1. For Alexander, the sense in which medicine is broken is that, in his view, medicine, along with many other fields, got taken over by wokeness. He links to another post where he describes the program at the 2019 APA meeting. Talks on intersectionality, microaggressions, or immigration were much more prevalent than ones on mental disorders such as OCD, which he thinks is a mistake. He isn't really concerned about Oz et al., since they're cast out of the priesthood. Instead, he's worried that the entire establishment got focused on the wrong goal. He would surely agree that this is much deeper than "a problem of a few priests besmirching the good name of an otherwise trustworthy priesthood". It's also much harder to pinpoint than making it about capitalism or efficiency.
2. You say: "Because they’re conventions, though, people might start wondering why they need priests. Maybe the priests are actually getting in the way. Clinical judgment, rather than being wise counsel, becomes an impediment to greater independence. People come to see physician’s judgment as a threat to their free choice. What we’ve seen in the world of healthcare over the past 20-30 years is something akin to the Protestant Reformation, in which Christians of the 16th century wanted direct access to God without the meddling mediation of a priest."
This is a great description, though at odds with what seems to be your view. The Protestant Reformation was a good idea! Physicians have been lamenting the rise of "Dr. Google" for a while, and now AI is creating a way to directly commune with health. Physicians aren't going away (nor should they), but their intercessory powers are waning. I don't want doctors to have control over what I do with my body in the same way I don't want literal priests telling me how to live my life.
3. You say: "In an attempt to “respect autonomy” over the past 50 years, the priests of medicine have ironically eroded their capacity to mediate between people and health."
This strikes me as a bit of revisionist history. There's no doubt that physicians care about autonomy, but this didn't come from within the priesthood. For the most part, it's people on the outside—patient rights groups, lawyers, journalists, and ethicists—who've had to force physicians to give up their power bit by bit. To be sure, there are physicians who have done important work from within, but the number of consults I've seen where the problem was giving the patient too much autonomy is far exceeded by the number where the physician wants to make the decision.
1. I may have over emphasized the capitalist "demon," but wokeness could be just another "demon." Either way, the goal of medicine is compromised. There are, I suspect, many "demons" afoot. Some of them might even be good things that we've just given too much priority.
2. There are some theological rabbit trails here that take us too far afield of our discussion about medicine (e.g., Protestants had to reckon with the fact that they do indeed need a priest, but that priest is the God-man, Jesus. That reckoning is imperfectly realized in all sorts of ways today). Being a Protestant myself, I agree the Reformation was a good idea, but I referenced it to sustain the spiritual metaphor and with a narrow connection to this idea of a priest being transformed from a mediator into an impediment.
3. I agree the profession wouldn't have changed without substantial external pressure. However, once that boulder shifted in the late 1980s early 1990s (at least in the USA), the landslide has been perpetuated by many routine bedside decisions. There's an ethicist, I forget his name but maybe you know, who wrote a book some time ago describing the concept of forced autonomy - not his phrase, he used a different term. Autonomists, maybe? Anyway, I regularly see clinicians explain a situation and some options and tell the patient (or surrogate) they need to choose; no one else can choose for them. The even see offering a recommendation as an impingement on autonomy. I regularly see patients who are starved for guidance and a recommendation after dealing with clinicians who refuse to offer any.
I can't speak to your experience as an ethics consultant, but I've found some of the ethics consults I get are when today's clinicians are reaping what yesterday's clinicians have sown. Everyone has said yes earlier in the care, but now things have gone so far, beyond what the clinicians now think is reasonable, but the patient (or surrogate) disagrees. The moral distress reflects an intuition that something has gone awry in the house of medicine.
Does the general public actually understand MDs as priests? Really? I work in clinical research administration, so collaborate with MDs; my husband is an insurance attorney and reasonably familiar with health law; our friends are similarly young white collar professionals, or pink collar teachers/nurses/etc.
None of us can take MDs seriously at this point, frankly. More than one woman I know has a story of their OBs sexually assaulting them or cheerfully handing out CPD diagnoses like candy to women who later VBAC’d larger babies. There’s the psychiatrist who claimed a case of celiac was anorexia and the parents should probably have CPS called on them for being in denial (it was, uh, celiac, and the kid was basically starving.) There’s the pediatrician and SLPs who both didn’t bother to suggest a child with a speech delay get a hearing test, only for mom to beg for one 9 months later (having been told she wasn’t trying hard enough, repeatedly, by the ped and the SLPs) and uh… the child failed the test. Couldn’t hear a thing. Otitis media.
Obviously the problem has many sources. Med school select for obedience and compliance. Private equity. Hospital CEOs. Clinicians have to see so many patients they can’t possibly do anything but stare at computers and check boxes (so why not cut out the middle man and have a robot do it, one asks)? I have met many MDs in my life and vanishingly few doctors, true doctors. They stand out in one’s memory and in a crowd. Scott flatters himself.
Stories abound of clinicians either stumbling in their roles our outright abusing their power.
To answer your question, I'm not many people consciously embrace metaphors about much of anything. They either unconsciously adopt them in their speech where they can have a subtle influence in how we think of our relationships and behavior (e.g., "I coached my child through dinner time" or "I'm done playing games with that co-worker"). However, by consciously picking up a metaphor to examine a role, it can provide new insights into how that role functions, as in the case of the priesthood of medicine.
Insofar as you find all those anecdotes disappointing, it might suggest that your expectations for clinicians are high. High in what regard? What is a "true doctor?" The priesthood metaphor might suggest some ideas about what "true doctors" should be doing.
As I wrote, though, I don't think this is the best metaphor to describe medicine. It can, however, help us think through some of the hidden facets of the field.
I would expect clinicians to look patients in the eye; use a combination of clinical evidence and judgment to make recommendations; admit when they were wrong and apologize; and stop calling the cops on people who don’t want to take their advice (OBs, this advice is mainly for you). The bar is low.
A true doctor is like a true plumber, a true chef, a true teacher, a true secretary: a person who fulfills the promise of their discipline to the best of their ability in good faith. Secretaries are not priests either.
Nice post, Josh. A few things stand out to me.
1. For Alexander, the sense in which medicine is broken is that, in his view, medicine, along with many other fields, got taken over by wokeness. He links to another post where he describes the program at the 2019 APA meeting. Talks on intersectionality, microaggressions, or immigration were much more prevalent than ones on mental disorders such as OCD, which he thinks is a mistake. He isn't really concerned about Oz et al., since they're cast out of the priesthood. Instead, he's worried that the entire establishment got focused on the wrong goal. He would surely agree that this is much deeper than "a problem of a few priests besmirching the good name of an otherwise trustworthy priesthood". It's also much harder to pinpoint than making it about capitalism or efficiency.
2. You say: "Because they’re conventions, though, people might start wondering why they need priests. Maybe the priests are actually getting in the way. Clinical judgment, rather than being wise counsel, becomes an impediment to greater independence. People come to see physician’s judgment as a threat to their free choice. What we’ve seen in the world of healthcare over the past 20-30 years is something akin to the Protestant Reformation, in which Christians of the 16th century wanted direct access to God without the meddling mediation of a priest."
This is a great description, though at odds with what seems to be your view. The Protestant Reformation was a good idea! Physicians have been lamenting the rise of "Dr. Google" for a while, and now AI is creating a way to directly commune with health. Physicians aren't going away (nor should they), but their intercessory powers are waning. I don't want doctors to have control over what I do with my body in the same way I don't want literal priests telling me how to live my life.
3. You say: "In an attempt to “respect autonomy” over the past 50 years, the priests of medicine have ironically eroded their capacity to mediate between people and health."
This strikes me as a bit of revisionist history. There's no doubt that physicians care about autonomy, but this didn't come from within the priesthood. For the most part, it's people on the outside—patient rights groups, lawyers, journalists, and ethicists—who've had to force physicians to give up their power bit by bit. To be sure, there are physicians who have done important work from within, but the number of consults I've seen where the problem was giving the patient too much autonomy is far exceeded by the number where the physician wants to make the decision.
Thanks for these reflections.
1. I may have over emphasized the capitalist "demon," but wokeness could be just another "demon." Either way, the goal of medicine is compromised. There are, I suspect, many "demons" afoot. Some of them might even be good things that we've just given too much priority.
2. There are some theological rabbit trails here that take us too far afield of our discussion about medicine (e.g., Protestants had to reckon with the fact that they do indeed need a priest, but that priest is the God-man, Jesus. That reckoning is imperfectly realized in all sorts of ways today). Being a Protestant myself, I agree the Reformation was a good idea, but I referenced it to sustain the spiritual metaphor and with a narrow connection to this idea of a priest being transformed from a mediator into an impediment.
3. I agree the profession wouldn't have changed without substantial external pressure. However, once that boulder shifted in the late 1980s early 1990s (at least in the USA), the landslide has been perpetuated by many routine bedside decisions. There's an ethicist, I forget his name but maybe you know, who wrote a book some time ago describing the concept of forced autonomy - not his phrase, he used a different term. Autonomists, maybe? Anyway, I regularly see clinicians explain a situation and some options and tell the patient (or surrogate) they need to choose; no one else can choose for them. The even see offering a recommendation as an impingement on autonomy. I regularly see patients who are starved for guidance and a recommendation after dealing with clinicians who refuse to offer any.
I can't speak to your experience as an ethics consultant, but I've found some of the ethics consults I get are when today's clinicians are reaping what yesterday's clinicians have sown. Everyone has said yes earlier in the care, but now things have gone so far, beyond what the clinicians now think is reasonable, but the patient (or surrogate) disagrees. The moral distress reflects an intuition that something has gone awry in the house of medicine.
Does the general public actually understand MDs as priests? Really? I work in clinical research administration, so collaborate with MDs; my husband is an insurance attorney and reasonably familiar with health law; our friends are similarly young white collar professionals, or pink collar teachers/nurses/etc.
None of us can take MDs seriously at this point, frankly. More than one woman I know has a story of their OBs sexually assaulting them or cheerfully handing out CPD diagnoses like candy to women who later VBAC’d larger babies. There’s the psychiatrist who claimed a case of celiac was anorexia and the parents should probably have CPS called on them for being in denial (it was, uh, celiac, and the kid was basically starving.) There’s the pediatrician and SLPs who both didn’t bother to suggest a child with a speech delay get a hearing test, only for mom to beg for one 9 months later (having been told she wasn’t trying hard enough, repeatedly, by the ped and the SLPs) and uh… the child failed the test. Couldn’t hear a thing. Otitis media.
Obviously the problem has many sources. Med school select for obedience and compliance. Private equity. Hospital CEOs. Clinicians have to see so many patients they can’t possibly do anything but stare at computers and check boxes (so why not cut out the middle man and have a robot do it, one asks)? I have met many MDs in my life and vanishingly few doctors, true doctors. They stand out in one’s memory and in a crowd. Scott flatters himself.
Stories abound of clinicians either stumbling in their roles our outright abusing their power.
To answer your question, I'm not many people consciously embrace metaphors about much of anything. They either unconsciously adopt them in their speech where they can have a subtle influence in how we think of our relationships and behavior (e.g., "I coached my child through dinner time" or "I'm done playing games with that co-worker"). However, by consciously picking up a metaphor to examine a role, it can provide new insights into how that role functions, as in the case of the priesthood of medicine.
Insofar as you find all those anecdotes disappointing, it might suggest that your expectations for clinicians are high. High in what regard? What is a "true doctor?" The priesthood metaphor might suggest some ideas about what "true doctors" should be doing.
As I wrote, though, I don't think this is the best metaphor to describe medicine. It can, however, help us think through some of the hidden facets of the field.
I would expect clinicians to look patients in the eye; use a combination of clinical evidence and judgment to make recommendations; admit when they were wrong and apologize; and stop calling the cops on people who don’t want to take their advice (OBs, this advice is mainly for you). The bar is low.
A true doctor is like a true plumber, a true chef, a true teacher, a true secretary: a person who fulfills the promise of their discipline to the best of their ability in good faith. Secretaries are not priests either.