Where will our future healthcare providers come from?

While I do not work with students or teach full time to healthcare providers at this time, I have in the past, am still involved in several interview days every year, and was once a medical school applicant who was interviewed herself. A lot has changed since then, mostly for the better, but after you read this, you may create an opinion on what hasn’t gotten better. Also, by “healthcare provider” I am referencing physician or midlevel (Physician Assistant or Nurse Practitioner).

I interviewed for medical school more than 20 years ago. Back then the healthcare system in the United States was really unlike what it was today, but I assumed that almost every generation sees a change in the healthcare system structure during their time. There’s lots of people on Substack who write about the changes of the healthcare system here in the United States and what we need to do to improve it and change it going forward. I am not necessarily one of those people as I do not have all the answers and am not able to suggest changes, but I’m definitely an objective complainer. It’s been 20 years since I started medical school and more than 15 since I entered the Emergency Department after residency to practice medicine independently. When I entered medicine, there were plenty of us, including myself who came from families also in healthcare. Today, I find, for better or worse, that is less so overall.

The student applicant who interviews for a healthcare provider graduate degree (MD, DO, PA, NP) falls into one of these buckets, but can have some sprinkling of elements from other buckets.

· A physician applicant that is legacy, comes from a family of physicians, and has been (almost) exclusively parented to become a physician.

· A physician applicant who sees the academic and research potential in healthcare and feels that the rigors will be well within their range of high intellect.

· A physician or non-physician applicant that sees becoming a healthcare provider as a calling and has pursued life skills and social skills necessary to adapt to the rigors of school and patient care.

· A non-physician applicant who has been influenced by one or more experiences in life that taught them they would like to serve others as they were served at one time.

· A physician applicant who sees medicine as a lucrative profession and knows that school is the stepping stone to that.

Out of all the other physicians and healthcare providers that I have worked with and become close with, none in my generation are keen on their children going into healthcare, especially to become a provider. It’s not that those of us who are physicians would not allow our children to go to medical school, we would actively discourage our children from going into any profession that has anything to do with becoming a healthcare provider in the United States. If anyone does advocate for their progeny to enter the medical profession at the provider level, they must have had a rare experience, the supports that can guarantee success, it is the family business in a since (legacy applicants), or the relative monetary value of medicine to them cancels out anything else they may endure.

I came from a healthcare family, but neither of my parents were providers. My father actually discouraged me from being a nurse as he entered his 30th year as a bedside RN of what would be a 45 year career. Both of my parents were Switzerland. Neutral. Not otherwise discouraging nor encouraging of my pursuits. I leave the rest for my book.

When I have been interviewing candidates for schools of medicine, it has exposed me to candidates that are not coming from families of healthcare workers of any kind. For sure there are young candidates going into MD or DO programs that come from families of physicians from other countries besides the United States. However, as we have seen cultural shifts in the first and second generations of new Americans, there may be some cultural shifts in desired professions as well.

Of the applicants for healthcare professional graduate degree programs (PA or NP) that I have been exposed to over the last several years, most seem to be pursuing an advanced healthcare field built upon their experiences as children and teenagers. They were exposure to healthcare during these very influential times either as a patient or as a family member of a patient. These experiences have shaped their understanding of what the best parts of the US healthcare system can be. Overwhelmingly they describe positive experiences and reflect upon the compassion and communication style of the providers (mostly PAs and NPs) they came in contact with. They describe situations in which they would have come upon several if not dozens of different healthcare providers but really center their positive experiences on one or two of these people and the great amount of empathy and professionalism they expressed in their care. These applicants do not refer to healthcare providers as a group but focus their reflections on the very few who have left core memories behind in the applicant.

It is these core memories, and the attached emotions connected to the perception of the compassion and empathy displayed by the provider that has led the applicant to want to exemplify that in their life and try to influence patient care in the same way they were positively influenced.

So, what does it say of the future healthcare providers for our future patient base? Will this mean future healthcare providers with better insights of what it means to be a patient or the family member of a patient? Will it mean that there will be more healthcare providers dedicated to a higher mission, a “healthcare as a human right” perspective, in providing care for the greatness of humanity rather than the compensation that comes with an elite level of practice?

If the US is going to change the healthcare system, everyone will have a role to play, including the healthcare providers and how we select them. The healthcare system has placed us into a rather passive role that we will need to escape from. It’s having future healthcare providers coming from backgrounds that are diverse in social and economic status, parents in diverse professions, and life experience. This will allow us to be better able to provide care for the same kind of patients going forward.

Right now, diversity seems to be centered on diversity of race and ethnicity, and this has been so for quite some time. However, for my perspective, I do not see that this has created more diversity and compassionate empathy and professionalism and healthcare. Diversity and ethnicity do not translate to diversity in belief or interest or what influences somebody to go into one professional or another. A person of certain ethnicity does not determine their empathy or how they actually interact with other people. A person’s ethnicity does not translate to a diversity of experiences or a diversity of connections with other diverse groups. The US future healthcare professionals, if they are to relate well to their patient groups, will have to come from those patient groups, and not necessarily from a group or family that is different from the selection committee.

What does this say of the current and past healthcare provider professionals? The current and past healthcare professionals, particularly physicians, do a bad job of handling their stress. Talking about their profession and patients, they put personification of intelligence, drive, confidence, and hierarchy above just good old patient care? Was a standard of living expectation one that compensated for the real negatives of practicing medicine? If it meant practicing in a much better system, I would gladly take that pay cut.

I didn’t ask my father why he didn’t want me to be an RN at the time. I figured it out later on my own. Looking back, he was right. I would give my child the same kind of simple advice that he gave me. There are so many other good things to be and do to help others. Unless you’re willing to make more sacrifices to try to change what healthcare has become, and what medicine has become, and be that kind of messiah, then currently it’s not worth it. At this time, there may have to be a baptism by fire and a realization amongst all the players (providers, patients, health systems, insurers, policy makers, etc.) that there needs to be such a significant change in how we practice, our approach, and what we expect from healthcare.

The applicant pool in the United States for post-baccalaureate healthcare providers is one with a spectrum of interest, baseline empathy, and compassion that is similar to that of the general population. A lot of them are still very young and have a quantity of life experience that, no matter what, cannot fully prepare them for not only the rigorous education, but the physical and mental commitment it will take. Everybody finds these out later, no matter how prepared they may believe themselves to be or state. Not even the legacy applicants really can have all that much preparation given the rapid transformation of healthcare over the decades. The healthcare and practice of medicine that their parents and grandparents lived through will be nothing like what they will live through.

So, what will the future American patient want out of their future healthcare providers in the United States? Would they prefer a legacy candidate who has been brought up with the purpose of having a career such as medicine to prolong the family’s status? Will patients prefer providers that have been patients or caregivers themselves? Is it the knowledge of the lifestyle experience of being a healthcare provider better than the knowledge of the patient experience?

Also, how do we really feel about prior academic rigor in grades and test scores that seem to the selection rubric to really matter the most, but usually doesn’t in the end. Average students have turned out to be superior providers. Spectacular students with squeaky clean records and GPAs that did not hesitate to hover a bit under 4.0, can turn out to be very average, very uncaring, and lack the social grit that is needed to interact with various other people from various other backgrounds and cultures. We just cannot learn how to treat people in a positive way from a textbook, nor can this be tested on in a standardized way. Can we test in college on perseverance, dedication, and time management? Maybe. Skills that are taught by life experience may have to be tested by further life experience.

Some of us in medicine are very proud of our ability to detect bullshit. However, we do make mistakes from time to time, and I’ll admit I have. However, one big mistake that a lot of us make is not recognizing the amount of bullshit detection patients also have. Patients are really good at spotting narcissists and those with ulterior motives. These are also skills not taught in classes or tested for on exams. They are taught in life and tested throughout life. Do we want our future healthcare provider to be able to recognize those things not said, read between the lines and adapt to their patient’s education and ways of communication?

Another thing I noticed during interviews for these healthcare professional applicants is that those that are coming from a largely under privileged population in this country, have been exceptionally poised and confident. Answers to the very tough questions can be well thought out, honest, and come from experience rather than just what should be said. They seem to have a different kind of confidence. They’re confidence may be coming from years of practice, conversations with other adults that are meaningful, and having people in their lives that they can rely on for guidance. While we may think that this is standard in the privilege classes, I don’t see the product of it in all the applicants from historically privilege classes.

When it comes to my time as a physician provider, I do hope that I have been able to positively influence at least one other person’s dedication and self-sacrifice towards the profession of medicine in some capacity. I hope that I did give enough empathy and compassion that it could bleed into another generation, and then hopefully bleed into another generation beyond that. But when it comes to my own child and the children of close friends around me, I cannot have that great influence.

The trouble is in healthcare these days, you can do your best and have your best intentions and try your hardest every day with every patient, but you’re working within great confines from multiple angles. All you can do is hope that your compassion and empathy and professionalism is seen and remembered.