J Health Serv Res Policy OnlineFirst, published on June 19, 2015 as doi:10.1177/1355819615589425
Perspective
Why are doctors dissatisfied? The role of origin myths
Journal of Health Services Research & Policy 0(0) 1–4 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819615589425 jhsrp.rsmjournals.com
Robert Dingwall
Abstract Leaders of the medical profession are increasingly concerned about the extent to which members have become discontented with their lot. Predictably, the profession tends to look outwards for explanations, to the changing social, economic and organizational contexts of health care. Sociologists, however, have long recognized that a ‘social problem’ is not an objective state of affairs but a complaint that the world falls short of the complainant’s ideals. If we want to understand doctors’ dissatisfaction, then, another approach might be to ask what would make them content. What are the ideals of medical practice? What are new doctors – and the wider public – led to expect that professional life will be like? How do these expectations relate to the contingencies and experiences of everyday medical work?
Keywords dissatisfaction, doctors, medical profession, origin myth
The origin myths of the medical profession One way in which expectations are created is through ‘origin myths’, stories about how a group came to exist in its current form.1–3 Myths make sense of present events in terms of the past, when heroic ancestors constructed the proper order of the world. Group members judge the present by reference to this version of history. These stories do evolve to reflect contemporary changes,4,5 but they have considerable power as benchmarks for assessing experiences as consistent or inconsistent with the group’s self-image. The contemporary origin myth has two notable features. First, it assumes that there is a global brotherhood – the gendered term is intentional – of doctors, who all subscribe to the same values and ideals. Although different countries may have their own national heroes, all modern doctors are descended from the Ancient Greeks through historical figures like Galen to the scientific revolution of the 17th century. Second, it asserts that the profession has always been distinguished by values of selflessness, altruism and concern for the general welfare: in England, the founding charter of the Royal College of Physicians in 1518 claimed to create a body that would ‘curb the audacity of those wicked men who shall profess medicine more for the sake of their avarice than from the assurance of any good conscience’. This defined the doctor as a member of a self-governing company of
equals, with deference only to age and experience. This was a community of mutual respect: in 1803, Percival’s Medical Ethics urged doctors not to criticize each other in public, especially in front of patients. A focus on intellectual rather than manual labour established the social status of doctors as gentlemen rather than artisans. Elements of this myth are still visible. Many medical schools stage ceremonies where new graduates swear a version of the Hippocratic Oath. A recent President of the Royal College of Physicians once told me about the rituals of his first human dissection class, where students were informed that many of the bodies were those of doctors who had gifted them for the instruction of the next generation – and that they should expect to do the same in their turn. Origin myths also represent the group to outsiders, presenting a vision of who they are, what they do and how they should be treated. Posen,6 for example, notes how these cultural representations have
Dingwall Enterprises, UK Corresponding author: Robert Dingwall, Dingwall Enterprises, 109 Bramcote Lane, Wollaton, Nottingham NG8 2NJ, UK. Email: [email protected]
Downloaded from hsr.sagepub.com by guest on November 18, 2015
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Journal of Health Services Research & Policy 0(0)
consistently depicted the ‘typical’ doctor for the last 2000 years: . . . usually a male, tends to be arrogant and paternalistic. He is a man of action rather than contemplation. He works hard but he is not a good family man. He is aggressively irreligious, though he has his own ethical standards. He frequently fights with his colleagues and he detests politics, politicians and administrators. He does not bear grudges against non compliant patients. Most medical doctors enjoy their status, their power, their high incomes and the intrinsically interesting nature of their work . . .
The global expansion of biomedicine has taken this myth to the furthest parts of the planet. Where rival versions have been created, as in postrevolutionary China, they have not survived reengagement with the international social and economic order.
A social scientific history of the medical profession Three specific questions arise: does it make sense to think of a 2000-year tradition of medical work? Does it make sense to think of a global medical profession with shared culture and values? Does it make sense to think of the medical profession without reference to the state?
The antiquity of medicine? The origin myth emphasizes continuity with the Ancient World, acknowledging the role of Arab scholars in preserving and developing knowledge through the European Dark Ages. If the defining characteristic of a profession is a legal – and hence state backed – monopoly of legitimate practice, then this does not exist anywhere until the 19th century. Whilst guilds of physicians can be identified from early modern Europe, they coexist with a variety of other practitioners in an open market. The history of the medical, and other health, professions must begin by understanding how the market came to be closed. In the 19th-century Europe, Ancient Greek and Roman writers were often thought to describe eternal virtues. The study of their work trained the moral character of the elites, which the profession aspired to join. Affiliation with such iconic cultures consecrated the myth of medicine by locating doctors within this great tradition. Their social standing justified their market privileges. This version of the myth has faced recent competition from alternatives that look towards the Baconian programme in science since the 17th century and, especially, at 19th century or early 20th-century
figures like Pasteur or Osler. However, these are no more historical figures than the supposed Hippocrates, but equally mythologized images of men who have become symbols of a scientific model for professional life. In the process, the sense of service to humankind has become more impersonal and technical, rather than a demonstration of virtue. Doctors are technicians, impersonally applying biomedical science rather than civilizing nations in the name of Hygeia and Asclepius. Some discontents may, then, arise from the tensions between the positive and the normative in professional practice.
A global medicine? In its origin myth, the medical profession transcends space as well as time. Wherever a doctor may be found, they form part of the same great whole, sharing common values and commitments. Members of the profession will, for example, always attend to the needs of patients before their own interests, even risking their own lives. This claim has recently been thrown into question when physicians have confronted emerging infectious diseases like HIV, SARS and Ebola. In fact, the expectation of self-sacrifice only seems to have emerged in the late 19th century: when bubonic plague came to London in 1665–1666, physicians were among the first to leave.7,8 The origin myth portrays the medical profession as invariably disinterested and humane. Empirically, this seems to have varied with the social and economic status of their patients, the nature of the condition being presented and the institutional constraints on medical behaviour.9 To the extent that the claims to altruism and compassion are questioned and subjected to regulation and accountability, we can see a potential for discontent. Doubting a doctor’s vocational commitment goes to the heart of what distinguishes a profession from a trade, a participant in a moral enterprise rather than a commercial one.
Medicine and the state Within Europe, professionalization was invariably driven by state action and state agendas, particularly as urbanization and democratization created new demands for public assistance in times of trouble. The precise configuration depends on the balance of local contingencies, particularly the relative strength of the state and the profession, as to whether the result is a national health service, where doctors become state employees or a social insurance system, where doctors are independent contractors with a greater or lesser degree of accountability for their use of public funds. The story is very different in the United States, where medicine struggled against rival healers and sceptical
Downloaded from hsr.sagepub.com by guest on November 18, 2015
Dingwall
3
state legislators throughout the second half of the 19th century.10 The outcome is a medical profession, whose unity is more rhetorical than real, created by the associations rather than the state: legally, the US effectively has 50 medical professions.11 European models were exported by the movement of individuals who looked initially to their home countries for standards of education and regulation. Consequently, decolonization tended to be accompanied by attempts to create local professional regimes and extend provision to the whole population. The modernity that was represented by political independence was to be matched by the provision of health care according to international models. In practice, many postcolonial states have been too weak and lacking in resources to achieve this, so European models of medicine coexist alongside indigenous practices in relatively open markets. Whilst the origin myth portrays the creation of the modern medical profession as a simple response by states to the obvious public benefits of supporting scientifically trained, allopathic practitioners, the historical record is more obviously one of struggle and mutual accommodation.
The discontents of doctors Modern doctors, then, find themselves in the middle of three conflicting claims. Are they technicians or moral reformers? Are they practicing a trade or a vocation? Is their principal obligation to the state or to the individual patient? In each case, tradition is pitched against contemporary conditions of practice. Historically, doctors have seen themselves as morally worthy people exercising a degree of benevolent paternalism in mediating between the individual needs of their patients and what passed for the best knowledge of the time. In Le Grand’s12 terms, they are ‘knights’, motivated by their vocation. As such, they receive a degree of societal respect and status, reflected in the rewards of professional work. The establishment of sickness insurance, national health or social insurance programmes initially allowed them to extend this benevolence to entire populations, largely without reference to cost. Over the last half century, however, the ‘knight’ image has given way to that of the ‘knave’. Economics has been a powerful solvent on the assumption of professional benevolence. All professionals are vulnerable to being seen as rent-seeking monopolists, whose behaviour needs to be regulated. Regulation pushes professional practice towards doing those things that are measurable and based on what is considered to have legitimate scientific evidence of benefit in the standard case. Doctors are directed towards a Fordist model of medicine, practicing in accord with algorithms.
This may be the core of professional discontent: people whose origin myths depict them as knights feel treated like knaves. The emphasis on measurement displaces the humane aspects of practice, whilst the emphasis on algorithms may achieve better results for average patients at the expense of improvization for the benefit of individuals. The profession is collectively asked to deliver on targets, with limited input into the construction of those targets or to the institutional complexes that create health problems. This bureaucratization runs alongside other policies directed at citizen–consumers, assuring them of their entitlement to a personalized, 24/7 service. This service will not challenge the morality of their behaviour because, as citizens, they are entitled to act as they choose, and will satisfy all their desires, because, as consumers, this is what they expect. Doctors, then, are frequently in the position of seeking to patch up the casualties of lifestyles and life choices, whilst reconciling the finite resources allocated by the well with the infinite demands of the sick. Their objections are likely to be dismissed as further evidence of self-interested knavery. Origin myths are an important source of ethical standards and aspirations for both doctors and society. A changing institutional environment may, though, render them irrelevant and a source of frustration at the tension between ideals and practice contingencies. Medicine’s origin myths challenge the limitations of bureaucratic medicine in delivering compassionate and individually appropriate treatment, demanding that performance metrics are tempered by clinical discretion. As Freidson13 saw, the professionalism of doctors may be the last defence of the patient against the inhumanity of corporatized health care. Against this, those who pay taxes or insurance premiums also have a legitimate interest in what happens to the resources they provide. Rewriting the myth to convey a more realistic understanding of the partnership between the state and the profession may help doctors to reconcile their aspirations with those of others and, at least, to recognize when a glass is half full rather than half empty. Author’s note A longer version of this paper was presented at the symposium ‘Doctors’ Professional Satisfaction, Quality of Care, and the Governance of Health Care Organizations’, Oslo, Norway, 2–3 June 2014.
Funding A fee was received for the original version from LEFO – Legeforskningsinstituttet/Institute for Studies of the Medical Profession, Oslo, Norway. This organization also paid expenses for attendance at the symposium.
Downloaded from hsr.sagepub.com by guest on November 18, 2015
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Journal of Health Services Research & Policy 0(0)
References 1. Malinowski B. Myth in primitive psychology. New York: W.W. Norton, 1926. 2. Eliade M. Myth and reality. Prospect Heights, IL: Waveland Press, 1998. 3. Eliade M. The myth of the eternal return: cosmos and history. Princeton, NJ: Princeton University Press, 2005. 4. Bohannan L. A genealogical charter. Africa 1952; 22: 301–315. 5. Whittaker EW and Olesen V. The faces of Florence Nightingale; functions of the heroine legend in an occupational sub-culture. Hum Org 1964; 23: 123–130. 6. Posen S. The doctor in literature: satisfaction or resentment? Oxford: Radcliffe Publishing, 2005. 7. Wallis PA. Dreadful heritage: interpreting epidemic disease at Eyam, 1666–2000. Hist Workshop J 2006; 61: 31–56.
8. Wallis P. Plagues, morality and the place of medicine in early modern England. Eng Hist Rev 2006; 121: 1–24. 9. Murcott A. Sociology and medicine: selected essays by PM Strong. Aldershot: Ashgate, 2006. 10. Whooley O. Knowledge in the time of cholera: the struggle over American medicine in the nineteenth century. Chicago: University of Chicago Press, 2013. 11. Horowitz R. In the public interest: medical licensing and the disciplinary process. New Brunswick, NJ: Rutgers University Press, 2012. 12. Le Grand J. Knights, knaves or pawns? Human behaviour and social policy. J Soc Pol 1997; 26: 149–169. 13. Freidson E. Professionalism: the third logic. Chicago: University of Chicago Press, 2001.
Downloaded from hsr.sagepub.com by guest on November 18, 2015
Perspective
Why are doctors dissatisfied? The role of origin myths
Journal of Health Services Research & Policy 0(0) 1–4 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819615589425 jhsrp.rsmjournals.com
Robert Dingwall
Abstract Leaders of the medical profession are increasingly concerned about the extent to which members have become discontented with their lot. Predictably, the profession tends to look outwards for explanations, to the changing social, economic and organizational contexts of health care. Sociologists, however, have long recognized that a ‘social problem’ is not an objective state of affairs but a complaint that the world falls short of the complainant’s ideals. If we want to understand doctors’ dissatisfaction, then, another approach might be to ask what would make them content. What are the ideals of medical practice? What are new doctors – and the wider public – led to expect that professional life will be like? How do these expectations relate to the contingencies and experiences of everyday medical work?
Keywords dissatisfaction, doctors, medical profession, origin myth
The origin myths of the medical profession One way in which expectations are created is through ‘origin myths’, stories about how a group came to exist in its current form.1–3 Myths make sense of present events in terms of the past, when heroic ancestors constructed the proper order of the world. Group members judge the present by reference to this version of history. These stories do evolve to reflect contemporary changes,4,5 but they have considerable power as benchmarks for assessing experiences as consistent or inconsistent with the group’s self-image. The contemporary origin myth has two notable features. First, it assumes that there is a global brotherhood – the gendered term is intentional – of doctors, who all subscribe to the same values and ideals. Although different countries may have their own national heroes, all modern doctors are descended from the Ancient Greeks through historical figures like Galen to the scientific revolution of the 17th century. Second, it asserts that the profession has always been distinguished by values of selflessness, altruism and concern for the general welfare: in England, the founding charter of the Royal College of Physicians in 1518 claimed to create a body that would ‘curb the audacity of those wicked men who shall profess medicine more for the sake of their avarice than from the assurance of any good conscience’. This defined the doctor as a member of a self-governing company of
equals, with deference only to age and experience. This was a community of mutual respect: in 1803, Percival’s Medical Ethics urged doctors not to criticize each other in public, especially in front of patients. A focus on intellectual rather than manual labour established the social status of doctors as gentlemen rather than artisans. Elements of this myth are still visible. Many medical schools stage ceremonies where new graduates swear a version of the Hippocratic Oath. A recent President of the Royal College of Physicians once told me about the rituals of his first human dissection class, where students were informed that many of the bodies were those of doctors who had gifted them for the instruction of the next generation – and that they should expect to do the same in their turn. Origin myths also represent the group to outsiders, presenting a vision of who they are, what they do and how they should be treated. Posen,6 for example, notes how these cultural representations have
Dingwall Enterprises, UK Corresponding author: Robert Dingwall, Dingwall Enterprises, 109 Bramcote Lane, Wollaton, Nottingham NG8 2NJ, UK. Email: [email protected]
Downloaded from hsr.sagepub.com by guest on November 18, 2015
2
Journal of Health Services Research & Policy 0(0)
consistently depicted the ‘typical’ doctor for the last 2000 years: . . . usually a male, tends to be arrogant and paternalistic. He is a man of action rather than contemplation. He works hard but he is not a good family man. He is aggressively irreligious, though he has his own ethical standards. He frequently fights with his colleagues and he detests politics, politicians and administrators. He does not bear grudges against non compliant patients. Most medical doctors enjoy their status, their power, their high incomes and the intrinsically interesting nature of their work . . .
The global expansion of biomedicine has taken this myth to the furthest parts of the planet. Where rival versions have been created, as in postrevolutionary China, they have not survived reengagement with the international social and economic order.
A social scientific history of the medical profession Three specific questions arise: does it make sense to think of a 2000-year tradition of medical work? Does it make sense to think of a global medical profession with shared culture and values? Does it make sense to think of the medical profession without reference to the state?
The antiquity of medicine? The origin myth emphasizes continuity with the Ancient World, acknowledging the role of Arab scholars in preserving and developing knowledge through the European Dark Ages. If the defining characteristic of a profession is a legal – and hence state backed – monopoly of legitimate practice, then this does not exist anywhere until the 19th century. Whilst guilds of physicians can be identified from early modern Europe, they coexist with a variety of other practitioners in an open market. The history of the medical, and other health, professions must begin by understanding how the market came to be closed. In the 19th-century Europe, Ancient Greek and Roman writers were often thought to describe eternal virtues. The study of their work trained the moral character of the elites, which the profession aspired to join. Affiliation with such iconic cultures consecrated the myth of medicine by locating doctors within this great tradition. Their social standing justified their market privileges. This version of the myth has faced recent competition from alternatives that look towards the Baconian programme in science since the 17th century and, especially, at 19th century or early 20th-century
figures like Pasteur or Osler. However, these are no more historical figures than the supposed Hippocrates, but equally mythologized images of men who have become symbols of a scientific model for professional life. In the process, the sense of service to humankind has become more impersonal and technical, rather than a demonstration of virtue. Doctors are technicians, impersonally applying biomedical science rather than civilizing nations in the name of Hygeia and Asclepius. Some discontents may, then, arise from the tensions between the positive and the normative in professional practice.
A global medicine? In its origin myth, the medical profession transcends space as well as time. Wherever a doctor may be found, they form part of the same great whole, sharing common values and commitments. Members of the profession will, for example, always attend to the needs of patients before their own interests, even risking their own lives. This claim has recently been thrown into question when physicians have confronted emerging infectious diseases like HIV, SARS and Ebola. In fact, the expectation of self-sacrifice only seems to have emerged in the late 19th century: when bubonic plague came to London in 1665–1666, physicians were among the first to leave.7,8 The origin myth portrays the medical profession as invariably disinterested and humane. Empirically, this seems to have varied with the social and economic status of their patients, the nature of the condition being presented and the institutional constraints on medical behaviour.9 To the extent that the claims to altruism and compassion are questioned and subjected to regulation and accountability, we can see a potential for discontent. Doubting a doctor’s vocational commitment goes to the heart of what distinguishes a profession from a trade, a participant in a moral enterprise rather than a commercial one.
Medicine and the state Within Europe, professionalization was invariably driven by state action and state agendas, particularly as urbanization and democratization created new demands for public assistance in times of trouble. The precise configuration depends on the balance of local contingencies, particularly the relative strength of the state and the profession, as to whether the result is a national health service, where doctors become state employees or a social insurance system, where doctors are independent contractors with a greater or lesser degree of accountability for their use of public funds. The story is very different in the United States, where medicine struggled against rival healers and sceptical
Downloaded from hsr.sagepub.com by guest on November 18, 2015
Dingwall
3
state legislators throughout the second half of the 19th century.10 The outcome is a medical profession, whose unity is more rhetorical than real, created by the associations rather than the state: legally, the US effectively has 50 medical professions.11 European models were exported by the movement of individuals who looked initially to their home countries for standards of education and regulation. Consequently, decolonization tended to be accompanied by attempts to create local professional regimes and extend provision to the whole population. The modernity that was represented by political independence was to be matched by the provision of health care according to international models. In practice, many postcolonial states have been too weak and lacking in resources to achieve this, so European models of medicine coexist alongside indigenous practices in relatively open markets. Whilst the origin myth portrays the creation of the modern medical profession as a simple response by states to the obvious public benefits of supporting scientifically trained, allopathic practitioners, the historical record is more obviously one of struggle and mutual accommodation.
The discontents of doctors Modern doctors, then, find themselves in the middle of three conflicting claims. Are they technicians or moral reformers? Are they practicing a trade or a vocation? Is their principal obligation to the state or to the individual patient? In each case, tradition is pitched against contemporary conditions of practice. Historically, doctors have seen themselves as morally worthy people exercising a degree of benevolent paternalism in mediating between the individual needs of their patients and what passed for the best knowledge of the time. In Le Grand’s12 terms, they are ‘knights’, motivated by their vocation. As such, they receive a degree of societal respect and status, reflected in the rewards of professional work. The establishment of sickness insurance, national health or social insurance programmes initially allowed them to extend this benevolence to entire populations, largely without reference to cost. Over the last half century, however, the ‘knight’ image has given way to that of the ‘knave’. Economics has been a powerful solvent on the assumption of professional benevolence. All professionals are vulnerable to being seen as rent-seeking monopolists, whose behaviour needs to be regulated. Regulation pushes professional practice towards doing those things that are measurable and based on what is considered to have legitimate scientific evidence of benefit in the standard case. Doctors are directed towards a Fordist model of medicine, practicing in accord with algorithms.
This may be the core of professional discontent: people whose origin myths depict them as knights feel treated like knaves. The emphasis on measurement displaces the humane aspects of practice, whilst the emphasis on algorithms may achieve better results for average patients at the expense of improvization for the benefit of individuals. The profession is collectively asked to deliver on targets, with limited input into the construction of those targets or to the institutional complexes that create health problems. This bureaucratization runs alongside other policies directed at citizen–consumers, assuring them of their entitlement to a personalized, 24/7 service. This service will not challenge the morality of their behaviour because, as citizens, they are entitled to act as they choose, and will satisfy all their desires, because, as consumers, this is what they expect. Doctors, then, are frequently in the position of seeking to patch up the casualties of lifestyles and life choices, whilst reconciling the finite resources allocated by the well with the infinite demands of the sick. Their objections are likely to be dismissed as further evidence of self-interested knavery. Origin myths are an important source of ethical standards and aspirations for both doctors and society. A changing institutional environment may, though, render them irrelevant and a source of frustration at the tension between ideals and practice contingencies. Medicine’s origin myths challenge the limitations of bureaucratic medicine in delivering compassionate and individually appropriate treatment, demanding that performance metrics are tempered by clinical discretion. As Freidson13 saw, the professionalism of doctors may be the last defence of the patient against the inhumanity of corporatized health care. Against this, those who pay taxes or insurance premiums also have a legitimate interest in what happens to the resources they provide. Rewriting the myth to convey a more realistic understanding of the partnership between the state and the profession may help doctors to reconcile their aspirations with those of others and, at least, to recognize when a glass is half full rather than half empty. Author’s note A longer version of this paper was presented at the symposium ‘Doctors’ Professional Satisfaction, Quality of Care, and the Governance of Health Care Organizations’, Oslo, Norway, 2–3 June 2014.
Funding A fee was received for the original version from LEFO – Legeforskningsinstituttet/Institute for Studies of the Medical Profession, Oslo, Norway. This organization also paid expenses for attendance at the symposium.
Downloaded from hsr.sagepub.com by guest on November 18, 2015
4
Journal of Health Services Research & Policy 0(0)
References 1. Malinowski B. Myth in primitive psychology. New York: W.W. Norton, 1926. 2. Eliade M. Myth and reality. Prospect Heights, IL: Waveland Press, 1998. 3. Eliade M. The myth of the eternal return: cosmos and history. Princeton, NJ: Princeton University Press, 2005. 4. Bohannan L. A genealogical charter. Africa 1952; 22: 301–315. 5. Whittaker EW and Olesen V. The faces of Florence Nightingale; functions of the heroine legend in an occupational sub-culture. Hum Org 1964; 23: 123–130. 6. Posen S. The doctor in literature: satisfaction or resentment? Oxford: Radcliffe Publishing, 2005. 7. Wallis PA. Dreadful heritage: interpreting epidemic disease at Eyam, 1666–2000. Hist Workshop J 2006; 61: 31–56.
8. Wallis P. Plagues, morality and the place of medicine in early modern England. Eng Hist Rev 2006; 121: 1–24. 9. Murcott A. Sociology and medicine: selected essays by PM Strong. Aldershot: Ashgate, 2006. 10. Whooley O. Knowledge in the time of cholera: the struggle over American medicine in the nineteenth century. Chicago: University of Chicago Press, 2013. 11. Horowitz R. In the public interest: medical licensing and the disciplinary process. New Brunswick, NJ: Rutgers University Press, 2012. 12. Le Grand J. Knights, knaves or pawns? Human behaviour and social policy. J Soc Pol 1997; 26: 149–169. 13. Freidson E. Professionalism: the third logic. Chicago: University of Chicago Press, 2001.
Downloaded from hsr.sagepub.com by guest on November 18, 2015
