I’d like to write about something near and dear to my heart- the field of medicine. For new readers, I was a medical student at the University of Wisconsins School of Medicine and Public Health before dropping out to follow my true calling. I spent eight years working my way into medical school and completed one year of the program, took a gap year, and then dropped out entirely once I knew it was in my heart to do so. I learned that medicine was not for me. I was convinced that it was the best choice for me when I didn’t yet know where my heart was (I would say few do at the age of 18). I was a good student, I liked science, I wanted to help people, and everyone told me medicine was a noble and great pursuit. Sound familiar?
As someone who was, at one time, as deep in the game of pre-med/med student life as one could get (4.0 GPA, President of my chapter of the American Medical Student Association, published scientist in Nature Medicine, a medical student at a top institution) and who now stands outside of it, I am privy to unique viewpoints and insights.
And I am worried. I am very worried for pre-medical and medical students. You all are my focus.
What I see happening is not something consciously being orchestrated by a few evil masterminds’, it is a conscious/unconscious, cultural/societal wave that has taken on an identity of its own. Here is that beast:
The medical-industrial complex is a machine. Medical workers are cogs. Independently acting cogs don’t mesh well in a machine. The autonomy that physicians of old were granted has been fading for years and may disappear entirely. This is well understood and perpetuated by the machine, as the machine runs most efficiently in this manner. The number of patients seen in a day, the time allocated to patients, the words that are able to be spoken, the treatments that are recommended, everything that is a potential autonomous choice for the health care provider is being taken out of the hands of the provider; the provider’s job is to follow the commands of the machine while trying their best to exercise their autonomy where they are yet able. And it is a delicate dance, if too much autonomy is stripped at once, the workers feel it too acutely and rebel. So it is a slow and steady chipping away. Take a little…let the fire settle…take a little more…let the fire settle.
This is all carried out for the sake of ‘maximizing efficiency and income’ for the machine, although sometimes disguised as ‘for the sake of best patient care and outcome’ (evil). At the medical systems which have become corporations valuing income and efficiency as their top priorities (as opposed to best possible patient care), the restrictions to providers’ autonomy are not being orchestrated out of a direct desire to reduce the autonomy of the workers, that is just a means of optimizing income and efficiency for the machine.
If you personally value ‘best possible patient care’ as your top priority and the corporation which you work at values ‘maximizing efficiency and income’ (How to know? Deeds, study the deeds and actions of the corporation), then your values and the corporation’s are unaligned and you will see the values of the corporation as creating ‘bad’ incentives and ‘problems’ for not only the patients, but all the workers in the machine who don’t share income and efficiency as their top priorities. My point is to bring understanding and empathy to those who find themselves stuck in a situation like this. Corporations were literally established to diffuse responsibility for the actions of the corporation, and once widely diffused enough, no one’s responsible and the corporation is its own beast. What is then asked of someone whose values are unaligned with the corporation is to take on ‘ultimate responsibility’, which is an enormously difficult task. ‘Ultimate responsibility’ is to see your role, no matter what and where in the ladder it lies, as part of the corporation, and, if you do not support the work/values of the corporation, to not support the corporation in any way shape or form. And again, let’s be careful not to pessimistically declare that the people who are part of the system are bad people. No. Not at all, everyone in the corporation is simply ‘doing their job’, many are just unable to see and accept ultimate responsibility and we can understand why…think what that would truly mean for said person. And the corporation likes it that way.
Many physicians whose careers have spanned this shift are unhappy. The loss of autonomy and the value shifts of the system are some of the many factors in the multivariable equation which looks at burn-out rates, suicide rates, dissatisfaction scores, willingness to recommend the career to others, etc. as the outcomes. (Interestingly, I see Medscape now requires an account to view their physician satisfaction surveys, but I highly recommend analyzing that data for yourselves).
So, if we indulge in this thought experiment, who will be the perfect cogs for the machine? Well, workers who share the values of the corporation, i.e. income and efficiency as their top priorities.
My heart lies with the pre-medical and medical students however, who value ‘best patient care’ as their top priority, and what I fear is this- we are being crafted by the machine into cogs to fit into the medical-industrial machine. Through cultural and societal displays, you are taught that being a physician is one of the greatest things in the world to be (Where is the message that what YOU feel in your heart to do is the greatest thing in the world for YOU to BE?), you are told to be completely selfless and that your life on this journey is one of complete service and self-sacrifice to the machine, you are applauded for doing so, you are put on a pedestal in society, you are guaranteed riches and power, you are trained from day 1 to check boxes, you are trained from day 1 to submit your autonomy to the machine and be at the hands of those who “decide your fate and future”, you are trained to play the game, you are trained to be grateful just to get a chance to play… I have worked so hard, I have done everything you asked, I have paid so much money, I have checked every box, I have sacrificed my desires, please oh please won’t you let me have a chance? Many of us crawl into a medical school after years of work and self-sacrifice, and then pay enormous sums to work ourselves silly, to enter a system where our autonomy is stripped, where we are not paid fairly for our work even once we start contributing to the system, and we are trained to just feel grateful to be there…because we were already broken. And now we are a better cog. Not perfect, because we don’t align with the values of the system, but at least we don’t rebel and we do exactly what the system wants. And we don’t ask questions. And we feel trapped. And we do OUR best to fulfill our personal values in a system that doesn’t share them. Many of us are just happy to take anything we can get at this point, the journey broke us, just let me stay, I have so much debt, I have invested so much time, I can’t possibly leave now. Do anything you like to me, I will play along. That’s a good cog. Now, this is of course not the case for everyone, but if you think this isn’t happening or doesn’t apply to you in some way shape or form…reflect.
And here is the thing, it is not necessarily good or bad, it just is, and it depends where your values lie. If you are someone who strongly values autonomy, if you are someone who most strongly values best patient care- know what you are getting into. If you are someone who feels the pressures of society pushing you into medicine, although it may not be truly in your heart, be aware of this. If you have pulled back the veil, are aware of all of this, and still know a path in medicine is in your heart, wonderful, we still need doctors.
If you are fighting the system because it is in your heart to do so, I wish you the best of luck, you are paddling against the tsunami.