You begin medical training by making promises. You swear oaths to your predecessors, to your patients, and to your creditors.
You are assigned to clinics and hospitals to learn from your betters. You listen to them, but when you see patients on your own you feel undone by all you cannot do. People fall ill in ways that startle you. Above all, ill people surprise you by placing their hopes on your unproven shoulders.
You persevere, you accrete experience, and around the time your first name is replaced by “Doctor,” you become accustomed to bearing these hopes. It takes a decade or so, but you find your own place in a clinic or hospital. You start teaching students of your own. You find yourself asking what you are doing in these clinics and hospitals, where people meet each other as patients and physicians.
Patients, practitioners, and policy makers ask the same question and conclude that we need to reform the healthcare system to which we now belong. Patients routinely survive illnesses that would have felled them only a few decades ago, but they are disappointed by clinics and hospitals. They complain that receiving healthcare is too alienating and too costly. Practitioners receive salaries and social status in excess of other members of caring professions, but report high levels of fatigue and frustration. They grouse that practicing medicine has become intolerable, and discourage students from becoming physicians. Policy makers appreciate the advances of medicine, but characterize the delivery of medical services as inefficient and ineffective. They are dispirited by the inequitable distribution of care. For all these reasons, we have decided it is time to reform healthcare.
When you hear about healthcare reform, it is often described like a boat race, with a discrete beginning and a certain end. Healthcare reform is something we can achieve or complete, something we can finish. When we reach the reform finish line, practitioners will provide care that will prevent many common illnesses. If people do fall ill, efficient practitioners will provide effective care at an affordable price.
When you practice medicine, healthcare reform seems less like a well-organized race and more like being at sea on an unmarked course of indeterminate distance. You cannot recall where the starting line is and cannot envision the finish line. You feel like a crewmember on a vast ship steered by multiple captains who cannot agree on the course. As you execute the shifting priorities of the captains, you become so concerned about keeping your place on the ship that you have little time to figure out where the ship is headed.
When you are lost, it helps to retrace your journey.
. . .
In The Finest Traditions of My Calling, I return to the oaths I swore at the beginning of my training, and to the best traditions of medicine to which they appeal. I discuss the ways medicine advanced by embracing science, statistics, industrial engineering, customer service, and social justice and the ways medicine is being transformed by healthcare reform. The book is not intended to be comprehensive—a conspectus or summary of all the reform efforts going on in healthcare—rather, it is a narrative search for a true reform, for the renewal of medicine. The search took me from a sprawling hospital to an ancient poorhouse, an army outpost, and a medical marijuana dispensary. It is a particular account by a specific physician, reflecting upon the oaths he swore, and wondering where this ship is headed.
At present, my own place on the ship is as the director of adult inpatient psychiatry at Denver Health, an academic safety-net hospital. At times, I have been a patient, a volunteer, a student, a trainee, an ethicist, a teacher, a quality-improvement officer, a researcher, an electronic medical record builder, and an administrator. Those experiences inform this book, which is about practicing medicine during healthcare reform and searching for a finish line, a fitting port. Even, perhaps, a port where healthcare is not simply reformed, but the practice of medicine is renewed.