“I believe I have a personal responsibility to make a positive impact on society.” 

– Dr. Anthony Fauci

I’ve thought a lot over the years about how to maximize my positive impact in the world. The word “impact” has been thrown around somewhat loosely in medicine. The one place we explicitly quantify it is in regard to publication; when ranking journals, we use the term “impact factor.” However, what about all the interactions we have with a patient where we don’t know that we’re making an impact until they tell us? Or the interactions where we assume we’ve made a big impact but in their eyes, little has changed? Impact in medicine is notoriously slippery — and yet, in this era of burnout, knowing that our work is making one is more important than ever. Below, I tease apart different ways of thinking through impact in medicine, and discuss which approach I’ve found most personally rewarding.

Impact Factor and H-Index

Impact factor is a quantification of how much a journal’s articles are referenced over the years. The more an article is referenced, the more impact it is thought to have, and the higher the impact factor for the journal. A corollary of this for the individual researcher is the “h-index,” which looks at the most referenced articles of that person over a period of time. The more articles that have been referenced frequently (relatively recently), the higher the h-index. The h-index does not reward a researcher who has a few articles that have been referenced thousands of times, but rather places value on the researcher who has had many articles referenced hundreds of times. This is thought to control for individuals who have only a few high impact papers, and favor the researcher who has had a more lasting impact. The h-index is now a frequent measure used in the consideration of faculty promotion.

However, these measures of impact come with a built-in problem: they can be gamed. These are metrics that are being imposed on a population of smart people, who will find ways around them. Journals may accept those studies that have a higher potential to be referenced, rather than choosing articles purely for the validity of the science. You may ask what the difference is, but some papers (such as reviews and technique descriptions) are more likely to be referenced than case reports. This is why many journals will limit the number of case reports accepted or label them as “letters,” which are not considered in the impact factor calculation. In addition, an article that is “open access” is more likely to be read (since you can read the entire article for free), and there is evidence that open access papers are more likely to be referenced. Authors and institutions also are aware of this open access advantage and may pay the open access fee (which is usually in the thousands of dollars) with the hope of improving their individual h-index. The h-index can be further gamed by self-referencing (however, this is now being controlled), or by having tacit agreements with colleagues to reference their papers if they reference yours (quid pro quo). 

As you can sense, I am a little cynical with regard to impact factor and h-index. I think an additional problem is that it becomes a self-perpetuating process: high impact journals receive the “best” papers (since authors want their papers to be referenced to improve their h-index), and high h-index researchers get more support. At this point in my career, I try to ignore these numbers and just accept (as a journal editor) good science or write (as an author) what I am interested in. However, I realize as a mid-to-late career faculty member (i.e., professor with tenure) that this is a luxury.

Clinical Education 

There are other (maybe better) ways to impact the world as a physician that are not related to research, which I think are sometimes ignored. A positive clinical impact is invaluable. This impact can be applied one patient at a time, or exponentially through education. I think education definitely increases its effect. By teaching medical students, residents and fellows, who then go out and treat thousands of patients, a teacher’s positive impact on the world is multiplied. My personal labor of love has been surgical videos, which allows me to reach even more students. 

However, on the flip side, a poor role model can propagate dubious behaviors in their students. I have seen this firsthand where a skilled physician with some flawed behaviors has passed those flaws onto the students who saw that physician as a role model, thinking those behaviors were acceptable or even admirable. In this case, the impact this physician had was negative.

Patient Feedback

Finally, we often talk about impact in terms of direct effect on patients. But when you try to tease out that impact, things quickly get complicated and even existential. I often find myself wondering things like: Is the impact one can have long-term on a child’s life greater than the impact one could have on a patient in their 80s? Does the care we provide individuals who are on a lower socioeconomic scale have a greater impact than the same care for a privileged patient? The answers differ based on which factors of a person’s life you isolate. It would be easy to say that fixing that problem for a person who is isolated due to disability is more “impactful” than fixing a similar issue for someone with resources — but that’s not necessarily up to me to determine. After all, although I may think that my intervention may have a relatively high — or low — impact on a life, unless I am in that patient’s shoes, I could never understand the impact that is made. My outside view of impact means very little. It is really the perception of the effect from the patient’s point of view that matters. I’ve had instances in which I’ve taken care of what I thought was a relatively minor or even forgettable problem, and then had the patient tell me how much it changed their life.

This means that what really matters when it comes to “impact” in medicine isn’t number of lives saved, or number of patients whose issues we resolve, or even number of publications we put out, but the actual feedback we receive from patients. I’m not talking about patient satisfaction scores; I’m talking about earnest remarks, be they off the cuff or sent via thank you note. The last thing I would ever want to do is quantitate this type of qualitative impact, because then there would be some of us who would figure out how to game it. Or, even worse, it might be used as a metric for some administrator’s evaluation of us. 

I know our jobs can be difficult due to outside factors (e.g., insurance and bureaucratic struggles, to name just a few), and it can be hard to appreciate that we’re even making an impact. But I promise you that we are. My personal experiences as a patient have allowed me to appreciate this from the other side.

I think Dr. Fauci has the right idea. Leave the world a better place than we found it. If we do our jobs (and model good behavior), we will have a positive impact on society. I think we are one of the few professions in the world that has this in our job description. What could be more rewarding?

What piece of positive patient feedback has made the biggest impact on you? Share in the comments!

Dr. Richard Allen is an oculoplastic surgeon in Houston, TX. He practiced at St. Erik’s Eye Hospital in Stockholm, Sweden from September to December of 2024 as a visiting professor. He is an avid cyclist and enjoys spending time with his wife outdoors. Dr. Allen is a 2024–2025 Doximity Op-Med Fellow.

image by AngieYeoh / Shutterstock