Article by Michel Accad, MD | “Doctor’s Orders” curated by editor Eric Donahue
Dear medical student community,
I am honored by this opportunity to offer you some advice on how to prepare for your professional career in what has become a treacherous health care system. I will not elaborate on why I think the health care system is “treacherous.” I will assume — and even hope — that you have at least some inkling that things are not rosy in the world of medicine.
Given I am a fan of Socrates, I won’t be telling you what to think. Instead, I will bring up some questions which I believe you ought to start thinking about, and hopefully trying to answer these questions will help you arrive at some version of the truth. Rest assured, I will point out some resources to aid you in your reflections.
I have grouped the questions into three categories of knowledge which I am sure are not, or just barely, covered in your medical school curriculum: the economics, ethics and philosophy of medicine. I have found that reflecting on these questions has been essential to giving me a sense of control over my career. I hope that you, in turn, will find them intriguing and worth seeking answers to.
One more thing before we proceed: don’t be overwhelmed by the depth of these questions and don’t set for yourself the foolish task of trying to answer them today, in a week or in a year. In many ways, these are questions for a lifetime of professional growth. I suspect that many of these questions do not often cross your mind, but I strongly believe that the mere fact of entertaining them will be of help.
So here we go:
The Economics of Medicine
- Is there a shortage of doctors? Is there a glut? How would you know? How can you anticipate the demand for services in your specialty of interest?
- As a physician, how should your economic value (i.e. your earnings) be determined?
- Who will ultimately be the hand that feeds you?
- Will you and the hand that feeds you see things similarly in regards to how your work should be valued?
- How does a society become prosperous and how does it become poor?
- What is a fair way to distribute resources in society?
- Does the national debt matter? How could it affect your career?
If you don’t have some clarity about the answers to these questions, you may be proceeding into your professional life with some naïve optimism and inadequately prepared to safeguard yourself financially.
Knowledge of economics does not always mean you will be immune to economic realities. But economic knowledge will allow you to take these realities into account as you make informed decisions about your career path and better weather potential storms than if you were caught by complete surprise. Granted, economists themselves often disagree with each other, and economics may be the only discipline where the Nobel committee can grant a prize to two economists with completely opposing views. Nevertheless, there is great benefit to having some grasp of economic principles, and if these seem flimsy on the surface, it’s usually because politicians and economists let their political views confuse their economic discourse, and not because basic, well-reasoned economic principles are themselves faulty.
If you want to get started, I can recommend two excellent and easy to read introductory texts: How an Economy Grows and Why it Crashes by Peter and Andrew Schiff and Economics in One Lesson, a classic collection of essays superbly written by Henry Hazlitt.
The Ethics of Medicine
- Do the ends ever justify the means? If so, when and why? If not, why not?
- Are there ethical principles that should always be respected? If so, which ones and why?
- Should medicine aim to provide the most good for the greatest number? Why or why not?
- Should doctors serve both the individual and society? Can they?
- How important is it to have good moral character? Why? What does good moral character mean?
- What is the goal of medicine?
Medicine is an ethical endeavor. Medicine is not about applying medical science or medical techniques, but about doing the right thing for the patient. Science informs you about the best means and technology helps you achieve those goals. But neither science nor technology can tell you what those goals should be.
We live in a pluralistic society where basic ethical principles are frequently a matter of dispute. This lack of ethical consensus, and the potential for conflicts to arise, understandably contribute to keeping ethics education to a minimum. You would, however, benefit from having as clear an understanding of your own ethical principles as possible. Otherwise, sooner or later you will realize that being ambivalent about the right course of action could cost you. Whether it’s a matter of properly allocating financial resources in the care of patients, or issues of life, death and justice, you don’t want to be in a position where hesitancy interferes with your ability to take a stand or make firm decisions, especially once you have committed to a job or a position where you are expected to make decisions (remember, that’s what “MD” stands for).
Ethical principles are not necessarily obvious or intuitive otherwise there would be no ethical conflicts in society. The better you can articulate and defend the principles that you stand for, the more prepared you will be in a system where ethical conflicts are likely to be increasingly common.
Although I do not necessarily endorse its content, you may wish to familiarize yourself with Principles of Biomedical Ethics by Beauchamp and Childress, only because this commonly cited and influential text reflects mainstream medical ethics ideas. But this should only be a start.
The Philosophy of Medicine
- Is obesity a disease? Why or why not?
- Is hypercholesterolemia a disease?
- If a disease is defined by a cut-off number (say BMI>30) is it a “real” entity? Is it a “social construct?”
- What is a disease?
- Do you agree with the World Health Organization’s definition of health? Why or why not?
- What does “normal” mean in a medical context?
- Should the medical community define what is healthy and what is not? If so, using what criteria?
- What can science tell us about health and disease?
- What are the main current problems in the philosophy of biology?
- What is a human being?
I hope you have found these philosophical questions somewhat relevant to the practice of medicine. I believe that they are. Unfortunately, not many people agree with me. Instead, the common attitude is to think that these questions are difficult to answer and that medicine has made great strides without having to resolve them. Why make a philosophical fuss?
I think a philosophical fuss is definitely in order when a health care system is teetering on the brink. Deep seated problems often mean that we’ve been operating on assumptions that need revisiting. As mere doctors we may not always solve philosophical problems, but we should be able to recognize the assumptions on which medical doctrine and health care policy invariably rest. Sometimes, those who promote a certain viewpoint will prefer that these assumptions remain unexamined. I think we can all benefit from having philosophical antennas.
Because the field of philosophy of medicine is virtually non-existent as an academic discipline, there is no standard textbook I can point you too. However, there are two compendia of essays that were edited in the last decades and that address some of the questions I have raised here. These are Concepts of Health and Disease: Interdisciplinary Perspectives, edited by Caplan, Engelhardt and McCartney in 1981, and Health, Disease, and Illness: Concepts in Medicine, edited by Caplan, McCartney and Sisti in 2004. Either one would be a good place to start.
Are you still with me?
If you are, you have realized that what I am giving you is a massive reading assignment. If I could summarize my recommendation in one word it would be this: Read!
A two word summary? Read more. If you haven’t done so already, you need to develop the habit of reading all the time and of reading long form: books and long essays. Reading is the only activity that will quickly give you real knowledge that you need, not only to survive, but to really thrive in these tumultuous times.
But don’t get discouraged by the sheer volume of the knowledge to be gained. The point here is to stimulate your curiosity about the proper questions, at a time when medical school demands are likely to quash your sense of wonderment. Rome was not built in a day and all you have to do is to keep on hand some material to gently chew on at your own pace, not to embark on an ill-advised intellectual binge for wisdom.
Once you get into that habit, you will find out that knowledge is not only empowering, but it is liberating.
And you’re not training to be a doctor to end up at the mercy of an unhealthy system, are you?
Dr. Michel Accad, MD practices internal medicine and cardiology in San Francisco. He raises more questions (and entertains answers to them) in his blog Alert and Oriented. You can follow him on Twitter.