If having work-life balance is important to you, then don’t become a doctor. That was Dr. Karen Sibert’s advice to students considering careers in medicine, in a controversial New York Times op-ed last summer. “You can’t have it all,” Sibert wrote, exhorting students — women mostly — to remember that “medical education is a privilege, not an entitlement, and it confers a real moral obligation to serve.”
If you want to work and be a mother, then you can find a job in journalism or professional cooking or law. But “if you want to be a doctor, be a doctor,” wrote Sibert, an anesthesiologist, concluding: “Patients need doctors to take care of them. Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient; it deserves to be a life’s work.”
Sibert’s piece likely sparked countless conversations — and moments of doubt — at medical schools around the country. Ours was no exception. In the wake of Sibert’s column, Gina Siddiqui, a medical student at University of Pennsylvania, where I teach, and I launched our own conversation about being a doctor-in-training and how doctors ultimately fit into the future of health care in the U.S. We recruited other students to participate, including second-years Alexandra Charrow, Derek Mazique and Ofole Mgbako.
What follows are excerpts of that roundtable conversation. Driving the debate was the question of whether being a doctor is in some way exceptional, more important to society than any other profession. I started the ball rolling thusly: “What do you guys think is your duty to society, and how do you feel it is different from that of your peers going into other fields? Should all doctors have to work full-time?”
The students’ responses:
Alexandra Charrow: Implicit in what you’re asking is the question of whether doctors are “special,” so special that we should be required to work additional hours and so integral to society that we have additional duties. For the 60 or so years that physicians have been able to actually cure people there has been an increasing fetishization of the field. Numerous TV shows and movies romanticize the occupation, feeding into a belief that medicine is the grandest and noblest of professions. Medicine is not the only profession with the power and duty to save lives — air traffic controllers save lives every day. Yet how many shows are there about air traffic controllers? We are not alone in our unwavering responsibility, our duties, and our power.
Derek Mazique: The complexity of medicine, the physician shortage, and the rise of managed care almost guarantee that physicians are no longer the only decision-makers in the room. So now, I think physicians are decidedly “less special.” Are they skilled and necessary for the average consumer? Yes, but so is their accountant.
Ofole Mgbako: Through my experiences with people living with HIV, I realized that the way people readily share the most intimate details of their lives and entrust their bodies with physicians is unlike any other profession. Each interaction with a patient is based on an unspoken covenant, a belief that the doctor not only will do no harm, but also will try to relieve suffering. I believe this basic, universal interaction between patient and physician engenders a greater responsibility on the part of physicians. It is difficult to speak to how much this dynamic sets us apart from the teachers, the lawyers, the scientists, the politicians. However, this dynamic does set us apart to some degree.
Regardless of how much more “exceptional” doctors may be — indeed, Sibert’s original argument was that doctors not only play a special role in society, but also that there are necessarily too few of them to justify any of us choosing to be a part-time doctor — our student moderator, Gina Siddiqui, concluded that forcing physicians to work longer isn’t necessarily the right answer. “I don’t know if it’s feeling special or a strong sense of duty or what, but on balance, I think most doctors will choose to work more, and coercing more hours out of those that don’t is unlikely to do much good for patients,” Siddiqui says. “For the record, I think everyone should think his or her job is special, just like every mom should think her kid is special.”
Given the students’ debate, I wondered further whether their views on the exceptionalism of doctors — and on the importance of work-life balance — were affecting their choice of specialty, particularly in light of the deepening primary care physician shortage. I asked them: “Do salary and lifestyle play a role?”
D.M.: Both my parents are in primary care, and seeing them practice has been a powerful example of how the field has changed. Perhaps most telling for me is how the current primary care situation is a perfect storm of low reimbursement and doctor burnout. Both of my parents have had to increase the number of patients they see — for my mother who is in private practice, that’s the only way she can keep the lights on. I didn’t go into medicine in order to emerge as a strictly lifestyle physician … but I did go into medicine expecting to forge meaningful relationships with my patients and to perform my intellectual craft to the utmost. Primary care in its current iteration makes these goals seem even more difficult. Of course, money is a factor, but these expectations of a personally fulfilling medical career also steer my decision-making process.
A.C.: Personally, I recognize the pressure and fear … that either my family values or career choices will have to change. I often meet physicians who tell me it’s possible to have both a family and a career, but for the most part, they are men with wives who have made the tough decision to work part-time for them. The women I have met have painted a more pragmatic picture — you can have what you want, just not all of it.
D.M.: All of us have been fixated on the profession, the role of lifestyle when picking a specialty, and our own particular experiences as medical students. But at the end of the day, our concern for the patient should be paramount, and it’s also worth exploring the effects that these choices will have on them. If a surgeon spends less time in the operating room, will he or she show a greater error rate and will more patients be harmed? If doctors work shorter shifts and hand off patients more, will discontinuity of care lead to a spike in adverse drug events and complications?
A.C.: This reminds me of the arguments hashed out concerning reduced residency work hours. Certainly there are many who still claim an 80-hour max workweek has reduced quality of care. However, others would argue that extra sleep, spending time with family, and eating regularly make up for reduced hours. I imagine that at some number of hours of experience, the quality of care reaches a plateau. With people working well into their 60s, 70s, and 80s, perhaps it is better to allow physicians to slow the rate at which they accumulate expertise in order to make their lifelong commitments to their specialty more sustainable. If doctors are able to fulfill other life obligations early in their career, they might be willing to stay in the profession longer, allowing society many years to benefit from a skilled physician’s services.
O.M.: What’s interesting to me is the tension between being a balanced, content physician who explores his or her interests outside of medicine and being an extremely driven workaholic who gives up family time and other hobbies in order to be engrossed by work. Thus, in addition to the monetary concerns Derek brought up, I think more medical students will be drawn to specialties that allow them the flexibility to explore other aspects of themselves in addition to medicine: in addition to [being] future doctors, my peers are journalists, writers, musicians, entrepreneurs and engineers.
As a teacher of medicine, I was inspired and not a little bit relieved that the students in our program had given so much thought to their training and the way their own values were shaping their decisions as up-and-coming physicians. But the question remained, How does the role of the individual doctor fit into the greater context of American health?
Our student moderator concluded with another shrewd observation about the state of our country’s health: that our well-being is bound largely to our environment, and not only to the quality or quantity of the health care we receive. “Looking back on our discussion, I am struck by how the increasing sophistication of medicine hasn’t made a single one of us feel a greater sense of control over health outcomes,” Siddiqui says. “The more we learn about the causes of disease, the more interrelated we realize our work is with farmers, urban planners and school counselors. In this environment, our aspirations to heal are bound less to our office hours and more to the communities we cannot afford to be strangers to.”
I am not surprised that the students pushed back against Sibert’s essay. This discussion could have easily become about self-determination and the right to determine the shape of one’s own career. But, instead, these students challenged Sibert by using humility and introspection — which bodes well for their future patients.
Dr. Meisel is a practicing emergency physician and assistant professor of emergency medicine at the Perelman School of Medicine at the University of Pennsylvania. He is medical editor of the LDI Health Economist from the Leonard Davis Institute of Health Economics. Follow him on Twitter at @zacharymeisel.