Two weeks ago, I stood in the back of a boisterous, packed auditorium as each of our school’s fourth-years received their match letters and proudly announced in front of friends, family, and classmates where they would be headed for residency. As peers enthusiastically cheered each other, significant others breathed sighs of relief and little kids looked around wide-eyed, awed at the spectacle.
As the fourth-years celebrated their initiation into a brave new world, I was struck by how much of medicine is a strict and hierarchical system. These students were being sent off based on a computer algorithm that had mandatorily assigned them to their residency programs. The reward for a (young) lifetime of hard work for these medical students was the next step on the long ladder: having gone from pre-medical student to medical student, there was internship, residency, fellowship, and board certification—many more rungs to go.
This strict system of medical education is largely comforting for us medical students. We are scientists, and by personality we like certainty. By studying and learning in system in which the rules and steps are clearly drawn—in which we know which steps we have to climb on our way to being certified for clinical competency— we can prepare ourselves to succeed within the confines of this structure.
A medical student myself, I sometimes wonder whether our focus and drive to succeed within this strict system undermines our curiosity about wanting to change the world in which we will one day work. Chatting with fellow medical students at a wide range of schools, I’ve found many people strangely uncurious about the delivery and payment systems that will control our professional lives. Perhaps we’re just too consumed right now with our medical studies to learn about policy issues not directly related to our current focus; a recent survey of deans found wide variation in the extent of health policy education across medical schools. Perhaps as scientifically oriented people, we’re just not interested in the complex economics of health policy. Our perhaps as aspiring healers, we thrive in fighting for clean moral goals—like improving the health of our patients—and don’t like the messy world of politics. Whatever the reason, the central truth is that we work so hard to become good doctors but don’t work nearly as hard to shape the system in which we are the central players.
Our collective lack of passion is especially critical in this moment. The dirty little secret of the massive health reform bill is that its failure or success will be largely determined not by the specific regulations contained within but by how well they are executed. State insurance exchanges can either be powerful tools for individuals and small businesses or they can be gutted structures with little practical utility. The same goes for ACOs, comparative effectiveness research, and the CMS Innovation Center. Our willingness to take charge in implementing, in good faith, the ACA’s payment and delivery reforms will shape the future of medicine.
One of the phrases I hate most is “ObamaCare” / “RomneyCare” / “<insert a politician’s last name here>Care”. Our health care system isn’t our politicians’. It’s ours, to make or break.