Note:  I wrote this column for the American College of Physicians in the Summer of 2007 for my fellow internal medicine physicians.  At a time when physician professional satisfaction was (and unfortunately still is) so low, particularly among internists, I wanted to remind my colleagues of the fundamental reasons we all first chose to enter the field of medicine.  For the non-physician reader, I hope you are reassured, at least a bit, that most of us doctors really do have your (i.e. the patients’) interests at heart and that our motivations are what you would want and expect.-EMM

“Some Good Things”

With the summer upon us, the kids out of school and vacation time imminent, now is perhaps a good time to reflect upon some of the positives of our profession. Most of the time, it appears that our lives as physicians, as well as our discussions concerning medical practice, are dominated by the issues of paperwork, insurance hassles, malpractice litigation, unfairness, underpayment, under-appreciation and overwork, all of which characterize the day-to-day life of the internist in the 21^st century. Nevertheless and somewhat surprisingly however, internal medicine remains the largest specialty choice in the National Resident Matching Program, applications to medical schools continue to rise (and have risen annually since 2002, reaching 19,815 applicants in 2006) and medical schools remain highly competitive, with less than one of two applicants accepted in 2006 (according to AAMC data). Children of practicing internal medicine physicians continue to unceremoniously follow their mothers’ and fathers’ footsteps into medical school. And, in the quiet and intimacy of honest conversation, a large proportion of internists will admit (almost embarrassingly) that they love being doctors and would choose the profession all over again if the opportunity were presented to them.

How then do we explain this disconnect between the real, pervasive, destructive and bureaucratic forces frustrating the practice of medicine today (and against which we struggle) and both 1) the resilience and loyalty of its current practitioners and 2) medicine’s continued popularity within the rising generation? I believe that the answer lies within the core values of our profession, in the essence of what we do every day. It is indisputable that no matter what occurs in the economic and political environment that surrounds us, the practice of medicine was, is, and will always be a noble profession. No matter that some bureaucrats may try linguistically to reduce physicians to “providers” and our patients to “clients”, we will always be doctors who care for patients, in our own eyes and the eyes of the public we serve. It is no surprise that in this post 9/11 world, a 2006 Harris pole found that doctors ranked only second to firefighters as the most admired profession in America.

A further exploration of the term “profession” may be informative. Professions are strictly defined as learned, self-regulating occupations that require extensive training, mastery of a specialized body of knowledge and skills, incorporate an internally-defined and administered code of ethics (to which members of the profession formally commit themselves via oath) and require regular advocacy for another group of people who themselves, lack the specific knowledge that would be necessary for their own advocacy in that specialty area. Originally, only the ministry, medicine and law were considered professions and although the term has broadened and become more inclusive in recent years, medicine still epitomizes the essence of what it means to be a “professional”. I would posit that it is the core values of professionalism inherent within the practice of medicine that create our unique relationship with our patients (that persists despite the external environment) and are the source of gratification that sustains us today.

At its most superficial level (as I frequently tell medical students and residents), physicians never have to arrive home in the evening, or look back after an entire career, wondering if their time has been well spent and they have accomplished something of value. At its core, medicine is a profession whose entire existence is dedicated to the relief of suffering and improving the life of our fellow woman and man. How can one ever question the value in that? But, our role in our patients’ lives is profoundly more intense and our responsibilities are far more weighty than those required of one human being simply helping another. I would suggest that the professional relationship that exists between an internist (or family physician) and his/her patient is rivaled only by that of a congregant and his/her minister for its intensity and its depth of candor and honesty. When patients seek physicians’ help to prevent and/or treat their illness, they voluntarily open a unique and intensely personal window of communication through which no one but us, as physicians, are permitted to see. They will tell us the most personal and intimate things about themselves; things that have never been articulated before, that are unknown even to parents, and sibs, and spouses. They open this window with the explicit expectation that we will use the information they provide wisely, to help them heal, confident and that we will not otherwise exploit or violate their privacy. What a privilege! And, what a responsibility! Furthermore, in our singular position as physicians, patients grant us unique access to their physical bodies in ways that would be unacceptable, even illegal outside of the doctor-patient relationship. We are allowed to touch and probe in the most intimate places, we are permitted to stick our patients with needles, cut them with knives and administer potentially toxic chemicals to them. Even just our simple words, gestures and attitudes can carry profound weight; providing compassion and hope and solace. We do all this with their (and society’s) confident expectation that we are acting selflessly and in our patients’ best interests. I don’t know how anyone can be anything but humbled by this responsibility! And, I don’t know how this unique relationship with our fellow human beings, this privileged profession which we occupy, can be anything but rewarding and fulfilling.

The unique access provided to us by our patients necessarily carries with it awesome responsibility. I am fond of challenging my residents not just to achieve clinical competency, but to aspire to clinical virtuosity. Do patients, whose intimate stories, emotions and physical bodies are splayed open before us deserve anything less than a virtuoso physician to heal them? In exchange for the level of unprecedented access they grant, is there not an absolute moral requirement that we, as physicians, become the most skillful and knowledgeable that we can possibly be? And, isn’t it this imperative, this challenge and responsibility, this one-to-one personal accountability to another human being, that sits at the core of the profession of medicine and that which both challenges and nourishes us as physicians?

One may be distracted by the dysfunctional regulatory and business environment in which we practice, but the core experience of being a physician can never be diminished. I believe that we as physicians are privileged to know our patients (and thus to experience humanity) from a unique perspective, one to which no other group of people in the entire world has access. We occupy a central and singular role in our patients’ lives, one that only a physician can fill. We prevent their illnesses, heal their sicknesses, share intimate concerns, celebrate victories and comfort their dying. Every day, we participate in and share the most intimate aspects of life with the wonderful diversity of humanity who seeks our help. And it is this extraordinary experience of being a doctor that provides us compensation far beyond dollars; an experience and a profession which enriches and rewards us personally as human beings as no other occupation can. This is the daily experience that we share uniquely as physicians and for which we can all be thankful. So, as the temperatures rise and you have a moment to contemplate your career in internal medicine, don’t forget the “good things”, the things for which you entered medicine in the first place, the things that make your efforts all worthwhile and which are just as real and just as available today as they were when you first decided to become a doctor.