Will Health Providers Survive Health Reform?


by Mark Dakkak

When I first told my primary care physician that I was leaving my hometown to start medical school, he sat me down in his office. He pointed to his copy of Sir Samuel Luke Fildes’ painting The Doctor, and confided in me “medicine isn’t always the noble profession you may think it is.” He warned that to spend quality time with patients involved “far too much work and far too little compensation”.


My ignorant bliss didn’t last long. I just finished The Darkest Year of Medical School, during which the ‘high-minded traits’ that my classmates and I entered school with began to erode.  The first year working in the hospital revealed that much of what we “learned about doctor-patient communication, bedside manner, and empathy turns out to be mere lip service when it comes to the actualities of patient care.” Dr. Ofri explains that the rigorous biomedical education that is standard to American medical schools “coarsens the very qualities that inspired students to enter medicine in the first place.” Our experiences in the hospital chisel away at the concepts we have of ourselves as future physicians. Unfortunately, we can be left with “shadows” of ourselves, as David Bornstein recently described, because “as the price of admission, medicine implicitly asks its members to leave aspects of themselves behind.”


There is already great pressure on medical students and physicians to reconnect with our values to address physician burnout and patient safety, but the stakes are rapidly rising. Open enrollment in the federal and state healthcare markets began last Tuesday. Depending on state decisions, Medicaid expansion together with other provisions in the Affordable Care Act could cut the number of uninsured in half, adding millions of newly insured patients to a stretched network of safety-net providers. Media campaigns opposing Obamacare are simultaneously threatening the trust that is fundamental to the doctor-patient relationship. If our healthcare workforce wasn’t already imploding, the increasing external pressure might just be the straw to break the camel’s back.


Now is the time to strengthen the future of the healthcare workforce. This means creating a learning environment that reinforces the core values that bring medical students into this field. David Bornstein argues that doing so can protect students “against the assaults of the medical curriculum and even the health care system itself.”


Wonderful programs are emerging. The Healer’s Art, a medical school elective described as a possible ‘fix’, brings veteran physicians and students side-by-side to connect with core values as a community. Similarly, last spring a narrative show called Voices of Medicine featured five Duke physicians, fellows and medical students. In the midst of my busy internal medicine rotation, hearing providers at all levels share their experiences recharged my commitment to the field. It meant the world to see supervisors struggling to hold on tight to their values.


But while extracurricular activities can be incredibly meaningful, more needs to be done in the workplace. First, students should be assigned to good mentors – not every MD deserves a chisel. A surgery fellow I was assigned to work with for three weeks did me a great favor by telling me to join the other team on the floor. I later learned my new supervisor was known around the health system for his teaching. Second, rotation schedules should include regular interaction with clinical mentors. By my 12th month of clerkships, I couldn’t wait to finish; I continued to live in a daze, being whisked between radiology sub-rotations every 2 days. Meanwhile, my friend who participated in the longitudinal clerkships of Duke’s Primary Care Leadership Track was emotional about his last weeks with supervisors he had developed close relationships with over the year. Lastly, standards of professionalism must be established with a confidential system in place to report mistreatment. Last month, I attended an ‘etiquette dinner’ event geared towards business and policy graduate students and was startled by the complete lack of norms in the medical profession. Even after a year, I can’t describe the ‘appropriate’ way to interact with team members.


Medicine’s struggle continues to gain publicity while external pressure builds to unprecedented levels. How will physicians welcome millions of new patients under their care? To survive the implementation of reform, the healthcare workforce must build its strength from the inside out. The medical education system needs to train doctors who grow into the values they bring with them rather than erode those values away. Maybe then, medicine will be the noble profession you may think it is.

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