Decades ago, physicians were among the most trusted members of their communities. Clinicians were viewed along with the clergy as venerable sources of knowledge, life experience and comfort. Much like religious vocations, careers in medicine were regarded as a calling. Physicians routinely cared for the poor without asking for remuneration, subsiding their endeavors with fees collected from those who could afford to pay. We spent countless hours relentlessly pursuing a diagnosis, partnering with patients to wage a war on death, and communing with families. We were routinely invited to our patients' weddings and funerals. Physicians were not excessively paid, but they were showered with respect and received preferential treatment in countless ways. (Remember MD license plates?) Physicians were commonly excused for minor traffic violations, simply because the police could imagine that they were in a hurry to see a patient. Most local jurisdictions granted physicians an exemption from jury duty, believing that they already provided an irreplaceable service to their communities. If you wanted reservations at short notice in a popular restaurant, you told them you were a doctor. Even physicians honored other physicians. Doctors who required medical care were given "professional courtesy." In the 1980s, I was a patient at the Mayo Clinic, and received incredible medical care for free; no one ever asked for insurance information, and I never received a bill. In truth, the tokens of respect were often trivial and elitist, and in most cases, no reasonable person should miss them. But their emblematic significance was unmistakable. As Paul Starr wrote in his book The Social Transformation of American Medicine,physicians were accorded a respect usually given to astronauts and coaches of championship football teams. Society also granted physicians a virtual monopoly in all aspects of medical decision-making. Extraordinarily, 40-50 years ago, more than 75% of Americans had great confidence in medical leaders, according to Dhruv Khullar, MD, MPP, in the New York Times last January. Despite exceptionally long hours, physician burnout was virtually nonexistent. In 2018, the days of universal respect for physicians are gone. Many patients now view practitioners as hurried and financially motivated, lacking empathy. No social courtesies are granted to physicians; on the contrary, physicians are generally viewed as being undeserving of elite perquisites. Laymen are suspicious of physician motivations. "Am I getting the treatment that is best for me or for my physician's pocketbook?" patients wonder. The decision-making authority of physicians has evaporated. Payers now tell physicians what they can prescribe, and healthcare systems remind physicians about the number of procedures they must perform to warrant their compensation. In a Gallup poll taken last month, Americans were asked about their respect for many of society's institutions and organizations. Only 36% said that they had a great deal of trust in the medical system. The good news: The "medical system" fared better than public schools (29%), big business (25%), and the criminal justice system (22%). The bad news: we fared much worse than the military (74%) and the police (54%) -- worse even than the Presidency (37%). The lack of trust in the medical system is a particular American phenomenon. The U.S. is tied for 24th place among 29 surveyed countries in a ranking of the proportion of adults who think that doctors can be trusted. Only 58% of U.S. adults trust physicians, as compared with 83% in Switzerland, 79% in Denmark, 78% in the Netherlands, and 76% in Britain. According to Khullar, just 25% of Americans feel confident about the health system -- a statistic even more dismal than the results of the Gallup poll. Some physicians may believe that the lack of public trust is related to a lack of public understanding of the demands on the profession. Non-physicians cannot understand the magnitude of information, the rigorous requirements for technical expertise or the complexities of healthcare delivery. Only physicians can understand what it is like to be a physician. Well, physicians certainly know what it feels like to be a physician AND a patient. So we should ask: When physicians need medical care, do physicians trust other doctors or the medical system to take care of them? I cannot find any formal surveys on this question, but I am fairly confident that uncertainties about competence and motivations may be especially high -- amongst physicians! Every week, I am asked by physicians who are wondering (and worrying) about the wisdom of medical advice or treatment that they or a family member has received. Why did they not take an adequate history? Why did they order tests that do not make any sense? Why did they recommend an elective procedure that had nothing to do with my chief complaint? When they found out I didn't need surgery, why did they stop caring for me? Why do they never respond to my phone calls or the questions I send by email? Do they really have the wisdom, experience and expertise to provide the best possible care? It is true that many physicians no longer have the time or staff to communicate effectively -- even with their physician patients. But based on personal experience, they certainly have the staff to make countless telephone calls to chase $10-$25 copays. Here is the good news: Physicians can rebuild trust. They can prioritize patient communication over revenues. They can take steps to make sure that patients are able to navigate the complex steps of healthcare. But to do so, physicians would need to really want to. They would need to refocus their attention on patients rather than themselves. Many readers who are physicians will certainly be inclined to dismiss my musings as old-fashioned and outdated, with little relevance to modern medicine. Most troubling, some may no longer even care if patients trust them. Indeed, many physicians fully acquiesce in the decline in medicine as a trusted institution. For some, the practice of medicine is now a job, not a calling (and for some, not even a career). Many try to fill the emptiness in their souls with the knowledge that they are well-paid or that they perform more procedures than their colleagues. The achievement of numerical targets has replaced trust and respect as a source of personal gratification. Yet, soaring rates of physician burnout attest to the fact that this substitution is likely to be misguided and futile. For some, the practice of medicine now resembles the board game Monopoly. Although popular, the game is also widely disliked. The game's goal is "grinding your opponents into dust," and cackling about it. My father could not tolerate playing Monopoly. His reason: There is no honor, dignity, or fulfillment in playing or winning. Within the game's value system, a player succeeds without garnering another's trust, and there is no mechanism by which a player's choices can invoke respect. Under all circumstances, when the game ends, the person with the most money still loses. Source
