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Monday, 20 June 2011

The Ethics of Practicing Medicine Part Time

Dr. Karen Sibert, an anesthesiologist in Los Angeles and a mother of four, created a major brouhaha with her tough op ed, in which she inveighed against part-timers in medicine, and told women contemplating medical practice that they "can't have it all." Here's the essence of Dr. Sibert's argument:
Medical education is supported by federal and state tax money both at the university level — student tuition doesn’t come close to covering the schools’ costs — and at the teaching hospitals where residents are trained. So if doctors aren’t making full use of their training, taxpayers are losing their investment. With a growing shortage of doctors in America, we can no longer afford to continue training doctors who don’t spend their careers in the full-time practice of medicine...

Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It’s fair to ask them — women especially — to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency. They must understand that medical education is a privilege, not an entitlement, and it confers a real moral obligation to serve...

Patients need doctors to take care of them. Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient; it deserves to be a life’s work.
Dr. Sibert has taken a lot of abuse for the politically incorrect argument she makes. But she makes five incontestable points: (1) the public makes a substantial investment in medical education, and is entitled to a return on that investment in the form of medical service; (2) with the aging of the baby boom, we anticipate a shortage of physicians, especially in primary care; (3) women make an increasing portion of primary care; (4) women choose part time careers more often then men do; and, (5) medicine should be seen as a calling, not a job.

That said, I believe Dr. Sibert is wrong. She's identified real problems, but the remedy she offers - a moral requirement for full time practice - puts the solutions onto the backs of individual physicians. In a time of epidemic, exhaustive labor is expected and required. But as a solution to chronic system failures, it's the wrong way to go.

There's been lots of writing about how to fix primary care, with the Medical Home being the chief current model. Some physicians have turned to concierge practice, in which they practice full time (as Dr. Sibert calls for) but limit their panel to a small number of patients who can pay the enrollment fee (which undermines the aim of providing wider access).

Over the years I've observed what "part time" practice means to my primary care colleagues. By ordinary work standards, "part time" is VERY "full time." Being part of a team that provides 24/7 access in a coordinated manner can offer excellent service to patients and allows for a sustainable career. I've been a patient in this kind of practice for the past 25 years, so I know first hand that it can work.

(For a rich picture of Dr. Sibert's analysis and reactions to her proposals, here's a link to "On Point," the excellent NPR program.)


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