No physician, however conscientious or careful, can tell what day or hour he may not be the object of some undeserved attack, malicious accusation, blackmail or suit for damages … “
– Assaults Upon Medical Men. Journal of the American Medical Association, 1892
It’s happened again: A well-liked doctor is killed by his patient. Last year’s horrific death of a physician in our community, a valued colleague shot in his office by a disgruntled if not deranged patient, was a shock. The recent physician slaying at Boston’s Brigham and Women’s Hospital echoed the senselessness of such an event. The health care workplace is supposed to be a sanctuary, a place where people come for care at the most troubling times, where we seek safety and reassurance. Those needing such care greatly depend on the providers. That’s why we are astonished by these events, or when soldiers or terrorists kill aid workers and use hospitals as centers for war operations. Physicians strive to be impartial caregivers for combatants, criminals, and all others. Indeed, the Red Cross and Doctors Without Borders are paragons of humanitarian service and self-sacrifice.
Physicians have traditionally enjoyed an unassailable halo, a mixture of healer, advisor, confessor. Their status has evolved from shaman roots over centuries of validation through various forms of discovery, and more recently the empirical rigor of the scientific method. Physicians have been appropriately bestowed with a higher degree of trust than most members of society. That said, why should the tragic death of a respected physician be any different than so many other recent senseless shootings, ones fueling angst about our mental health system, and the nature of our social fabric? In that context, perhaps it isn’t. Yet the event stimulates reflection, and may also serve as a metaphor for the potential decay of a profession.
Today’s chaotic health care system is being transformed because patients, payers, providers and policy makers all see that system as too expensive, dysfunctional, irrational, and at times threatening. The regulatory and financial burdens placed on limited providers can result in long wait times and short “face times” with patients. The high expectations raised by the latest medical technology can be shattered in individual cases. Patient frustrations regarding access to, results from, and costs of needed services, can reach the boiling point for some. No wonder then that studies show that workplace violence disproportionately affects the health care setting. Though emergency rooms and psychiatric facilities are the most common sites, regular wards and doctor’s offices are not immune.
Physicians are often objects of powerful feelings — both positive and negative. The patient may view the clinician as a savior, a god, a magician. Yet to some the clinician may be the symbol of a health care system gone awry, if not the tool of one’s particular suffering. Violence stems from the complex dynamics of a given individual’s specific situation. Violence can be a flash reaction to frustrating helplessness, fear, humiliation and/or passion for righting wrongs. Indeed, the doctors’ unique cultural role may make them iconic, visible scapegoats for health care’s failings, if not actual targets for retribution, particularly now as their stature is being eroded by a combination of external forces and some of their own making.
The arrival of managed care transformed the doctor-patient relationship by interposing external agents for authorization of visits, choice of appropriate care, and payment transactions. Increasingly, traditionally autonomous physicians, once independent operators of a medical service, are becoming line workers in large systems. The majority of newly minted ones choose employment, as opposed to private practice — given the daunting regulations and financial pressures with reimbursement for medical services squeezed. The demand for primary care physicians to become “gatekeepers” for assessment and triage to specialty services, and the lack of sufficient numbers of such physicians requires increasing use of “physician extenders”. Though valued and trained members of the health care team, these nurses and physician assistants lack the MD “ticket,” the full extent of its professional training, in many cases they lack the privileges of prescribing drugs, and performing high skill procedures. They still lack the associated cultural halo, yet their increasing deployment sends a subtle message: that MD “ticket” may not be as valuable as previously thought.
There is growing legislation to allow nurses to write prescriptions. Pharmacists give flu shots, nurse staffed mini-clinics are seen in shopping malls, and even Kaiser is opening nurse staffed clinics in Target stores. This “down-licensing” of medical care may actually be a more efficient approach to population health delivery, prevention, and ease access at lower cost. Early data suggests it can benefit the health care system, but whether it actually improves outcomes will be a carefully studied question. Additionally, Google and Web MD have turned everyone into a “diagnostician”. Consumers have even started asking Siri for health advice, no doubt soon aided by Watson. Patients come to doctors armed with downloaded material targeting their condition, challenging the value of the doctor’s knowledge. Lawyers do so regularly.
This devaluation of the profession of medicine is of some societal concern. Physicians are professionals not simply because they get paid. Sociology, the social science that studies human interactions, organization, and institutions, defines a profession as an occupation which regulates itself through systematic, required training, and collegial discipline. Paul Starr’s 1980’s Pulitzer Prize-winning book, The Social Transformation of American Medicine, discussed this well. A profession becomes legitimized by having a base of technically specialized knowledge. A profession’s validated knowledge rests on rational or scientific grounds; that is, an evidence base. That knowledge and competence is continually validated by the community of peers, and its continuing education standards. Perhaps most importantly, that professional knowledge results in judgment, advice, and actions oriented towards a set of substantive societal values – health and well-being in the case of medicine. Service rather than profit is enshrined in its code of ethics.
Hence the profession is cognitive, collegial, and moral. Because of this process of legitimization, physicians achieve a coveted status of professional authority. Authority is a valuable asset. It increases the probability that people will obey a legitimate command or call to action and that a particular definition of reality and judgment of meaning and value will prevail as valid and true. For example, we heed doctors’ warnings about smoking, taking needed medication, vaccinations for personal and societal benefit. Physicians’ authority also creates a dependency condition: Patients acknowledge the professional’s superior competence within a deep context of emotional and physical needs in the patient – physician relationship. A component of this dependency condition actually promotes therapeutic success. Therefore, professional authority is worth preserving and nurturing.
When physicians abuse their professional authority they contribute to the profession’s devaluation. Medical school is expensive, doctors train for years, they sacrifice early paychecks, and miss family time to attain and maintain the ideals of their calling. A false sense of entitlement in some is understandable. Some may define themselves as professional simply as being paid for their service, and define professional success in financial terms. Clearly, the transformation of health care poses challenges for most doctors, and threatens to commoditize their specialized core assets. Sensing an increasing loss of control, a growing frustration with their redefined industrialized role, it is easy for doctors striving to maintain the true ideals of their profession to become disillusioned, if not downright cynical. Cynicism can corrode all human values and can also corrode the values of a profession.
We cannot prevent precious loss of life from random, senseless, deranged acts of violence. However we as doctors, as well as payers, policy makers and patients, should strive to sensibly prevent a noble profession’s pernicious loss of its cognitive, collegial and moral value system, one that is precious to us all.
Michael Brant-Zawadzki is executive medical director of physician engagement, Hoag Hospital, Newport Beach, CA.
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