Vocation in medicine

Why do you do what you do?

Much has been made of importance of professionalism in medical practice. And, whilst much ink has been spilt on the mechanics of ensuring that medical students develop professional behaviours, less attention has been paid to intrinsic motivation, the answer to the question: Why should I behave in this way?¹ Indeed, professionalism risks being seen as ‘just a game’ to be played.² In older parlance, we used to speak of profession, rather than professionalism. Profession referred to the vow of commitment made by those entering the occupations of divinity, law, medicine, and the military. Such profession or commitment extended to the point of risking one’s life: A fact, whilst still obvious in the case of the soldier, is perhaps not usually considered by applicants to medical school. In modern times, in the West at least, medicine was seen as a low-risk endeavour: Until now, until the coronavirus.

The virus has taken its toll on healthcare workers - doctors and nurses. A BBC report early in the course of the pandemic noted the deaths of 163 doctors and 40 nurses in the first wave of coronavirus in Italy.³ and yet we still showed up for work. It is clearly more than a job; more than an occupation to be performed whilst exhibiting professional behaviours; it is, I think, best described as a vocation.

However, vocation is a word that has lost its gloss of late. It is widely used merely to describe any job. Vocational qualifications may be obtained in fields as diverse as travel and tourism, IT, performing arts, and floristry. Clearly the practise of medicine is different to work in these areas. I am therefore suggesting that there is a need to understand and recover the concept of vocation.

Doctors often speak of a having sense of vocation but what do they mean? The word itself has its roots in the Latin vocare meaning “to call”. This concept of vocation originates from religious life – describing the sense of feeling called by God to follow a certain path or career. Personally, as a Christian, I understand that sense of calling but what does it mean in today’s more secular age? If one is not called by God, then in what sense may one be said to have a vocation? How can we best define and use the term to help our students and trainees find and understand their ’calling’ in medicine?

Outside of the spiritual context, Duffy and Dik define calling as “a transcendent summons, experienced as originating beyond the self, to approach a particular life role in a manner orientated toward demonstrating or deriving a sense of purpose or meaningfulness that hold other-oriented values and goals as primary sources of motivation.” ⁴ This distils down into three components: an external summons, meaning/purpose, and prosocial motivation.⁵ Whilst some may experience a sense of summons or destiny, another common feeling is that of work being a ‘perfect fit’ with one’s skills and passions. This may assist us in helping us our students and trainees understand their sense of vocation. We cannot generate a sense of external call from a higher agency but we may be able to help them find their calling in the weaker sense of finding their perfect fit. This may be good career advice to give students or trainees in normal circumstances but what about when times are hard; when this translates to personal risk for the doctor? Philosopher Nassim Nicholas Taleb describes the importance of having ‘skin in the game’. ⁶ For the physician, skin in the game, participation in sharing the risk, is a must. To have skin in the game is only the beginning. Taleb identifies a deeper level of involvement. This is to have ‘soul in the game’ as demonstrated by artisans. “Artisans put some soul into their work: They won’t sell something defective or even of questionable quality, because that would hurt their most deeply felt values.” Artisans “do things for existential reasons first” and have “sacred taboos, things they will not do”. We need to help our students and trainees come to terms with risk and uncertainty in practice. (Though I must say how impressed I have been by the commitment of the trainees in the hospital where I work.) “How much you truly “believe” in something can be manifested only through what you are willing to risk for it.” Understanding the value of having ‘skin in the game’ can help us respond to the challenges of practice. A sense of vocation important for the individual physician at every stage of their professional life. Intrinsic motivation is a factor leading students to apply to medical school,⁷ it influences choice of specialty,⁸ and protects against physician burnout. ⁹ It is also important for patients and coheres with compassionate care.¹⁰ Intrinsic motivation is what keeps us at work even when the stakes are high.

And so, whilst vocation, severed from its religious roots, has the potential to be misunderstood and neglected it can also embolden and encourage. Indeed, psychologist Daniel Brown notes the combination of proactive perspective, spirituality and motivation as being important factors promoting human thriving. ¹¹ You can prosper in medicine as a job or career, you can struggle through the dark times following your profession, but I think to really thrive requires a vocation.