I have been interviewing applicants for surgical internship for more than two decades. This year, however, what I heard from them left me somewhat depressed about their personal futures and that of the medical profession.
I should add, parenthetically, that my hospital is part of Harvard Medical School and we are fortunate to attract extremely talented and dedicated young people. The doubts that these prospective interns expressed were not on the basis of what they perceived to be personal inadequacy, intellectual or emotional, but what they considered to be the quality of life that they, as future doctors, would have.
Their remarks, which I wrote down, were in response to my general questions about what they thought of medicine as a career.
One interviewee said: “My father and mother came to this country in 1947 from Poland. He is a carpenter and by the time I finish my training, I will be $100,000 in debt. It’s like having a mortgage but no house to show for it. Medicine has changed so much in the past few years. There will no longer be external rewards, just internal. Maybe that’s a good thing; then people will go into medicine for the right reasons.”
Another applicant commented: “Medicine is going to lose its cottage industry look. It’s a business today and it will be a government-regulated business. Doctors will no longer be able to make the obscene amount of money they do.” This person was an upper-class, prep school graduate, old New England stock. He was concerned that the medical expenses of the United States “now consume 10 percent of the gross national product.”
I pressed him on this point. “Why is that bad? What is more important than the health and well-being of the citizenry?” This question surprised him, and his response was that “if medical costs continue to go up, then the public will demand even more government control and we will have excessive intervention and regulation.”
Another interviewee had other worries: “I am sure that medicine of the future will not attract the kind of people it does today. Some of my friends say to themselves: ’Why should I go 4 years to medical school and then spend another 4 or 5 years in a residency only to finish $75,000 in debt—and then to go into practice and find that malpractice insurance is so high and Blue Cross-Blue Shield pays relatively less and less for more and more work?’”
These classmates, he said, have “gone into law—3 years only—and then will get a job that supports them—no night work also, or they will go to business school—only 2 years. And they will also be able to help people, but they will end up on the board of trustees of the hospital where I am working almost as an employee.”
I admit that I might not have interviewed a representative sample of medical students. I also would acknowledge that generalizing from the remarks of a few individuals can be as erroneous as thinking that one has discovered the heart of France after having spoken with the local baker. Furthermore, I know that in the days of Osler and Halsted, who, incidentally, charged enormous fees for those times, physicians bewailed the changes in the medical marketplace. Imagine the shrieks when Congress passed the first in come tax in 1913! The Cassandras predicted the end of medicine as “we now know it,” and they were right. However, it was not the end of medicine as a meaningful life for a physician.
Of course, a surgeon is an optimist. Who else would expect to make others better by sticking knives into them? And this particular surgeon, who happens to live in Boston, where the Red Sox are certain to win the pennant—next year—is even more susceptible to self-delusion. Yet, all this notwithstanding, I am confident that despite the “gathering storm,” those who want to help others will still find much gratification in medicine as a career. While it is true that the averageincome will undoubtedly become less, boredom will be rare, and we should not forget that tedium is rife in many, if not most, jobs.
My predictions—and they have the present value of the ruble under the Czar—are that medicine will go through a temporary dip in prestige but will recover when the public realizes that doctors alone are not responsible for the major costs of medical care. The people and the politicians will then have to decide how much they want to spend for what type of services. If they desire intensive care for their family, organ transplants, or long-term support for the retarded or mentally ill, they will have to pay the price. They might even decide that “defense” costs are too costly. It would be a utopian’s paradise if every nation opted to have 80 percent of its gross national product going into medical care and environmental protection, leaving too little for weaponry and war.
I also predict that as doctors’ incomes fall, malpractice rates will also decline, and the cost of medical education will fall or be supported by federal funding. With a rise in economic pressures, the distribution of doctors will improve; to make a living, physicians will have to go to places that they ordinarily would not choose.
And what about respect? Ultimately, each doctor will have to win it, as he or she still does in that singular relationship between patient and physician. People will continue to sicken and die, and they will still have to call a doctor, not the post office.