Recently, my colleague Lisa Rosenbaum, MD, and I led a series of interactive grand rounds titled, “Is Medicine a Job or a Calling?” These conversations were inspired by our own angsty discussions about shifting expectations in our teaching and observations of often divisive social media threads. Rosenbaum has thoughtfully explored the origins and implications of this generational divide in her New England Journal of Medicine series and podcasts, which should be required for every physician — young and old.
In our presentations, we relay our own unsettling experiences and exposit the extremes — from “In my day, it was a privilege to be a doctor,” to “My demanding job is a means to earn a living and pay my debts, and life is what happens outside of work.” Then we turn to the audience for their lively feedback. Predictably, the front row (boomers) responds first, and the back rows (in training or recently trained) wait patiently before adding their equally heart-felt perspective. Consistently, the word “calling” becomes a generation-dividing fulcrum.
The front-row doctors reminisce nostalgically about their treasured memories caring for patients and families in their most desperate hour, and the trust they earned; these physicians then point to the essential medical and life lessons learned over exhaustively long hours of dedication. They recall their pride in supporting the hospital’s mission to care selflessly for the most vulnerable.
From the rear, we hear versions of, “my job doesn’t love me, why should I love my job?” Rather than sensing appreciation for the value of their sacrifice, they report feeling like widgets in a huge, inefficient, possibly unsustainable, and rarely patient-focused health industry, whose mission seems to have become making money.
Changing Times, Changing Perspectives
A calling refers to a vocation or way of life that ministers to (cares about) others. Implicit in this definition is selflessness and uncompensated or undercompensated service. Clergy remain the most prominent example of a calling.
For my generation (graduated medical school in 1991), caring was our central professional identity, but it came with unwritten expectations and privileges. Medicine offered fewer therapeutic options; less regulation and billing rules; more continuity with hospitalized patients and their families over the ebbs and flows of their illnesses; and assuredly more time in the hospital. With the predominance of white men in my cohort, fewer of us were expected to play large roles at home and in child rearing, sadly.
In 1938, Rufus Cole, MD, lightheartedly summarized the intern’s assignment: “During your intern days the hospital should be your home, your workshop, and your playground… Learn to shun outside affairs that will complicate your life…rejoice if you are too poor to own an automobile…avoid the movies, you will find sufficient tragedy as well as comedy close at hand. Above all, avoid like a plague entangling affairs of the heart…I am still convinced of the soundness of Dr. Osler’s advice to ‘put your affections in cold storage during your intern years.'”
It was a simple calculus — we trusted that our hospitals and program directors had our backs and that our long hours would lead to respected careers and a comfortable lifestyle.
Young physicians today are equally talented and dedicated and generally have mastered a broader bag of medical and sociological tools based on amazing scientific and therapeutic advances, increased cultural awareness, and access to ever-expanding on-demand knowledge. They are certainly just as caring as their senior colleagues, but the landscape of what that means has shifted. Young physicians (including my son, 2022 graduate) have a very different view of the job-calling divide.
Recently minted doctors often carry huge medical school debt. Their friends who chose different paths are raising families and building equity, while young physicians have little control over their assignments and schedules. Those schedules are increasingly dictated by hospital fiscal needs determined by executives with seven-digit salaries while physicians in training earn minimum wage or less. With the evolution of electronic medical records designed as a billing capture accelerator, a very heavy portion of their time is spent in front of computer screens.
Meanwhile, they are acutely aware of the conflicting priorities and high cost of care. Primary care is under-supported and overwhelmed; residents routinely report that they must write prescriptions for each other because they cannot find a primary care doctor or don’t have time to see one. So-called “not-for-profit” teaching hospitals — built on the model of charitable care — increasingly focus their growth strategy on lucrative procedures at the expense of less flashy primary care, especially among vulnerable communities.
Rather than as a point of pride, at our presentations and in online forums, young doctors view the word “calling” as a code-word for “being taken advantage of.”
The Way Forward
“The c-word” has emerged as a potent symbol of the generational divide in medicine. In both camps, the c-word encodes dissatisfaction and disappointment. Senior physicians lament the devolution of professional commitment that some see as lacking. Younger physicians march to unionization as a means of assuring work-life balance and a seat at the healthcare decision-making table.
As a training director for a quarter-century and a proud father of a decidedly modern and skeptical young physician, I see opportunities for common ground: lowering the barriers to physician agency and restoring meaning by making “care” the central determinate of physician training assignments.
We should recognize that professionalism — and judgement about adherence — requires a broader context, emphasizing the ability of providers to deliver the highest level of another c-word — care — to all patients. Of course, this is a high bar within our often-dysfunctional and overly complex systems. Rather than a checklist of arbitrary or subjective attributes, such as hours in the hospital or sacrifice, the relevant measure of professionalism should become the quality of care, as measured by metrics meaningful to patients such as timely access, affordability, respect, and peace of mind. This conversation can promote a productive realignment between disaffected learners and their curmudgeonly teachers; and more importantly, between citizens and their industrial-sized health systems.
This shift will require radical redesign of the medical school and residency curricula, including by creatively extracting trainees from their data-entry, cut-and-paste roles in favor of experiences that assure meaningful and longitudinal time with patients and families. Educational programs that connect students with the most experienced physicians can enrich learning. Such changes will require increased flexibility and individualization to accommodate diverse (e.g., age, backgrounds, trajectory) trainees, which stands in stark (and wonderful) contrast to the vanilla white “good old days.”
These changes will invariably conflict with financial optimization. To be sustainable and impactful, such change will require inviting medical trainees (and other staff) into the boardrooms for bidirectional and difficult conversations about what the real hospital mission is and the consequences of derivative fiscal choices.
My son is unconvinced by my pollyannaish speculation. He (and presumably others in his generation) thinks that redefining medical school curricula to be more focused on care sounds great, but he is skeptical that the incremental changes I suggest will counter a hospital’s inevitable attraction to fiscal expedience through consolidation, targeting high-return procedures over preventative care, and private equity quick-fixes, for example. As a resident physician, he sees a bloated healthcare industry serving its own stakeholders’ interests over patients’ care. He thinks a more caring healthcare system is probably only possible through large-scale reform. If a national political solution is off the table, and his generation can’t improve the cost-to-quality equation and increasing access barriers from within, then fiscal strain and social unrest will follow. If his generation can’t say “no,” then he predicts the market will say “no.”
So, while we may never agree on the “calling” versus “job” debate, at the end of the day, young and older physicians can agree that our current overpriced, too often inaccessible, and inefficient system is sorely in need of an overhaul for our patients’ and our nation’s wellbeing.
Acknowledgement: I appreciate the helpful contributions of Andriana Friel, APRN, and Daniel Katz, MD.
Joel T. Katz, MD, MACP, is an infectious diseases physician, senior vice president for education at the Dana-Farber Cancer Institute, and associate professor of medicine at Harvard Medical School in Boston.
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