Appendix 54 - Swing to the Right

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

From the Journal of Medical Education: "Medical students generally become more conservative on political and economic issues in the profession and less committed to choosing a practice based on patient need."[618]

Realistic Limitations

From an article in JAMA:

In the last decade, medical students have become much less inclined to be primarily motivated to seek a meaningful philosophy of life and correspondingly more motivated to become financially very well off. The self-indulgent sense that many house-staff physicians and medical students have of being entitled to a privileged status and income is reinforced when young physicians see their well-off teachers and role models refuse to care for indigent patients.[619]

Reported in an article called "Third World Medicine in First World Cities," a 1994 study of doctor's offices in ten cities found that less than half would give Medicaid patients an appointment or an authorization for a walk-in visit; "Not accepting Medicaid" was the most common reason given.[620] New England Journal: "Physicians who limit their office practice to insured and paying patients declare themselves openly to be merchants rather than professionals [and foster] the myth that physicians as a group are greedy and self-serving, rather than dedicated and altruistic."[621] Some physicians express pride in their greed. "Altruism is a flawed morality," one doctor writes, ''a fundamental illness gradually consuming the field of medicine."[622]

One of the most dramatic changes noted was a loss of interest in working for, "political or social change in medicine." From JAMA:

All too quickly the lofty thoughts and humane motivations almost amorphously disappear. We don't discard them, we just lack the time to tend to them, and, like a garden, untended and uncultivated, our dreams become overgrown, tangled, and choked.[623]

From an article in the Journal of Medical Education:

General values of helping people do not indicate much social concern since students become less willing to make personal sacrifices for patient need and less likely to support reforms of the medical profession aimed at helping poor and working class Americans.

Although a student may begin medical school with dreams of social justice and medical reform, after four years of struggle and sacrifice that same student has a personal stake in the established system, and this stake appears less secure when liberals start to initiate changes.[624]

The article's author chalks this up to students becoming, "more realistic about physician's limitations."

Minority View

From the book M. D. Doctors Talk about Themselves, "When you work in an emergency room in a bad neighborhood of a big city... your liberalism goes out the window. Gone. It really changes your attitudes about people who live in the inner cities, about minorities."[625]

"'When we first began,'" one student said in an interview, "'there was a lot of talk about organizing ourselves and going into the ghettos to work. But after a while we started questioning how this would affect us as doctors. The talk changed to, 'I don't want to practice in a ghetto; I want a nice office, a good practice, and a comfortable life.'" The interviewers conclude that the students' earlier idealistic altruism shows signs of being tempered with self-interest during the clinical years. 'When I first came to medical school," one third year student commented, "I used to think it would be great to help people, but now I'm not so sure - I'm leaning more toward my own interest."[626]

Patient Welfare

In a recent study of professional student perceptions on healthcare, law students were more likely to feel as though procedures such as liver transplants, kidney transplants, cataract surgery, and open heart surgery should be universally provided compared to medical students, who were more likely to feel that society should not have universal access to these interventions.[627] Using survey questions like, "Good medical care for every individual should be a right not a privilege" and, "Everyone should be entitled to the same quality of medical care whatever their financial means," medical students showed a significant (p<.007) conservative swing to the right as they progressed through medical school.[628]

Family practice residents - "perceived as being more accessible and humanitarian than other physicians" - were surveyed as to their perceptions of poor patients. Twenty-five percent felt that, "Most poor people become poor as a result of lack of effort on their part rather than circumstances beyond their control;" "poor patients tend not to appreciate the work of physicians..." and that, "Government spending on poverty programs should be... greatly reduced." One landmark sociological study noted, "At almost no time did any [doctors in the study] consider the effects of the context of training on the treatment of the indigent patients they treated and neglected or abused as house officers."[629]

One in five family practice residents agreed with the statement, "I think we are coddling the poor; most people live well on welfare." A half believed, "Young women in poverty often get pregnant to have babies so that they can collect welfare support." One half felt that, "the poor are more likely to 'take advantage' of the healthcare system," and 72% believed that, "a small deductible or co-payment should be required to prevent this from occurring." The poor, of course, in national healthcare utilization surveys are less likely to see doctors, despite having a greater need, more chronic diseases, etc. I wonder what these 72% of family practice residents think requiring further payment will do for the health of the American poor.

If physicians are so worried about healthcare costs maybe they should start by looking at their own salaries. From the book Medical Costs, Moral Choices: "It is utterly hypocritical for doctors, health-care administrators, academic analysts, and policy makers to close their eyes to the level of doctors' incomes amidst an otherwise vigorous concern for making healthcare worth the increasing money we pay for it."[630]

In a study of medical student attitudes on physician fraud - for example billing Medicare or Medicaid for thousands of dollars for services not performed - "most students felt that moderate penalties - fines, suspension from the [Medicare or Medicaid] program, community service, or a simple warning - were sufficient punitive responses...." The authors of that study keenly point out, "It remains an open question whether students would support similar penalties if they were dealing with cases of fraud or abuse perpetrated by program recipients."[631]



[618] Leserman, J. "Changes in the Professional Orientation of Medical Students." Journal of Medical Education 55(1980):415-422.

[619] Miles, SH. "What are We Teaching about Indigent Patients?" JAMA 268(1992):2561-2562.

[620] Whiteis, DG. "Third World Medicine in First World Cities." Social Science and Medicine 47(1998):795-808.

[621] Elias, PH. Letter. New England Journal of Medicine 314(1986):391.

[622] Ziegler, DK. Letter. The Pharos 1997(Winter):39.

[623] Henry, JB. "Dean's Welcome Remarks to the Class of 1986." JAMA 249(1983):1589-1590.

[624] Leserman, J. "Changes in the Professional...." Journal of Medical Education 55(1980):415-422.

[625] Pekkanen, J. MD: Doctors Talk about Themselves New York: Delacorte Press, 1988:83.

[626] Becker, HS Boys in White New Brunswick: Transaction Publishers, 1991:3,67,171,245.

[627] Wilkes, M, I Coulter and E Hurwitz. "Medical, Law, and Business Students' Perceptions of the Changing Health Care System." Social Science and Medicine 47(1998):1043-1049.

[628] Maheux, B and F Beland. "Changes in Medical Students' Sociopolitical Attitudes During Medical School." Social Science and Medicine 24(1987):619-624.

[629] Light, DW. "Toward A New Sociology of Medical Education." Journal of Health and Social Behavior 29(1988):307-322.

[630] Menzell, PT. Medical Costs, Moral Choices Danbury: Yale University, 1964:228.

[631] Keenan, CE, et al. "Medical Students' Attitudes on Physician Fraud and Abuse in the Medicare and Medicaid Programs." Journal of Medical Education 60(1985):167-173.



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