|LEADERSHIP IN ACADEMIC MEDICINE
|Year : 2016 | Volume
| Issue : 1 | Page : 89-94
The bent twig of humanity and the physician as a serious man: How the thoughts of Isaiah Berlin and Simone de Beauvoir may explain the fracture of medical independence and practice in America
Thomas John Papadimos
Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA
|Date of Submission||22-Dec-2015|
|Date of Acceptance||13-Mar-2016|
|Date of Web Publication||2-Jun-2016|
Thomas John Papadimos
410 West 10th Avenue, Columbus, OH 43210
Source of Support: None, Conflict of Interest: None
Physicians face many significant challenges in these times of new laws and regulations, new institutional alignments and consolidations, government oversight, and scarce resources (especially in regard to reimbursement and research). In the face of these challenges, the independence and autonomy of the medical community are threatened, especially that of Academic Health Centers. This situation is further exacerbated by the flight of physicians, in order to protect their livelihood, to large umbrella organizations (including universities) to which they now must provide or express some allegiance and conformity. The writings and thoughts of Isaiah Berlin and Simone de Beauvoir, noted 20th century philosophers, will be used to explain the evolution of society (using Berlin's view of nationalism) and of people (de Beauvoir's view of the serious man) in order to help interpret the 21st century fracture of medical independence and autonomy in America.
The following core competencies are addressed in this article: Practice Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-based Practice.
Keywords: Academic medical centers, management, medical economics, medical philosophy, medical practice
|How to cite this article:|
Papadimos TJ. The bent twig of humanity and the physician as a serious man: How the thoughts of Isaiah Berlin and Simone de Beauvoir may explain the fracture of medical independence and practice in America. Int J Acad Med 2016;2:89-94
|How to cite this URL:|
Papadimos TJ. The bent twig of humanity and the physician as a serious man: How the thoughts of Isaiah Berlin and Simone de Beauvoir may explain the fracture of medical independence and practice in America. Int J Acad Med [serial online] 2016 [cited 2020 Jul 10];2:89-94. Available from: http://www.ijam-web.org/text.asp?2016/2/1/89/183331
| Introduction|| |
The challenges facing physicians are substantial, and include International Classification of Diseases-10 implementation, the Health Insurance Portability and Accountability Act (violations thereof), meaningful use two, maintenance of certification, getting paid, collecting copays and deductibles, administrative burdens, rising operational costs, pay for performance, payers dictating health care, patients dictating health care, keeping pace with technology, staff retention and avoiding liability, and independence versus employment. Survival as an independent practitioner may entail diversifying a medical practice or joining an independent physician association., While American physicians have traditionally enjoyed an independence of practice, consolidation of independent practices into larger groups or organizations, may provide a higher quality of care for patients. In line with this view is the recent evidence demonstrating that private independent/solo practicing physicians, or small group practices, may have low rates of preventable hospital admissions. Nonetheless, whether in a large group or a very small group, physicians want the best for their patients, but physicians would also like preservation of their independence and autonomy in decision-making. While engaging in the provision of health care, physicians of the 21st century will also have the additional obligation of making the world a better place through improved quality of care, a reduction of health care disparities among different populations, and improving patient safety.
Amidst all of these challenges many physicians have chosen to take refuge in large organizations for economic security and to avoid “burnout.”, However, as their sought-after refuge in these organizations progresses, physicians do limit their autonomy and independence through their confederation with large medical conglomerates, insurers, and over-arching government domination. How has this occurred? It is most likely a product of the historical evolution of society that affected the economic, political, and social development of an environment in which a physician matures. In this commentary, the thoughts of Isaiah Berlin and Simone de Beauvoir will be applied to the philosophical dialectic as to what historical forces have influenced or caused physicians to take refuge in monolithic bodies/organizations in ever increasing numbers (in order to preserve their income and time, and thus, their place in society) with a self-inflicted consequence of a loss of independence. Moreover, in so doing, do they become the serious men of whom de Beauvoir warns? Herein women and men are referred to as “he” or “him” or “man” because of the context and fashion in which Berlin and de Beauvoir expressed their ideas.
| Discussion|| |
Isaiah Berlin was an important 20th century philosopher. He was an unapologetic defender of individual liberty and moral and political plurality. In 1946, Isaiah Berlin wrote his classic book, “the crooked timber of humanity” where he addressed nationalism in a chapter entitled, “The Bent Twig: On the rise of nationalism.” He assessed the impact of new technology, growth of industry, the rise of countries, the progress of science, the disintegration of Christendom, social classes and political alliances, and “the search for origins, pedigrees, connections with, or return to, a real or imaginary past.” His thoughts on nationalism resonate in regard to the historical context of the development of today's physicians and their medical practice. How do his thoughts apply to their practice of medicine?
According to Berlin, the new scientific methods of the 18th century had convinced philosophers Turg and Condorcet that these new methods of inquiry would empower “those who knew how to organize and rationalize the new society,” and that a time of “truth, happiness and virtue” would become sustainable. Berlin went on to explain that early 20th century philosophical thought informed us that applied science, well-organized banking and industrial entities, along with the “replacement of religions by secular propaganda into the service of which artists and poets would be drafted as they had once worked for the glory of the church” would prevail. Man would gain power over nature, and that this secular movement would produce results for the good of the public through rational, not democratic precepts. In other words, the Christian Church which had oversight of much of peoples' lives through the 19th century would be swept aside in the new century (the 20th century) wherein there would be a transformation of “political and social movements into monolithic bodies, imposing a total discipline upon their followers, exercised by a secular priesthood claiming absolute authority, both spiritual and lay, in the name of unique scientific knowledge of the nature of men and things.”
Berlin further reminds us that even popular and influential science fiction writers such as Jules Verne and H.G. Wells were convinced by this philosophical perspective and professed agreement through their writings that “the new elite scientific planners” would destroy ignorance, prejudice, and all that was absurd for the establishment of a successful society. However, it was acknowledged by much of the philosophical establishment that such scientific planning could lead to pressure on individual freedoms and democratic ideals, and that “the government of persons will be replaced by the administration of things.” These conditions created a concentration and consolidation of capital, a growth of big business, the establishment of a military-industrial complex and “the sharpening of social and political conflicts and the construction of one single, technocratically organized managerial world.” In this context, the managerial world would play and prey on the basic needs of man, which now and over the previous thousand years, have included sustenance, sex, and conversation, but most of all, man needs to be part of a group.
So the administrators of “things,” instead of the government of persons, lead by a technocratically organized managerial class, resulted in the societal condition of universalism, a “leveler” of societies and men. In other words, universalism “reduces everything to the lowest common denominator which applies to all men at all times, draining both lives and ideals of that specific content which alone gave them a point.” Historically, who were the great arbiters of universalism, or levelers of society? Berlin instructs us that Caesar, Charlemagne, the Romans, the British Empire, the Crusaders, and missionaries were the great levelers and instigators of universalism. Universalism, or the great “leveler” of physician independence or autonomy, requires paternalism to succeed.,, This paternalism is provided by large enterprises, i.e., monolithic bodies. Today the US Government and Insurance Companies, and even Academic Health Centers (AHCs) can be added to the list of monolithic bodies; all of which need an unflagging income stream. In the case of AHCs, their income stream is secured through reliable providers of health care, who can provide them with patients/clients. There is little doubt that these large enterprises seek conformity and need physicians to work in concert for organizational success in order to increase their profits; and in effect, redistribute physician wealth, directly or indirectly, through practitioner loss of remuneration or an increase in practice expenses. Hence, while Isaiah Berlin elaborated on the above points in regard to the rising nationalism of the nation state in the 20th century, cannot the same line of reasoning be applied to the rising phenomenon of corporate capitalism? Are these conditions not applicable to what has happened to the practicing physician: A forced secular universalism by industry, insurers, and government technocrats? Are not all the modern day AHCs, insurers, and governments monolithic bodies that impose discipline in return for sustenance, i.e., scientific planners who tend to the administration of things?
This historical socio-politico-economic development has caused some physicians to retire; others to temper their clinical practice with other means of remuneration, and others to just suffer on. What of those newly minted physicians; those young ones now coming into the ranks of medical practice? Do they not want their independence and income preserved? In order to do so, to what monolithic bodies, or objects, do they owe their allegiance? Has the phenomenon of corporate nationalism become the universal leveler of medical practice? If so, then physicians have become a form of the corporate proletariat. Physicians are the assemblers of relative value units (RVUs) and weighted RVUs; assembly line legions loyal, if not loyal, then subservient to middle management technocrats who provide for them. Have physicians lost themselves in the insurer, in the health system, in the university, in the community medical center, in the federal government, etc.? I have used the word “in” instead of the word “to” because physicians are no longer beholden “to” something (such as an ideal), but have become lost “in” something. That “in” is the object, to which they sublimate their “self” in order to “be” in receipt of something they believe to be more important than their independence. The object provides more security through less risk and less independence. However, to become part of this object, one has to be or become a serious man. What is meant by a “serious man”? Is this seriousness a desirable condition?
Simone de Beauvoir wrote “The Ethics of Ambiguity” in 1948. At the end of World War II, she was the most distinguished female writer in modern France. She was a dramatist, philosopher, novelist, and a leading existentialist. In this eloquent treatise, she explains who becomes serious and how this occurs. In this work, she launches into “the central ethical problem of modern man: What shall he do, how shall he go about making values, in the face of his awareness of the absurdity of his existence.” Her thoughts and reasoning about the serious man resonate in today's healthcare environment (even though in 1948, this reasoning was applied to how serious men facilitated totalitarianism - see below). The serious man is someone to watch out for, or in the context of this commentary, someone to avoid becoming.
In view of what physicians have experienced over the past decade in regard to medical economics, it can be argued that a physician may feel the need become a serious man (in order to preserve his position in society) thereby causing himself, “to submerge his freedom in the content which the latter accepts from society. He loses himself in the object to annihilate his subjectivity.” Furthermore, “the serious man gets rid of his freedom by claiming to subordinate it to values which would be unconditioned. He imagines that the accession to these values likewise permanently confers value upon himself. Shielded with these “rights,” he fulfills himself as a being who is escaping from the stress of existence.”
Here, the reader can imagine the possible inclination of physicians to seek solace and safety under a broad corporate umbrella in order to maintain a value, possibly monetary or one of prestige, so as to preserve their position in society even though a measure of freedom/autonomy is lost. It is of concern that, “the thing that matters to the serious man is not so much the nature of the object which he prefers to himself, but rather the fact of being able to lose himself in it.”
Physicians of today may believe that they are boxed into a corner economically and politically, and that there is no “out” for them. It truly gives them a slave-like attitude in that “the less economic and social circumstances allow an individual to act upon the world, the more this world appears to him as a given.” This is exactly the attitude of slaves and indentured servants. The health care world of today may seem to be an intolerable “given” to many physicians.
Let it be perfectly clear, physicians do have the necessary social, technological, and economic instruments to escape this situation (although they may have less income as a result of an action that gives them more freedom), and whichever physician does not want to use these instruments to escape the circumstances thrust upon him “consumes his freedom in denying them.” When a physician decides not to escape this circumstance he makes himself into a serious man, according to de Beauvoir, “he dissimulates his subjectivity under the shield of rights which emanate from the ethical universe recognized by him; he is no longer a man, but a father, a boss, a member of the Christian Church or the Communist Party.” More specifically, de Beauvoir directly speaks to the topic of the great doctor or great professor as a serious man.
“Proust observed with astonishment that a great doctor or a great professor often shows himself outside of the specialty, to be lacking in sensitivity, intelligence, and humanity. The reason for this is that having abdicated his freedom, he has nothing left but his techniques.”
The serious man evolves into someone who does his job for his organization because, “he needs fortune, leisure, and enjoyment…Thus confusing a quite external availability with real freedom, he falls, with a pretext of independence, into the servitude of the object. He will range himself on the side of the regimes which guarantee him his privileges.”
According to de Beauvoir, it is serious men who allow the conversion of a democratic society to one of totalitarianism. While this may seem to be an extreme use of de Beauvoir's thought when applied physicians, it does lead to an important allegation: Have not 21st century physicians fallen into league with monolithic corporate medical structures for security? In doing so, physicians have gained “things,” but lost substance, and some measure of public's trust.,
This amalgamation of the thoughts of Berlin and de Beauvoir can further be translated into the field of medical research. How so? physicians have abdicated their roles as leaders in research trials of drugs that are of use to the public's health  because research funding from the National Institutes of Health has substantially decreased. This has caused US physician scientists, specifically academic physicians, to turn their attention towards industry money.,, Industry has pursued “blockbuster drugs” that have very large earning potentials while orphan drugs of value to the general public's health have been ignored. Academic physicians have allowed these trials to be designed “by industry scientists in concert with regulators, often with little or no independent academic input.” In regard to clinical trials, which have become “big business,” their “rapid expansion, coupled with egregious instances of fraud or lapses in quality, has resulted in the implementation of auditable data systems.” This has resulted in substantial increases in the cost of performing clinical studies. Here, again, physicians have sublimated themselves to the object (pharmaceutical and device industries) in order for gain (income, prestige, job security, etc.). It is not that physicians should not take or use such monies to do the public good/research; if they need such funding, they should accept it. However, researchers must absolutely be engaged in the design, data collection, evaluation, and publishing processes. Academicians must find a way to have a voice in these efforts. They must invest their time and leadership in their research enterprises in order not to become serious men who allow their “self” to be marginalized, and as a result, not protect their patients or their research process to the best of their abilities. Physicians must reassert an independence of thought to all processes with which they are involved.
Hence, where does all this change leave the relationship between physicians and patients? The evolution of society in relation to medical practice seems to have led to the devolving of the doctor-patient relationship. New health care laws and regulations have driven doctors away from small practices, toward hospital employment. In a matter of 12 years, the number of physicians owning their own practices has dropped from 57% to <33% (in 1983 it was 75%). Physicians now have to see more patients per day and consequently, spend less time with them so as to make their quotas in order to preserve their salary that is now provided by the organization to which they belong. In the ever-enlarging group practices, patients have a smaller chance of seeing the physician of their choice when making a visit for an illness. In addition, new electronic health records while making some parts of medical practice easier, such as billing, will limit prescriptive and consultative authority for physicians in large organizations. Furthermore, clinical decision support systems are now being created and introduced to “help” physicians make clinical choices, such as in diabetes., However, these systems may move from being a “best suggestion” to quite possibly becoming treatment requirements. The most far-reaching change may be International Business Machine's Watson Health, an evolving artificial intelligence that is touted to have the entire history and literature of medicine within it, thereby potentially becoming the ultimate diagnostic/prescriptive authority.
Furthermore, do large organizations make physicians, or influence physicians, to do what they normally would not? It is a relevant question. In the end, with today's evolutionary changes in the practice of medicine, the patient must ask, for whom does my doctor work? Hospitals can offer more money and guaranteed multi-year contracts. Hospital systems, as they acquire greater portions of the healthcare marketplace, have the ability to increase costs and thus profits, while at the same time curtailing competition. While physicians should always do what is best for their patients, the question arises as to whether they will actually do so. Moreover, finally, in regard to research, according to the Organization for Economic Cooperation and Development, approximately two-thirds of research endeavors in scientific and technical fields are carried out by industries, and only 20% and 10%, respectively, by universities and governments., Here, a subsequent question arises as to who will make the research choices of the future and for what reasons? Maybe such evolutionary changes are a leap forward for patient care, and open potentially new options for patients, and then again, maybe not. Only time will tell. It is the academic community that must sit on the ramparts and keep watch.
| Conclusion|| |
The two works referred to in this commentary were written nearly seven decades ago. The principles highlighted by these author-philosophers seem to be applicable to the medical establishment of today. The public's perception of physicians as educated and “special” still persists, but does this perception really hold true? Have physicians been molded by the historical, political, economic, and social forces described by Isaiah Berlin only to become the serious men disparaged by Simone de Beauvoir?
Even though physicians may not be able to immediately change the political and economic landscape that affects the practice of medicine, an assertion of independence and leadership at all levels of practice, research, education, and management is mandatory, especially in AHCs. A professional insistence on such involvement will help patients, medical practices, and enhance the reputation of the profession. The 21st century fracture of medical independence and practice, including research practice, must be addressed. It can only be successfully addressed by those who practice the art of healing through a concerted effort of leadership on all political, social, and economic fronts. Physicians must remain active, concerned, engaged, and vigilant in regard to all aspects of their environment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pofeldt E. Diversifying your practice. Med Econ 2015;92:41-2, 44.
Woodcock E. IPAs: Joining forces to retain independence. Independent physician associations can help doctors meet the business challenges of independent practice, but do your homework before joining. Med Econ 2015;92:47-50.
Baker LC, Bundorf MK, Royalty AB, Levin Z. Physician practice competition and prices paid by private insurers for office visits. JAMA 2014;312:1653-62.
Casalino LP, Pesko MF, Ryan AM, Mendelsohn JL, Copeland KR, Ramsay PP, et al.
Small primary care physician practices have low rates of preventable hospital admissions. Health Aff (Millwood) 2014;33:1680-8.
Holmboe E, Bernabeo E. The 'special obligations' of the modern Hippocratic Oath for 21st
century medicine. Med Educ 2014;48:87-94.
Drummond D. Physician burnout: Its origin, symptoms, and five main causes. Fam Pract Manag 2015;22:42-7.
Shanafelt TD, Gorringe G, Menaker R, Storz KA, Reeves D, Buskirk SJ, et al.
Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc 2015;90:432-40.
Fuchs VR, Cullen MR. The transformation of US physicians. JAMA 2015;313:1821-2.
Esmaeilzadeh P, Sambasivan M, Kumar N, Nezakati H. Adoption of clinical decision support systems in a developing country: Antecedents and outcomes of physician's threat to perceived professional autonomy. Int J Med Inform 2015;84:548-60.
Berlin I. The Crooked Timber of Humanity. Princeton, New Jersey: Princeton University Press; 1946.
Berlin I, editor. The bent twig: On the rise of nationalism. In: The Crooked Timber of Humanity. Princeton, New Jersey: Princeton University Press; 1946. p. 253-78.
Davidov G. Setting labour law's converge: Between universalism and selectivity. Oxf J Leg Stud 2014;35:543-66.
Barnett M. Accountability and global governance: The view from paternalism. Gov and Regul 2015. doi 10.1111/rego/12082.
Kabeer N. The politics and practicalities of universalism: Toward a citizen-centered perspective on social protection. Eur J Dev Res 2014;26:338-54.
McKinlay JB, Arches J. Towards the proletarianization of physicians. Int J Health Serv 1985;15:161-95.
de Beauvoir S. The Ethics of Ambiguity. New York: Kensington Publishing Corporation, New York; 1948.
de Beauvoir S. Personal Freedom and Others. In: The Ethics of Ambiguity. New York: Kensington Publishing Corporation, New York; 1948. p. 35-73.
Mechanic D, Schlesinger M. The impact of managed care on patients' trust in medical care and their physicians. JAMA 1996;275:1693-7.
Blendon RJ, Benson JM, Hero JO. Public trust in physicians – U.S. medicine in international perspective. N
Engl J Med 2014;371:1570-2.
Selker HP, Califf RM. The need for academic leadership in full-spectrum translational research. Clin Transl Sci 2011;4:78-9.
DeMets DL, Califf RM. A historical perspective on clinical trials innovation and leadership: Where have the academics gone? JAMA 2011;305:713-4.
Childers MK. Increasing need for academic leadership in clinical trials. PM R 2012;4:391-3.
Eisenstein EL, Collins R, Cracknell BS, Podesta O, Reid ED, Sandercock P, et al.
Sensible approaches for reducing clinical trial costs. Clin Trials 2008;5:75-84.
Harrison JD. Health Care Law Driving Doctors Away from Small Practices, Toward Hospital Employment. Available from: https://www.washingtonpost.com/business/on-small-business/health-care-law-driving-doctors-away-from-small-practices-toward-hospital-employment/2012/07/19/gJQALB9bwW_story.html. [Last accessed on 2016 Jan 09].
Forrest GN, Van Schooneveld TC, Kullar R, Schulz LT, Duong P, Postelnick M. Use of electronic health records and clinical decision support systems for antimicrobial stewardship. Clin Infect Dis 2014;59 Suppl 3:S122-33.
Pappada SM, Cameron BD, Rosman PM, Bourey RE, Papadimos TJ, Olorunto W, et al.
Neural network-based real-time prediction of glucose in patients with insulin-dependent diabetes. Diabetes Technol Ther 2011;13:135-41.
Pappada SM, Cameron BD, Tulman DB, Bourey RE, Borst MJ, Olorunto W, et al.
Evaluation of a model for glycemic prediction in critically ill surgical patients. PLoS One 2013;8:e69475.