Physicians today are increasingly viewed and treated as skilled workers instead of professionals. The difference is fundamental, and lies at the root of today’s epidemic of physician burnout.
Historically, there have been three Learned Professions: Law, Medicine and Theology. These were occupations associated with extensive learning, regulation by associations of their peers, and adherence to strong ethical principles, providing objective counsel and service for others.
Learned Professionals have, over many centuries, worked independently in applying their knowledge of Law, Theology or Medicine to the unique situations presented by those who seek their services. They have done this work with a significant freedom that has been balanced by their commitment to the fundamentals of their disciplines and responsibility to their professional corps. They have answered to their clients, their profession and to the legal system of their countries, perhaps with the exception of where the Church has defied or resisted Government.
Skilled workers are different from Learned Professionals in that they, although their work may be highly complex, don’t independently interpret the theories behind what they do, but instead follow strict protocols and orders from supervisors. Examples of skilled workers are nuclear reactor operators, commercial jet pilots and Certified Public Accountants. No matter how much skill we require from nuclear reactor operators, for example, everybody sleeps better at night if they always follow their protocols and we assume that there are protocols for every imaginable scenario.
This is how many people, and particularly those who are now in roles of administration and finance in Government and the healthcare “industry”, have come to view Medicine; they think it is too important a job to trust individual providers to do well in without lots of supervision and protocols even more detailed than those in the nuclear or airline industries.
A few, narrow, specialties in Medicine and probably also in Law and Theology, might lend themselves to closer comparison with running a nuclear plant or flying passenger jets, but the definition of the Learned Professions is that they deal with not only complexity of but also with the uncertainty caused by the infinite human variation in expression of their science.
The narrower areas of Medicine, like joint replacement surgery, have tempted many to compare Medicine with manufacturing, for example. But even joint replacement surgery requires a level of judgement that goes far beyond the manufacturing paradigm, beginning with making the assessment, in collaboration with the patient, whether joint replacement is even indicated and safe for the individual in the first place.
The management of everyday conditions like diabetes, hypertension, depression and abdominal pain requires solid scientific knowledge, yet also involves high degrees of uncertainty and complex decision-making with infinite variables to consider. In other words, to think these conditions can safely be managed by protocols is naive; “guidelines” in Medicine are only broad brush strokes of the general principles we follow or at least consider, but would be detrimental to countless patients if actually followed as if they were protocols.
The argument has been made that Medical Science has grown so exponentially that individual doctors can never stay informed enough to make independent judgments about patient care. Logic dictates that this explosion requires even more independent judgments, because it is simply not possible to develop “protocols” for everything. Anyone can see that a patient with four or five conditions will have issues where what is done for one condition has a negative impact on another, for example. We face this issue in almost every patient encounter.
The other day, I had to prescribe an antibiotic for a patient with a serious blood clotting problem. The antibiotic I thought of using could interfere with my patient’s blood thinner, and the ones that don’t interfere are less effective. There are no protocols for that.
The same day I talked with a student about the risk of serotonin syndrome when you co-administer certain medications. For example, modern antidepressants and common migraine medications could theoretically cause this syndrome. My student had read it in a textbook and our computerized databases warn us every time that prescribing them both may not be a good idea. The literature reports this interaction to be rare enough that major headache societies support using the combination with common sense precautions when both medications are indicated. Making that judgment in individual cases requires knowledge of the drugs, understanding of the patient’s condition, and awareness of the current literature, because textbooks quickly become outdated.
I also talked with my student about the new study that suggests that more aggressive blood pressure targets for treatment of hypertension than the JNC 8 “guideline” are associated with lower rates of cardiovascular events. Which number should one strive for – in a high risk middle aged patient, and in a frail, elderly, patient?
This is why Medicine should still be classified as a Learned Profession. And this is why doctors must hone and honor their scientific knowledge and critical thinking. And this is also why patients, who can get any isolated piece of fact they would ever want from the Internet, still need us as trusted guides, whose understanding of Medicine runs deeper than sound bytes, blog posts, news flashes – and “guidelines”.
A Country Doctor Writes: 
Medicine is an art, a gift from the gods-Look at the New Testament in the Christian Bible.
There are steps that most healers follow throughout the world, and it little matters if the healer is wearing a white lab coat in the US or Germany, or wearing a bone through the nose in Africa, SE Asia or a remote part of a Pacific Island. Does the patient have a fever? Treat that. Does the patient have pain-what type? how accute? Treat that unless you live New Mexico, USA, because the DEA could strip you of your license. Do I need to say more?
These wars against ____ ______ should be expressed through public education, not pressure on doctors to follow paradigms and protocols that remove the independence and fount of wisdom the doctor has, and ignoes the needs and will of the patient. Doctors should not be punished financially, if they actually care for the patient’s real needs and conditions. How can government panels and Congress judge the practice of an art form?
I’ll go to hypothyriodism and high blood pressure. I was receiving too much hormone replacement suppliment. My TSH showed that I was out of range on the high end, but 5 different doctors refused to to lower my THS, while my BP climbed and climbed. Doctor number 6 immediately reduced my TSH, and my BP dropped from 220/120+ into mostly normal range. BP readings. BP protocol calls for BP meds, weight loss, and lifesyle changes-even mental behavior counseling. I am so grateful for doctor #6.
Yes, I’m a bit chubby. My oncologists had me put on 20 lbs in 6 weekss, so I could survive radiation treatment for my nose and mouth. They want me to maintain this weight. As I told a few artless health care providers, what difference does it make for me to loose weight, if the weight loss causes me to fail? The only meds that I take are Flonase, Zantac, thyroid replacement hormone, an antihistamine, and suppliments like Fish Oil, CoQ-10, Probiotics, and vitamins under the supervision of an oncology hemotologist, who is deinately a health artist.
Thankyou for bring this issue up, and letting me explain how I think that an artist works.
Excellent piece of writing. Well said.
The noose is tightening around the neck of physicians. Now the powers that be are talking about bundling a patient, and the buzz word is starting to be heard in the media.
Bundling is so illogical. The purpose is to reduce medical costs, but bundling will cause poorly paid doctors to double their staffs. A recent study reported that administration staff is the fastest growing part of medical care and is also the fastest factor for the cost of medical care. A few days ago, it was commented in an Anestheiology journal the patient that wants pain to be handled will be willing to pay more. I suppose that patients will pay a lot more for the extra administrative staff.
Bundling would slow down the initial treatment that is supposed to be more patient centered.
Bundling a toilet. Yesterday we tried to bundle a new toilet. When we tried to shut the water off to the toilet so we could drain it, remove it, and replace it, the turn off valve wouldn’t turn off. We had to turn the water off to the house, turn off the water heater to prevent that blowing up, and then replacing the toilet shut off valve. So we had to buy new parts and it took a bit over an extra hour to finish the job. I lit the hot water heater, while the toilet was being caulked. I will add that the supply company tried to send me off with one box-the tank, instead of the second box with the toilet boil. It took time for them to get the order online to see if I was correct.
This was the operation for a toilet-not a human with kidney disease, Zika, high blood pressure, and the toilet did not have a will of its own.
Dear Country Doctor, very well said! How do we convey this to the decision makers? We shall have to learn from the lawyers.
Well done. I couldn’t agree more. However, the administrators of these big hospital based systems, believe that we, physicians ,should just be employees and replaceable upon need or desire. The goal of hospital based systems is to own and control. Middle level management controls the choices of what is available based on cost, not upon outcome data, or the needs of our patients.. Medicine is evolving, and many younger physicians will never understand that the bureaucrats are actually making medical decisions for healthcare because they are learning to operate under the bureaucratic guidelines. The next concern will be determining if physicians will be medically liable for carrying out the restrictions of the hospital or employer restrictions? Currently on a daily basis, I have a new patient explain to myself, a fulltime pain management physician, that I am ethically required to prescribe the higher doses of opioids, because they are autonomous and that is their treatment that was started by someone else, and it works. I explain the risks of these high dose opioids per CDC recommendations, Federation of Medical boards, and FDA consideration. I explain the lack of outcome data , at times spending 45min face to face with the patient. The patients are well versed on their rights. They tell me that they don’t do injections, and won’t consider surgery. They tell me that Chiropractors are scary, and physical therapy doesn’t work and cost too much. They tell me that the fifth vital sign is pain, and it is unethical to allow them to suffer. These are complicated times in medicine, and the bureaucrats and attorneys will attempt to control the evolution of medicine as a practice. Fellow physicians can be our own worst enemies, as some physicians believe all pain problems can be solved without any intervention, or medications, and will support these models, and the creation and use of all the other guidelines. Physicians will also support the loss of the intellectual independence because they will be trained in that model, and it will feel normal to them. The practice will evolve and the environment will partially control the evolution. It is important for the more seasoned physicians to carry the torch of autonomy to our younger colleagues, so we have a chance to remain independent.