“Knights are motivated by virtue. They want to make the world a better place. Knaves are selfish. They desire to extract as much as possible for themselves. Pawns are passive. They follow external rules and regulations…”-Sandeep Jauhar (in his book Doctored) reviewing a concept put forth by Julian Le Grand.
He also reviews a 2010 essay from JAMA by Drs. Jain and Cassel in which these concepts were applied to medicine: “In the halcyon days of the mid 20th century, physicians were viewed as knights. After Medicare was created…doctors’ salaries actually increased…But as doctors profited, they were no longer seen as knights. They were increasingly perceived as knaves bilking the system…”
“A congressional investigation found that in 1974, surgeons performed 2.4 million unnecessary operations costing nearly $4 billion…”
“If doctors were mismanaging their patients’ care, someone else would have to manage that care for them. Beginning in 1970, health maintenance organizations were championed to promote a new kind of health care delivery built around price controls and fixed payments.”
Price controls and fixed payments meant external rules and regulations.
I finished medical school until 1985.
Most patients I cared for were members of a healthcare organization with rules and regulations, formularies, the need for pre-approvals, case managers, etc..
I was a pawn?
Unfortunately, surveys conclude that the knighthood to knavery to pawn transition adversely affected physicians satisfaction with their career choice.
Recent surveys also report that 60-70% of physicians would not recommend a medical profession to their children or family members.
This is unfortunate.
Despite the challenges, just always do your best to advocate for and help your patients navigate through our complex, expensive, and often frustrating, healthcare system and do whatever necessary to cognitively reframe at the end of a chaotic day.
I frequently re-read quotes from a 1996 article by George S. Poehlman MD during my career:
“Medicine allows us to participate in the lives of others and it’s a privilege granted to few…remain humbled by this honor.”
“You will become an amateur anthropologist on whom people’s stories are bestowed-those of the privileged and poor, the old, wise and weak, the young, irreverent, and the strong. This is what makes men and women of medicine wise.”
Hopefully, physicians will stop discouraging younger generations from choosing a medical career!
We will all need caring, competent pawns down the road.
