Does prestige belong in medicine?

An air of prestige has accompanied a career in medicine for centuries. Today, those in medicine are still largely respected, but different factors — including the democratization of information, an increasingly polarized society and new care models — are changing the public's view of physicians and the patient-provider relationship. 

"Historically — for centuries, really — a career in medicine has been one that was meaningful and highly valued by communities," said Gary Kaplan, MD, who has 43 years of healthcare experience and served as CEO of Seattle-based Virginia Mason Franciscan Health from 2000 to 2020.

Fast forward to 2022, and research indicates some physicians' own interest in and positive perception of the field may be declining, with some even second-guessing a career in medicine entirely. Only 68 percent of physicians under age 40 said they would choose medicine again if they could redo their careers, down from 76 percent the previous year, a Sept. 23 Medscape report found. 

To understand how and why the perception of medicine has changed — and what benefits or drawbacks this brings to the profession — Becker's spoke with two physician leaders with a combined 82 years in the industry. 

An evolving view of medicine and the patient-provider relationship 

An esteemed view of physicians dates to at least 91 B.C., when a Bithynian physician named Asclepiades established Greek medicine in Rome. "He brought a prestige to Greek medicine" and laid the groundwork for Greece's Methodic school of medicine, which significantly influenced how medicine is practiced today, researchers wrote in a 2017 study published in Medicines.

Throughout history, different theoretical models of the doctor-patient relationship also existed. From the time of ancient Greek physician Hippocrates through the 1970s, most of these models were highly paternalistic and based on the idea that physicians are the sole experts and decision-makers regarding medical care. 

A growing recognition for patient autonomy and values began to shift the physician-patient dynamic in the 1970s.

"There was a huge transformation in American medicine — in particular in the 1960s and 1970s — that paralleled what was going on in the country with the civil rights movement, feminist movement, and the antiwar movement and challenging authority," said Joseph Carrese, MD, a bioethicist, physician and professor in the department of medicine at Baltimore-based Johns Hopkins.

"We went from a system where doctors … know best — a very paternalistic, hierarchical model — to one where patients took center stage with patient autonomy and self-determination," he said. "The model of the doctor-patient relationship changed to one where now, I think appropriately, [it's] sort of a partnership."

Today, shared-decision making dominates the lexicon in healthcare, which the Agency for Healthcare Research and Quality defines as "a model of patient-centered care that enables and encourages people to play a role in the medical decisions that affect their health." 

Although healthcare now operates on this much more balanced model, several factors stand to threaten the level of trust and respect patients have toward physicians' clinical expertise. 

The rise of the information age. Patients have a seemingly infinite amount of information at their fingertips, which means physicians are no longer the single voice of reason or expertise. 

"Sometimes that's challenging to the physician-patient relationship," Dr. Kaplan said. "But I would submit that it's really an opportunity because the more aware, the more dialed in a patient is to their own health and well-being, the better they will be able to embrace healthy behaviors and the advice of their clinicians."

Disinformation's prevalence has also grown in recent years, contributing to an increasingly polarized society. As a result, some people are clinging to a "default suspicion of authority," Dr. Kaplan said. He pointed to Anthony Fauci, MD, the nation's top infection control leader and director of the National Institute of Allergy and Infectious Diseases, as a key example.  

"I know of no greater physician contributor to our profession and to the health of our society than Tony Fauci," he said. "And yet there are many people who don't trust him for all kinds of conspiracy theories and things about him, none of which are true."

This skepticism of federal health officials and public health information can often outweigh patients' trust in their own physicians' medical opinions. Dr. Carrese said he has several longtime patients who refuse to get COVID-19 vaccinations and disregard other medical advice gives them, despite having a strong patient-physician relationship. 

"I have no ability to make a dent in their views," he said. "At the same time, those people — some who have been seeing me for years — will agree to get other vaccinations or other new meds I'm recommending."

Disruptors in healthcare delivery. Speed and accessibility are at the forefront of healthcare's consumerism era, with disruptors such as Amazon and CVS Health set to dig deeper into healthcare delivery. Amazon plans to acquire virtual and in-person primary care company One Medical — a $3.9 billion deal that would give Amazon more than 180 clinics with employed physicians across two dozen U.S. markets. 

Disruptors in the care delivery space tout their moves as a bridge to better access, improved outcomes and lower costs. But in reality, those pros come with potential cons. As virtual and on-demand healthcare services grow and different companies try to own different segments of the care journey, patients' healthcare could become more segmented. And while there will always be situations where patients must see a provider they have not previously, disruptors' growth in healthcare could make those instances more common. 

"Every other commercial on TV is about online healthcare," Dr. Carrese said. "You can get medications for this problem or that problem without having ever seen the prescribing doctor before, and that raises concerns and questions in my mind. 

"The core of your care, ideally, should be with someone who knows you as a person. There's definitely literature supporting the idea that if you know a patient better … that absolutely leads to better care." 

Taken together, growing access to virtual and concierge-style healthcare may begin to further shift society's view of the medical field away from one where providers are largely viewed as trusted experts to one where they are more recognized solely for providing a service or fulfilling a request. 

The bottom line 

A reflection on the evolving perception of physician-patient relationships naturally leads to the deeper question of whether prestige belongs in medicine. The answer is not so simple. 

"In many ways, physicians have been held up on a pedestal by their patients and by their communities," Dr. Kaplan said. "In some ways, it's affirming, and yet it also has challenges." 

As the past two years have shown, distrust in physicians and other health experts can significantly hinder public health efforts and complicate patient relationships, according to Dr. Kaplan. 

"Hopefully, the pendulum will swing back because you need the power of science," he said. "We need the power of relationships, and I think the physician-patient relationship is one that is most important."

At the same time, leveling the hierarchy between physicians, care teams and patients could open the door for more shared decision-making and strengthen the patient-physician relationship. Dr. Kaplan cited the book Helping: How to Offer, Give, and Receive Help by organizational development expert Edgar Shein, PhD, which says an optimal helping relationship cannot include power imbalances. Putting physicians on a pedestal in which their word trumps all could undermine — or altogether obscure — patients' valuable perspective and opinions about their own care. 

"I don't want to be regarded with prestige by my patients in the sense that I'm put up on a pedestal and I'm seen as above them and more important than them," Dr. Carrese said. "I would like to be highly regarded and trusted and respected because I've earned it."

There is no better time than the present to reflect on whether the profession as a whole is doing enough to earn patients' trust and respect, Dr. Carrese said. Although trust in physicians fell during the pandemic, patients had more trust in their own personal physicians (84 percent) than the healthcare system as a whole (64 percent), according to a 2021 survey conducted by NORC at the University of Chicago. At the same time, most physicians (98 percent) said spending time with patients is an important part of trust building, but 77 percent of patients said they do not think their physicians spend enough time with them. 

If the lofty view of medicine declines, there is also a risk "that we will not continue to attract the best and the brightest," Dr. Kaplan said. This trend is already playing out in some specialties. For example, fewer medical students are opting to specialize in primary care, a 2019 report from Kaiser Health News found. While internal medicine was seen as a prestigious field in the 1970s, higher-paying, high-tech specialties such as orthopedics or gastroenterology are now among the most competitive and prestigious specialties. 

"I'm not advocating for medicine to not be a sought after or prestigious profession, but the reason people go into medicine should not be because they want to be in a prestigious profession," Dr. Kaplan said. "It needs to be about the work and the mission and the opportunity that we physicians have to create more health and a better environment for all of us."

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