Since it strikes at the very core of what this blog is all about, I couldn’t pass up the opportunity to comment on Dr. Karen Siberts recent op-ed piece (http://www NULL.nytimes NULL.com/2011/06/12/opinion/12sibert NULL.html?pagewanted=1&_r=2&sq=sibert&st=cse&scp=3) in the New York Times. She argues that, especially given the current shortage of primary care doctors in this country, being part of the medical profession confers one with the moral obligation to serve and, as such, conflicting interests, such as raising a family, should take lower priority. I worked with a radiology attending once who expressed a similar view of his relationship to his profession this way, “It would be irresponsible of me to have kids because I spend so much time working. I wouldn’t be able to spend enough time with them.”
The notion that doctors have a moral obligation to serve – to make their profession their top priority, their “life’s work,” as Dr. puts it, or their otherwise full-time endeavor – comes out of the still prevailing view that doctors have an obligation to the public as well as their patients. There are, of course, ways in which this is absolutely true. As licensed professionals, doctors do have certain obligations to the public, among them to maintain patient confidentiality, to practice in accordance with current standards of care and to address any dangerous or unethical behavior in their colleagues. As Dr. Sibert correctly points out, the practice of medicine is a privilege. Where I very strongly disagree with Dr. Sibert, is that being afforded the privilege of providing a particular service confers an obligation to do so. What is the nature of this obligation? How much medical care are doctors obliged to provide? How many hours per week is enough? What kinds of conflicting interests justify taking us away from the practice of medicine? These are personal considerations which every professional must answer for him or herself, not questions for public to answer.
There are a subset of physicians who do have a unique service obligation. The National Health Services Corps (NHSC) as well as many state funded organizations will pay back all or a portion of new physicans’ medical education debt in return for a commitment to practice in an underserved community for a specified time period. Doctors in these programs enter into a very special contract with the state and therefore have a unique obligation to serve the public which other doctors do not share. Yes, it’s true that residents’ salaries are paid largely by medicare. But, far from conferring true financial or symbolic debt upon residents, this payment is in return for valuable services that doctors provide during residency. If anything, it is the government who is indebted to new doctors for the years of nearly free service they are compelled to provide throughout the course of their training.
It is absolutely true that we have a current shortage of primary care providers in this country. However, we cannot and should not depend on doctors’ intrinsic motivation to work more simply because it is needed, or to move to rural areas simply because that is where they are needed, anymore than we should any other professional to do so. As much as we enjoy it when people voluntarily do things which are not in their own self-interest in order to benefit society, change needs to come through rational healthcare policy. The Affordable Care Act represents a first step in this direction by increasing funding for NHSC scholarships and with new grants to increase the number of primary care residencies. This is how the problem must be addressed. A doctor’s relationship to his or her profession and the number of hours per week that he or she decides to practice is a matter of personal, philosophical reflection, not a matter of moral obligation or public debate.