--Bring All Your Medications in a Bag to Your Next Office Visit
Dr. Karen Sullivan Sibert wrote a lovely, politically incorrect, thoughtful, incendiary op ed in the Sunday New York Times about the effect of women in medicine who believe their first job is being a mother and their second is being a medical doctor.
Dr. Sibert writes in the long tradition of the older physician looking disapprovingly at the younger doctors who follow, who seem less committed, who seem soft, coddled and insufficiently tough and dedicated to be worthy of the world's most demanding and ennobling profession.
From Googling her, it appears Dr. Sibert is about 58 years old, graduated from Princeton in 1974 and from Baylor Medical School ten years later in 1984--so there was a gap between her college and her beginning medical school of about 6 years, during which she may have got married, had a couple of kids and got a start on raising them.
She practices in a specialty which is demanding in the sense of requiring a physical presence with the patient, after hours on call and long stretches of uninterrupted attention to a single patient. On the other hand, Anesthesiology is one of those four specialties of the ROAD to happiness, being high paying, relatively less demanding in time and on call--the others being Radiology, Dermatology and Ophthalmology.
Residency training programs are the most competitive for these spots, presumably because medical students now look to these coveted spots as the doorway to a happy life of prosperity without much pain. The dermatologist does not get called in on weekends or nights, and really does not need hospital privileges and his patients do not get very sick and when they do, he hands them off to the oncologist or to someone else. Radiologists often do not see the patient at all, dealing only with images of the patient, and so never has to give bad news or answer vexing, emotionally draining questions. He simply speaks to the referring physician and sends the patient the bill. Ophthalmologists do have to meet the patient face to face and they have some pretty delicate and sometimes nerve wracking surgeries to perform, but for some golden years, ophthalmologists gave up all those more taxing parts of their specialty and opted out of vitrectomies and cataract surgery for LASIK surgery, which was low pressure and highly compensated.
I was reminded of the National Public Radio show which reported a confrontation between the Dean of Medicine at Mount Sinai Medical School in New York city and a fourth year medical student who had been top of his class, but who chose a training program in Florida of minimal academic standing. He could have done his gastroenterology training at the finest Harvard programs and the Dean was disappointed his name was followed by a community hospital program and it made her list of graduating seniors look bad. The student said, "If I trained at Harvard, I'd be slaving away doing research for some faculty twelve hours a day, trying to learn endoscopy and colonoscopy during the remaining six hours. In Florida, I can do my colonoscopies from 9 in the morning to three PM and be on the boat with my family by 4 PM."
Such were his values. He knew why he went to medical school and what he wanted from medicine. He was honest enough to say so to his Dean's face.
It reminded me of my encounter with the Chief of Medicine when I was a fourth year medical student. I had just finished a fourth year elective down at New York University in the department of dermatology. I loved it. It had just enough surgery, lots of patient interaction, a wide variety of diseases and instant diagnoses. I brought in the form for a recommendation from the Chief of Medicine for the derm program at NYU. Cornell, my school, did not even have a department of dermatology. The Chief held up the form between finger and thumb as if it were a soiled piece of toilet paper.
"We have trained you to save lives. You did a nice job during your subinternship in Medicine. You learned how to bail out patients in sepsis, how to get a deathly ill patient through the night, alone, with confidence. And now you want to leave medicine? For this? We were going to rank you highly for a spot in our internship class. But we want to train people at this institution who are going to go out and save lives."
I slinked out of that office with my tail dragging along the floor.
Those were the days when you were either a doctor or you were ashamed of not being a doctor once you got the chance.
There was no mention of time on boats or of time with family.
But eventually, the younger doctors refused to go to Saturday morning Grand Rounds because they could not go to their kids' soccer games and they argued Grand Rounds could be held during the week. They put forth the argument that family time was a reasonable thing for doctors to demand, that the medical profession could be arranged to accommodate family life. Male doctors said this, not just female doctors.
It is true female doctors take more time off, work part time more often, but male doctors do not put in the hours or sacrifice home to profession the way they once did.
And when you make the argument about precious and limited places in medical school, well that is true if you are talking about Baylor or Columbia P&S or Duke. It is no so true of Florida State and who knows how true it is of any of the hundred plus chiropractic schools which grant DO degrees?
And, the fact is, from my viewpoint in New Hampshire, many if not most patients get their primary care from nurse practitioners or physicians' assistants who are practicing independently of physician supervision.
What Dr. Sibert is really complaining about is the devaluation of what it means to be a physician. You work really hard to get into a school like Baylor. You take ridiculous courses (of doubtful value) like organic chemistry, calculus, physics, which are designed to cull the herd, not to select the best physicians and surgeons. And when you get that degree, you feel proud.
But then you see others, who are also called "Doctor" who do not seem to place the same value on being the best physician, the most dedicated physician they can be. They seem to look at the profession as if it were, at best a trade, something to generate profit, and not the focal point of their lives.
But then again, when I was a medical student the old dinosaurs used to disparage the interns and residents who were training me because they worked only every third night on, rather than every other. In the Days of the Giants when men were men (and their were few or no women doctors) you worked every other night, which meant you worked all the time. Your night "off" was just a recovery night to sleep and when you awoke, you were back on the ward.
Trouble with the Days of the Giants, the patients were not as sick; there was not nearly as much you could actually do for the patients and there was only a 50/50 chance of helping any patient. Now the odds are much improved; the technology has transformed medical practice--thyroid sonogram has supplanted thyroid physical exam; endoscopy has replaced hourly hematocrits;CT and PET and MRI have made autopsy confirmation of diagnosis less critical.
Things have changed.
Money has driven most of these changes; technology has driven other changes.
But mostly, we have a dysfunctional system of selecting tomorrow's doctors and a dysfunctional system for training them. We have Deans and Chiefs who do not embody toughness and dedication.
At a forum for parents of medical students a graduating fourth year student told his story of having been accepted to Columbia P&S and going into the Dean of Admissions saying he wanted to defer his acceptance so he could work at Goldman Sacks for a year, to get the finance bug out of his system. (And to earn some money for medical school.) The Dean agreed.
In my day, the Dean would have said, "If you are so insufficiency dedicated, we withdraw our acceptance." Medical school admission was a glittering prize. You had to prove yourself worthy of it.
That's not true at too many medical schools any more.
