It was just like any other screening visit and I had already organized the clinical trial documents in preparation for the patient’s arrival. The moment that the electronic medical record refreshed to show that our 9 a.m. patient arrived, I knew it was my cue. I brought the patient back to the exam room and told him that the doctor would be with him soon. The patient, EM, a man in his 70s, was here for a clinical trial evaluation for a drug aimed to slow the progression of his neurodegenerative disorder. After the study doctor finished his portion, I concluded the visit after an hour of blood draws, EKGs and questionnaires. I, a relatively new clinical trial coordinator, returned to a mountain of screening documents and meticulously went line by line through the inclusion and exclusion criteria to ensure the patient was eligible for the trial. EKG — not great , cognitive assessment — passed, motor exam — passed, and then I froze when I read the words “substance use.” I read EM’s response: 3-4 glasses of wine and one drink of “hard alcohol” per night. I rechecked the exclusion criteria and my heart sank as I read “history of heavy drinking or alcoholism.”
I took a breath and knocked on the study doctor’s door to break the news. I entered and explained what I learned about EM’s alcohol consumption. As I waited for his disappointment, I was met with the response: “I do not think it is an issue.” I reminded him of the exclusion criteria and a past patient who had to be removed from the trial due to excessive alcohol use. He replied: “That patient was an alcoholic, EM is just a social drinker. Please let him know that he’s eligible for the trial.” I was stunned. How was the previous patient an “alcoholic” while EM was “just a social drinker?” Was it because the former was Latino while EM was white? Or maybe it was the fact that the “alcoholic” patient was publicly insured while EM was a wealthy businessman and that our department was in need of more donors? To me, the answer was all of the above. I was angry at this double standard and desperately wanted to protest this decision but instead, I sheepishly replied “Okay, will do.”
A few years have passed since then, and I often sit and reflect on those patients and that day in particular. I think about how righteous I felt in my disdain and how that doctor’s choice perplexed me. But now I feel I better understand it. I entered medical school with the image of the art of medicine as the one practiced by the European nuns who provided free care for the poor. I envisioned the oath I took would uphold the ethical tenets of beneficence, non-maleficence, autonomy and justice as unwavering. However, as I look back on my first year of medical school, I realize how much the modern practice of medicine is shaped by the tug of war between its core values and powerful self-interested institutions.
I witnessed this tug of war in medical care several times over this past year. There were the numerous times I sat in the lecture hall when physicians would start their lectures with “unfortunately, I have no disclosures.” There were days they lectured about exciting new therapies to treat formerly incurable diseases that annually cost more than my private school’s tuition. Additionally, there were too many times, while I volunteered at a free clinic, that I saw patients who were unable to get quality of life improving procedures because we couldn’t find a doctor who accepted Charity Care. It was in these moments that I thought back to EM’s screening visit and started to piece it all together.
From the insurance plan reimbursements to pharmaceutical industry consulting gigs, there are constant incentives for doctors to favor wealthy patients and high-cost therapies. In academia, there’s the pressure to expedite VIP patients’ visits or conduct more clinical trials to bring in more money for the institution. Similarly, in my first days of medical school, student conversations centered around the importance of “pumping out the most publications” (regardless of their merit or clinical utility) to appeal to the top residency programs instead of focusing on learning the knowledge and skills to provide excellent clinical care. The temptation to climb the never-ending ladder of prestige, profit and power is at odds with the core values of the practice of medicine. Every day doctors face the choice of who they really work to serve.
As I reflect on all I’ve learned this year, I think back to those nuns and wonder if they would recognize the majority of our modern medical innovations and procedures, but more importantly, would they still see the same altruistic mission in medicine today? While I don’t mean to sound overly critical, I do believe that most doctors begin their medical journey with the sole focus of providing the highest level of care for all of their patients, but it appears ever more challenging to stay the course. I often think about years down the line when it will be my turn to wield the power of the white coat. Will I stand firm in my goal to provide equal and just medical care to every patient despite the many forces that will urge me to waver? I can only hope that my answer will be yes.
Image credit: Signing HB2700 (CC BY-NC 2.0) by oregongovbrown
Contributing Writer
The Warren Alpert Medical School of Brown University
Samuel is a medical student at The Warren Alpert Medical School of Brown University in Providence, Rhode Island class of 2027. In 2021 he graduated from Macalester College with a Bachelor of Arts in neuroscience. He enjoys playing tennis, running and traveling in his free time. After graduating medical school, Sam would like to pursue a career in neurology.