A Parable, Medically Updated

Truth dresses in rags. Parables dress in fine clothes. When they walk together, they are seldom ignored. Let's talk about money...

A parable told of two brothers, one of whom was wealthy, the other very poor: The poor brother asked his rich brother, “What accounts for your wealth?” He answered him, “It is because I do evil deeds.” The poor brother then went and did as his brother, but his evil actions bore him no fruit. He returned to inquire, “See, I have done as you do, but why hasn’t success come my way?” This time the rich brother answered him, “It is because you have done evil only in expectation of wealth and not for the sake of the evil deeds themselves."

When someone applies to medical school, invariably the question, "Why do you want to be a doctor?" is asked. I've always suspected that the answer never mattered—each applicant has certainly rehearsed his reply well in advance—but that the delivery would.

Did the applicant spit the answer out, did he feign philosophical introspection, did he fake surprise at the question, did he make eye contact, or did he read the essay off an invisible power point presentation? Maybe the question is asked because it is simply expected. It remains part of a medical tradition that each prospective candidate must be exposed to.

Whatever the reason, the answer is never, "To get rich." Everyone instinctively knows that, while there is no one right answer, there certainly are distinctly wrong ones. And this one would head the list of wrong answers.

My colleagues are now up in arms, fighting the protracted economic warfare they perceive being waged upon them. Reimbursements are being cut and procedures are moving out of offices and back to hospitals, based on diminished reimbursements. Affiliations are broken, then reformed, driven by bottom lines. Mergers become acquisitions as the big swallow the small. The Mother of All Medical Battles, the mandated creation of ACOs (Accountable Care Organizations), will soon have specialists, primary care providers, and hospitals all fighting over who gets which piece of the monetary pie. It will be a zero-sum game where each winner must mandate a loser.

This Medical Armageddon looms over physicians, and I fear it will not bring out the best qualities of our profession. We want to be richly rewarded for our years of training, hard work and long hours.

My father, an immigrant, worked as a furrier, bent over a sewing machine five and a half days a week, 10 hours a day. He commuted an hour each way, on bus and subways, to a dirty factory loft in Manhattan's garment district. That was hard work and long hours. In comparison I, as an Internist, do a cake walk each day. With reserved parking.

That is why I find this parable so intriguing. Who are we today, as a profession, and what do we want to be? Did we really want to be rich and make lots of money when we applied to medical school? Is that what we really want now? Is that what will consume our profession and define us? What are we going to prove to our patients, our families, and each other?

This is not about which brother we are in the parable. It is about what we may try to do in the expectation of wealth. And what our results will be.

-alan berkenwald, md