In a recent issue of a national anesthesiology journal, a physician wrote in to complain about the poor dress of his colleagues. Many, he said, now go to work in open-collared shirts and jeans, thus showing a lack of respect for the medical profession.
Arguments over attire are common these days in medicine. During my residency a few years ago, attending physicians would insist on keeping for themselves the exclusive right to wear long white coats, while requiring everyone beneath them to wear short ones. Their obsession with these fine distinctions recalled the fussing of the czar’s civil servants over ribbons, braids, and epaulettes. The purpose was not so much to help solidify an actual chain of command at the hospital as to ensure that the stature achieved by those wearing the decoration was recognized by everyone.
There is something ridiculous and at the same time touching in the way doctors are now fighting over clothes. There is also something significant in it. In a world of managed care and government-directed medicine, many doctors cling to such trappings in an effort to preserve their self-esteem. Selecting a wardrobe may seem a paltry preoccupation, but it is one way to regain a feeling of autonomy and importance.
The peculiar mixture of self-doubt, fear, and resentment that now forms the consciousness of many American doctors cannot be explained by falling incomes alone. True, depending on the specialty, there has been a decline in income over the last decade, much of it traceable to the rise of managed care. But that change is slight as compared with the revolution in consciousness I have observed as a practicing physician. Although doctors complain about earning less money, about their ungrateful patients, about too many hours spent in the office, these concerns are in the end secondary. What really bothers them, whether or not they articulate it fully, is the dramatic loss of prestige undergone by the medical profession, a profession that once enjoyed tremendous power and influence in American society without even having to exert itself.
How did this happen? In seeking to explain it, many doctors themselves point to managed care. In hospital corridors, they cry that managed care has turned what was once a higher calling into just another business. But this simply begs the question. Why did managed care descend upon the medical profession with such great force, and succeed so brilliantly; and why now?
Although medical science itself is a rational discipline, doctors did not, traditionally, pursue the rational ends of business: namely, profit and self-interest. A generation ago, for example, there was nothing that actually prevented doctors from advertising their services in order to boost their incomes, but most refused to do so and were contemptuous of those who did. Their attitude was not unlike the attitude of career military men toward soldiers who fought only for profit. Such soldiers were no longer professionals; they were mercenaries.
The analogy is apt in more ways than one. The peculiar honor codes of the military profession—the asceticism, the harsh discipline, the willingness to tolerate physical abuse—find a parallel in a medical ethic that once encouraged doctors to work 48 hours straight, and to think it right and good to do so. Today, by contrast, just as the military attracts young men and women not by telling them how much they will suffer but by paying for their education and giving them skills they can later use to advance themselves in the market economy, so, too, older doctors murmur quietly that working 48-hour shifts is “crazy,” while interns and residents demand a more “rational” schedule—the schedule of ordinary, business-minded professionals.
“Crazy” notions were, however, what once gave medicine and, to a lesser extent, law and academia their unique character. Nor did they seem in the least crazy to the people who believed in them. Rather, they were bound up in ideals of service that ultimately trace back to the guilds and professional associations of pre-capitalist Europe. In the modern, democratic period, such ideals came to attach themselves to the learned professions, which (however remunerative they sometimes proved to be) held themselves aloof from the values of profit and self-interest.
All this is now going by the boards. But the real culprit is not managed care, which merely took advantage of an opening. There has been, rather, a confluence of factors—of which one, surely, is the loss by the medical profession of its great patron, the one ally that used to protect doctors from the market economy and that helped sustain the peculiar ideals of their profession. I mean the state.
This may seem odd. After all, American doctors have notoriously feared the state. In particular, they have feared that government would socialize the health-care system and turn them into civil servants. But the reality has been otherwise. Through the regulatory apparatus that guaranteed doctors their autonomy and the right to organize themselves, and through support of the fee-for-service system (even in the government’s own program of Medicare), the state long kept medicine safe from challenge by market forces, enabling the profession to survive intact with all of its archaic beliefs and quirky ways of doing things. It was only with the passage of legislation in the 1980’s and 1990’s giving corporations the freedom to organize the delivery of medicine that the state abandoned the medical profession to business.
In some ways, to be sure, this changeover was like the dropping of the other shoe. At the encouragement of the tax system, employers had long since begun to assume responsibility for the health insurance of their employees; but with this responsibility came no control over costs. When those costs increased dramatically in the mid-1980’s, employers started demanding a more rational and efficient approach.
Gradually this demand was met. First, the state required that employers offer managed care within their menu of plans; being cheaper, this option soon became the one most employers offered exclusively. Then, the state itself established a managed-care version of Medicare for senior citizens. With this acquiescence by government in the demands of business, the ring closed around the medical profession. Ever since, doctors have been recast in the mold of their new masters, and willy-nilly have adopted their masters’ worldview.
But the loss of state support was only one element leading to the triumph of the managed-care model. Another and perhaps more consequential one was the completion within medicine itself of what may be called the scientific revolution.
For over a century, medicine had made a concerted effort to become a branch of hard science. Early on, the goal was to draw a distinction between it and other healing arts, like shamanism and witch-doctoring. But the major thrust soon became to validate medicine by resting it on the twin pillars of measurability and predictability. In time, expert medical practice became identified with precision, accuracy, and scientific knowledge—to the detriment of the comforting and interpersonal skills that were once the hallmark of successful doctoring.
In retrospect, we can discern four stages in this gradual process. In the first stage, starting in the early 20th century, the emotional troubles of patients were turned over to the care of psychiatrists and psychologists. As late as the 1920’s, most mental illnesses like depression and neurosis were handled by internists and general practitioners using general medical techniques. Today, nonpsychiatrists still manage most cases of mental illness in the United States, but they do so by prescribing pills in accordance with predetermined diagnostic criteria. In the meantime, talk therapy and other forms of counseling, whose purpose is to delve into a patient’s special problems with subtlety and nuance, have become the province of the psychiatric specialty and its companion discipline, psychology.
In the second stage, also starting in the early part of the 20th century, the social problems of patients were similarly farmed out. With advances in medical knowledge, doctors found they could no longer attend to aspects of care that were separate from illness but nevertheless critical, like the role of a patient’s socioeconomic environment in determining the course of a disease. As a result, medical social work came into being, with the first department built at the Massachusetts General Hospital in 1905.
Unlike the division of labor between nonpsychiatrists and psychiatrists, the division of labor between doctors and social workers was probably a necessary development: physicians could simply no longer spend time chatting with a patient’s neighbors. Nevertheless, the rise of social work caused yet another component of care to be removed from the purview of physicians. As a medical professor once put it, patients started to shoot past doctors like comets, crossing but for a moment their field of vision before fading into oblivion.
The third stage took place only within the last two decades, as the ethical dilemmas surrounding patient care became less and less the responsibility of individual doctors and their conscience. Today, many hospitals in the United States have multidisciplinary committees for resolving such problems as when to remove a brain-dead patient from a ventilator or how to dispense information about a patient’s illness without violating doctor-patient confidentiality. The result, as Sally Satel and Christine Stolba have recently documented in COMMENTARY (“Who Needs Medical Ethics?,” February 2001), is that moral issues are no longer inextricably intertwined with the medical profession.
In the fourth stage, also of recent vintage, the general spiritual duties of doctors have been relegated to self-help groups. Some doctors now encourage their patients to contact such groups—either in real space or on the Internet—when they want a shoulder to cry on or someone to talk to for more than just fifteen minutes.
Having lost the emotional dimension of the patient to psychology and psychiatry, the social dimension to social workers, the moral dimension to bioethicists, and the spiritual dimension to self-help groups, doctors have been reduced to mere engineers of the body. And that is where managed care comes in.
It was once hard to “manage” doctors according to traditional business methods for the same reason that it is hard to manage ministers and painters; so much depended on individual philosophy, personal attitudes, creativity, inspiration. Doctors who were responsible for the social, moral, emotional, and spiritual dimensions of patient care could not easily be governed by fixed rules or procedures. It would have been like telling a painter to paint with just one or two colors.
But engineers are easy to manage. Their tools are predictable. Their thinking is predictable. Their output is predictable. And so, when doctors gave up the intangible, unquantifiable aspects of personal doctoring and became engineers of the body, they paved the way for business to come in and manage them, too.
A final contributing factor to the triumph of managed care is the mass influx of women into the medical profession.
In 1970, 13 percent of medical students and 8 percent of practicing physicians in the United States were women. By 1999, those figures had risen to 50 percent and 22 percent respectively. By the year 2010, women may comprise a third of all physicians in the U.S. This is an enormous change, with far-reaching consequences. One of them has been the formation of an entirely new attitude toward medical practice.
As a physician working in a large community hospital, I often meet medical students who come to me for career advice. When I tell the females among them that anesthesiology offers major advantages, especially a flexible work schedule that will make it easier to have a family, some of them get very angry. They rattle off their degrees and accomplishments, emphasize their commitment to their career, and throw down the gauntlet to any man contending for the top jobs in the field. These young women, often between twenty-three and twenty-five years of age, carry within them an attitude imparted early in their careers: that their highest goal is to succeed professionally in a man’s world.
But by the time these students graduate and, now over the age of thirty, come looking for jobs in anesthesiology, they tend to exhibit a dramatic change in consciousness. Very quickly during the interview they inquire about part-time and “flextime” arrangements, something too insulting even to mention only a few years earlier. Between those two points in time, they seem to have stumbled upon a piece of wisdom they could not be told and to whose secrets experience alone is the key.
The desire of many women physicians to work in some kind of flexible arrangement has been well documented and much discussed. On average, women physicians in the United States work 85 percent as many hours as male physicians, but this number does not tell the whole story. For what often emerges is two different populations: those women who work full-time in order to satisfy their career or financial goals, and those who reduce their hours significantly to accommodate family life.
In my own experience, women physicians who are divorced or unmarried, or who have husbands with only average incomes, tend to go into practices that carry the greatest workload and have the fewest number of managed-care patients—and are therefore the most remunerative. By contrast, those with husbands who earn high salaries gravitate toward less grueling arrangements, often in managed-care practices. In one study, women physicians who were also married to physicians worked fewer hours and assumed a greater share of domestic responsibilities than women physicians married to nonphysicians: the husband’s high salary made it easier for the wife to put her career on hold and raise the children.
Simply by exercising their natural urge to have and raise children, in other words, women physicians have introduced into the profession a new way of thinking about how medicine should be practiced. They have taught male doctors that an entire world beckons—family, personal obligations, leisure activities—and that medicine need not be all-consuming.
Those steeped in the traditions of the medical profession, usually males over fifty-five, often take a dim view of this new approach. They look upon women physicians as a disruptive element: disruptive, that is, to the professional ideal in which being a physician is and should be the defining element of one’s existence, the element to which everything else in life must properly be sacrificed. Younger male doctors, by contrast, are much more comfortable with the new approach. Not only do they admire the women physicians who carve out time to pursue other interests, they envy them. Many would, if they could, cut back on their own hours in order to engage in other activities.
In any event, once these new attitudes toward medical practice were put into place, managed care became not only the most logical way to organize the profession but really the only way. The business approach—shifts, time sheets, night duty, and all the rest—is indispensable in an environment where the practice of medicine is just a job.
Medical science will always be with us, but the old ways of the medical profession are disappearing before our eyes, and they are likely to disappear completely within another generation. Young doctors, most of whom now go straight from training into managed care, tell me in conversation that their one guiding principle is simply to achieve the right balance in life: enough money, enough time off. As for the demands once put on physicians by a rigid professional ethic, they are no longer considered within the bounds of possibility.
One can think of a number of positive sides to this decline in medicine’s professional ideal—including a revision of the old, contemptuous attitude among doctors toward labor for profit. America has a long tradition of judging all occupations to be equally honorable, but even I can recall as a college student how those of us who were going into medicine looked down on those who were going into business. We were more noble, while they were somehow degrading themselves. Among working doctors, this prejudice seems to be on the wane.
There may be other benefits as well. In the past, doctors worked around the clock and occasionally performed their duties half-asleep. This was not a serious problem when medicine was less advanced: it does not take much brain power to carry a specimen to the lab and prepare a slide—one of the duties of yesteryear. But now that medicine is extremely complex, requiring high levels of cognition at all times, well-rested physicians are a greater necessity.
But these gains are more than offset by the losses. In hospitals, the assembly-line approach to patient management, in which doctors go on and off shift, prevents continuity of care. Under managed care, for example, it is commonplace for an attending obstetrician to meet a mother-to-be for the first time five minutes before she begins to push. Outside the hospital, decisions of physicians are governed by statistically derived rules promulgated and enforced by HMO’s. The consequences of all this have yet to be fully assessed, but they are unlikely to be benign.
Nor are changes in the manpower burden in a hospital or in a physician’s autonomy and discretion the end of the matter. The medical profession was once imbued with a special gravity, a solemnity that went beyond the seriousness that comes from dealing with life and death. Both my father and my grandfather were physicians, and I retain vivid memories of their approach to their calling. Even at home, my grandfather never ceased being a physician; whenever the phone rang or someone came to the door, my grandmother would say, “Yes, the doctor is here,” or “No, the doctor will be back shortly,” with the unquestioned expectation on all sides that he would make himself available as soon as he could and whenever he was needed. As for my father, I remember watching him conferring with other doctors—men of forty, looking like old men and dressing like old men, their faces etched by worry but also by purpose, following the rites demanded by the decorum of their profession whatever the inconvenience to themselves.
Now, when I look around at doctors my age, I see men and women of forty looking like boys and girls and dressing like boys and girls. They are dedicated to caring for their patients, and they take great pride in their competence. But they are also careful not to overstep the thin line that divides the world of doctoring from the rest of life. For them, the practice of medicine is technically more complicated than it was for previous generations of physicians, and their success rates are higher; but medicine is only one compartment, albeit often a very interesting one, of their lives.
Yet, even among younger doctors, many are plainly having difficulty making their peace with the way things are today. In the new division of labor, they supply the technology and manual skill, but they have been separated from life’s great meanings. Doctors can operate and prescribe, but they cannot counsel, judge, lead, or support. At one level of consciousness, they feel muzzled, if not robbed as human beings.
The predicament doctors find themselves in is nicely illustrated by the otherwise puzzling encroachment into standard medical practice of one version or another of alternative medicine. The mere fact that so much of alternative medicine is not grounded in science means that in practicing it one is doing more than measuring, calibrating, categorizing, and fixing; one is becoming seriously involved in the mysterious workings of a single person’s soul.
Of course, in order to justify the use of alternative medicine, or its inclusion as a legitimate topic of instruction in medical schools, it has become necessary to turn it, too, into a branch of hard science. Hence the feverish and largely futile search for evidence of its efficacy.1 But that is another story—and, for most doctors who practice alternative medicine, beside the point. For them, it is precisely because alternative medicine cannot be encompassed by science that they value it.
The culture of the medical profession once enabled doctors to exercise a wide-ranging influence over their patients. That influence extended well beyond what was attributable to their medical powers alone, or to the treatment they had embarked upon in any given case, and into the realms of opinion and belief. There were, of course, potential dangers in the degree of personal authority they thus wielded, but for most patients there was also a profound reassurance and comfort to be had from it—just as, for doctors themselves, there was something inexpressibly fulfilling in work that required not only acumen, dexterity, and some intellect but also delicacy, worldly wisdom, and a slow, deep labor of the spirit.
Being a businessman, a part-time worker, or an engineer of the body holds its satisfactions, at least for some, but for those who expected more out of medicine it is causing restlessness, boredom, and a deep self-doubt. This is what it is coming to mean to be a doctor in a society that lacks the ideals of doctoring.
1 See “The New Snake Oil,” by Samuel McCracken, COMMENTARY, June 1999.