Nurture the Young

Imagine a child-rearing approach we do not see in pediatric offices — neglect until adolescence, with earnest effort from then on. One would not expect this to succeed. Yet this is exactly how most of us help our professional young grow up into the world of organized medicine.

Ask a first year medical student to define "organized medicine" and you will hear "Sutter" or "Kaiser." No wonder — traditional medical school curricula allot little space to such topics. Perhaps we should expect this, given the amount, complexity and importance of the science. But teaching science without teaching the social, economic and political context of the profession is like giving swimming lessons while ignoring how to survive in the ocean.

Exceptions exist, notably the nation's only course on the politics of healthcare, taught by CMA President Elect Bob Hertzka. Fifteen years and 400 students from its inception, "Introduction to the Politics of Medicine" has been at the top of student ratings at UCSD for almost a decade.

Not in most medical schools, however. The tendency is to view academic medicine as a pure pursuit, and organized medicine as an irrelevant and money-motivated trade group. Demands for grants and tenure, or simply devotion to the hard science, can easily overshadow general issues affecting the profession. Medical students are more likely to hear negative than positive comments about organized medicine, if they hear anything.

This is understandable if one looks, for example, at a recent hot list of CMA sponsored and opposed legislation.¹ Half the sponsored bills involve physician reimbursement. All opposed bills concern blocking competition for activities over which physicians want to maintain control.

Such lists are a distorted reflection of CMA interests and actions. They comprise a collection of jugular issues in no way representative of the breadth and depth of active concern in organized medicine, a concern better reflected in the range of resolutions before the recent CMA House of Delegates.²

Taken in isolation, however, political activities of the profession can confirm suspicions of young physicians that organized medicine is opposed to change or progressive ideas. Having failed to teach young physicians the political context of practice, we should not be surprised when they emerge thinking that organized medicine should be avoided if not fought whenever possible.

Residency seems to make things worse. Academic mentors can be indifferent or even hostile to organized medicine, while tending to venerate specialty societies. Graduating residents of all types emerge into the profession with an identity more deeply rooted in their subset skills than their place among the larger community of physicians.

On this backdrop of neglect, organized medicine jumps in again at the point of professional adolescence. We are surprised at the lack of buy-in, and appalled at the anger and defiance toward what we hold to be key values of the profession.

Our earnest efforts are too little and too late, and we deserve the response.

This is ironic in view of a dramatic increase in support for involvement in recent years. Joseph Silva, MD, Dean of the UC Davis School of Medicine and an active member of the CMA Board of Trustees, set a goal in 1998 of having all UCD medical students be members of SSVMS, CMA and AMA. Beginning that year with the incoming first-year class, all four years of medical students became members of those three organizations. And have been since.

SSVMS also has reached out vigorously to students and residents. Witness the efforts and support of SSVMS staff in providing information, activities, monetary support, guidance, charitable opportunities, and continuity with organized medicine following residency.³ The substantial involvement of CMA with young physicians in its YPS and RPS sections is another example.⁴

Despite these efforts at academic, county medical society and state levels, the bulk of residents do not join organized medicine as they matriculate. Of the four major health systems in our region, for example, at least two have physician membership levels in CMA/SSVMS well below 20 percent. Something is missing...

Erik H. Erikson in his classic book Childhood and Society⁵ described "trust vs. mistrust" as a cornerstone of a healthy personality arising from a "quality of care that transmits a sense of trustworthiness and meaning." He suggested that discontinuities in care increase a natural sense of loss as a child gradually recognizes his separateness from parent. A resulting basic sense of mistrust may occur and last throughout life. Simply put, only a well-nurtured child develops trust and a sense of security.

While young physicians are not children, there are clear parallels between Erikson's theories and the stewardship of young physicians by the organized house of medicine. Discontinuities in that stewardship (if not simply pervasive neglect) eventually lead to mistrust of organized medicine by many young physicians. By contrast, more consistent nurture by subspecialty organizations during critical times of professional development leads to trust and alignment.

Only later, when the realities of professional life are hard-learned, is the pertinence of organization across the entire profession evident. For the point of organized medicine is not so much to support income as it is to preserve a potency to provide good care. A bankrupt health system cannot do this. As far from altruistic ideal as it may seem, physicians organized across the full continuum of the profession can more effectively influence sound health policy than can subsets of physicians. This is not immediately evident as students enter medical school; it must be taught.

By and large, we have not been doing this very well. Although we excel at teaching the science of medicine, we fail at teaching the profession. We should change this.

Young physicians need and deserve more of our nurture than they get. While courses such as the Politics of Medicine are helpful, Dr. Hertzka will tell you that what is needed are more mentoring and more inclusion of what medical students and residents care about in organized medicine, rather than specific courses across the state. Our professional young need more of our quality time, not more class time.

EVERY medical student and resident deserves a mentor who can teach the interplay between medical science and the social, political and economic context of the profession from their own individual point of view. For this to occur, every physician, whether practicing or retired, should BE a mentor on an ongoing basis. As in the days of apprenticeships, this should be a self-imposed professional expectation.

Opportunities abound, and the health of the profession and its charge lies in the balance. We have only ourselves to blame if we continue the old pattern.

There might be surprises. But it's not worth betting the farm on them.

paul.phinney@kp.org