How to safeguard your career in a treacherous healthcare environment.

[the following post is a slightly edited version of an article kindly commissioned by In-Training,  a website run by and for medical students. The advice I give in the article is based on lessons I learned long after finishing medical school, so I hope you will find this piece of interest, even if you are well established in your healthcare profession.]

Dear medical student,

I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.

I will not elaborate on why I think the healthcare system is “treacherous.”  I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.

I am also not going to give any actual advice.  I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions.  The real advice will come to you naturally as you proceed to answer these questions for yourself.  I will, however, direct you to some resources to aid you in your reflections.

I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.

I have found that reflecting on these questions has been essential to give me a sense of control over my career.  I hope that you, in turn, will find them intriguing and worth investigating.

One more thing before we proceed.  Don’t be overwhelmed by the depth of the questions posed and don’t attempt to answer them today, in a week, or in a year.  In many ways, these are questions for a lifetime of professional growth.  On the other hand, I believe that the mere task of entertaining these questions in your mind will be helpful to you.

So here we go:

Your understanding of economics

Sample questions:

• 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 in your professional life with some naïve optimism and inadequately prepared to safeguard yourself financially.

Granted, knowledge of economics does not always mean you will be immune from the effect of economic realities that are beyond your control.  But economic knowledge will afford you to take these realities into account as you make informed decisions about your career path, and allow you to weather any potential storm better 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 to two excellent and easy-to-read introductory texts: How an Economy Grows and How it Crashes by Peter and Andrew Schiff and Economics in One Lesson, a classic collection of essays superbly written by Henry Hazlitt.

Your understanding of ethics

Sample questions:

• 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? (And what does that mean?)
• What is the goal of medicine?

Make no mistake about it, medicine is first of all an ethical endeavor.  Medicine is not about applying medical science or medical techniques, but about doing the right thing for the patient.

Science will inform you about the best means to achieve certain goals, and good techniques will help you achieve them.  But neither science no 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, however, will 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 “M.D.” stands for).

Ethical principles are not necessarily obvious nor intuitive, otherwise, there would be no ethical conflicts in society.  The more you can articulate and defend the principles that you stand for, the better prepared you will be in a system where ethical conflicts are likely to be increasingly common.

You may wish to familiarize yourself with Principles of Biomedical Ethics by Beauchamp and Childress.  I do not necessarily endorse its content, but this is a commonly cited and influential text which reflects mainstream ideas about medical ethics.  This should only be a start.

Philosophy of Medicine

Sample questions:

• 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 W.H.O. 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 the healthcare 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 healthcare policy rest.  Sometimes, those who promote a certain viewpoint will prefer that its 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.  I’ll admit it.  If I could summarize my recommendation in one word it would be this: Read!

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.  Read outside of your comfort zone.  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.

And don’t get discouraged by the sheer volume of the knowledge to be gained.  As I said earlier, the point here is to stimulate your curiosity about the proper questions, at a time when medical school demands are likely to quash you 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 become a doctor to be at the mercy of an unhealthy system, are you?