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From giants to just plain folks

August 23, 2005 -- In an essay in today's New York Times, "Practicing Medicine Without a Swagger," Columbia physician Barron H. Lerner suggests that the days when physicians arrogantly "ruled the roost" are over. He says that while those days "may have been fun," today physicians are more likely to be treated as "employees" than "royalty." And "most hospital employees, including physicians, believe that the humbling of doctors has been for the best." The piece suggests that all that's left of physicians' former power are "occasional reminders" and "periodic perks." Dr. Lerner deserves credit for his discussion of past abuses. But his piece trivializes the continuing problem of undue physician power, ignoring the extent to which the medical hubris it describes affects patient outcomes and undermines nursing practice, and offering a subtle whitewash of disruptive physician conduct, which is a significant factor in the global nursing crisis.

Lerner's piece is mostly a short recounting of his own experience, with a few historical assertions and cultural references. He emphasizes long resident shifts as a major factor in physicians' feelings that they were entitled to be "rude" and to "rule the roost." Lerner claims that physicians had "relatively little power" until the early 20th century, but that scientific advances and discoveries enhanced their reputations. Those who built hospitals began to give physicians special parking lots and dining areas. Lerner notes: "Rewarded in terms of money and prestige, some physicians became vain and arrogant, making extraordinary demands and openly misbehaving." He singles out surgeons as the most notorious abusers, citing the 1991 William Hurt film "The Doctor" as an example. But he says that other physicians behaved poorly as well, noting that some residents with whom he worked in the 1980's modeled themselves after an abusive physician in the 1978 book "The House of God." This kind of conduct was tolerated, Lerner writes, because many physicians ran hospitals, and they protected their peers.

Lerner asserts that things began to change with the anti-authoritarian social changes of the 1960's, the increase in female physicians, and new regulations dictating a "more humane schedule," which makes it "harder for doctors to expect favors." Lerner states that "[t]he 'days of the giants' may have been fun, but humanistic patient care has become paramount." Of course, there are still those occasional reminders and perks: though almost every other clinical worker is addressed by his or her given name, Lerner says that physicians are still addressed as "Dr. ___," even "when they ask to be called by their first names." Lerner ends by describing his flu vaccine last winter. The nurse giving the injections, who had known Lerner since he was a resident, demanded that he skip over the dozen employees ahead of him in line. Lerner "paused," "nervously glanced around," and "quietly" complied.

We commend Dr. Lerner for his discussion of past abuses, and for suggesting that most believe a more egalitarian, "humanistic" approach is better. But this piece still amounts to a dangerously persuasive whitewash. As Suzanne Gordon and others have shown, the medical profession has fought aggressively from the 19th century until today to retain power, and to prevent other groups, particularly nurses, from getting it. Over time, nurses developed a complex system of deference that concealed their own mastery, preserved the prevailing sense that physicians provided all important care, and permitted the dysfunctional relationship with physicians that continues to threaten patients and nurses around the world. We detect no irony in Lerner's description of this system as "fun," but regardless, it is a distressing trivialization of social oppression that has ruined many lives.

Nor did physicians enjoy power simply because they were so hard working and made medical advances. As noted above, they fought hard for that power. And despite the changes Lerner describes, physicians continue to wield undue influence, for a number of reasons including money: hospitals view physicians as revenue generators, while nurses are seen as cost centers. Meanwhile, the cultural changes to which Lerner refers have made the Marcus Welby image obsolete, but what Gordon aptly terms the "medical superstar narrative" continues in more subtle form. Physicians may be seen to have serious flaws, and they may be women and minorities, but they are still commonly deemed to be the heroic providers of all significant care. Key policy decisions flow accordingly: the amount spent on medical training and research dwarfs that spent on nursing and other health fields.

Physicians may well feel that they have been "humbled" by the lessening of their apparent influence. But as a profession, medicine continues to enjoy unrivaled social and economic power, and the abuse of it remains a major public health problem. The two examples of continuing deference that Lerner describes may seem like small matters, harmless remnants of a bygone era, but they are not. Every time nurses accord physicians undue deference, it degrades the nurses and inflates the physicians' sense of importance, making it that much harder for nurses to get the respect and resources they need, and to perform their vital roles as patient advocates. (Incidentally, many nurses today do not address physician colleagues by their surnames.) When nurses are afraid to challenge physician care plans, as too many still are, patients die. They get the wrong medications, they have the wrong operations, and their concerns are not addressed until it is too late. Undue deference allows incompetent physicians to continue to operate, with sometimes deadly results, as recent cases around the world have made clear. Undue physician power is also a significant element in the nursing shortage. It is a factor in poor clinical working conditions--including verbal and physical abuse--as well as the lack of adequate resources for nursing education and research, and the extreme devaluation of nursing that continues in the mass media. An example of physicians' continuing dominance of influential media? Two of three lead health pieces on the Times site today were written by physicians. Such physician-authored pieces are a regular feature of its health section and of other elite publications, such as The New Yorker. Such publications almost never run anything by a nurse.

We hope that in the future Dr. Lerner will politely decline invitations to special treatment. And we hope that nurses will allow "Barron" to wait in line like everyone else.

See the article "Practicing Medicine Without a Swagger," by Barron Lerner in the New York Times.

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