The following are my thoughts triggered from this article about the increasing dissatisfaction of doctors with their professions compared to what they had thought it would be.   The article makes a point that the practice of medicine has changed a lot in recent decades so that the bulk of demand of time from the doctor has little to do with caring for patients.   My observations are not able the specifics of the medical field, but more about the nature of work.

What caught my attention was an observation that the mid-20th century was the golden age of medicine when doctors were highly regarded throughout society and they had a lot of autonomy for how they practiced their profession.   The discussion implied that the fun of the profession went down from there.    Although I am not in the field, I do recognize a shift in perception of the desirability of the profession from how it appeared 50 years ago and how it appears today.   Despite the fact that today we have far better medical options to improve outcomes for more patients, I can imagine that the daily experience of providing care may have been more rewarding in the past.

I discussed this earlier when I discussed income inequality in terms of people making choices to go into professions that allow them to devote more of their time to individuals.   These professions include the medical professions.    In these professions, a single individual client would have the practitioner’s undivided attention for a significant portion of the practitioner’s working hours.    The above article refers to this attention in terms of the doctor’s chance to build a relationship with a patient.   Unfortunately, such devoted attention limits income opportunities because of the limited ability of the client to pay.

Much of the more lucrative fields involve serving large populations of largely anonymous clients.   If someone produces a product or service that satisfies a huge population, then even a small contribution from each customer can add up to be very large income.   As I mentioned in my post, people sometimes make the choice of a less lucrative career because they find value in that direct experience of delivering a service to individuals, one at a time.

Back to the article’s description of the golden era of medicine when doctors were more highly regarded by society, the article mentioned that at that time the doctors made annual salaries $50k (adjusted for inflation) compared to around $200k now.   This key piece of information deserves more attention than the article gives it.   In that earlier period when doctors were highly regarded in society, they were not very highly paid.  This makes sense because they were giving their services in a way that allowed them to concentrate more time on individual patients.  But also, we get the impression that those earlier era doctors enjoyed and valued their profession more than modern doctors making several times more in salary.  According to the surveys, despite this increased compensation many doctors are considering leaving the field (presumably to make less money) or discouraging others from entering it.

I also described this in my earlier post.   For many people, the added income doesn’t compensate for the lost value of the satisfaction of deliver a service to an individual they have developed a relationship with.

I appreciate the needs of a substantial portion of the population to find meaningful work where they can see the results in terms of helping individuals.  We should allow some professions to exist that allow people to practice this kind of career.   It just happens that some professions have become so specialized and exclusive that their time needs to be more efficiently distributed over a large population allowing for less time per patient.  Doctors are one of those professions.

Perhaps it is true that the practice of being a doctor is not what the individual hoped to experience.  That may be a sign that the individual chose the wrong field.

Contrary to the article, I think it is unfortunate that we must allow doctors to spend as much time with patients as we do currently.   Their skills and experience can be better used to help more patients if they spent even less time per patient.   Also, because the practice must allow for this direct interaction with patient partially for the benefit of personally satisfying experience of the doctor, we break up the potentially longer interaction available to the doctor’s assistant or nurse.

For example, recently I went in for a routine doctor’s visit.   When I arrived, the doctor’s assistant personally greeted me in the reception area and escorted me to the exam room.   After measuring my weight and blood pressure, he talked a bit to discuss my health history he read from the computer.   Even that much time was enough to begin a relationship but he had to leave me alone to wait for the doctor to spend some time with me to discuss current conditions and to take a listen to my heart and lungs.   Then, the doctor left me alone for a bit for the assistant to return to draw some blood and escort me out.

The visit involved two relationships instead of one, and a substantial fraction of the time that I was in the exam room was spent alone.  The assistant could have handled this entire routine visit end-to-end.  This would have allowed even more time to provide that assistant a career-satisfying opportunity to build a relationship with the patient.   Nothing the doctor said or physically performed could not also have been performed by the assistant.

I realize that the doctor was better trained to hear or feel things that may be early signs of something of concern, but most of this was done in analog approaches.   The stethoscope was listened to directly.   The blood pressure gauge was read directly.   Even the scale was an analog scale perhaps identical to what was used 50 years ago.   Each of these measurements could have been made digitally including high fidelity recordings of sounds and touch.   These could all have been performed by a single individual, the assistant, to provide a greater opportunity to deliver an individualized service.

The doctor could have reviewed the recordings in a matter of a few seconds to determine whether there would be a need for a follow up.   There was little need for two people to share a patient.   I realize that my visit was a healthy-care visit.  I had no complaints and he found nothing to be concerned about.    However, I can still imagine a similar division of labor for unhealthy instances.  Given a specific complaint, the assistant can perform additional checks.   If something of concern was found, it is likely a follow-up visit would need to be arranged in any case.  In the few rare cases where the condition may require immediate attention by a doctor, the assistant can request one to come in for this particular case.   Most of the time for most of the patients would be spent with the assistant who requires less training.   Even though the assistant may earn less money, he may obtain a more satisfying work experience of direct delivery of medical attention to a patient.

Undoubtedly, the practice of medicine has changed radically in the past 50 years.   We have much higher demands on the highly skilled doctors with the consequence that they are not permitted to spend as much time with patients.   Unfortunately, some of the older doctors entered the field anticipating more time with patients than they are allowed to perform today.   Today, we need their skills to be made available to a much larger population of patients.

Nonetheless, we should recognize that many people find motivation in providing direct services to individuals.   We should allow professions to emerge that maximize time with medical patients.   In my example, we could allow the assistant to spend the full office visit time with the patient.   High quality health care would still be available because digital recordings of his measurements and patient discussions will be available for review by the skilled doctor.  This may require some changes in upgrading the technologies (digital stethoscopes, sphygmomanometers, scales, video recorders, etc), but these are very affordable today.

The result will allow for one profession (the assistant) to maximize the experience of the personalized delivery of medical care and another to maximize the application of highly trained skills to a large population of patients.

In the earlier post, I described this as an inevitable choice people need to make when choosing a career.   Careers that reward by delivering services to individuals will require less training and provide less income.   More lucrative careers will require more training and more anonymous delivery of services with the potential for more income.

Although the general notion of the practice of being a doctor is pretty much the same as it was 50-100 years ago, it appears that the earlier era of doctors made a deliberate choice to enter a lower paying profession that gave them the satisfaction of providing individual attention to patients.   Those same people when entering the profession today may opt to become nurses or physician assistants, especially when those professions are updated to allow for more interaction by recording the observations for quick review by a remote qualified physician.   By obviating the need for the doctor to interrupt the interpersonal session between the assistant and the patient, the profession of the physician’s assistant could have a similar reward and appreciation afforded to the storied doctors of yesteryear.