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Once upon a time, doctors believed that work was the core of personal identity and life goals, and practicing medicine was a noble profession with a strong sense of mission. However, the deepening profit seeking operation of the hospital and the situation of Chinese medicine students risking their lives but earning little in the COVID-19 epidemic have made some young doctors believe that medical ethics is decaying. They believe that a sense of mission is a weapon to conquer hospitalized doctors, a way to force them to accept harsh working conditions.

Austin Witt recently completed his residency as a general practitioner at Duke University. He witnessed his relatives suffering from occupational diseases such as mesothelioma in coal mining work, and they were afraid to seek a better working environment due to fear of retaliation for protesting against working conditions. Witt saw the big company singing and I appeared, but paid little attention to the impoverished communities behind it. As the first generation in his family to attend university, he chose a career path different from his coal mining ancestors, but he was not willing to describe his job as a ‘calling’. He believes that ‘this word is used as a weapon to conquer trainees – a way to force them to accept harsh working conditions’.
Although Witt’s rejection of the concept of “medicine as a mission” may stem from his unique experience, he is not the only one who critically considers the role of work in our lives. With the reflection of society on “work centeredness” and the transformation of hospitals towards corporate operation, the spirit of sacrifice that once brought psychological satisfaction to doctors is increasingly being replaced by the feeling that “we are just gears on the wheels of capitalism”. Especially for interns, this is clearly just a job, and the strict requirements of practicing medicine are conflicting with the rising ideals of a better life.
Although the above considerations may only be individual ideas, they have a huge impact on the training of the next generation of doctors and ultimately on patient management. Our generation has the opportunity to improve the lives of clinical doctors through criticism and optimize the healthcare system we have worked hard for; But frustration can also tempt us to give up our professional responsibilities and lead to further disruption of the healthcare system. To avoid this vicious cycle, it is necessary to understand which forces outside of medicine are reshaping people’s attitudes towards work, and why medicine is particularly susceptible to these evaluations.

From mission to work?
The COVID-19 epidemic has triggered an all American dialogue on the significance of work, but people’s dissatisfaction has emerged long before the COVID-19 epidemic. Derek from The Atlantic
Thompson wrote an article in February 2019, discussing Americans’ attitude towards work for nearly a century, from the earliest “work” to the later “career” to “mission”, and introducing “work ism” – that is, the educated elite generally believe that work is “the core of personal identity and life goals”.
Thompson believes that this approach of sanctifying work is generally not advisable. He introduced the specific situation of the millennial generation (born between 1981 and 1996). Although the parents of the baby boomer generation encourage the millennial generation to seek passionate jobs, they are burdened with huge debts after graduation, and the employment environment is not good, with unstable jobs. They are forced to engage in work without a sense of achievement, exhausted all day long, and keenly aware that work may not necessarily bring the imagined rewards.
The corporate operation of hospitals seems to have reached the point of being criticized. Once upon a time, hospitals would invest heavily in resident physician education, and both hospitals and doctors were committed to serving vulnerable groups. But nowadays, the leadership of most hospitals – even so-called non-profit hospitals – are increasingly prioritizing financial success. Some hospitals view interns more as “cheap labor with poor memory” rather than doctors shouldering the future of medicine. As the educational mission increasingly becomes subordinate to corporate priorities such as early discharge and billing records, the spirit of sacrifice becomes less attractive.
Under the impact of the epidemic, the feeling of exploitation among workers has become increasingly strong, exacerbating people’s sense of disillusionment: while trainees work longer hours and bear huge personal risks, their friends in the fields of technology and finance can work from home and often make a fortune in crisis. Although medical training always means economic delay in satisfaction, the pandemic has led to a sharp increase in this sense of unfairness: if you are burdened with debt, your income can only barely pay rent; You see the exotic photos of friends “working at home” on Instagram, but you have to take the place of the intensive care unit for your colleagues who are absent due to COVID-19. How can you not question the fairness of your working conditions? Although the epidemic has passed, this sense of unfairness still exists. Some resident physicians believe that calling medical practice a mission is a ‘swallow your pride’ statement.
As long as work ethics stem from the belief that work should be meaningful, the profession of doctors still promises to achieve spiritual satisfaction. However, for those who find this promise purely hollow, medical practitioners are more disappointing than other professions. For some trainees, medicine is a “violent” system that can provoke their anger. They describe widespread unfairness, abuse of trainees, and the attitude of faculty and staff who are unwilling to face social injustice. For them, the word ‘mission’ implies a sense of moral superiority that medical practice has not won.
A resident physician asked, “What do people mean when they say medicine is a ‘mission’? What mission do they feel they have?” During her medical student years, she was frustrated by the healthcare system’s disregard for people’s pain, mistreatment of marginalized populations, and tendency to make the worst assumptions about patients. During his internship at the hospital, a prison patient suddenly passed away. Due to regulations, he was handcuffed to the bed and cut off contact with his family. His death made this medical student question the essence of medicine. She mentioned that our focus is on biomedical issues, not pain, and she said, “I don’t want to be part of this mission
Most importantly, many attending physicians agree with Thompson’s viewpoint that they oppose using work to define their identity. As Witt explained, the false sense of sacredness in the word ‘mission’ leads people to believe that work is the most important aspect of their lives. This statement not only weakens many other meaningful aspects of life, but also suggests that work can be an unstable source of identity. For example, Witt’s father is an electrician, and despite his outstanding performance at work, he has been unemployed for 8 years in the past 11 years due to the volatility of federal funding. Witt said, “American workers are largely forgotten workers. I think doctors are no exception, just gears of capitalism
Although I agree that corporatization is the root cause of problems in the healthcare system, we still need to take care of patients within the existing system and cultivate the next generation of doctors. Although people may reject workaholism, they undoubtedly hope to find well-trained doctors at any time when they or their families are sick. So, what does it mean to treat doctors as a job?

slack off

During his residency training, Witt took care of a relatively young female patient. Like many patients, her insurance coverage is insufficient and she suffers from multiple chronic diseases, which means she needs to take multiple medications. She is often hospitalized, and this time she was admitted due to bilateral deep vein thrombosis and pulmonary embolism. She was discharged with a one month old apixaban. Witt has seen many patients suffering from insufficient insurance, so he is skeptical when patients say that the pharmacy promised her to use coupons provided by pharmaceutical companies without interrupting anticoagulant therapy. In the next two weeks, he arranged three visits for her outside of the designated outpatient clinic, hoping to prevent her from being hospitalized again.
However, 30 days after discharge, she messaged Witt saying that her apixaban had been used up; The pharmacy told her that another purchase would cost $750, which she couldn’t afford at all. Other anticoagulant drugs were also unaffordable, so Witt hospitalized her and asked her to switch to warfarin because he knew he was just procrastinating. When the patient apologized for their “trouble,” Witt replied, “Please don’t be grateful for my attempt to help you. If there’s anything wrong, it’s that this system has disappointed you so much that I can’t even do my own job well
Witt regards practicing medicine as a job rather than a mission, but this clearly does not diminish his willingness to spare no effort for patients. However, my interviews with attending physicians, education department leaders, and clinical doctors have shown that the effort to prevent work from consuming life inadvertently increases resistance to the requirements of medical education.
Several educators described a prevalent “lying flat” mentality, with increasing impatience towards educational demands. Some preclinical students do not participate in mandatory group activities, and interns sometimes refuse to preview. Some students insist that requiring them to read patient information or prepare for meetings violates the duty schedule regulations. Due to students no longer participating in voluntary sex education activities, teachers have also withdrawn from these activities. Sometimes, when educators deal with absenteeism issues, they may be treated rudely. A project director told me that some resident physicians seem to think that their absence from mandatory outpatient visits is not a big deal. She said, “If it were me, I would definitely be very shocked, but they don’t think it’s a matter of professional ethics or missing out on learning opportunities
Although many educators recognize that norms are changing, few are willing to publicly comment. Most people demand that their real names be hidden. Many people worry that they have committed the fallacy passed down from generation to generation – what sociologists call the ‘children of the present’ – believing that their training is superior to that of the next generation. However, while acknowledging that trainees may recognize basic boundaries that the previous generation failed to understand, there is also an opposing view that the shift in thinking poses a threat to professional ethics. A dean of an education college described the feeling of students being detached from the real world. He pointed out that even when returning to the classroom, some students still behave like they do in the virtual world. She said, “They want to turn off the camera and leave the screen blank.” She wanted to say, “Hello, you’re no longer on Zoom
As a writer, especially in a field lacking data, my biggest concern is that I may choose some interesting anecdotes to cater to my own biases. But it’s difficult for me to calmly analyze this topic: as a third-generation doctor, I have observed in my upbringing that the attitude of the people I love towards practicing medicine is not so much a job as a way of life. I still believe that the profession of doctors has sacredness. But I don’t think the current challenges reflect a lack of dedication or potential among individual students. For example, when attending our annual recruitment fair for cardiology researchers, I am always impressed by the talents and talents of the trainees. However, even though the challenges we face are more cultural than personal, the question still remains: is the change in workplace attitudes we feel real?
This question is difficult to answer. After the pandemic, countless articles exploring human thought have described in detail the end of ambition and the rise of ‘quiet quitting’. Lying flat “essentially means refusing to surpass oneself in work. The broader labor market data also suggests these trends. For example, a study showed that during the pandemic, the working hours of high-income and highly educated men were relatively reduced, and this group was already inclined to work the longest hours. Researchers speculate that the phenomenon of “lying flat” and the pursuit of work life balance may have contributed to these trends, but the causal relationship and impact have not been determined. Part of the reason is that it is difficult to capture emotional changes with science.
For example, what does’ silently resigning ‘mean for clinical doctors, interns, and their patients? Is it inappropriate to inform patients in the quiet of the night that the CT report showing results at 4 pm may indicate metastatic cancer? I think so. Will this irresponsible attitude shorten the lifespan of patients? It’s unlikely. Will the work habits developed during the training period affect our clinical practice? Of course I will. However, given that many factors that affect clinical outcomes can change over time, it is almost impossible to understand the causal relationship between current work attitudes and future diagnostic and treatment quality.

Pressure from peers
A large amount of literature has documented our sensitivity to colleagues’ work behavior. A study explored how adding an efficient employee to a shift affects the work efficiency of grocery store cashiers. Due to customers often switching from slow checkout teams to other fast-moving teams, introducing an efficient employee may lead to the problem of “free riding”: other employees may reduce their workload. But the researchers found the opposite: when high-efficiency employees are introduced, the work efficiency of other workers actually improves, but only if they can see the team of that high-efficiency employee. In addition, this effect is more pronounced among cashiers who know they will work with the employee again. One of the researchers, Enrico Moretti, told me that the root cause may be social pressure: cashiers care about their peers’ opinions and do not want to be negatively evaluated for being lazy.
Although I really enjoy residency training, I often complain throughout the entire process. At this point, I cannot help but recall with shame the scenes where I evaded the directors and tried to avoid work. However, at the same time, several senior resident physicians I interviewed in this report described how new norms emphasizing personal well-being can undermine professional ethics on a larger scale – which coincides with Moretti’s research findings. For example, a student acknowledges the need for “personal” or “mental health” days, but points out that the high risk of practicing medicine will inevitably raise the standards for applying for leave. She recalled that she had worked for a long time in the intensive care unit for someone who was not sick, and this behavior was contagious, which also affected the threshold for her own application for personal leave. She said that driven by a few selfish individuals, the result is a “race to the bottom”.
Some people believe that we have failed to meet the expectations of today’s trained physicians in many ways, and have concluded, “We are depriving young doctors of the meaning of their lives.” I once doubted this view. But over time, I gradually agree with this view that the fundamental problem we need to solve is similar to the question of “chicken laying eggs or egg laying chickens.” Has medical training been deprived of meaning to the extent that people’s only natural reaction is to see it as a job? Or, when you treat medicine as a job, does it become a job?

Who do we serve
When I asked Witt about the difference between his commitment to patients and those who see medicine as their mission, he told me the story of his grandfather. His grandfather was a union electrician in eastern Tennessee. In his thirties, a large machine at an energy production plant where he worked exploded. Another electrician was trapped inside the factory, and Witt’s grandfather rushed into the fire without hesitation to save him. Although both eventually escaped, Witt’s grandfather inhaled a large amount of thick smoke. Witt did not dwell on his grandfather’s heroic actions, but emphasized that if his grandfather had died, things might not have been much different for energy production in eastern Tennessee. For the company, grandfather’s life can be sacrificed. In Witt’s view, his grandfather rushed into the fire not because it was his job or because he felt called upon to become an electrician, but because someone needed help.
Witt also has a similar view on his role as a doctor. He said, ‘Even if I am struck by lightning, the entire medical community will continue to operate wildly.’ Witt’s sense of responsibility, like his grandfather, has nothing to do with loyalty to the hospital or employment conditions. He pointed out, for example, that there are many people around him who need help in a fire. He said, “My promise is to those people, not to the hospitals that oppress us
The contradiction between Witt’s distrust of the hospital and his commitment to patients reflects a moral dilemma. Medical ethics seem to be showing signs of decay, especially for a generation that is highly concerned about systemic errors. However, if our way of dealing with systemic errors is to shift medicine from our core to the periphery, then our patients may suffer even greater pain. The profession of a doctor was once considered worth sacrificing because human life is of paramount importance. Although our system has changed the nature of our work, it has not altered the interests of patients. Believing that ‘the present is not as good as the past’ may just be a clich é d generational bias. However, automatically negating this nostalgic sentiment may also lead to equally problematic extremes: believing that everything in the past is not worth cherishing. I don’t think that’s the case in the medical field.
Our generation received training at the end of the 80 hour workweek system, and some of our senior doctors believe that we will never meet their standards. I know their views because they have openly and passionately expressed them. The difference in today’s tense intergenerational relationships is that it has become more difficult to openly discuss the educational challenges we face. Actually, it was this silence that attracted my attention to this topic. I understand that a doctor’s belief in their work is personal; There is no “correct” answer to whether practicing medicine is a job or a mission. What I don’t fully understand is why I felt afraid to express my true thoughts while writing this article. Why is the idea that the sacrifices made by trainees and doctors are worth it becoming increasingly taboo?