Strangers at the Bedside?
The concept of having “strangers at the bedside” encapsulates the recent evolutions regarding medical practitioner identity and responsibility. Two factors – the availability of a larger number of university-trained physicians, as well as the apportioning of medical services into specialties and subspecialties – have transformed the persona of a practitioner from what was normally a neighbor that had knowledge of medical generalities to what is now a physician that contacts patients with regards to very specific complaints. This means that most physicians are not directly involved in the day-to-day lives of the patients, and is one of the main reasons why the relationship between doctor and patient is not as intimate as it once was.
Events in history when medical practitioners have taken advantage of patients and society have also created a schism between the two groups. Such events include Nazi human experimentation on prisoners (including children) in the early 1940s, the Tuskegee syphilis experiment that spanned the decades between 1932 and 1972, and most recently, the hepatitis studies carried out on disabled children at Willowbrook State School. Society has reacted to events like these by publicly shaming medical practitioners or denouncing the credibility of clinical medicine.
As historian David Rothman has stated, all these factors led to an “erosion of trust” between doctor and patient. Society today does not feel like doctors can be trusted with making key decisions about patient welfare. Nor is it expected that they should have to. In today’s medical climate, the patient is empowered. Patient autonomy overrides doctor guidance, except in very specific circumstances. The pure jurisdiction of the physician is diminished, and this is reflected in laws that can dictate the actions of medical practitioners. One of the first times this was witnessed was in 1976, when the New Jersey Supreme Court ordered doctors to remove Karen Ann Quinlan from a respirator, despite the fact that the physicians refused this request when the parents first made it. This case served as precedent for many others.
These developments yield several advantages – to multiple stakeholders. First and foremost, I believe that this ultimately reduces much of the emotional strain on physicians themselves; especially those that regularly encounter moral dilemmas or dubious cases. Today, physicians can consult a number of unions, review boards or other governing bodies about their decisions. It is these outside groups that define the moral codes physicians must work by. In a way, I believe it is less taxing to “follow the rules” versus “making them up”. At the very least, a physician can trust that by following the guidelines he or she is provided with, there is no extra burden or accountability for failures that might ensue. Theoretically, this provides a form of protection to the physician. However, as I have witnessed with my experiences in Lebanon, a doctor cannot always rest assured that there will be no prosecution if he or she follows the rules, for outside influences – such as the media, social movements or even political parties/figures – sometimes have undeniable sway.
While the physicians we see might be “strangers”, another obvious strength is that they are specialized in what they do. This incontrovertibly leads to a higher level of understanding regarding the basic and applied science of a doctor’s specialty or subspecialty. Surely, this would lead to better outcomes for patients as well as more directed and productive research.
However, this system also complicates medicine. It leads to an environment where interactions between doctor and patient are minimal and impersonal. Many experts would argue that not only can this impact patient satisfaction, but that physician decisions regarding the wellbeing of patients cannot be thorough unless there is a foundation in the relationship between doctor and patient. There is the danger of the quality of healthcare breaking down in this case, however, there are specific things that can be done to prevent this happening. I think the linchpin compromise is communication between all the different practitioners that a patient visits, and this is facilitated in specific situations where hospitals or medical centers share databases of patient information. This would provide the collective team of experts the opportunity to piece together a broader picture of the patient and give any treatments a clear direction and purpose. This doesn’t only help the patient, but it also would mean that physicians are less likely to make mistakes. Their interests are protected too. And finally, if this can be accomplished effectively, physicians can consolidate society’s faith in a safe and self-regulating medical service.