This is a Call
The recent Wall Street Journal article “Young Doctors Want Work-Life Balance. Older Doctors Say That’s Not the Job” kicked off a lively and important debate. The title alone stoked the intergenerational angst that permeates much of the professional world these days. Medicine is no stranger to this angst — it existed long before all the talk of work-life balance. I was a second-year resident when the 80-hour work week restriction was enacted. This regulation was not well received by many of my superiors who weren’t shy about expressing their displeasure.
Bear-poking headline aside, the article raises a related but slightly different question. Is medicine a calling or a job? It’s a complex question that hints not only at generational differences but also at larger issues facing the profession (burnout, loss of autonomy, lack of ownership). In this week’s post, we’ll delve into the calling vs. job debate, why it may not matter, and why it’s important to not to let it distract us from the bigger picture.
What is a “calling” anyway? How many people feel their job qualifies as one? Surely some do — but it can’t be everyone. In high stakes professions like health care, law enforcement, or the military, is it a problem if you don’t view your job as fulfilling a higher purpose? These professions require a level of personal sacrifice that the average 9-to-5 doesn’t. But does that mean they should completely define who you are as a person?
“Medicine as a calling” has a dark side. It’s been used to justify what can be a harsh, abusive, and toxic culture. Some see it as a prerequisite to withstand the rigors of medical training and the demands of a medical career. Lack of a deep, personal connection to the profession means you might not be up for the task. There’s a growing backlash towards this viewpoint, as outlined in the WSJ article. Has “medicine as a calling” been oversold as a vestige of a past reality or ideal that no longer exists? Today’s health care realities counter the romanticization of life as a physician. In short, being a doctor might be a calling, but it also might just be a job. The truth, as it often does, lies somewhere in between.
Legacy is strong in medicine — doctors are often children of doctors. Coming from a long family line of physicians makes a career in health care a natural choice. This is not unique to health care; many feel drawn to the family business by those who came before them. For others, the call to medicine is based on personal experience with illness. Experiencing the frustrations of a convoluted and broken system firsthand frequently spurs a desire to enter the medical field. In all these scenarios, it’s easy to understand the call to medicine.
I entered medical school in 1998 at the age of 21. How many 21-year-olds know their life’s calling? I’m pretty sure I didn’t. Maybe medicine was a calling, and I just didn’t fully realize it at the time. After all, my family has a medical background. My great grandfather was a doctor. My father had a lengthy career in health care administration and my mother was a nurse anesthetist. Despite this, I never felt pressure to become a doctor. My parents appreciated my academic success but never placed expectations on my career path. (Truth be told, my mom wanted me to be a veterinarian.) Neither of my siblings is in health care.
Becoming a doctor represented an opportunity to challenge myself personally and intellectually while impacting people’s lives. That my great-grandfather was a physician was not lost on me, but it wasn’t a major deciding factor. My parents’ careers subtly influenced my decision to apply to medical school. But I wouldn’t say I felt called to become a doctor. I was too young and naive. In fact, I’d argue I’ve only recently found my calling — to combine my clinical expertise, interest in technology, and passion for care improvement to innovate care delivery.
This career evolution makes sense to me. Sure, some people develop a calling early in life. They have a seminal experience or life-defining epiphany that profoundly shapes their personal journey. A certain profession meshes with their life’s mission and sets their path. Many others don’t find their calling until after they’ve wandered for a bit. And that’s the challenge with medicine as a calling vs. a job. Because it takes so long to become a doctor, the decision to pursue a medical career is often made early. It’s a life-defining decision long before you’ve had any real-life experience. How can you have a calling when you barely have a clue?
You don’t have to consider medicine a calling to be a really good doctor. But if being a doctor is just a job, it’s a job unlike many others. For most, it is not a 9-to-5 that allows you to punch in and out. Becoming a physician is as much a lifestyle decision as it is a career decision. The hours are long, even after training. The job tends to follow you home — difficult cases and unfavorable outcomes weigh on you. I still don’t sleep well the night before a complex surgery. Complications are a reality of the job no matter how talented you are. It’s hard to turn off being a doctor. Viewing medicine as just another job can lead to an existential crisis. For some, it’s a cruel epiphany to realize that, after years of training and mountains of debt, medicine is neither their calling nor something they can treat like a typical job.
The WSJ article generated a lot of discussion. But the “calling vs. job” debate got conflated with the larger problems plaguing physicians. We should refocus the discussion. Instead of asking whether medicine is a calling or a job, we should be asking what we can do to make it a more attractive profession. Doing so would prevent people from leaving and ensure that our best and brightest still see value in a medical career. Work-life harmony is possible with the understanding that the balance will always be a bit skewed. As many pointed out, dissatisfaction with a career in medicine is linked to loss of autonomy, a worsening economic environment, and a lack of ownership. Solving these issues will create a workforce of physicians up for the job — one that increasingly views medicine as a calling, even if it didn’t start out that way.
Small Incisions
In Vermont, Where Almost Everyone Has Insurance, Many Can’t Find or Afford Care (KFF Health News)
Vermont is one of the healthiest states with low uninsured and unemployment rates. But Vermonters pay the highest prices, and its providers and insurers are struggling financially. Wait times are up. Patients are leaving to get care in neighboring states (driving costs up even further). The University of Vermont Medical Center controls two-thirds of the market but has driven up commercial rates to offset low-paying public insurances. Rural hospitals struggle to attract doctors, are losing specialty services, and are at risk of closing. More coverage does not equal better coverage. Declining public insurance reimbursement leads to cost shifting (which harms businesses). Consolidation drives up rates. Strict regulations stifle innovation and competition. It’s a sobering microcosm of all that can go wrong in American health care. And a constant reminder of where the problems, and solutions, lie.
The Curious Persistence of Site-Dependent Payments (JAMA)
“A hallmark of health policy is that even simple fixes are hard to implement.” Could have stopped the article after the first sentence and would have had a profound, hard truth. But this article is another lesson in the manufactured complexity of the American health care system. Employer HR departments are overwhelmed and underinformed. Middlemen obfuscate processes while profiting from the confusion. Hospitals and health systems flex their lobbying muscles and status as the largest employers in a region to protect their own interests. But there is hope here, and nonhealth system employers are getting smarter and banding together. A fifty-year-old piece of legislation (the Employee Retirement Income Security Act, or ERISA) is finally being leveraged to its full potential. A growing trend is emerging — smart people working on viable solutions.
What you need to know about CMS' TEAM payment model (Advisory Board)
Joint replacement surgeries continue to be a key area of focus for CMS value-based care initiatives. CJR and BPCI are sunsetting in the next year or so, set to be replaced by the Transforming Episode Accountability Model (TEAM). Like CJR, TEAM is mandatory — something the AHA is already pushing back against. To be fair, some hospitals participate in multiple value-based care (VBC) models including ACOs. These programs are challenging and costly to administer, placing a significant burden on smaller, less resourced facilities. CMS has offset this by offering different TEAM tracks with various levels of upside and downside risk. Will TEAM be successful where other CMS/CMMI models have struggled? Or will it be another example of complexity begetting failure? Elegance is simplicity — something we haven’t yet seen with VBC models. Maybe the simple answer is to let health care markets go to work.
Ben Schwartz, MD, MBA
Editor-in-Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
Thanks Ben... my commentary below on the WSJ article.
Since seeing my first OR at four years of age, being a doctor was always a calling for me. Anniversary dinners, birthday parties, and even holidays with my family, have been cut short with call from the hospital about a sick patient. The long hours, little or no sleep, and at times, an overwhelming number of patients, was our duty to see through, in the name of patient care.
I am both reflective and sympathetic – as a surgeon I was less available for my family, and even when I was physically there, I was not always present; my pager or cellphone always took precedence.
We must do better… if our physicians are not healthy, how can they be at their best for their patients?
I greatly enjoy how you can step back and look at things from a little distance even though you are knee deep in it.
I agree with much of your take on this but would also challenge that again maybe we aren't asking the right questions. If we decide that being a physician isn't a calling but rather simply a jobber we as patients and a society ready to accept that as well?
If being a physician is simply a job then it should be reasonable that those that are better at it should get paid more. Are we ready to accept a model that those with money get better care? Are we as patients and society ready to accept that if I'm a higher risk lower profit I get bumped for the more straight forward higher profit case? Are we ready to accept that if the day runs long and our case doesn't get to the OR by 5 that we get moved to the next day or available slot or that we get charged time and a half for "overtime".
We continue to focus on "fixing" healthcare from the physician perspective when the reality of whats broken is all those that have "job" profiting off the work . Those that say healthcare is too complex to fix are those that are adding the complexity. Those that say they wish to fix burnout are those that are adding the burnout. I literally know 1000s of doctors I spend hours with them and not once have I heard a surgeon say "if I have to do one more rotator cuff or total knee or heart bypass ..... I'm going to explode" I do consistently hear "if I have to do one more preauthorization or one more peer review with someone whose never seen my patient or if have to log onto one more useless EMR.
If we really wish to fix this we need to start Fromm the physician patient and work up not from the revenue down.