Has Your Doctor's Success Required More Competitiveness Than Compassion?

I am a patient, mentor, scientist, and health training innovator who is totally blind and a very brittle type I diabetic. My unique history of mentoring, research and managing disability convinces me that we allow our physicians to be ignorant of how 145 million chronically ill Americans and millions more with disabilities like me--and possibly you, too--live, love, work, and yes, die.

I have worked with hundreds of caring people from first year undergraduates to full attending physicians and am convinced our current system too often promotes physicians in training based on their ability to be competitive, not compassionate. We create health professionals who are neither experientially nor psychologically prepared to see the rewards in managing people like me - or your spouse's grandparents, who need more than $1 trillion a year in long-term assistance. Our system all too often asks untrained friends and families to provide assistance before and after the brief, "interesting"(aka complicated or unusual) interventions too many physicians offer before we are shuffled off to other people who support us through the long, relatively uneventful slog we face after we leave the clinic.

Our physician training system currently increases suffering for patients like me and the millions of community caregivers who help us. It raises healthcare costs and adds significantly to physician burn-out because we neither select for empathy nor prepare future doctors to understand how patients work, live, and die.

Even though their training doesn't teach the empathy young people often lack, I've had to tell the hundreds of candidates for medical school admission whom I've mentored that a great "story" includes outstanding scores, grades, recommendations, extra-curriculars, and research. Most of these require lots of study but no interpersonal skills. Almost every pre-medical student I have mentored complains that earning outstanding scores, grades, and recommendations rewards competitive behaviors, not compassionate ones.

Many full-time pre-health advisors and most pre-medical students believe admission to "dream" medical schools like Harvard, Stanford, or Washington University requires lots of time doing laboratory research. This is supported by data from the American Association of Medical Colleges showing that "good" research is particularly attractive to these schools that ideally train academic physicians; but most of whose graduates will primarily work with patients.

Unfortunately for millions of patients who depend on our healthcare system, most students who earn degrees from primary care focused schools like the Medical College of Georgia also shoot for "dream" schools like Emory. Emory therefore shapes the applicant pool of MCG whose faculty recognizes that training students to manage the chronically ill and the caregivers who give 40 billion hours a year helping patients, is likely to decrease costs and suffering more than Emory's arcane research will.

Doing "good" research requires competition to get noticed by the "right" lab director. Once in a lab, undergraduates working toward their bachelor's degrees often experiment on yeast, flies, or mice for at least fifteen hours a week during the year and fifty or sixty hours a week in summer. Their co-workers in the lab are socioeconomically similar to them (i.e.: they are generally far younger, better educated, healthier, wealthier, and less likely to be African American or Latino than most patients are). Lab work, therefore, doesn't offer much interaction with patients whose lives are very different than those of our future doctors.

Once in medical school, students keep competing. They need high grades along with high "board" scores to get into the "best" residencies. They learn and regurgitate 20,000 facts. They must put thousands more hours into lab work in order to publish papers that are, again, necessary to get into competitive residencies and later, prestigious fellowships where strong pressure to publish still exists. Little time is opened for trainees to work in patients' homes or offices even though they will learn more in homecare about how your elderly uncle manages his health than in medical school classes or residency rotations.

After fellowships, which often require trainees to spend 50% of their time in the lab, they become attending physicians. They now know behaviors leading to good grades, scores, research, and recommendations (often ignoring their interactions with co-workers or patients), will help them succeed in medicine.

And then....life changes. Self-focused behavior is still OK, (after all, practicing physicians can and do refuse to take patients who probably won't do well) but helping people very unlike themselves is finally the full time job - a job young doctors aren't psychologically, experientially, or emotionally prepared for.

How can this be changed? First, service is quantifiable just like scores and grades. The American Medical College Application Service which handles students' applications currently classifies service as "significant" or not. Most physician assistant training programs require candidates to show 500 hours of direct patient contact before applying. Medical school applicants (who spend almost twice as much time in school but who aren't required to have patient contact before applying), should have 1,000. Second, we must implement programs that put training dollars into community/family medicine much as the Institute of Medicine asked us to do in July 2014. This would make primary care more financially attractive to students who must often become specialists, not because they want to, but rather because they need to pay off up to $350,000 in debt and can't do this in family medicine. Waiving medical school debt for primary care physicians would reduce the long-term cost of healthcare. Medicare, which funds most residencies and would save billions by emphasizing primary care, should fund only residencies and fellowships with no more than 10% of their training time in research and require 90% time on direct patient care. This would also spread the $15 billion we spend yearly on resident training across America rather than supporting only a few well connected East Coast hospitals.

Scores, grades, and many recommenders will always reward selfishness, but these proposed changes would quantify service time, decrease financial incentives for specialization, and increase clinical service time. By taking these actions we will better prepare our future physicians to help the rest of us live full and healthy lives.