AMA Journal of Ethics^®

“What is medicine really about?” One could easily imagine a seasoned medical school professor posing this to a fresh group of first-year medical students on their first day of training. The new students would be hanging on to every word, eager to absorb even the smallest bit of information. Perhaps this question would be the introduction to their first lecture on pathophysiology or clinical diagnosis. How shocked these new physicians-in-training would be if their esteemed professor responded to the question in one word: service. “Medicine is about service. We are all here to serve others—our neighbors, our communities, and even complete strangers.” What a surprising and apt answer that would be; acknowledging that above all else, medicine is a profession of service.

In a field dominated by ever-changing technologies and conventions, service remains constant. The purpose of this issue of Virtual Mentor is to remind us of the medical profession’s commitment to serving others—a commitment that can easily get lost among competing priorities. The authors in this issue succeed in affording us the opportunity to rediscover the importance of service in our careers—much as former JAMA editor in chief Catherine DeAngelis did in her insightful and timely 2009 commentary “Commitment to Care for the Community” [1]. As you begin to peruse this August issue of VM, I encourage you to think of your very first patient—the healthy newborn baby in need of routine care or the 70-year-old veteran with COPD being admitted for an exacerbation. Think of the connection, no matter how small, you made with that patient as you attempted to play one small role in serving his or her needs—even if you forgot to perform half of the physical exam to your senior resident’s obvious disapproval.

What does service mean? Need every seasoned physician work at a clinic dedicated to the homeless to truly serve? Need every medical student spend an elective rotation working in a third-world country? Need every resident take precious time to help uninsured patients fill out public insurance applications? I think that the answer to these questions is a resounding “no”—and I believe most of this issue’s authors would agree. As physicians, we need a heightened but not overly simplistic awareness of our responsibilities. Instead of asking “should I be doing more?” or “am I doing enough?” one might ask “do I do something each day to make a difference?” I think our health care system would be more responsive to the health needs of our nation’s communities if all health care professionals—nurses, physicians, and administrators alike—asked themselves this question and made a conscious effort to act upon it each day.

Returning to the medical school lecture hall, perhaps that same professor would have the honor of congratulating the medical students as they walked across the stage at commencement. Perhaps he or she would proudly lead them in the Hippocratic Oath—that historic moral compass of medicine. Although the modern Hippocratic oath does not mention “service” by name, it makes clear the commitment we all share:

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug…

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick…

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm [2].

We serve in a health care system in which 50 million Americans are uninsured, including 7.5 million children—drastically limiting this group’s access to quality medical care [3]. Health disparities, despite an increasing body of research, persist in an era of advancing therapeutics. Socioeconomic status is a major determinant of health status; a family’s income level seems to be a predictor of the overall health and well-being of its members [4]. The questions of who is to blame or who is responsible for the broken nature of the American health care system are nonstarters (to borrow from current political jargon). The real question should be who is best charged with making it better. If we, as a profession, take our commitment to service seriously—reaffirming it each day in the clinic or on the hospital units, I contend that we can steer our health care system toward reflecting the ethics on which our profession is founded.