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The downside of a free lunch: Incentives and the medical student

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

money on hook  smallDoctors are people, too, and they respond to incentives. That was the message we got from a recent health-policy class session that discussed various ways of paying doctors for their work, and how this can play a role in patient care. In an ideal world, physicians would be motivated only by what is best for their patients; however, the reality is that doctors, like all people, can be influenced by external factors such as money, autonomy, and time.

This got me thinking about the incentives that currently shape my life as a medical student. While we would all like to say that the choices we make are determined only by our own internal desire to maximize our learning and become the best future physicians possible, even the most idealistic student among us would have to admit that incentives, big and small, influence our decisions every single day.

On a day-to-day basis, incentives determine how we budget our time and focus our efforts. For example, given the huge demands on our time and our budgets, the promise of a free lunch provides a strong incentive for us to attend lunchtime seminars and panel discussions – even if the subject matter is not of immediate interest or relevance to us.

In class, because of the Pass/Fail grading system during our pre-clinical years, our external incentives are not our class grades, but instead the standardized board exam that will play an important role in our residency applications. Our collective ears perk up every time our professors say “This always shows up on the boards,” even if we are told that the particular information is rarely (if ever) applied in real-world clinical practice.

In the bigger picture, as we begin to explore various specialties and avenues for practicing medicine, it is impossible to ignore the reality that average salary, lifestyle, and autonomy vary hugely from one specialty to the next, and from one type of practice to another. Not feeling very passionate about private-practice urology? Does that change when you find out that urologists make about twice the annual salary of a family medicine doctor?

The reality is that our intrinsic motivations to make the world a better place by becoming the best possible physicians do not always align with the incentives that medical school, and the larger health-care system, provide. We are incentivized to spend time and effort on things that will not help us be better doctors, and in the long run we might even be incentivized to make decisions that will reduce the amount of good we can bring to the world. Is it the job of policymakers and medical educators to better align incentives to create the desired outcomes for our health-care system? Or do we, as future physicians, need to shoulder more responsibility to do the right thing, passing up the literal and figurative “free lunch” in the process?

Maybe there is an ideal middle ground for each of us – a place where the incentives align at least reasonably well with our own internal goals. In that case, one of our tasks as medical students for the next several years will be to find it.

Nathaniel Fleming is a first-year medical student and a native Oregonian. His interests include health policy and clinical research.

Photo by Tax Credits

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