Chapter V: The Motivation of Physicians
Fenigsen, Richard, Fenigsen, Ryszard, Issues in Law & Medicine
During the twenty years of the attack on medicine that I witnessed in Holland, the media, politicians, and "people in the street" expressed the opinion that doctors' sole reason to do their work was the big money they were making. The anti-medical prophet Ivan Illich, much quoted at the time, disagreed, he knew that what motivated the doctors to work was the greed for power.
On the other extreme, the Polish school of medical ethics, and in particular one of its founders, Dr. Teodor Heiman, asserted that love of suffering mankind, and nothing else, should be the doctor's motive to practice medicine. (54) When I was a student at the Medical School, this statement by Heiman worried me a lot. Much as I tried, I could not find in my soul any genuine love of mankind, suffering or not. Further in this chapter, I shall describe what I used to feel coming to see a patient. It was quite a mixture of emotions, but love was not one of them. I had, therefore, serious doubts; perhaps I was unfit to become a doctor?
My first sobering reflections came after my first encounters with unpleasant patients. At times one comes across an obnoxious, abrasive individual, or a hostile psychopath. We certainly did not love such persons. But we paid no attention to their outbursts, and treated them the same as all other patients. If love were the doctor's motive to help patients, these people would be left without medical assistance.
Is money the incentive? I recall an elderly gentleman who on a Sunday evening fifteen times lost consciousness due to an intermittent heart blockage. Fortunately, every time he responded to a thump on the chest, and this was what I was doing waiting for the surgical team to gather. It was in the early days of pacemakers, before the invention of transvenous electrodes. Effective temporary pacemakers did not exist, and implanting a pacemaker was a huge affair; one had to open the patient's chest, cut the pericardium, and sew two button-like electrodes to the surface of the heart. In the meantime, an incision was made on the abdomen in order to implant the battery. Two thoracic surgeons (one of them the head of the department), a general surgeon, a surgical resident, and an anesthetist were working on the patient, while I was following his heart rhythm. I looked around the operating theater, and it occurred to me that if this were to be done for money, my patient wouldn't survive. I simply wouldn't be able to assemble such a team on a Saturday night. The Hospital's two surgeons on duty were operating on emergency patients in other theaters. The doctors working on my patient were not on duty. They canceled whatever plans they had for that Saturday evening, and rushed to the Hospital. On duty or not, they could not refuse assistance when someone's life depended on it. They would not do that for a fee. They did not grumble, and, on the contrary, felt rewarded because the novelty of the procedure made it particularly interesting.
In Polish Hospitals where I spent the first half of my professional life, I was earning decent money doing private practice and collecting my salary as head of the department and outpatient clinic, but other members of the team, some of them experienced physicians, were sadly underpaid. As in any team, a few were nice but undistinguished people; others, receiving the same miserable salaries, impressed and inspired me by their dedication, mental concentration, persistence in thinking of a patient, and constant desire to improve their knowledge and skills. I learned a lot from them.
I think of the consultants I met in 1961-62 at Hammersmith Hospital in London, and Oxford's Radcliffe Infirmary. They were doing excellent research, simple, rigorously controlled, and purposeful, and very good teaching, and provided prudent, effective, high-quality patient care. At that time, they were paid little more than 200 pounds a month while their counterparts in continental Europe earned thrice that much in salaries, in addition to lucrative private practice. …