Clinical Guide The Nerd's Guide to Pre-Rounding Table of Contents Part 12. Soapbox Physicians and the Snare of Egoism Physicians are notoriously self-involved. This country’s traditional medical culture reinforces narcissism and competitiveness in its members, almost from the first day of pre-medical training. While being concerned for one’s own personal well-being is a natural human trait, when taken to extremes, it can produce a great deal of disharmony. In the case of our own profession, overemphasis on the physician as the center of her own universe has led to some of the unnecessarily brutal aspects of medical training in this country. It also explains why our profession, more than any other allied health profession, is struggling enormously in the face of a changing American healthcare system. Many doctors in this country still operate as if it’s 1970-something, and each doctor is his own corporation: "I am Dr. Bob Jones, Inc." At most, they might conceive of themselves as part of a small group of affiliated fellow physicians. This fails to face up to the reality: To managed care and to integrated health systems like Kaiser, we are widgets—cogs in their machines. The fact that I, Dr. Bob Jones, am especially skilled in taking care of older patients, or catching tricky diagnoses, or working with depressed patients, or whatever - whatever individual skills I’ve cultivated in myself in which I take great pride - is totally invisible to the health care corporations.[19] American doctors persist in the delusion of themselves as individual corporate entities. Their interest in maintaining their individuality, self-determination, and mild competitiveness against their peers, above and beyond any inclination to cooperate with those peers, is part of why doctors are failing so miserably to adapt to the rapid changes in U.S. health economics. If you could give out letter grades to the health professions for adjusting to the new conditions, doctors would get an "L"—for "Losers." Our inadequacy is especially clear when you compare us to nurses, PA’s, PT’s—most of the other professions are thriving. Meanwhile, docs are working harder than ever, yet satisfaction levels among young primary care doctors are actually lower than those for older docs. I think our profession could get a clue from other professions, such as nurses, in which individuals are unified, and cooperate within professional organizations and unions. To thrive, and not just survive, physicians are going to have to start thinking about the well-being of their profession, not just of their own specialty or individual practice. In medical education, the profession has fostered this sense of competition with practices such as numeric rank of students by test performance—as if we were Fortune 500 companies, whose worth is measured unidimensionally. The unfortunate psychological effects of the ruthless competitiveness fostered by such practices were only slowly realized. There is a reason grades were eliminated at UCSF for the first two years. Some of us wonder what effect it might have to eliminate them from the entire process. What does this have to do with us? As you embark on the wards, consider how the sense of competitiveness emerges, in yourself and your peers. Resist the temptation to focus on your own performance, to the exclusion or even detriment of your classmates. And consider how an over-emphasis on self-interest within our profession as a whole has been our undoing. If you’re going to compete with anyone, compete with yourself. Many of us arrive at medical school with the goal of producing one excellent doctor - ourselves. The truth, however, is that we are here to produce as many excellent doctors as we can - ourselves, our classmates, our teachers, our residents, and even our attendings. The flow of knowledge on the physician team is not unilateral. We, too, have something to teach our superiors. I took the effort to assemble the above guidelines, simply because I want each and every one of you to be the best you can be on the wards. If these notes have helped you, think about that, and look for opportunities to extend similar assistance to your peers as you wend your way through third year. I’m sure you’ll take good care of your patients on the wards. Take good care of each other, too. [19] Comment: The June 22, 2000 New England Journal of Medicine features an excellent, and overdue, editorial about the abuses by the U.S. drug industry. It may seem that buying lunch for a bunch of tired, overworked students and residents is harmless. But companies have the excess money to throw around on such perks for us because of their de facto monopolies and exploitation of U.S. consumers, who pay for companies' huge profit margins. Such perks have been shown to influence prescribing practices-based on factors obviously beyond the literature. I'm not trying to rain on the parade, and in 3rd year I did at times indulge in a free lunch (but usually I packed my own). Still, it's important to remember that there's no such thing as a truly "free" lunch. In fourth year, I had the occasion to sit in on a drug company lunch at a certain subdivision of the Dept. of Medicine. The rep had bought three times as much food as the entire department could eat! At the end of the day, there were still whole platters of food, untouched. Not wanting to see them go in the garbage, I took them to the student lounge at UCSF. If you see platters of uneaten food sitting on a table after lunch, ask the responsible administrator to please call Foodrunners.org at 415-929-1866. This SF-based group picks up leftovers from businesses and takes them to homeless shelters in the City. You may need to store the food in a fridge for 24 hours. To my knowledge, only the UCSF Dept. of Family and Community Medicine has made it official policy to decline drug company lunches. Other departments at UCSF would do well to follow suit. Many medical centers, such as UPenn, have made this universal policy. Meanwhile, individual medical students and doctors can take a pledge to decline drug company promotions (including the often slanted promotional "literature" handed out during lunch) at http://www.nofreelunch.org. [Back]