When we're enjoying our studies, we rarely stop to ask why we're doing medicine. It's only when the course seems difficult, or when we've suffered a setback, that we question whether we should bother to continue. But whatever you currently feel, why not take a few minutes to think through your motives?

In the past twelve months I've spoken to two groups of medical students about this subject. Each group contained future doctors, but the similarities ended there since one group was in Southampton and the other was from Tirana, Albania. Within each group the differences were also considerable, since both contained students from diverse cultural and family backgrounds. Despite this, both groups were united in suggesting that there are four possible reasons why most people go into medicine.

Status

The first possible motivation for choosing a career in medicine is status. Most of us deny that status has anything to do with our career path, but I suspect that it may be more important than we first imagine. Think back to your pre-university days: didn't a career in medicine seem just a cut above the rest? Can you remember the quiet pride in your parents' voices, which stoked your own self-esteem as you admitted to your friends and family that you were considering applying not for science, or maths, but for medicine? And now that you have a place at medical school, are you not proud to be there? We start off humbled by the privilege, but soon sense that here, at last, we really belong, and have found our rightful place in the world.

When we started at medical school we found ourselves treated differently from those around us. From Freshers' Week onwards we were considered a valuable source of medical knowledge by our friends, even though we knew no information of clinical relevance! Within weeks of starting medical school it was widely known on campus that we had dissected dead bodies in anatomy, taken blood in physiology and tested our own urine in biochemistry. Our course is twice as long as many other undergraduate degrees, and while exams for other students remain a distant threat we often suffer several every term. All of these factors combine to make us feel rather special.

Once we have graduated as doctors we continue to risk feeling that we are someone special. The morbid fascination that people have for surgery, the strange powers of healing that they ascribe to us; all of these factors enhance our standing. Although the status of doctors is continually questioned by patients, other staff and the media, there remains for some reason an aura around us. Unless we are very careful, we can begin to think that we really are superior to others.

It is not that we don't disapprove of the old stereotype of the proud, arrogant doctor. If we read about Theodor Billroth (see box 1) or hear old stories about the way things used to be, we know that we could never be like that. We want to be accessible, not to scare our patients by affecting superiority. I would suggest, though, that what we are rejecting when we scorn doctors like Billroth is the old trappings of status, not elevated social position per se. If we are honest with ourselves we will find that we do in fact have high social status, and the experience is not at all disagreeable.

As with general surgery, social status may be considered to have early and late complications. The early complication threatens us all from the time we first set foot in medical school - pride. Medical training develops useful characteristics, including perseverance, a mind that retains intellectual minutiae, and a strong stomach! These characteristics, however, do not make us better people; they merely prepare us for a difficult job. Why then do we allow ourselves to become so proud of these qualities? Instead we should concentrate on developing characteristics that will serve us in every aspect of our lives, such as compassion, humility, and self-control.

Once we've graduated as a doctor, the most obvious drawback of relying on status to provide motivation is that it doesn't get us out of bed at three o'clock in the morning when it's snowing. Social prestige never provides the inner strength that we all need to persevere when the job is simply hard work.

Furthermore there are late complications of status that tend to make us worse doctors. First, not all patients believe that the sun shines out of our white coats, and we tend to get resentful that these patients don't realise just how important we really are. Second, when we think of ourselves as special, we tend to look down on our patients and come to assume that their problems are entirely their own fault. This failure to identify with our patients as fellow humans leaves us with a lack of compassion for them.

To summarise, status is an important part of being a medic, even though we protest that it does not motivate us. We find ourselves unshakeably proud of our position, but also realise that it is inadequate for motivation insofar as it does not encourage perseverance. Furthermore our spiritual health is endangered when, instead of allowing God's spirit to develop good inner characteristics in us, we allow ourselves to become proud of our external achievements. Finally, we may find ourselves becoming the worst kind of doctor: resentful of our ignorant patients and lacking compassion towards those with whom we cannot identify.

Money

The second reason for choosing medicine as a career is the money that follows. This may seem a bizarre statement to make given the current state of student finances, with the average final year student debt £12,915 in 2002 and set to rise even further.[2] It is difficult to see how anyone could hope to pay off this sort of debt within five years of qualification. Even taking debt into account, however, it is likely that as soon as you graduate you will enjoy more disposable income than most other working people in Britain. Within five years of qualifying you will be earning more than double the average income for a British household. Medicine remains a lucrative profession.

There are various drawbacks with relying on money to provide motivation. As with status, money does not provide us with the perseverance we need to care for our patients. In addition, there are two special dangers inherent in money of which we all need to be aware. The first of these is that money will never leave us satisfied; the second is that we may come to value money more highly than our patients.

No matter how much we earn, we are rarely satisfied. Most people spend more than they can afford, with the result that they feel underpaid. British doctors are not immune, tending to compare themselves with lawyers and brokers rather than with nurses and teachers when they consider their income. Perhaps you have heard the response attributed to John D Rockefeller when he was asked how much money was enough: 'Just a little more...'

My experience of money is that when I start a new job, or when I receive an increase in salary, I feel grateful for a short while and privileged to be well paid. Later though, especially if I have overspent for the month, I start to anticipate the next pay rise or think of ways to increase my income further. I find it a continual struggle to be satisfied with what I have, and often have to be reminded that my greed does me no good at all (see box 2).

If the first danger of money is harmful to us, the second is harmful to our patients. As soon as money becomes involved in the doctor-patient interaction there is a risk that we might treat patients unfairly. I have seen this in other countries, where unnecessary tests are arranged to increase the doctor's fee, but it can happen here in Britain as well. Here is a personal example from my own practice.

One of the morbid perks of being a doctor is that you are paid a fee for signing a certificate releasing a dead body for cremation. It's currently about £40. I worked as a house officer in a small district hospital, where we were not only paid for filling in 'crem forms', but also given an extra fee if the patient had a pacemaker, because these needed to be removed. A patient was brought in after a stroke; she was almost completely paralysed and didn't speak or otherwise respond to her relatives. A chest X-ray was performed as a matter of routine and I found myself pleased to see that she had a pacemaker fitted. In other words, I was looking forward to the fee that I would receive once she died and I removed her pacemaker.

I tell that story to my shame, but I think that it is important to stress how much of a trap money can be. Everyone knows the saying, 'Money is the root of all evil'. It may be that our English proverb misquotes the Bible's warning (see box 2), but it remains useful advice. If we look to money for our fulfillment, we will always remain dissatisfied. If our patients become secondary to our greed, we will treat them unfairly. Money will ensnare us unless we are very careful.

Intellectual stimulation

The third reason for choosing medicine as a career is found in the intellectual challenge and stimulation that medicine provides. This challenge starts early on in our studies but also persists after graduation. One of the great privileges of being a doctor is having a job that continues to throw up surprises and stimulate us to fresh thinking.

When we first get to medical school we find ourselves in a love/hate relationship with all the new terms that are thrown at us. Occasionally we wonder why lecturers use complicated terms when simpler ones would do - why say 'superior' when everyone else says 'above'? Nevertheless, we do enjoy our increasing understanding of technical and Latin terms, all part of the specialist knowledge that entitles us to belong in 'the medicine club'.

Many doctors find that the intellectual satisfaction continues after graduation, especially once the panic-stricken chaos of being a house officer has developed into the organised chaos of being a middle-grade. I work in the Emergency department of a teaching hospital, and often find myself faced with a case of major trauma. Working alongside paramedics, nurses, anaesthetists, general surgeons, orthopaedic surgeons, radiographers and others, my role is usually to ensure that we're all working in a co-ordinated way. It's great fun!

However, there are obvious disadvantages in relying on intellectual stimulation to motivate you as a doctor. The first of these is purely practical. Although my job is often stimulating, most of the time it is not intellectually satisfying. In fact it's often boring. I see the same patients with the same problems and the same stubborn refusal to sort their lives out. They certainly present a challenge, but that challenge is not intellectual.

The second reason why intellectual satisfaction is a poor motivating factor is that it leads us to care for patients in ways that are less than holistic. Patients are more than just cases; we instinctively know that it's wrong to think of someone as 'an appendicitis' or 'the man with the abscess'. Our patients are people with thoughts, feelings, and dreams; their relatives depend on them for love and security. We are called, not merely to know about our patients, but to care for them.

Before leaving status, money, and intellectual stimulation, let us summarise their strengths and weaknesses. Each of them, at some stage, may contribute to our medical practice. It is easier to be generous from a position of status; a well-paid job can inspire gratitude, and intellectual curiosity can drive us to take careful histories and perform thorough examinations. Ultimately, however, these three motives will not help us to develop the perseverance we will need, and we have seen that they can also be harmful. Instead we need a motive that is pure and also practical, which will benefit us as well as our patients.

Serving others

Our fourth and final motivation is the determination to serve others. This is the motive you probably felt most strongly before you reached medical school. It may have sounded like a cliché as you said it, but at your interview you probably expressed that you wanted to help people. As a motive it is the most obviously pure. Unfortunately, however, medical school tends not to nurture the idea of serving others. There are at least three reasons for this.

Serving others is undermined first by the cynicism that develops among medical students. Most of us don't have it when we arrive at medical school, but somehow we bring it out in each other. For some reason it is uncool to care. Thus junior doctors sneer at enthusiastic medical students, while students smile patronisingly at sixth-formers who persist in saying that they want to help others: 'You'll soon have that knocked out of you!'

Second, serving others is undermined by the secular scientific philosophy that has crept into medicine. Hospitals grew out of the Christian emphasis on the need to care for the sick, and medicine was dominated by doctors who had inherited the Christian service ideal. If we relinquish the idea that we are God's creatures, created to serve him and to love our neighbour, then we find ourselves without a reason to care. If we are the products of mindless evolution then there is no reason why we should protect the weak; we have no basis for altruism.

Third, there are practical realities that make it difficult for doctors to serve their patients. Juniors' hours have generally decreased over the past few years, but other problems continue to increase. Shift patterns have affected continuity of care, so that patients we admit when we're on take we never see again. Attendances at Emergency departments and admissions to wards continue to rise, loading further pressure on to the health system. Low staffing levels among nurses adds to everyone's workload. Pressures on doctors are considerable.

Despite these difficulties, I believe that serving others is the best motive in medicine. The service ideal remains under threat from medical school cool, medical philosophy, and the practical realities of the NHS. Nevertheless, it will develop our perseverance, promote the best care for our patients, and encourage us to act from the purest of motives. No other motive will suffice.

A basis for service

Finally, then, on what basis should we serve others? I would suggest that it is because God has called us to do so. If we think of our advantages as God-given then we can discern a purpose behind them (see box 3). Once we have considered these, we need to listen to Jesus' words: 'From everyone who has been given much, much will be required'.[4]

Not only is it our duty as Christians to serve, but it can also be a response of joyful thanks in the light of what God has done for us. We have been saved from the penalty of our sins and saved for the joys of eternal life with God. Our service to others should be the ourworking of our gratitude to him.

By what will we allow ourselves to be motivated? Status, money and intellectual stimulation are all helpful, but we will use them selfishly unless we devote ourselves to God. Since he has given us all of these privileges, calling us to love him and serve others, then acting on that will make us better doctors. And not just better doctors, but better students, better friends, better spouses, and better parents. Jesus sent out those who followed him with these words:

Heal the sick, raise the dead, cleanse those who have leprosy, drive out demons. Freely you have received, freely give.[5]