The problems faced by physicians who wish to contribute to the public good are similar to those of other professionals. We live in an era in which groups, including both professional and government organizations, seek and maintain power through the complex use of language and control of information. This tends to create a power imbalance that erodes the legitimacy of individuals; they are rendered passive victims of ideology constructed to produce solutions that are not necessarily in the best interests of society as a whole.
Rose identifies one particularly problematic ideological axiom: the view that the well-being of an individual patient should always supersede the welfare of others. On the surface, the logic of this approach seems laudable. However, zealous attention to the needs of individual patients, carried to an extreme, creates a climate of self-interest, with physicians competing for resources deemed necessary to provide piecemeal solutions. Because the disinterest required to meet the health care needs of society in general is absent, the health care system flounders and scrambles to meet the needs of special rather than common interests.
Patients have a responsibility to become more knowledgeable about the health care system. As physicians, we can assist by providing information that is free of dialect, rhetoric and propaganda. Furthermore, we must respect our patients' ability to evaluate this information. Finally, we should trust our patients to make informed decisions concerning their health care. In short, we all must become more democratic. The alternative is to be contemptuous and assume that our patients are ignorant, an attitude that only undermines their attempts to reject passivity and to become actively involved in health care.
John F. Anderson, MD
Provincial medical advisor
British Columbia Ministry of Health
Victoria, BC
If the editors of CMAJ were trying to provoke controversy, they could not have done better than publish this article.
When I saw the title I suspected that I was in for yet another diatribe against our profession. Little did I suspect, however, that I would be served such a feast of à la carte misinformation and non sequiturs, and from one of our own!
The first thing that caught my eye was the title, which the author no doubt picked up from one of the plethora of management treatises published over the past few years. If Rose wished to entitle his article more accurately, he might have chosen "How doctors wield power over their helpless patients" or "Physicians no longer accountable." It is indeed disturbing that a medical student in his final year has acquired such a distorted and cynical image of his profession.
I was particularly disturbed at his liberty with the facts. His
statement that "physicians . . . are not directly accountable
to the public" rankles. We are accountable not only to the
public but also to our hospital authorities, regulatory and licensing
bodies, governments and the law. Physicians today, as Rose may
soon discover, are more accountable than any other profession
or group in
society, to a degree that no other group would tolerate.
Rose also has a lot to learn about patients' attitudes toward health care. Most patients want only one thing: state-of-the-art health care that is available to everyone, all the time, free. When they are told the realities of cost-effectiveness, they get a glazed look in their eyes. They simply do not give a damn, and they never will until measures are taken to make them aware of the costs involved. The responsibility to raise awareness should lie with government, not with individual practising physicians, who are already running faster and faster just to stay in the same place.
Rose's assertions about the "power" and "ascendant position" that physicians enjoy would be humorous if they were not so absurd. Never have physicians been subjected to such intense questioning of their authority and competence. Never have patients been so arrogantly uncooperative and noncompliant. Never have physicians been so widely and unfairly challenged before the law for their actions and standards of practice. And never, in recent history, have we been so poorly rewarded for our efforts.
G. Allan Taylor, MD, FRCSC
Assistant professor of surgery
University of Ottawa
Ottawa, Ont.
Rose advocates that primum non nocere be replaced with primum homo sanus in patria sana. This is a very parochial standpoint. We are all citizens of the world, and, consequently, physicians' first responsibility is to the health of humanity as a whole. This should be the context in which physicians treat their patients, according to Rose's logic. I hope that my physician is an old reactionary and will consider my interests first when giving me important advice.
Andrija D. Duic, MD, FRCPC
Toronto, Ont.