First the good news.
We live in an era of increased anxiety related to our health. Too many people are demanding too many services for too much money resulting in less than optimal outcomes. The good news? Even in the face of substantial challenges and uncertainty, trust of physicians (and healthcare providers in general) remains high. In fact, according to Gallop polling administered over more than three decades, the US public continues to rate the honesty and ethical standards of physicians among the highest of all professions (see chart below, and CLICK HERE FOR LINK). Although physicians rank very highly, the nursing profession deserves credit for their solid lock on first place.
Perhaps more significant than the current high trust ratings, are the trends over the past 30-40 years. During this period, almost every profession has seen an erosion of public trust. Journalists, judges, lawyers, bankers, clergy and politicians all have all experienced major reductions in public confidence. This is perhaps not surprising given the increasing speed and transparency of information flow…familiarity breeds contempt.
Healthcare providers have bucked the overall trend, and are rated as more honest and ethical than they were in the mid-1970’s. In an era of uncertainty and change, it is very good news that the public still has a high degree of confidence in the providers of care.
Now for the word of caution.
The trust place in healthcare providers is not immutable, and cannot be taken for granted. A case in point, bankers enjoyed a stable and relatively high level of trust (41% Very High or High) as recently as 2005. By 2009, this number had plummeted to 19%, following the global economic meltdown.
Jain and Cassel emphasized this point in their 2010 article in JAMA, Societal Perceptions of Physicians: Knights, Knaves and Pawns? (CLICK HERE FOR LINK). Jain and Cassel refer to a 2006 book by economist Julian Le Grand, Motivation, Agency, and Public Policy: Of Knights and Knaves, Pawns and Queens. Le Grand observed the changing public attitudes regarding civil servants in Great Britain. Immediately following World War II, civil servants were held in the highest possible regard. Schoolteachers, physicians, policemen, child welfare workers and others were heroes, part of a concerted national effort that defeated Hitler. What followed, according to Le Grand, was an era of good will and public optimism that lead to an expansion of state services… “a triumph of collectivism”.
Today, the same groups that once were celebrated are viewed as part of a faceless monolith of public services that deliver low quality services for undesirably high tax rates. Part of Le Grand’s hypothesis is that as society’s view of the motivation of a profession changes (e.g., are they Knights, Knaves or Pawns?), there is a direct impact on public policy.
Knights are driven by virtue, and are predisposed to do the right thing. Per Jain and Cassel, physician knights are stewards of the healthcare system. They can be trusted to manage resources effectively. They are life-long learners because they have an inherent love of learning. First and foremost, they are advocates of the patient. If society believes in physician knights, the public policy implication is that minimal regulation is required…knights will do the right thing to protect us…just get out of the way and let them pursue their vocation.
Knaves are driven by self-interest. Money, fame and lifestyle considerations are of primary importance, and the needs of patients are secondary. Knowledge is acquired, or research is performed, out of some expectation of personal gain. If society believes in physician knaves, then public policy must prevent malfeasance. Rules and regulations must be established to guard against greed and monitor potential conflicts of interest that may impact patient care decisions. Think of the financial regulatory environment after the US housing market collapse.
The poor physician pawns blow where the breeze takes them, helpless to act and at the mercy of the environment. They do their required continuing education because they are told to do so. If you need them to order fewer lab tests, they will comply. If next month you want them to do more lab tests, they will comply. They are reeds in the wind. From a public policy perspective, physician pawns are mindless automatons; production units with little judgment, unable to engage in autonomous decision-making. Regulation must therefore be highly prescriptive. Since physicians cannot make decisions, society must carefully create a script for them to follow.
If you accept Le Grand’s premise, then public perception drives policy and regulation. However, I think it is more of a cycle, or more accurately, a spiral. Behavior of the profession drives public perception. Public perception drives regulation. But regulation also influences behavior (which drive perception, then regulation, etc.).
Imagine two good parents have three generally well-behaved and respectful children…a teenager, child and infant. The parents have faith in their children. The children seem inclined to do the right thing. Because of the trust the parents have in the children, they are given a high degree of autonomy. They are child knights. One weekend the teenager is involved in a momentary indiscretion (you may choose your indiscretion). The transgression was not heinous, but showed poor judgment.
Perhaps the parents will continue to regard their eldest as a knight. However, if he slips towards knave status in their eyes, the parents could respond by ramping up the regulation. Curfews might be added, expectations for frequent communication heightened, friends more carefully scrutinized, social media sites monitored, etc. What influence would this heightened level of supervision, and decreased parental trust have on the teenager and middle child? It is not unreasonable to expect the children might become less transparent; they might become less communicative; they might lie about friendships and activities. In other words, the regulation designed to protect the family and children accelerates the journey to knave status. The reactive behaviors influence the parents’ opinion of the child, stimulate more rules and oversight, and drive more knave-like behavior. The cycle continues.
But what of the infant child in the family? Raised in an environment of rules, restrictions and guardrails, the child develops without the opportunity to test boundaries, make mistakes and be rewarded for making good decisions. The infant potentially grows into a child who needs regulation to survive, incapable of working through difficult problems independently. The child pawn requires more and more detailed rules, as he appears incapable of developing independent moral thought.
So by way of analogy, physicians who act like knaves will drive public perception, which in turn drives regulation, which impacts behavior and the spiral continues. One concrete example: Medicare billing guidelines are very tightly linked to documentation of the history and physical examination (because physicians are viewed as knaves by Medicare, prescriptive documentation guidelines are enforced to prevent overbilling). One of the areas of documentation is the “review of systems” (ROS). The physician asks questions about symptoms attributable to a specific organ system – cardiovascular, respiratory, gastrointestinal, genitourinary, etc. Medicare defines four levels of charges, ascending in complexity and payment. For the lowest level, no ROS is required at all. The next level up, the ROS is “problem pertinent”, and can be limited to the system directly involved with the illness under evaluation. The next highest level requires documentation the physician asked the patient about 2 to 9 systems. The highest level requires the physician ask about 10 or more organ systems. Especially in the era of electronic medical records, where much documentation is driven by checkboxes, it is not unreasonable to assume that some of the 900,000 physicians in the country will over-document their review of systems – a very small number deliberately, a much larger number innocently. Healthcare systems and practices invest in audit systems to try and catch and correct these errors in documentation. Medicare ramps up investigations to try and catch those acting badly. More regulations are spawned, and the spiral continues.
So are physicians knights, knaves or pawns? An environment that is moving towards increased guardrails and regulation runs the risk of demoralizing the knights, and creating knaves and pawns. Recognizing this risk, physicians and healthcare providers must work to interrupt the cycle by committing to fundamental principles of professionalism. Individual physicians, and the advocacy and accrediting bodies representing them, must hold sacrosanct one principle: first and always, the duty of a professional is the protection and promotion of a patient’s health. All other forms of self-interest must be unequivocally secondary. Once commitment to professionalism starts to erode, we are headed down a path where the primary protector of a patient’s well being are the rules and regulations governing the physician-patient interaction – not the physician.
Today, the same groups that once were celebrated are viewed as part of a faceless monolith of public services that deliver low quality services for undesirably high tax rates. Part of Le Grand’s hypothesis is that as society’s view of the motivation of a profession changes (e.g., are they Knights, Knaves or Pawns?), there is a direct impact on public policy.
Knights are driven by virtue, and are predisposed to do the right thing. Per Jain and Cassel, physician knights are stewards of the healthcare system. They can be trusted to manage resources effectively. They are life-long learners because they have an inherent love of learning. First and foremost, they are advocates of the patient. If society believes in physician knights, the public policy implication is that minimal regulation is required…knights will do the right thing to protect us…just get out of the way and let them pursue their vocation.
Knaves are driven by self-interest. Money, fame and lifestyle considerations are of primary importance, and the needs of patients are secondary. Knowledge is acquired, or research is performed, out of some expectation of personal gain. If society believes in physician knaves, then public policy must prevent malfeasance. Rules and regulations must be established to guard against greed and monitor potential conflicts of interest that may impact patient care decisions. Think of the financial regulatory environment after the US housing market collapse.
The poor physician pawns blow where the breeze takes them, helpless to act and at the mercy of the environment. They do their required continuing education because they are told to do so. If you need them to order fewer lab tests, they will comply. If next month you want them to do more lab tests, they will comply. They are reeds in the wind. From a public policy perspective, physician pawns are mindless automatons; production units with little judgment, unable to engage in autonomous decision-making. Regulation must therefore be highly prescriptive. Since physicians cannot make decisions, society must carefully create a script for them to follow.
If you accept Le Grand’s premise, then public perception drives policy and regulation. However, I think it is more of a cycle, or more accurately, a spiral. Behavior of the profession drives public perception. Public perception drives regulation. But regulation also influences behavior (which drive perception, then regulation, etc.).
Imagine two good parents have three generally well-behaved and respectful children…a teenager, child and infant. The parents have faith in their children. The children seem inclined to do the right thing. Because of the trust the parents have in the children, they are given a high degree of autonomy. They are child knights. One weekend the teenager is involved in a momentary indiscretion (you may choose your indiscretion). The transgression was not heinous, but showed poor judgment.
Perhaps the parents will continue to regard their eldest as a knight. However, if he slips towards knave status in their eyes, the parents could respond by ramping up the regulation. Curfews might be added, expectations for frequent communication heightened, friends more carefully scrutinized, social media sites monitored, etc. What influence would this heightened level of supervision, and decreased parental trust have on the teenager and middle child? It is not unreasonable to expect the children might become less transparent; they might become less communicative; they might lie about friendships and activities. In other words, the regulation designed to protect the family and children accelerates the journey to knave status. The reactive behaviors influence the parents’ opinion of the child, stimulate more rules and oversight, and drive more knave-like behavior. The cycle continues.
But what of the infant child in the family? Raised in an environment of rules, restrictions and guardrails, the child develops without the opportunity to test boundaries, make mistakes and be rewarded for making good decisions. The infant potentially grows into a child who needs regulation to survive, incapable of working through difficult problems independently. The child pawn requires more and more detailed rules, as he appears incapable of developing independent moral thought.
So by way of analogy, physicians who act like knaves will drive public perception, which in turn drives regulation, which impacts behavior and the spiral continues. One concrete example: Medicare billing guidelines are very tightly linked to documentation of the history and physical examination (because physicians are viewed as knaves by Medicare, prescriptive documentation guidelines are enforced to prevent overbilling). One of the areas of documentation is the “review of systems” (ROS). The physician asks questions about symptoms attributable to a specific organ system – cardiovascular, respiratory, gastrointestinal, genitourinary, etc. Medicare defines four levels of charges, ascending in complexity and payment. For the lowest level, no ROS is required at all. The next level up, the ROS is “problem pertinent”, and can be limited to the system directly involved with the illness under evaluation. The next highest level requires documentation the physician asked the patient about 2 to 9 systems. The highest level requires the physician ask about 10 or more organ systems. Especially in the era of electronic medical records, where much documentation is driven by checkboxes, it is not unreasonable to assume that some of the 900,000 physicians in the country will over-document their review of systems – a very small number deliberately, a much larger number innocently. Healthcare systems and practices invest in audit systems to try and catch and correct these errors in documentation. Medicare ramps up investigations to try and catch those acting badly. More regulations are spawned, and the spiral continues.
So are physicians knights, knaves or pawns? An environment that is moving towards increased guardrails and regulation runs the risk of demoralizing the knights, and creating knaves and pawns. Recognizing this risk, physicians and healthcare providers must work to interrupt the cycle by committing to fundamental principles of professionalism. Individual physicians, and the advocacy and accrediting bodies representing them, must hold sacrosanct one principle: first and always, the duty of a professional is the protection and promotion of a patient’s health. All other forms of self-interest must be unequivocally secondary. Once commitment to professionalism starts to erode, we are headed down a path where the primary protector of a patient’s well being are the rules and regulations governing the physician-patient interaction – not the physician.
Seems to me, the majority of physicians are knights. If they aren't is there a chance we can help empower them to become knights? That may be our virtue. Lynne
ReplyDeleteAll of the physicians I have encountered are certainly "knights."
ReplyDeleteI agree. ALl the physicians that I have encountered have been Knights as well, but knaves and pawns are definitely amongst the profession.
ReplyDeleteSo i ask the same as Lynne, is there a way to empower a knave/pawn to become a knight? #greatquestion