Psychotherapist and Holocaust survivor Viktor Frankl famously enjoyed quoting Nietzsche’s observation, “He who has a why to live for, can bear almost any how.”
The more lay expression, “Where there’s a will, there’s a way,” covers similar ground. When we have a Why for doing something, the How can be cultivated. Determining how to do something before examining why, in turn, puts the cart before the horse.
Why Become a Doctor?
When it comes to training healthcare providers–doctors especially–we seem to be systemically preoccupied with the How of equipping students to become providers, yet give little to no thought to the Why. We’ve put inordinate faith in the self-selection process to let students answer the question of any Why with respect to medical school. The assumption seems to be that successful students will all have answered the Why of medical school many times over: to keep up with school work, do well on the MCAT, run the gauntlet of interviews, documentation, and experience-gathering necessary just for application into med school–each stage suggests they must have all the motivation they could need already. How else could they survive?
And there again in medical school, students must be answering the Why with every study session, late night, every clinical round and internship, with commencement and the pursuit of a specialty or area of practice. They find a way, year after year; the will must come from within. Our ancient logic asserts that the How follows the Why–the way unfolds before the force of will–so all our doctors must have covered all questions of motivation to have arrived in medicine at all.
Medical school itself is a crucible for the individual that turns survival into a competition. Advocates love to assert that competition drives us to be our best, that it is at the heart of innovation, excellence, and growth. Medical students might also point to the stress of competition as source of personal health decline, confidence loss, and a distraction from the real substance of what healthcare–the Hippocratic stuff, the patient care, the teamwork and the lifesaving–is supposed to be all about.
You might call suicide the extreme reaction to losing sight of one’s Why. Doctors have a particular tendency to take this path out of medicine, out of healthcare, and out of existence. The trend is so pronounced it has finally come out that medical school trains future doctors for burnout, self-destruction, and unsustainable stress at least as effectively as it prepares them to practice medicine. We’ve made the How of becoming a doctor such a trial of identity, medical students lose their grasp of the Why entirely.
How We’ve Failed our Doctors
Standardized tests are our favorite gatekeepers of opportunity, yet hilariously poor predictors of actual medical performance–they correlate only slightly with grades, and not at all with performance. We’ve screened pre med students for the hard skills medical students will need, under the assumption that the requisite soft skills of real caregiving will emerge naturally as a result of clinical experience–shadowing, mentoring, practicing.
We aren’t so much screening our med students for skills as we are conditioning them to assessment: cogs in a machine to be prodded, examined, and reconfigured according to the demands of the machine. We talk about compassionate care, continuums of collaboration, of quality-first, patient-centric systems; but we build these systems with medical students who are taught to compete ruthlessly, eat their young, and eventually escape into administration or out of medicine entirely.
Sadly, medical school in this respect is a preview of medical practice, where burnout is further bolstered by the demands of ever-changing expectations, regulations, standards, and general disruption to the doctor-patient relationship upon which healthcare is supposed to rest.
If burnout is driving providers out of healthcare, then part of the problem must be that the Why is being sacrificed on the altar of How. The burdens of technology–reporting, coding, attesting, learning, duplicating–substitute a How of policy for a Why of care provision. All the details doctors must contend with are multiplying, and at no point in their long, grueling education are they encouraged or empowered to take care of themselves, or put their own Why ahead of the How of being in healthcare at all.
The Game Has Changed
It may be that our system of recruiting, screening, and training doctors and caregivers is in need of an even bigger shakeup than the one still being rolled out across the American healthcare system. The individual is no longer at the center of caregiving; high technology and artificial intelligence notwithstanding, we need collaborative teams to achieve what we now expect from our health systems. Integration, communication, data-gathering and resource sharing are all being prioritized by lawmakers, payors, and increasingly the patients themselves.
Somehow, we’ve changed the nature of medicine itself without getting a doctor consult first. We developed EHRs to streamline billing, but not end-user experience; we’ve set goals with lofty ambitions of quality-control, but designed them so that strained clinics carry the costs of compliance; we’ve entered a paradigm that requires new skills both hard and soft, and we don’t yet tell young applicants what those are until they find themselves struggling to exhibit them.
Worst of all, we are treating physicians like they are doing just another job, when for decades the allure and the esteem of doctors was that being in healthcare was not just another job–it was an art, a calling. Disaffected physician parents are warning their children away from medicine, and by extension, abuse and disappointment.
With all our tools, technology, and ambitions, we ought to be able to take better care of those we charge to take care of us. Schooling should be empowering, rather than debilitating. We ought to let doctors answer Why, and find an arsenal of How to see them through.