As you may have noticed these past few weeks, I’ve been thinking a great deal about anti-doctor sentiment. Whether it’s at a party or at lunch, on Twitter or in comments on news articles or on blog posts, there’s this anger at doctors. Doctors do their jobs poorly, doctors are trained “wrong” from the get-go, doctors should simply be replaced by nurses because nurses do the same thing and they do it for less money, doctors have the American Medical Association (AMA) which is a monopoly and is at the root of so many of our problems in healthcare, and so on. As you may have also noticed, I’m pro-doctor. I think there’s a lot of misplaced anger and a lot of misunderstanding about how the system works. Even so, I decided it was time to pick at some of these knots. If we’re going to rebuild the healthcare system - and we should - we have to address this issue. And it’s bigger than people realize, in that it’s a larger and more fundamental issue than the doctor or doctors at whom they’re angry.
So where do we begin? Which knot do we start with? Well, when I conducted my research on electronic health records (EHRs), I considered the issue of professional practice and identity. What does it mean to people to be a doctor? What sorts of knowledge and practices are encompassed in “clinical” work? What do you do all day? These questions are important to me because I think they tie into some of the fundamental issues with the healthcare system. They’re tied in to problems with arguments being lobbed at the education system more broadly, and with something we’ve been discussing for a few weeks, these ideas of symbolic and social exclusion.
As you might expect, when I asked doctors these questions during in-depth interviews, they found them interesting - but sometimes tough to answer. Many respondents paused and became very thoughtful. We talked about how it was one of the more abstract topics in the interview - along with “what does the patient’s chart represent to you?” Even so, I received a lot of wonderful responses to the question, “What does it mean to you to be a doctor?” Caring for patients was a theme. Multiple clinicians also gave me responses like “making a contribution to society” and “doing something that’s valuable.” This theme of value is one worth examining. What is this value doctors experience? What is the value doctors can, or should, provide?
I’m not talking about monetary value, or how physicians should increase profits. I’m talking about a more fundamental value that doctors can provide as not only individuals but as the profession of “doctors.” This would help us understand why and how - perhaps if - doctors and nurses play different roles and offer different types of value that should - but sadly, often do not - complement each other. For those who are working on problems like EHR, this idea of value, along with these larger contested issues of professional identity and practice, can provide insight into why clinicians balk at doing work they consider to be “clerical” in nature. Where does that fall compared to the knowledge that is “theirs”? What’s the value in it? What’s the value compared to the value they think they can provide?
People argue that the bulk of the work doctors do should be given to nurses: they do it already, they often do it better, and they do it for less money. The problem here lies in understanding the value intrinsic to different roles and how they work together. Nurses have long been undervalued, which is not news. But how does it help to devalue doctors, rather than to understand the value both provide and can more effectively provide together? If you simply train both types of professionals, won’t that push each group to just become ever more protective of the boundaries that define “their” professional, expert knowledge - see Andrew Abbott’s The System of Professions: An Essay on the Division of Expert Labor for more on this. If you keep changing the names of the credentials and expanding the available credentialing options, won’t that just create rival classes of professionals rather than a collective, healthy ecosystem in which different types of skill, knowledge, and intellect are needed and used?
Here’s where it starts to get complicated: Could the intrinsic value be the same? Are doctors and nurse practitioners offering inherently different values? Or is it more appropriate to say that the value is much the same but the training is different, so we focus on the curriculum and the credentials, which allow us to argue that one is more socially and financially valuable than the other?
We tend to think of value in these social and financial senses. We assume being a doctor offers social and cultural capital, and we assume one becomes a doctor in part because of the social and cultural capital one already has - the ability to access and afford education, to find internships and residencies, to establish practices. We also assume that doctors make a lot of money. On the whole, this is not untrue: physicians make a good living, and many types of physicians are well-paid. But if you average out an internist’s salary on hours worked, given the amount of paperwork PCPs have - unpaid labor - and standard time off (if taken), you may find the salary comes closer to that of a high school teacher (on an anecdotal basis, and as most of you know, my mother is an internist and we did this with her salary). Further, not all doctors make what you think they make: Some types of surgeons make in an hour or two what can take some types of primary care physicians a few days, if not a week to bring in. (For the record, there are some types of specialized advance registered practice nurses (ARPNs) - also known as nurse practitioners (NPs) - who make more than some primary care physicians. And also for the record, nurses and NPs do have prescriptive authority (the ability to prescribe medicine), but the laws on their autonomy differ state by state.)
Again I return to this idea of value. Why is a surgeon more highly valued than a primary care practitioner? Why is a physician more highly valued than a nurse? What do we value?
We have come to value the credential. Credentialing theory’s roots are Weberian in nature, and if you remember your Weber, this means that our ever-expanding system of diplomas serves our ever-expanding bureaucracy. For those who are calling now for the end of higher education, or to find a better way to train our next generation than “useless degrees,” you’ve been beaten to the punch by the seminal work by Randall Collins called Credential Society: A Historical Sociology of Education and Stratification. You’ve also been scooped by a somewhat less pessimistic text by David Labaree called How to Succeed in School Without Really Learning,
Setting aside the historical reasons within the industry that many specialties, especially the surgical specialties, make more money than primary care physicians - and thus are more “valued,” I argue we value as a society value surgery/specialization over primary care. We like to think we’re being taken care of by certified, highly trained people. We like action. Not hard work, although many of these surgeons work very hard. We think action is great, and we like this idea of a highly “skilled” professional who can perform tasks.
We don’t like being treated like parts, but we don’t want to do the work of seeing ourselves as a whole person. We also like the idea of being invincible until we’re not, and then having someone who can come in and save the day.
You know what we like less? Ideas. Intellect.
Before surgeons write to me to yell because you think I’m saying that being a specialist or a surgeon doesn’t require ideas or thinking or intellect, hang on: I’m not. But I do think that primary care is different. It requires a different type of thinking, rather than action. One internist, in an in-depth interview, told me her advisor asked her why she was going into primary care because she was “so brilliant.” He practically begged her not to. Primary care isn’t highly “specialized” in the same way that urology or podiatry is, and that makes us devalue it: In our evermore bureaucratic society, who likes a general practitioner? We like specialization. In a more bureaucratic society, specialization makes you smarter, better, more valuable. Primary care requires - or it should, ideally - knowing a pretty good amount about basically everything, and how those everythings are intertwined not only with each other but with the social and emotional stressors in your life, the different medical issues you’ll be having, and more. It’s a lot more talk-y and think-y, a lot less do-y. In which case, we stick it at the bottom of the value pyramid. We forget that primary is in the name.
The problem, I think, is that the value has been lost from the very start, at the top of the system. Because we are focused on the credential and the title, knowledge becomes codified into “doctor” and “nurse” knowledge and is jealously guarded. I do not agree that medical school should be abolished, nor that we should forget higher education - quite the opposite. I think school, before on-the-job training like internships and residency, is needed to help teach all of us how to think. To teach us that in every situation there’s more than a what, there’s a why and a how of what to do, and we must understand the process, to make decisions about each individual, or group, or set of situations. In other words, rather than see school as a place to learn a “skill,” we can use school as the place to share that most dangerous of things: ideas. We can teach people to think critically, particularly in a medical situation. Diagnosing is only partly scientific. It is also a human, intellectual process. This is part of the anger being directed at the medical profession: “I went to the doctor and she didn’t figure out what was wrong with me for so long.” “This problem became a huge, serious issue because no one bothered to THINK.”
Perhaps it is in the focus on the wrong value system that we forget about the value they want to and can offer: not only the ability to care, but the ability to provide this necessary critical thought. How do we teach that? Abolishing the system or dismantling it entirely is not the answer. Simply adding more complexity to the credentialing system weighs the system further and takes away from this value focus. Can nurses do the job of doctors? We haven’t defined what anyone’s value is, so how do we know? Giving better access to people who are capable and who may not otherwise be able to become a part of the system because of institutional barriers (education, finances) is important. We need to restructure the system to value the right things: not only patient care, saving lives, preventing disease, but also this type of critical thinking, this type of care. Whatever we call our caregivers - doctors, nurse practitioners, clinicians, - we need them not only to care, we need them to be able to provide the right value.