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It is not so long ago – and certainly within the living memory of many Journal readers – that health professionals were gods. To be slightly more precise when it comes to definitions of the spheres of Heaven, nurses were ministering angels, the general practitioner (GP) was a benign and infallible minor deity, while the consultant – particularly in life-or-death specialties such as childbirth or oncology – was Jupiter Himself. One may note the gender of the reflexive pronoun.
Times have changed in medicine as well as in religion. Nowadays if we have not quite reached the Age of Reason, we are certainly living in an age of reasonable doubt. Society now rarely affords health professionals the same quasi-divine status; where there was faith now there are benchmarks and targets, where there was utter trust now there are tabloid headlines, public enquiries and questions in the House.
Is the Internet to blame?
The cause? Many would claim that one key factor is the Internet, leading to patients entering the consulting room armed with multiple printouts by means of which they not only self-diagnose their condition but also demand specific and instant responses to their medication prayers. (This approach at best irritates and at worst blocks sensible diagnosis and treatment.) Albeit that I am a huge fan of the World Wide Web, I agree that it is partly responsible for the current trend of what one might term ‘medical agnosticism’. Universal information, like universal education, is largely wonderful, but it can not only undermine public belief in formal religion but also fuel a tendency to general scepticism.
That said, I do think that the factors behind any current loss of faith in the health profession are more subtle and complex than Google and Wikipedia. In Britain perhaps one trigger occurred 60 years ago at the birth of the National Health Service, which by bringing ‘free’ access to health care may have devalued the currency. If health care is hard to come by, a grateful patient may attribute almost supernatural powers to the physician; if health care is instantly available at a surgery near you, the worship factor may be more muted. Contrariwise but with a similar effect, the increasing rise in personal insurance-based health provision in countries around the world can mean that the patient has a sense of entitlement that levels out their relationship with their health provider; here it may be the patient who plays God.
Perhaps too, the agnostic shift gathered pace when the self-help movement was born, gave its first wailing cry on the American East Coast, then proceeded to toddle its way around the world on a mission not only of equality but also of self-determination. By the time the movement reached some kind of adolescence, it did what all adolescents naturally do: rebelled. One's doctor – like one's parents – was not God, had no authority, and was absolutely not going to be allowed to boss anyone around.
To take a simple but milestone example, the book Our Bodies Ourselves (1971) was a huge step forward in empowering women to take charge of (and responsibility for) their own health and well-being; it was also founded on a strong and determined criticism of the medical profession's dominance. To quote one of the book's instigators, Nancy Miriam Hawley: “[Up to now we haven't been] encouraged to ask questions, but to depend on the so-called experts. Not having a say in our own health care frustrated and angered us. We didn't have the information we needed, so we decided to find it on our own”.
The media effect
Over the decades, such justifiable rebellion seemed further justified by an increase in shock-horror stories about the medical profession. My very first Consumer Correspondent column nearly 10 years ago covered the press witch hunt against hormone replacement therapy in the wake of the Million Women Study; as I write, the recent re-evaluation of that study is triggering yet more media attacks on the medical profession for ‘getting it wrong’. To add a more horrific example, in Britain the case of serial killer GP, Harold Shipman, did not exactly enhance the image of the trusted, local health professional.
Alongside such hard news stories there has also been a proliferation of broadcast entertainment that bows to ratings by majoring not just on medical drama but on medical catastrophe. Good doctors make poor storylines, and so we have seen a shift from the largely reliable Dr Finlay to the emotional roller-coaster of the UK's Bodies and the USA's ER, and we have witnessed a shift from Your Life in Their Hands to Confessions of a Nurse.
Resulting from all the above and adding to the dynamic is a growing sense that we are all experts now. The average patient entering the consulting room a century ago was often 15 years of education behind their doctor. Now they're likely to be at most 7 years behind and often equally lengthily trained in their own chosen field; the result can be a downgrading of the medical professionals' credibility.
Plus, a patient carries into the surgery not only the aforementioned wisdom of the Web but also received wisdom from their parents, spouse, children, colleagues and next-door neighbours (not to mention the chat rooms on Mumsnet, the medical adverts on the television and the edicts of media doctors and psychologists like myself, however well-informed.) Patients may truly believe that their knowledge about their own medical condition is vast.
Whatever the cause, then, it is sad but true that over the last half century, society has begun to un-deify those whom they once regarded as gods. In addition, that process has been accompanied by strong and often negative emotions that have reinforced the process. The fact is that when faced with ill-health, disability or imminent death, folk may well be grateful to be instructed, directed and supported; but they may also demand that such instruction be utterly accurate, such direction be absolutely correct and such support be compassionate beyond what can reasonably be expected of any carer. When the service is not delivered perfectly by a profession that has previously been cast by society as infallible, there may be not only public disillusionment but also public anger.
Good or evil?
Which leads us inevitably to the big question: is such un-deification good or evil? Has society, in downgrading the health profession from gods to mere mortals, done itself a disservice? Have we lost immeasurably when we threw the baby of trust out with the bathwater of deification?
I could argue that we have. A health professional who is seen as all-powerful has a unique power to comfort even if their power to heal is sometimes limited. The GP who – by his own later admission – deceitfully assured my terminally-ill mother that she would survive her cancer probably didn't thus prolong her life by a single day, but he did give her several months more emotional peace. She believed in him and so she believed what he told her. Nowadays, my mother would probably have herself researched her progress, swapped notes with others on her ward, and – most crucially of all – doubted her GP's prognosis even though he was ‘The Doctor’. In that situation, blind faith was for my mother infinitely preferable to sceptical anxiety.
And certainly many of the health professionals I talk to regret the agnostic shift for just those reasons. It's not that such professionals crave power or even control, but they do regret the loss of the ability to give consolation and healing in which patients comprehensively and consistently have faith There is a certain sense of frustration, of wanting patients to “take my word” rather than questioning every little thing or viewing their own partially informed judgement as of greater validity than the professionals'. The phrase “Trust me, I’m a doctor” has lost its calming if occasionally patronising tone, and has now become in society's terms a joke and in the mouths of health professionals a sincere plea.
For professionals do sometimes feel disrespected, devalued or even blamed by society as a whole if not by individual patients. In a world where few people now believe there is such a thing as divine intervention of any kind to save them from pain and death, the only recourse many people feel they have when faced with those life events is to accuse, condemn or sue the person on the front line. The rise in medical litigation is not, at root, based on a love of money but on a need for emotional payback. For many reasons, therefore, we should challenge the all-sceptical trend.
A fine idea
And yet, and yet … those Journal readers who regularly peruse my column will already have guessed my final judgement: that medical agnosticism is actually a fine idea. We are in transition here, so it's impossible for me – or for anyone, surely – to predict the long-term result. But I do believe that a shift from seeing the professional as all-powerful to seeing professionals and patients as equally powerful is largely for the good.
Yes, patients' full acceptance of personal responsibility will take a while to happen, and those on the front line in family planning and genitourinary medicine clinics may argue that it's certainly taking its time. And yes, a sense that the buck stops with patients could result in their ignoring sound medical advice, turning to suspect alternatives, or choosing instant hedonism over long-term health. But I would argue that those who see themselves as equals rather than acolytes will be more likely to step up, and that active participation in health care is a better option for patients than is dependent ignorance. I believe that partnership is better than worship. I also, incidentally, believe that partnership is better than being worshipped.
I suspect that most of the profession would agree with me (except, understandably, after a 12-hour day at the sharp end dealing with a stream of ‘patients from hell’). I suspect that most Journal readers would claim that a patient who can talk through their situation with a physician on an equal level gets a better outcome, and that the health professional who actively welcomes and encourages that kind of involvement also gets a better outcome – not only by gaining more information but also by receiving more compliance. Yes, both need to acknowledge where expertise lies: on the professional's side expertise in medical matters, on the patient's side expertise of their own body and their own life. But in the end, collaboration surely benefits both parties (Boxes 1 and 2).
Ten elements that might affect your patient's belief in you
▶ How long you have known them
▶ The level of rapport you have with them
▶ How far they identify with you (e.g. same gender, age group)
▶ What qualifications or accreditations you have
▶ Their general experience of the practice/clinic in which you work
▶ Their lifetime experience of diagnostic and treatment success for themselves and others
▶ Their experience of your response to their problems and requests
▶ How fully they have successfully confided in you about their personal situation
▶ How dependent they are on you for their treatment and care
▶ How life-threatening their condition is
Eight ways to help patients step up to health care partnership
▶ Ask for and take seriously their existing knowledge or current assessment of their condition
▶ Discuss what influences their approach to health care (e.g. friends, family)
▶ Guide them towards reliable and informed opinion sources (e.g. specialist websites)
▶ Encourage questioning of evidence
▶ Allow discussion of treatment options
▶ Encourage awareness of the biasing affect of emotion on health choices
▶ Promote patient reliance on informed instinct
▶ Demonstrate your credibility by following through on agreements and telling the truth
So let professionals acknowledge – and most of us do – that the laity have a crucial role to play. Let patients, however, acknowledge that, absent a deity, it is down to them to decide their own fate. And let us all acknowledge that just as the post-religious era in general is hitting bumps along the road, the newly-navigated relationships between health professionals and their patients will not be plain sailing for a while yet. But in the medical arena at any rate, I for one am glad that the gods are stepping down from the clouds.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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