The Physician’s Compact

The shamanistic healing role is a powerful one across many cultures. Still, the special authority physicians occupy in our culture is to a large extent dependent upon the long years of medical training where professional competencies develop that permit physicians to assert their professional authority within their own cultural context.

Physicians and other clinicians are exempted from social taboos within their professional roles related to physical contact and solicitation of confidential information from patients. Social aversions to disease, death, and decay are disregarded in order to restore health or relieve suffering. In doing so, physicians are allowed to probe the most intimate aspects of a patient’s life for the purpose of healing or relieving pain to a far larger extent than other healthcare workers have traditionally been permitted.

Within the confines of the professional relationship, physicians ask about a patient’s bowel habits, sexual history, and the most private aspects of life. A surgeon opens the body to excise an infected appendix or breast malignancy within the proper clinical context of diagnosis and treatment without presumed boundary violation.

Stereotypically, contemporary Western physicians are recognized for their highly analytic academic achievement, diligence, perseverance, and self-abnegation. They are presumed to have the capacity for delayed gratification (i.e., status comes only after years of school and sacrifice), and the capacity to work without aversion when exposed to human suffering and disease.

A physician undergoes a prolonged apprenticeship; by the end of training, the physician is expected to effectively communicate with patients, be empathetic and discrete, and have flawless technical diagnostic and treatment skills. They will have been expected to work very long hours, sometimes neglecting food and sleep, sometimes delaying the adult roles of marriage and parenthood.

After four years of college, four years of medical school, a year-long internship, two to four years of medical residency, one to three years of fellowship for some specialists, and successful results on multiple licensing and competency exams, the long apprenticeship is completed. From a cultural perspective, this professional journey is a prolonged stage of adolescent development that is deemed necessary for professional expectations to be fulfilled.

Developmental psychologists delineate stages of life from infancy through adulthood that people must successfully navigate, one after another, in order to be prepared for the challenges of the next stages of life. Superimposed on these traditional developmental stages is the very long training journey of the medical profession. Physicians cannot successfully fill their ultimate professional roles and meet their challenges until they complete their pro-longed training. Jean Piaget focused upon adolescence as a time of mastering concrete operations. Contemporary medical education requires mastering technical skills through many years of training, whether the skills are procedural, diagnostic, or therapeutic.

The professional identity of a physician as a fully licensed interventional cardiologist, for example, requires four years of college, four years of medical school, three years of an internal medicine residency, and four years of cardiology fellowship training. With no breaks in training, an 18-year-old high school graduate would be 33 years old before they had established an identity as an interventional cardiologist in the American medical education training system. In the traditional private practice model, the cardiologist subsequently has to complete the steps of passing boards and credentialing exams and becoming an employed physician for two or more years before becoming a full partner in a medical practice.

Currently, most physicians in training state they intend to become employed by a health system upon completion of their training, perhaps to bypass additional years of delay in full professional status in the setting of high levels of debt induced by the many years of medical education. What are the consequences for the physician and for society wrought by requiring such a prolonged period of training in order to achieve full professional status?

Among the most schooled professions, physicians achieve their full authority later in life than do all other professionals. This delay’s impact on physicians personally and its impact on patients and the society they serve and by which they are supported needs to be carefully considered because much of the success or failure of healthcare delivery system transformation will require proficient physician leadership.

Physicians, who have delayed their full entry into adult professional roles longer than most of their contemporaries, have not necessarily been trained or selected adequately for leadership roles. Additionally, they have definite expectations about what this delay should ultimately bring to them, including high social status, adequate compensation, and meaningful work with appropriate autonomy in professional decision-making. When the implied social contract implicit in these expectations is not met, dysfunctional physician behavior may disrupt improvements in health system delivery.

The previously anticipated secure financial compensation at the end of their training is no longer certain for physicians who are experiencing declining reimbursements, loss of status, patients identifying alternative medications or non-traditional practitioners as equally qualified or valued, and consumerist pressures for improved access, results, and transparency. Physician-to-physician comparative data publicly accessible on the Internet adds competitive pressures that make compensation more dependent upon performance than on licensure in and of itself.

Despite its length, physician training does not include enough substantive attention to running a business, nor does it fully equip today’s physicians for the evolution of healthcare that is occurring around them. Statistical process analysis, team-focused approaches to patient safety, and results-based, information-driven infrastructures upon which 21st-century healthcare systems will be based is not part of the skill set of the current physician workforce, nor is it part of the implicit bargain physicians thought they made with American society when they chose to spend their young adult years in the prolonged apprenticeship of medicine.

Cumulatively, these inherent challenges in the American medical education system, to some extent, stifle the opportunities for physicians to engage in leading the changes necessary for optimal patient care.

Excerpted from Reframing Contemporary Physician Leadership: We Started as Heroes , by Grace E. Terrell, MD, MMM, CPE, FACP, FACPE.