I want to be a doctor. I will be applying to medical school in June. I have shadowed a doctor extensively. I volunteer at a county hospital in Oakland. I have gotten my feet wet in the medical field and hope to go farther soon.
At this point in my career, it is important to begin thinking about the many ethical dilemmas that come into play in medicine. One of the most pressing issues concerns underserved communities, and how to motivate young doctors to serve these populations, especially those of lower socio-economic status.
The current system focuses on exposure to these populations by incorporating free clinics into the rotations for medical students. The thought behind it is that exposure will help create a level of comfort with those types of patients. The end goal is to foster a sense of altruism and “feeling good about yourself” for working with these patients.
However, as the paper “Learning the Moral Economy of Commodified Health Care” points out, this system has inherent faults. Since the health care system in the US is based on profit for care, clinicians come to expect something in return for their services. Normally this is money. However, in a free clinic this doesn’t happen, so they come to expect something else. They expect a moral economy, where in return for their services, they are able to “feel good” about themselves. These student doctors feel that they are giving their time and effort out, and come to expect something from the patient in return, namely a sense of gratitude and a promise of personal responsibility in order to maintain the health provided by the clinician. In these free clinics, the doctors become “ethical clinician-citizens” who hold the power of bestowing health upon those less fortunate, and follow their own personal moral system in order to treat all patients equally. However, this unfair expectation leads to certain negative outcomes. Clinicians begin to view patients as worthy of care based on how responsible they seem or how grateful they are. They ignore any underlying factors or experiences that may affect how the patient acts in these clinics. They view this line of work with a sense of entitlement. It also allows for compromised care to be justified in free clinics. Because it is seen a “you get what you pay for” system, it becomes alright to provide inadequate care in these clinics. Students who aren’t properly trained are allowed to perform procedures they wouldn’t otherwise be allowed to do. Patients are expected to wait exorbitant amounts of time for single use treatments with no follow up, and do it all with a smile on their face.
The end result of all this ranting is young doctors who, although trained in underserved communities, have reinforced negative stereotypes about such populations and free clinics in general. Not only is this an unhealthy mentality for a health care provider to have, but it actually discourages clinicians from seeing such populations in the future.
Obviously, I didn’t express the argument as well as the actual paper did. I suggest reading it if you are interested. But I’ve definitely seen this issue in practice, in all of my clinical experiences. And the solution seems to be to emphasize an education that covers the root causes that lead to poverty, and how that affects the patient experience. This understanding shifts the focus to the patient rather than being on the clinician and what they get out of it. The system as currently formatted isn’t working, so maybe it’s time for this kind of change. This is what I’d like to write about for my cultural commentary.