In his commencement address at Kenyon College in 2005, the late author David Foster Wallace told the story of two young fish swimming along. They pass an older fish swimming the other way who greets them: “Morning boys. How’s the water?” As they swim on, one of the younger fish responds to the other, “What the hell is water?”
Feeling and appreciating your body of water takes experience, maturity, and occasionally someone else making you aware of your daily surroundings. It was not until a few years into my career as a Family Medicine physician that I realized the furious pace at which American physicians learn to swim, insulated in a system that operates in stark contrast to that of other countries around the world.
What kind of young physicians is our system creating?
Six months into my first year of residency, I was on a rotation with an energetic Orthopedic Surgeon. Our residents looked forward to our time with him. Residency training is a time for young physicians to drink from a fire hose of information during long work hours, learning not just clinical medicine but also the business of healthcare. As we stood outside the exam room preparing to see the next patient, the topic of medical malpractice came up. He stated, “Every time I walk into a patient room, I see the patient in front of me, the insurance representative on the right, and the malpractice lawyer to the left.”
At morning report following nights on call in the hospital, we would present each admitted patient to our Attending Physician who taught us clinical pearls and also regaled us with stories regarding malpractice cases that had arisen from similar situations. He helped us refine our documentation and ensure our trail of charting and medical care would back us up in the event of a lawsuit.
Several times faculty physicians reinforced my plan to order studies to ensure a life-threatening condition was ruled-out. Many could have been reliably excluded with physical exam signs or patient risk factors, but I had been trained to rely on technology to definitively prove my clinical hunch. I have never been the subject of a medical malpractice lawsuit, but I practice as if I have.
So each month, I gathered nuggets of information from my professors regarding medical business practice, detailed documentation, and using technology to prove diagnoses. These lessons all slowly seeped deep into my practice habits. And, much like an older brother repeating a parents’ teachings to a younger impressionable sibling, I taught these to junior residents and medical students.
Then came several stints in a rural health center in Kenya and a three-month course in tropical medicine put on by the London School ofHygiene and Tropical Medicine in Tanzania and Uganda. My classmates were from the United Kingdom, Australia, Germany, Tanzania, Uganda, and even Botswana, among other countries. Out of the 57 young physician students from around the world, I was the only American. Through work in the resource-limited health center in Kenya and a subsequent year of teaching medicine in East Africa, and discussions with my tropical medicine classmates, I started to see my water more clearly.
Fear of medical malpractice lawsuits and defensive medicine are unique American system attributes. The private fee-for-service system without a firm foundation of public care is an American trait. Patient cost sharing having no basis on the actual cost of care makes the US health sector unlike any other. Mountains of educational debt following medical school are only found in the American system. The large pay increase that first year as an independently practicing physician after postgraduate training is a massive incentive only present Stateside.
How do these elements affect healthcare delivery in one of the strongest economies on the planet?
In the documentary film Escape Fire, former Centers for Medicare and Medicaid Services Administrator Donald Berwick says he does not blame anyone in the American system for doing what they are doing. Hospitals fill hospital beds because they are incentivized to do so. Physicians enter lucrative sub-specialties at times partially motivated by the need to pay off educational debt, and many go straight through medical school and residency eager to absolve that debt. Seventy-six per-cent of American physicians graduate medicalschool with an average of almost $190,000 of educational debt. Can we blame them for sometimes seeking more profitable specialties and blazing straight through training? I finished training as quickly as possible at the age of 29 with just over $200,000 in debt and no savings, and then entered practice in the fee-for-service system. And the path of least resistance was to follow the volume-based carrots laid out by my predecessors.
The lessons of older physicians are percolating down to breed younger physicians with similar attitudes. And that should be concerning. What were once young idealistic physicians, are now caregivers entering a post-Affordable Care Act system with the same views as a physician who was raised in the fee-for-service scheme.
How do we incentivize young physicians to enter the right mix of specialties and shape them to serve an aging population in a changing system?
We must start by addressing the cost of medical education. Without the heavy debt burden, financial incentives lose their power. Next, improve the pay during postgraduate training, while encouraging, through funding or built-in time away from the home institution, extended breaks in training if the physician so chooses. This time away could be used for international rotations, administrative or policy placements, or exploring research opportunities that interest them. For example, young British physicians take months, sometimes years, away from their postgraduate medical education to work with non-governmental organizations (NGOs) or in academic settings in low-income countries. During this time out of their comfort zone, physicians have more time for self-reflection while pursuing personal interests. This may very well extend the length of training, but without debt creating the race to finish, this would be less bothersome to young physicians. In fact, many young physicians start out craving these seemingly extracurricular experiences, but there is currently little time or support for what would be key to a physicians’ personal and professional growth.
When the system of education changes to encourage outside perspective gathering experiences, our system may well end up with physicians whose incentives better align with the most important healthcare player of all: the patient. That physician will be more confident in her physical exam skills rather than relying on technology, which will in turn lower costs in the most expensive healthcare system in the world. That physician will be more in tune with herself and the need to care for herself before caring for others, thus lowering chances for burnout and improving longevity. That physician will be more empathetic to patient needs, leading to higher quality care.
One must smell poverty to recognize the stench of inequality. You have to be confronted with true hopelessness to detect suffering. You must feel, at some point, uncomfortable to identify vulnerability.
Learning medicine takes years of study, sacrifice, and repetitive pattern recognition. Caring for another human takes a self-awareness that requires an intimate full sensory appreciation of your surroundings. And only with these skills sharpened, can the leaders of our health system take that vital swim alongside their patient.