In Clinical Practice

General medicine Social determinants of health
Volume 195 - Issue 4

Taking a stab

Author:  Ron Elisha

Med J Aust 2011; 195 (4): 177-178. || doi: 10.5694/j.1326-5377.2011.tb03273.x
Published online: 15 August 2011
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There has been much written in the medical press about general practitioners subjected to violence. Prevention of such violence has been taken on board by medical defence organisations as part of “risk management”, and this is well and good, but it implies that the violence is the problem in and of itself, rather than simply a symptom of a deeper malaise.

So, while it may well be in our best interests to place our chairs near an exit, train our staff to defuse tense situations and have our panic buttons at the ready, these all represent symptomatic approaches to the problem, and should not distract us from its root cause.

Thirty-five years ago, when I began my medical career, physicians were considered god-like — lofty, infallible, unassailable. The patrician doctor (usually male) would stop at the foot of the bed (with underlings in tow), utter a diagnosis, pronounce sentence (otherwise known as treatment) and move on. Questions were not encouraged.

Patients remained largely ignorant of the nature of their condition, the whys and wherefores of treatment and the risks involved. Few railed against this state of affairs, which reflected their expectations, based on the assumption that the doctor would invariably act in their best interests.

Cruikshank’s “British beehive” (http://collections.vam.ac.uk/item/O155895/print-the-british-bee-hive/) prevailed — everything was in its place, and all was right with the world. No doctors were stabbed.

There is something to be said for “benevolent despotism”, which mostly operates far more decisively and efficiently than its Westminster counterpart, a system that remains slow, cumbersome and hamstrung by competing interests. The assumption is that doctors are benevolent in their despotism, an assumption which generally holds as true today as it did then, despite the fact that honorary medical officers have given way to consultants.

But slaves have been freed, the South has been desegregated, Indigenous populations have been enfranchised and the tyranny of paternalism has been replaced with the tyranny of information, a far more prickly and elusive master who, though ruling through fear, cannot be unseated through insurrection.

The role of death as society’s greatest leveller has been largely usurped by the internet, and perhaps it is no coincidence that the rise in violence against medical practitioners has been most evident in the past decade, since its inception.1

For two generations now, society has been bombarded with a tsunami of media-generated headlines, slogans, myths, misinformation, disinformation, political correctitude and dumbed-down, vastly oversimplified, reader-digestible distillations of what passes for knowledge. This has resulted in a populace as pitifully under-equipped for medical decision making as it is convinced of its credentials to engage in it.

Dumping the internet into the midst of this social foment is tantamount to placing a weapon in the hands of a murderer. And this is precisely what has happened.

The mirage of patient empowerment — based though it is, on the illusion of knowledge — has, by extension, resulted in doctor disempowerment. We are now the natural victims.

Were our patients happy with their new-age lot in life, all of this would probably come to nought. But the handmaiden of information is choice, whose tyranny is as vicious and unremitting as it is subtle.

Paucity of choice meant that the patient of bygone days harboured few expectations. Hence, they were rarely disappointed. If a person had a job at 20, it was more than likely that they would still have one at 50, even if it was the same job. And it was equally likely that they would still have the knowledge and expertise to do that job, even with little ongoing training. Things didn’t change much. Life was predictable.

But we now live in an age of rapid, accelerated change —something inherently anathema to human biology. Jet-lag has broadened to “life-lag”. When we arrive at work in the morning, we are never quite sure that we will still have a job that evening. And even if we do, we remain uncertain that we can cope with the ceaseless bar-raising that has become the lot of the accreditee.

Along with the technology that has “freed” us has come a plague of choice — complex, often purposeless technical choice that we, as the butt of the IT joke, are not qualified to make. So we put our trust in the “experts”, whose interests remain more vested than altruistic. Choice, it seems, comes with a price tag redolent of coercion. And once you’re on the merry-go-round, there’s no getting off.

Mobile phone contracts rival the theory of general relativity in their complexity. Computers consistently malfunction, requiring the intervention of a generation of pimply, postpubertal postliterate empiricists, and invariably demand frequent and overpriced upgrading. This is capitalism at its most razor-sharp, mercilessly herding the helpless consumer before the cow-catcher of its rapacity. The consumer is now the consumed; capitalism is perfected.

And so society is now peopled with waves of anxious, uncertain, harried folk, constantly feeling put-upon and ripped off, operating on a hair-trigger fuse that only requires the slightest irritation (“I’m sorry, but there are no appointments available till this afternoon”) to throw the switch.

Even the role of psychosis in several of the more notable violent incidents can be sheeted home, at least partly, to the wholesale levelling of society’s playing field. For, as an ill conceived token gesture in the direction of patient empowerment, many socially ill equipped, mentally ill patients who should still be in lock-up care have been released into the community. The world, it seems, is drunk with empowerment.

Suckled on the teat of so-called “reality TV” (as if there could be anything further removed from reality than the highly fabricated environments of this pernicious medium), the present generation has been led to believe that Rome can be built in the time it takes to fry an egg. Ordinary citizens, devoid of training, can become opera stars overnight. Or master chefs. Or television show hosts. Or simply celebrities, famous for nothing more than being famous. All of this supports the perennial Hollywood myth that anyone can be or do anything their shiftless heart desires, regardless of intelligence, talent or the capacity for work.

But there is a time when even the drunkard must sober up; when the illusion of empowerment, based as it is on a drive for the elimination of perceived elitism, is seen in the clear light of day for what it really is: the loss of respect for knowledge. Not cereal-box-coupon sloganry, nor shotgun-style prescribing information overload, nor Wikipediatric lowest common denominatricks, but good, old-fashioned, hard-won, rote-learned, experience-based, rigorously tested knowledge. What the political correctionists among us call elitism, I refer to as expertise. Expertise based on knowledge.

The patient–doctor relationship does not represent a team, it represents an unequal pairing in which the doctor has the knowledge and the power and the patient does not.

At the time I entered medicine, it was seen by most of my peers as more a calling than a service, a perspective shared by many of our patients. That is no longer the case.

Until society relearns the centrality of these values, doctors will continue to be stabbed. But this is just the opinion of a mere medico.

Provenance: Commissioned; externally peer reviewed.

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