Robert Frost and the Decline of the Medical Profession

The title of this post is deliberately mysterious, but you’ll understand it at the end.

At my 50th medical school reunion in June, my classmates agreed that while the goals of medicine are as valid as ever, the profession itself is in decline. Here’s a quote from the Preface to our reunion book:

“A frequent refrain is our disappointment in the evolution of medicine in the 21st century…The art of medicine appears to have diminished in value.”

This isn’t just a reaction by grouchy old guys (my class, like other medical schools at the time, had relatively few women). In a recent survey of 13,575 physicians, 84% agreed that medicine is in decline, and 58% would not recommend medicine to young people.

Disillusionment among current physicians has not reduced the number of applicants to medical school. According to the American Association of Medical Colleges, applications were at an all-time high last year. The increase may reflect in part the reduced allure of consulting, finance, and law. The medical students I teach are aware of older physicians’ gloomy view of medical practice, and feel that they’re approaching the field with realistic expectations.

I believe the main cause of the disappointment in the “evolution of medicine” is our society’s inept efforts to deal with the need to curtail costs and improve quality in the running-amok health system. We’ve strangled physicians with cumbersome, poorly designed bureaucratic processes and reduced their income at the same time. That’s a recipe for unhappiness in any profession.

I expect our health system to do better in the future. But my interest in this post is in how I and my classmates – almost all of us around 75 – are reacting to the perceived decline in our profession. I observed four main reaction patterns:

1. “The new generation is ruining the profession.” A few of us blamed today’s physicians for not being more like us. We described them as “nine to fivers” who have turned medicine into a “cut and paste field.” This perspective by the elderly on the young is as old as Homer. In the Odyssey the goddess Athena disguises herself as the elderly sage Mentor and says to Odysseus’s son Telemakhos:

“…That son is rare who measures with his father,
and one in a thousand is a better man…”

(I sometimes quoted these lines to my sons when they were young and I felt they were getting too big for their britches.)

2. “I don’t want to be too negative, but…”  Several of us described struggling against the temptation to say some version of “a pox on what the profession has become.” Here are two representative quotes from the reunion book:

“I regularly and consciously spend some energy trying not to be a routinely disapproving curmudgeon, since there are, currently, a great many aspects of American society and government that are not, I think, admirable or working well.”

“Perhaps [with regard to my criticisms] it’s just me becoming ‘crusty’.”

3. “We were lucky.” Here’s how a recently retired classmate put it:

“My philosophical words are these: Be happy with what we 75 year old grads still have, and with the happenstance of being in the fortunate cohort…”

In his view – and I agree – it wasn’t our unique virtue that made medicine such a great career for us. Good luck as to when we entered the profession had a lot to do with it.

4. “Medicine is in a mess – let’s fix it!” A number of classmates are working as advocates – locally on projects in their own environment or nationally on behalf of a single payer health system. One classmate used his reunion book entry to exemplify what he believes we should be doing:

“I retired in 2000…Since 2006 I have been quite active in the national organization Physicians for a National Health Program…our country is an outlier among industrialized countries in terms of health care costs, health outcomes, and lack of universal health care coverage…”

I align myself with the “let’s fix it group.” Activism is part of the ethos of the Over 65 project, as exemplified by posts like “A Retirement Community’s Private and Public Affairs,” “Activism by the Elderly,” and “The Elderly not Resting on their Laurels.”

As I thought about the activist response to what is happening in my profession, two of my favorite Robert Frost poems came to mind. They’ve stuck with me since I wrote about them in a college paper 55 years ago. In The Oven Bird the last two lines capture the challenge I and my classmates experienced in words I find haunting:

The Oven Bird

There is a singer everyone has heard,
Loud, a mid-summer and a mid-wood bird,
Who makes the solid tree trunks sound again.
He says that leaves are old and that for flowers
Mid-summer is to spring as one to ten.
He says the early petal-fall is past
When pear and cherry bloom went down in showers
On sunny days a moment overcast;
And comes that other fall we name the fall.
He says the highway dust is over all.
The bird would cease and be as other birds
But that he knows in singing not to sing.
The question that he frames in all but words
Is what to make of a diminished thing.

As a college student I had a penchant for melancholy. For that state of mind, Frost’s One Step Backward Taken told me that I could do something to make the situation better and wasn’t doomed to wallow in a depressive mood:

One Step Backward Taken

Not only sands and gravels
Were once more on their travels,
But gulping muddy gallons
Great boulders off their balance
Bumped heads together dully
And started down the gully.
Whole capes caked off in slices.
I felt my standpoint shaken
In the universal crisis.
But with one step backward taken
I saved myself from going.
A world torn loose went by me.
Then the rain stopped and the blowing,
And the sun came out to dry me.

I recently learned that a grandson who’ll be starting the tenth grade next month has the idea of medicine as a career. If that interest continues I’ll tell him that a majority of physicians recommend against medicine as a career, but that as long as he approaches it as an activist, not a disempowered, resentful victim, it will be a great career.

Jim Sabin, M.D., 75, is an organizer of Over 65, a professor of population medicine and psychiatry at Harvard Medical School, and a Fellow of the Hastings Center.

6 Responses to “Robert Frost and the Decline of the Medical Profession”

  1. Susan Goold

    If you haven’t read it yet, read Barron Lerner’s _The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics_. It speaks to differences I have also noticed in the art of medicine (being of Barron’s generation, with a physician father) and have advocated against!

    • Jim Sabbin

      Hi Susan
      Thank you for the recommendation. I’ve requested the book from my local library.
      I want readers to know how grateful I am to you for your wonderful leadership of the AMA Council on Ethical and Judicial Affairs this past year!

  2. Jonathan Rhoads, '64

    Despite the frustrations of practice and possible loss of autonomy, the medical care enterprise can do more for the sick and injured than ever before. Life expectancy is increasing.
    An increased emphasis on health education for the public, and engendering healthy life styles should be sought. The ACA was really health insurance reform, not health care reform. Millions now have health insurance who did not have it before. Since it is harder for companies to cancel it, it costs more. The AMA supported the ACA. Unfortunately it did not include anything for physicians such as limitations on liability, and it will probably lead to lower incomes for physicians.
    I believe we can deliver more health care than the public is willing to pay to have delivered to the entire population. Ways need to be found to avoid futile care, and possibly near-futile care.

    • Jim Sabbin

      Hi Jonathan
      Thank you for the comment. Physicians of our vintage appreciate how much more is possible in 2014 compared to 1964. I agree that even if economists are correct when they say that “liability reform” wouldn’t make much difference for health care, liability concerns are a kind of poison for medical practice. I’d add to the factors you cite for cost savings activities like the “Choosing Wisely” campaign, in which the different specialties examine their own practices and make recommendations to peers about interventions that don’t create benefit for our patients.

      • Carol Eblen

        Yes! You are right! What is really sickening is that the “liability” factor and the “safety” factor concerning hospitals and physicians resulted in the LACK of NOTICE by any state or federal law to Medicare/Medicaid Patients from either the hospitals/physicians or Medicare/Medicaid that any further hospital treatments will NOT be reimbursed under the existing CMS/Advantage Insurance protocols.

        Obviously, the bioethicists, the academics, didn’t warn the people, the Medicare/Medicaid patients that the special interests in our for-profit health-care system were moving Medicare away from “fee for service” to “managed care” and “managed death” reimbursement protocols that would save money for Big Insurance.

        Also, the bioethicists/academics have worked with the AMA to render the unilateral covert/overt(default) DNR code status in hospitals to be merely an “ethics” violation and not a tort or a crime —which it would be under existing law in may States and especially in Missouri.

        • Manuel

          Thus, becoming a phsaiciyn will enable me to establish personal connections with those living in inconvenient settings and allow these people to have as much healthcare as they should have as a basic necessity to live without diseases that may be prevented easily. Being a phsaiciyn is one of very few privileges that help me to give hope and opportunities to those who deserve and are able to appreciate. It is not just about helping people, but making differences to make this world more reasonable