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 health care 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 judgment 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” is a family physician who blogs at A Country Doctor Writes:.
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