In a previous Thursday Review focusing on Burnout, Deborah Lathrop1 emphasized the necessity for healthcare providers to have a space to
to address any pain from hidden grief. Lathrop’s discussion of disenfranchised grief is sensible, considering the changes in medicine in the last 30 years.
The question, then, once we know the importance of acknowledging and mourning the changes is, “What next?”
Writing in Qualitative Health Research, Brian Castellani and Delese Wear have published a summary of 50 physicians’ thoughts on how to practice medicine in “the corporate age”. Castellani and Wear try to match the professional experiences of real physicians, theoretical underpinnings, and practical advice for current and future physicians. Their work ties together ethics, storytelling, and even clarifies and expands some of Lathrop’s work.
Professionalism and Double Agency
Central to Castellani and Wear’s article is the concept of professionalism, which they base on Marcia Angell’s work. Professionalism in medicine, according to Angell, is the
struggle to balance cost and care in the era of managed care.2 The authors think this conflict between
running a business and
fulfill[ing] extraordinary obligation3 is a good starting point to talk about what professionalism means in healthcare. Angell calls this double agency, that the essence of what it means to be a doctor (and any other healthcare practice by association) is to
practice a set of contradictory beliefs.
They also acknowledge that this conflict
has plagued medicine since the American Medical Association (AMA) first codified its ethics, circa 1847.4 In this way, the idea of double agency is important, but doesn’t go far enough in explaining current medical practice. Castellani and Wear carry Angell’s ideas one step further. Because medicine is a practice, with its own
values, rituals, and commitments, they talk about medicine and its practice as a culture. The conflict and professionalism of cost vs. care has existed for a long time. What is new in the “corporate age” is that medical culture no longer primarily concerns itself with that balancing act.
Medical culture is now one culture among many cultures. There is still a theoretical autonomy which physicians have, but that autonomy is now inside of
a formidable which challenges the actual autonomy of decision making. The main conflict of medicine is no longer cost vs. care, but medical culture vs. other neighboring and related cultures. Castellani and Wear name this fact professional decentralization.
range of incentives
This is where the authors’ discussion of ethics begins. We can understand healthcare before the corporate era as being primarily occupied with the double agency relating to cost vs. care. Today, healthcare providers’ double agency consists of being the intermediary between their patients and other systems, including hospitals and insurance companies. The entire framing of Castellani and Wear’s article refers to the fact that this is not something that healthcare training and/or medical school prepares them for.
Instead, the systems and cultures which have decentralized medical professionalism have provided their own Ersatz ethics, which is their own professional standard: “cost-effectiveness”, or — put bluntly — profit:
The other major challenge to the culture of physicians is the way that managed care is redefining medicine’s ethics. In the world of corporate health care, ethics becomes economics. As a chief executive officer of a managed care company recently explained to us,Economics is a surrogate for the ethical struggles this country does not want to face. Until we have these discussions, managed care will continue to use cost-effectiveness as a means for deciding between good and bad care.
The other interesting ethical consideration which the authors raise is the notion of decision making power. When double agency meant the balance of cost vs. care, the capacity to make decisions rested with the healthcare practitioner. The ethics of cost vs. care was, then, the ethics of the practitioner. After medicine’s professional decentralization, the clash of cultures means that the loss of authority practitioners feel means they also feel that they are losing their own ethical standards.
For healthcare providers — and for physicians foremost — the power to make decisions is linked with what decisions they are able to make. As Castellani and Wear put simply,
Discussions of power and ethics are interdependent.
When physicians consider themselves beholden to those for whom they work, they find themselves, grudgingly, adopting an ethics of economics because they feel a loss in power. Therefore, they become employees working in a system under contractual obligation to management and its bureaucratic and capitalistic amorality. Buying into this new viewpoint, physicians, as double agents, find themselves lacking the skills necessary to provide an effective counterbalance. Therefore, unable to hold on to their culture of power or ethics, they settle for securing their own individual position, which improves neither the care of patients nor the future of medicine.
One physician had reframed the issue clearly for himself:
The proactive part is that you’ve got to be able to stand up and say, (My emphasis.)
Listen, who am I in it for? … Who you work for is your patient. Whenever you forget that, that’s when you create jeopardy … because patients know.
The profession and culture of medicine has given way to professional decentralization and the presence of many cultures clustered around patient care. This means that the narratives healthcare providers have received and cultivated through their training and experience no longer prepare them to navigate their work. Castellani and Wear call this narrative dysfunction:
Narrative dysfunction is the breakdown that physicians experience when the stories used to construct their professional culture no longer work.
Culture (professional or otherwise) is really a set of stories that people use to organize and guide their social interactions with one another. Without these stories, the interactions that people have with themselves and with others begin to break down, primarily because the organizing practices necessary to anchor their daily life are absent.5
The authors’ idea of narrative dysfunction picks up where Lathrop’s work on disenfranchised grief and mourning leaves off. Mourning the changes in medicine and the loss of the primacy of physicians in medical culture is important as a beginning. The next step is to construct narratives which are functional.
In addition, Castellani and Wear’s discussion of ethics comes alongside mourning, and offers a warning about the particulars of bemoaning the changes in medicine.
When physicians, for whatever reason, lack the narratives necessary to live in the present or the near future, they turn to telling stories about the past. This new type of storytelling, which is neither the past nor the future but rather somewhere in the in-between, helps them deal with their current problems by allowing them, in mournful fashion, to glorify the past and demonize their current situation.
Mourning the change from medical professionalism to professional decentralization risks becoming
camaraderie only in commiseration.
Such commiseration, however, is problematic because it allows residents and doctors to do two things: First, it allows them to demonize and externalize their problems, blaming the system; second, it allows them to feel victimized and prey to the forces of decentralization and therefore unable to enact any larger power over their situation.
If the only new stories to enter into the “corporate age” of healthcare are stories of mourning, then physicians will never shift their profession from balancing cost vs. care to mediating between the patient and systems/cultures which affect their care. Instead, physicians will relinquish all balance and mediation, and look after their own interests, which will most certainly be followed by all of the other types of healthcare providers around them. Never moving past mourning
allows physicians to focus on their own immediate concerns and take a narrow view of their situation rather than push themselves toward social change and a larger activism.
New Stories in Changing Times
Castellani and Wear sketch out how stories can help healthcare find its way out of narrative dysfunction. They describe the ability to find and execute these new stories as being proactive. This is the exact word used by the physician who questioned, “Who am I in it for?” A proactive physician is able to realize that the focus of their their profession’s power, ethics, and practice is no longer only on balancing cost and care. A proactive physician knows that it’s necessary to view the medical profession as also being an agent moving between the systems and cultures which effect cost and care and the patient.
The authors call this realization morally navigating systems, and state that this navigation redefines professionalism
as working well within, while bringing a moral compass to, today’s corporate and bureaucratic health care system. This redefinition of “profession” sees the reality of corporate-age care and can
learn how to work well within it. Castellani and Wear list several examples of useful knowledge from their interviews, including DRG codes, and how to tailor a chart to make it obvious to insurance companies why a patient has to be in the hospital. They mention in passing that this kind of business and administrative knowledge isn’t necessarily taught in med school.
As soon as Castellani and Wear detail how knowledge is necessary to be proactive, they establish that it’s not enough:
As Foucault explains, “What would be the value of the passion for knowledge if it resulted only in a certain amount of knowledgeableness?”6 Knowledgeable physicians are everywhere in the system. They demonstrate their knowledge through their ability to survive; they know enough to tend to their immediate needs but not enough to free themselves or anyone else from their current professional crisis.
All stories begin with problems. If medicine is going to find its way out of its narrative dysfunction, the new narratives that guide it will have to search for the problems at the core of current medical practice.
Physicians, if they are going to move beyond their current situation, need more than the memorization of profession, something medical educators help them do well: Physicians are not supposed to think about profession, they are only supposed to learn it. Stuck now in a crisis, they search for a solution, but only within the narrow confines of what they already know. They keep looking for the answers by reflecting on the knowledge they already have.
The Big Picture and the Way Out
We can only find new narratives by finding moral answers to new problems. Castellani and Wear emphasize that the knowledge of how healthcare works is only useful if it awakes a critical attitude. This critical attitude is based on a healthy mistrust, not of people, or necessarily of systems, but
the mistrust of knowledge as it seems. It is the mistrust of the perceptions and roles … and the mistrust of the knowledge used to run the corporate and bureaucratic health care systems in which they work.
Such mistrust, such critical awareness, the authors write,
makes up a sociological consciousness. This is a term they borrowed from the work of the sociologist Peter Berger.7 A sociological consciousness pushes past the immediate facts and applicable medical knowledge to examine a larger context of people, culture, and systems acting on one another. This is exactly the area where stories shine, and why a sociological consciousness is the way for the ethics of healthcare to find its way out of narrative dysfunction.
Unsurprisingly, the authors illustrate their point by telling a story.
A family practice residency director told us how he invited a recently sued colleague of his, who was bitter and depressed because of it, to talk with his residents about the joys of obstetrics. What the residents got instead was a lecture about the terrors of malpractice despite the fact that this colleague was not successfully sued.
“And the last bomb he drops,” the residency director said, “was ‘And don’t do obstetrics!'”
Politely waiting until his colleague’s scare tactics were over, the director spoke to him in private. “Why would you say that?” he asked. “You didn’t get sued in an obstetric case!”
“Yeah, but you know,” said the colleague.
“No, I don’t. Know what?”
“Well, you know. … You can really get sued in OB.”
“You can get sued doing anything.”
“Well, you know … but those are big suits.”
The interaction between this director, his colleague, and their residents is a good example of what happens to physicians in the absence of a sociological consciousness.
[The director’s colleague] cannot go through that again, and he does not want the residents to either, so he counsels them to stay away from obstetrics and they will be okay. The residents feel vulnerable too because they lack the tools necessary to situate the colleague’s story. No debate took place, and no facts were handed out. What they got instead was a monologue, paranoia, and the summons, “Don’t do obstetrics!”
We asked this director and several other proactive physicians how they would have handled the situation differently. All of them gave us the same basic answer. First, they would have given the residents the facts. They would have explained to them that nowadays in nonrural areas most family physicians do not do obstetrics (a growing trend since the 1980s) because of the threat of lawsuits and high malpractice insurance premiums. … They also would have explained that there are many ways to ensure against malpractice, for example, talking with patients about the potential risks involved in pregnancy and making them feel like a part of the treatment process,…establishing good connections with local and regional obstetricians and pediatricians, and learning to live with the threat of lawsuits and the realities of our litigious culture.
Second, they would have made it clear to the residents that, in the end, being afraid is not a way to live. If residents want to do obstetrics, then they should.
The director’s colleague was still in mourning. In the absence of any new narratives, the story being told was simple: “Don’t do obstetrics, you’ll get sued.” All of the physicians Castellani and Wear interviewed pushed past that to see a more complex reality of people, system, and cultures acting on one another. Yes, lawsuits are always possible. Among other ways of dealing with the issue, though, is a simple tool: communicating risks with patients and inviting them to be involved with their care. Storytelling can help immensely with this, but there’s also another layer to the story:
doing something you love [like .
caring for women and their babies] almost always outweighs the associated costs
One of the advantages of stories is that they don’t work well until the teller has found a compelling problem. This problem-finding capacity of a good storyteller is one of the reasons that narrative is an essential tool to help healthcare providers in a changing environment.
Physicians need new ways to critically and self-reflexively think about the new corporate health care systems, the authors conclude,
in which they work and find ways to integrate cost with care, ethics with economics, and professional commitment with bureaucratic expectation. The only way to move from narrative dysfunction to new ways of thinking is to tell new stories.
The article reviewed: Castellani, Brian, and Delese Wear. “Physician Views on Practicing Professionalism in the Corporate Age.” Qualitative Health Research 10, no. 4 (2000): 490–506. https://doi.org/10.1177/104973200129118598.
2 Angell, Marcia “The Doctor as Double Agent.” Kennedy Institute of Ethics Journal 3, no. 3 (September 1993): 279–86. ↑
3 Spece, Roy G., David S. Shimm, and Allen E. Buchanan. Conflicts of Interest in Clinical Practice and Research. Oxford University Press, 1996. ↑
4 Rodwin, Marc A. Medicine, Money, and Morals: Physicians’ Conflicts of Interest. Oxford University Press, 1995. ↑
5 Wear, Delese, and Brian Castellani. “Conflicting Plots and Narrative Dysfunction in Health Care.” Perspectives in Biology and Medicine 42, no. 4 (1999): 544–58. https://doi.org/10.1353/pbm.1999.0009. ↑
6 Foucault, Michel. The Use of Pleasure: Volume 2 of the History of Sexuality. New York, NY: Vintage Books, 1985. ↑
7 Berger, Peter L. Invitation to Sociology; a Humanistic Perspective. Doubleday, 1963. ↑