Medical Business Ethics in St. Louis, an educational center established to teach medical business ethics across all stages of a medical career. The Bander Center works to ensure that discussion of the ethical dilemmas explored in this issue continues in the medical community.
Whether or not medicine is a business, it cannot ignore the business world. Medicine and business are inextricably interrelated. Ours is not the first generation to grapple with these questions. As a careful reading of Robinson’s article indicates, medicine and business are often discussed together. Their relationship is adjusted as succeeding generations enter medicine and redefine it. The authors in this issue have made valuable contributions to the greater conversation that will help shape medicine for our time.
