Unhappy Medicine?

This past week I became aware of the results of a recent survey conducted by the Doctors Company. The Doctors Company is the nations largest medical liability insurer. The survey was done among >5000 U.S. physicians with good representation across specialties, age, sex, etc. One result particularly stood out:  Only 11% of physicians today would recommend medicine to a friend or family member.


Contrast the 11% figure with the 39% of Harvard's 2010 graduating class marching onto Wall Street. It is true there is an apple and oranges quality to this comparison but if the nations best and brightest college graduates become more aware of the discontent in medicine and even law (see http://tinyurl.com/2g5ahq4) the number heading to Wall Street may climb even higher.


Why all the unhappiness? To be fair there is no single answer to this question. A struggling economy doesn't help. Uncertainty about the future of health care doesn't either. I would, however, like to suggest one possible answer that relates to bioethics.


Anne Fadiman’s book The Spirit Catches You and You Fall Down has been widely praised as a fine example of medical anthropology that emphasizes the need for greater cultural competence among U.S. physicians. The book centers on the life of Lia Lee – a Hmong girl with severe epilepsy born in the U.S. to native Hmong parents. Despite both cultures seeking to do what was best for Lia neither succeeds. The immiscibility of the two cultures made a difficult situation worse. While the book is particularly sympathetic to the Hmong people, the struggles felt by the involved health care workers is also featured. There is a sense of defeat among the health care workers as there was no effective communication between themselves and the Hmong people. The clinicians in time may have become more cultural competent among the Hmong but there is no doubt which view of medical science they saw as 'correct.'


Given the calamities between Lia Lee's family and western medicine there is hope for positive change; western clinicians becoming more accepting of different and sometimes divergent cultures and lifestyles. Indeed this sort of perspective aligns well with a growing sense for patient-centered care. There is, however, the possibility that lots of different cultures and/or lifestyles could render a sort of paradox of choice. Just as too many options for a given type of product may tip at some point to induce consumer dissatisfaction, perhaps too many cultures contribute to clinician dissatisfaction?


Among the cited reasons for physician dissatisfaction is disparate expectations of patients. There must be settings where the expectation gap arises from differences between cultures. Lia Lee’s parents had expectations of Western medicine that could not be realized. While health care may attempt to accommodate different cultures insofar as they interface Western medicine per bioethicist Tristram Engelhardt there is ultimately no basis to define which culture is ‘right.’ Should I consult the shaman or another physician in this difficult cross-cultural case? Reacting to this view some might say, ‘but it is not important to know which is correct’ this is a setting of ‘both’ ‘and.’ Herein is the appeal of choice but does western science, to which medicine draws its strength, accommodate more than one 'right' answer? What moral guidance can be gained without a referent? Some aspects of choice between cultures can be celebrated but not all. Lo Mein and wienerschnitzel can appear on the same menu but there is not ordinarily a buffet for the answers to scientific or moral questions.


Facing any given patient, a clinician today cannot be sure of the merit of his or her wares. Is longer life a good thing or a bad thing? What is normal human function to which medicine aspires to restore? Do we 'fix' the seizures or just better appreciate the families perspective that the seizures portend a future in shamanism? The clinician today may be unhappy because at the end of the day the same act in two different patients may in the one be heroic and the other failure and in both cases divergent from the physician's personal view on the 'correct' outcome. Practicing medicine has become less linear. It is an unreasonable expectation that as a clinician becomes more adept at his or her care, patients will inexorably ‘benefit.’ Benefit can become so nebulous an outcome that short of a stable referent clinicians cannot help but at times become despondent.


Wall Street does often look more appealing. Money is a much more universally and easily understood good...even if love of it is the root of all evils.