January 31, 2011
Out of Camelot, Knights in White Coats Lose Way
By SANDEEP JAUHAR, M.D.

When I look at my career at midlife, I realize that in many ways I’ve become the kind of doctor I never thought I’d be: often impatient, at times indifferent or paternalistic.

Of course, the loss of one’s ideals is a crucial component of the midlife phase, often leading to depression, nostalgia and regret: the proverbial midlife crisis. And it occurs to me that my profession is in a sort of midlife crisis of its own.

The modern era of medicine began a little less than 40 years ago, with the Health Maintenance Organization Act of 1973, which ushered in the age of managed care. Managed care was supposed to save American medicine by stemming the rise in spending initiated by Medicare. It failed to do that. Instead, it did away with the kind of medicine that made people want to be doctors in the first place.

In the last four decades, doctors have lost the special status they used to enjoy.

Physicians used to be the pillars of any community. If you were smart and sincere and ambitious, the top of your class, there was nothing nobler you could aspire to become. Doctors possessed special knowledge. They were caring and smart, the best kind of people you could know.

Today, medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future.

But while doctors often blame managed care for their situation, managed care didn’t create this crisis. It originated from the abandonment of ideals that made managed care necessary in the first place.

In a recent essay in The Journal of the American Medical Association, Dr. Sachin H. Jain and Dr. Christine K. Cassel discuss the conception of physicians as “knights” or “knaves” (an idea developed by the economist Julian Le Grand in his study of British civil servants).

Knights, they wrote, practice medicine to save and improve lives. The best thing government can do is to get out of their way and let them do their jobs. Knaves, on the other hand, put their financial well-being before their patients, often ordering tests and studies for personal gain. Government needs to guard against their malfeasance.

The history of American medicine over the past half-century can be interpreted through this framework of changing perceptions. In the mid-20th century, physicians were among the most highly admired professionals, comparable with Supreme Court justices. It was a period when life expectancy increased sharply (to 71 years in 1970 from 65 in 1940), aided by such triumphs of medical science as polio vaccination, penicillin and heart-lung bypass. Depictions of physicians on television were overwhelmingly positive. Doctors were able to trade on this cultural perception for an unusual degree of privilege and influence.

Organized medicine used this influence to try to defeat nationalized health insurance plans like Medicare, seeing them as an attempt to undermine income and autonomy. Doctors were content with the status quo. They could regulate fees based on a patient’s ability to pay and look like benefactors. They viewed Medicare as the end to medicine as they knew it. It turned out that they were right, but not in the way they imagined.

After Medicare was created in 1965, doctors’ salaries actually increased, as demand for physicians’ services skyrocketed. In 1940, in inflation-adjusted 2010 dollars, the mean income for American physicians was about $50,000. By 1970, it was nearly $250,000, nearly nine times the per-capita gross national product. (It has dropped since then, to about six times per-capita G.N.P.)

But as doctors profited, they were increasingly perceived as knaves, bilking the system. “It was a free-for-all,” a senior physician at my hospital who worked through that era told me recently. Doctors, he said, were helping each other game the system; the operative phrase was “I’ll scratch your back if you scratch mine.”

“Before Medicare,” he went on, “doctors were not so focused on making money. Professional attainment still meant something. But if you call attention to this you are considered a ... .” He struggled for the right word.

“Troublemaker?” I offered.

“Yes, a bad apple. There are so many unnecessary procedures. But all these doctors are board-certified. Who am I to tell them what to do?”

The transition from knighthood to knavery had major consequences. In 1973, fewer than 15 percent of several thousand practicing physicians reported any doubts that they had made the right career choice. In 1981, 48 percent of office-based doctors said they would not recommend the practice of medicine as highly as they would have 10 years earlier.

In 2001, 58 percent of about 2,600 physicians questioned said their enthusiasm for medicine had gone down in the previous five years, and 87 percent said the overall morale of physicians had declined during that time. And nearly half of 12,000 physicians questioned recently said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether. Three-quarters said medicine is either no longer rewarding or less rewarding.

This growing discontent has serious consequences. One is a looming shortage of doctors, especially in primary care. Try getting a timely appointment with your family doctor. In some parts of the country, it is next to impossible. A report published in November 2009 by the Association of American Medical Colleges projected a shortage of as many as 150,000 physicians by 2025.

But perhaps the most serious downside is that unhappy doctors make for unhappy patients. Patients today are increasingly disenchanted with a medical system that is often indifferent to their needs. There has always been a divide between patients and doctors, given the disparities inherent in the relationship, but this chasm is widening because of time constraints, malpractice fears, decreasing income and other stresses that have sapped the motivation of doctors to connect with their patients.

Of course, doctors are not the only professionals who are unhappy today. But as the sociologist Paul Starr writes, for most of the 20th century medicine was “the heroic exception that sustained the waning tradition of independent professionalism.” It is an exception whose time has expired.

Abandoning core professional ideals, and the resultant change in perception and policy, has taken a bigger toll on the profession than doctors could have imagined in that midcentury golden age. Sadly, those once heroic knights have only themselves to blame.

Dr. Sandeep Jauhar is a cardiologist and the author of “Intern: A Doctor’s Initiation.”

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