Medical power

NB This is a rewritten version of the post. Thanks to those who commented on the first version

I have written this because like many, perhaps most GPs I feel very uneasy about power. I aspire to a partnership with my patients, teamwork with my fellow health professionals and a more equal society. I feel very strongly that power is a privilege and medicine is a vocation and a public service, or as Iona Heath recently described it, ‘a labour of love’. Usually medical power is viewed in negative terms, an unreasonable acquisition of privilege and abuse of patient trust and public respect for personal gain. Whilst I don’t deny that medical power is abused terribly in this way, I am concerned that power is shifting away from professionals and democratically accountable government, and I am not sure that this is in our patients’ best interests …

The origins of medical power.

“In Rome the doctors were slaves at first. There was a great need for them and as such a high price was paid for such slaves as for eunuchs. Some of these slaves were released by their masters out of gratitude for services they had rendered. In this way the Roman medical profession started its development. Beginning in the 3rd century B.C. Greek physicians emigrate. First these are adventurers who meet strong opposition. But more and more arrive. Their superiority is recognised and they are encouraged to come. The armies keep many physicians employed. The step upward upon the social ladder begins. In the year 46 B.C. Julius Caesar presents all Greek physicians who have settled on Roman soil with the freedom of the city of Rome. Augustus knights his body physician, Musa. The privileges become greater. Physicians are relieved of taxation and of the duty of serving in office, of military service and of taking lodgers. But who is this physician in antiquity? There was no examination to ascertain his fitness as there is today. Anyone may call himself physician and reap the benefits. Restrictions are felt to be necessary. Under Antonius Pius a “numerus clausus” is established: in every city community, are to receive the privileges. They are the ‘valde docti’. Admission to this group is regulated by the common council and in Rome by the emperor himself. Now one must give proof of one’s knowledge. This is the beginning of a state approbation”
Henry Sigerist Man & Medicine, The Physcian p.301

How doctors are powerful.

“The physician’s profession gives him power. The physician knows poisons. More than that: chemical, physical and biological forces of high potency are placed freely in his hands. The physician enters all homes on the strength of his profession. Secrets are divulged to him which the patient would hesitate to tell to his closest relations and they give the physician power over the patient” Sigerist. ibid

Since Henry Sigerist wrote this in 1932, we have become more powerful. We can force patients to stay in hospital under the mental health act and force them to have treatment. Our professional opinion in law and in politics carries significant influence. We also have social or structural power because we tend to be wealthier, healthier, better educated, more articulate and more socially connected our patients. Because our power is also due to the underlying structure of society, forty years of widening social inequalities have augmented medical power at the same time as dis-empowering the majority of our patients.

Whenever we speak we are exercising power. Doctors are trained in and practice daily the skills of persuasion. I have had patients refuse to discuss immunisations with me on the grounds that I might persuade them that they are wrong to refuse when they have already made their minds up. Patients fear that their doctor might try to convince them of something that is not in their best interests. There is good evidence that when they are fully informed, patients choose less orthopaedic surgery than their surgeons recommend and that doctors choose less intervention at the end of their lives than they recommend for their patients.

The words we use can be lethal or life-saving. For a patient who has lost the will to live, if we are insensitive or compassionate the balance in which their life hangs may be tipped one way or the other. One of my patients cried for weeks after his last GP who he had known for years told him he wouldn’t care for him any longer if they couldn’t agree about his treatment. The patient didn’t expect this condition to be placed on their relationship.

Whatever our social standing, patient autonomy, (self-governance, or control/ power over their own body) is undermined by illness. When we are unwell we very frequently feel out of control, especially if confused, distressed, anxious, disabled, in pain and burdened with the uncertainty that goes with a complex or potentially serious diagnosis. Patients feel powerless by the ‘enormous range of privileges that any doctor – even the most junior – possesses by comparison with a person lying in a hospital bed.’

Malign power.

“It must be clear that the misuse of this power is a serious menace to society. Society tolerates the physician and honours him because it urgently needs his counsel and his help, but it has always endeavoured to protect itself from abuse of the physician’s power by establishing standards of medical behaviour … The standards which regulate medical behaviour have their origin in three different spheres: the government, the medical profession and the individual conscience” Sigerist ibid.

According to George Bernard Shaw, ‘all professions are a conspiracy against the laity’, and the medical profession is singled out as ‘a conspiracy to hide its own shortcomings’. Bernard Shaw was writing at a time when GPs were shopkeepers dependent on ongoing custom from their patients. The NHS got rid of this fee-for service model because it created ‘perverse incentives’; as Shaw pointed out, “Having discovered that one could ensure for the supply of bread by giving bakers a pecuniary interest in baking, that one should then give surgeons a financial interest in cutting off your leg is enough to make one despair of political humanity”. Our present day move in the NHS towards a model of competition between healthcare providers would surely make him despair.

Shaw’s attitude towards medical professionals finds its contemporary expression in the notion of Knights and Knaves in which professional Knights that act altruistically are recast as Knaves who are self-interested and must be restrained by regulation. It is revealing that this has recently been put forward by health economist Julian Le Grand who has been very influential in health policy in the UK for the last decade. The alternative to medical autonomy we’re being offered is not one of patient empowerment through relationships with professionals, but of patient independence and self-care. At the same time there is a shift from professional autonomy to regulation and the responsibility for delivering care is being gradually removed from healthcare professionals who will act in the interests of the corporations who employ them. GPs are being encouraged to devolve responsibility for patient care to nurses and step ‘up’ to the role of commissioning care.

Patients are not necessarily empowered by dis-empowering doctors, especially if that results in doctors having less power to use on behalf of their patients.The rise of corporate power, especially in relation to health care and information technology is particularly pertinent, given that global companies are investing in both areas simultaneously.

We need to go back to Foucault and think again about the new ‘medical gaze’ once our biometrics are under constant surveillance. ”

“th[e] extended medical gaze has redrawn the boundaries between health, illness and disease to promote a regime of total health. Under this regime, the individual is not just subjected to the technologies of medical surveillance, but is expected to engage in the practice of self-surveillance.” Surveillance & Society

Before long we will carry our ‘pocket-panopticon’, a smart-phone uploaded with our medical record, constantly monitoring our behaviour and biometrics. Our insurance premiums will be constantly updated according to our behaviour and health status. Skip the gym or put on a couple of kilos and the premiums go up. Go for a run and take our medication without missing a dose for a month and they go down. A little glucose in our urine and they double. Our data will be private if we can afford the optional opt-out fee, but for most people the apps, patient forums and access to medical advice online at our convenience will be paid for by submitting our personal data for constant monitoring. We will be subject to a constant stream of adverts for screening promising to detect ‘silent-killers, diet pills and exercise machines promising to help us lose weight and an infinite array of therapies all backed up by patient testimonies.

This dystopian (for me at least) view is one vision that concerns me because the new global corporate players in healthcare have financial interests in all these technologies. I am also worried because those involved in health policy appear to believe that this is a viable, beneficial vision of the future. They fail to recognise that human empowerment is a consequence of meaningful relationships.

Power and the doctor-patient relationship

Andrea was my last patient on Monday evening. It was a little after 8pm and I had been working solidly since shortly before 8 in the morning. I was very tired and my mind was drifting towards thoughts of home comforts.

Evening appointments at our surgery have been introduced so that patients who find it difficult to attend in working hours can come after work. We tend to see people who are younger, healthier and wealthier than we do in the day. In some ways their problems can be equally time-consuming; people expected to thrive under pressure often find it very hard to admit they need help and when they do the problems have gone quite far. But we also see a increasing numbers of people who have private health care …

… “I promise I won’t keep you, I’ve only come for a referral”, she said as she put her phone on the desk between us.

Consultations that begin with a promise of brevity are usually long and a referral is rarely straightforward, but I replied, “Of course, tell me what do you need?”

“I need an MRI scan of my back, this is the third time it’s flared up and I really need to find out what’s going on”

The path of least resistance and the quickest way to finish my surgery would be to email the request form to the private company our PCT commissioned a few years ago and reassure her that they will probably contact her within a couple of weeks. Then bid her farewell and do some of the remaining and increasingly burdensome administration before heading home.

Andrea is articulate, intelligent and assertive and has made a decision. But I aspire to have a relationship with my patients in which we make decisions together. From here, at least in the doctor-patient relationship, power begins to intervene. From one perspective, articulated by journalist Matthew Parris, a GP is little more than a ‘glorified receptionist’ a functionary between patient and specialist. I am not sure whether he meant that he thinks GPs are little than glorified receptionists, or whether he thinks access to specialists would be improved if we were and so GPs ought to be treated as little more than glorified receptionists. This is why requests like Andrea can irritate GPs. But from Parris’ perspective, he has made his decision and his power/ autonomy is undermined by a doctor insisting that each decision is discussed. By standing in his way I am imposing my authority. Doctors also have power over our patients by virtue of the intimate questions we ask and the personal details we know of about our patients. Andrea may not even wish to discuss her back pain with me.

Patients ‘may’ be empowered by having direct access to specialists, medical investigations, drugs and other treatments but access in itself may not be empowering if the healthcare is inappropriate. Used inappropriately, investigations and drugs can cause more harm than good, and if paid for by the NHS or an insurance fund, unnecessary scans deprive another part of the system of funds or increase costs to taxpayers or other insurance scheme members. In the US $210bn is wasted on unnecessary services every year, accounting for 8% of total healthcare costs. This is almost twice the entire NHS budget.

From my perspective I need to be sure that an MRI of her spine is appropriate and that another possible diagnosis hasn’t been overlooked. In order to do this I need to ask her questions and perform a physical examination and perhaps arrange alternative tests. My conscience is clear as to my intentions, but what I cannot deny is is that my work as a GP involves, indeed depends on an unequal balance of power. In consultations this creates tensions which can damage the therapeutic relationship especially when there is a struggle to gain the upper hand.

Corporate healthcare brings unforeseen dangers. Richard Branson’s Virgin corporation are now running at least 350 GP surgeries. Recently they were offering their GPs a share of the profits whenever they referred a patient to Virgin physiotherapy. If they were to run a diagnostics unit performing MRI scans with the same incentives, then a GP seeing Andrea might be thinking about his bonus, rather than her best interests.

Power and partnerships.

Power is not only a malign force, as even Foucault argued,

“what makes power good, what makes it accepted, is simply the fact that it doesn’t weigh on us as a force that says no, but that it traverses and produces things, it induces pleasure, forms knowledge, produces discourse. It needs to be considered as a productive network that runs through the whole social body much more than a negative instance whose function is repression” Foucault 1984: a 61. Quoted from DA Lupton

The imbalance of power between doctors and our patients means that we have power to share; it enables us to use our knowledge, skills and connections to serve our patients.

the structural and symbolic power wielded by doctors is what makes good and right healing actions possible. Doctoring as Leadership, the power to heal

More than simply sharing knowledge we are our patients’ teachers, helping them to make sense of often overwhelming, confusing or inaccurate information. Though of course, we learn a great deal from our patients, we are the ones who have been trained for years to understand medical science. We help our patients make connections with services and specialists, we help them to get housing, employment and benefits. We share time, kindness and comfort, “a therapeutic alliance emerges when patients perceive their therapist as a warm, helping, and supportive person, a powerful other who is engaged and shares responsibilities in a common struggle to alleviate the patient’s suffering” (ibid).

“The characteristic of medical practice is service. Or as expressed by Paracelsus: the reason for medicine is love. Hence such characteristics as readiness to help, love of mankind, spontaneous sacrifice will be found in all medical ideals.” Sigerist

Our patients need us to be trusted partners in care and we need their trust. And so we must acknowledge the power we have, the damage it has done and the harm we continue to do. We need to be more sensitive to its impact on the doctor-patient relationship. We must think very seriously about how best to use our power to serve our patients; is it really in their interests if we are subject to greater government regulation and the demands of profit-seeking global corporations? What must we do to remove incentives that encourage profit seeking and the abuse of power amongst our professional peers?

We are at an important point in time where we must choose whether we are going to stand by our patients or join the corporations that are seeking power and profit over and from, every aspect of our lives.

References:

Schei, Edvin, Doctoring as Leadership The power to heal. Project Muse http://www.ncbi.nlm.nih.gov/pubmed/16960309 The inspiration behind this blog post.

Doctors as Victims by John Launer. “I am becoming concerned at how easily doctors notice when they are affected by other people’s power, and how difficult they find it to acknowledge their own power”

When Managers Rule. Brian Jarman BMJ 2012

Power to the people: Patient in command. Powerful essay be Bernard Lown http://bernardlown.wordpress.com/2012/11/03/power-to-the-people-patient-in-command/

French and Raven’s five forms of power. Understanding where power comes from in the workplace.

Markets fail to solve the problem of power, in fact they tend to compound it. George Monbiot, Guardian.

David Loxterkamp. The Dream of Home Ownership. http://annfammed.org/content/7/3/264.full Lovely essay about the importance of independent general practice.

The Rise of the Corporate Physician and the Metastasis of Big Corporations http://hcrenewal.blogspot.co.uk/2012/10/the-rise-of-corporate-physician-and.html “Public discussion has raised more questions over the last few months about physicians taking care of patients as corporate employees”

Lupton, DA. Medicine as Culture: Illness, Disease and the Body in Western Societies. Sage Publications 2003 Wonderful, highly recommended book.

Welch. H. Gilbert. Overdiagnosed: Making People Sick in the Pursuit of Health Beacon Press. April 2011

Medical Education for Social Justice. Paulo Friere Revisited http://www.springerlink.com/content/7j1rv333170671j2/ Fantastic essay about power and medical education.

Donaldson, Liam. Commentary, The Doctor’s Dilemma, a response http://ije.oxfordjournals.org/content/32/6/915.full

Your phone will soon be your new doctor http://gigaom.com/2012/09/30/your-phone-will-soon-be-your-new-doctor/