Medical Authority

Susan R. Johnson, M.D., M.S. Professor of Obstetrics & Gyynecology, and Epidemiology. Associate Dean for Faculty Affairs.University of Iowa;Friday August 22, 2003.

Aesculapian Authority
Here is the general question: why do patients listen to their doctors, usually believe and do what they say, and, why, despite increasing complaints about the medical care system, does the public continue to list physicians as among the most admired of professionals?
The theory of Aesculapian Authority is an attempt to answer these questions.
Aesculapius you know something about. The definition of “Authority” that applies here is “power derived from opinion, respect, or esteem; a claim to be believed or obeyed.
The theory was developed in 1957, not by a physician, but by an organizational development expert, TT Paterson. He had already developed a general theory of 5 different types of authority that support different groups such as government officials, military leaders, etc. He was then asked by a physician named Humphrey Osmond, a psychiatrist at the University of Alabama, about what was the source of authority for physicians. Paterson realized that he could not explain the authority of physicians by any one of his categories, but rather by a combination of 3 of the types: sapiential, moral, and charismatic.
Sapiential Authority
Sapiential means “having wisdom,” and so sapiential authority refers to the power physicians have as a result of what they know. This source of authority is obvious.
The scientific content of medicine is what attracted many of you to medicine in the first place.
(For me, in my 4th grade classroom was a book titled Huber the Tuber. No, this was not about potatoes, but rather, about tuberculosis. During WWII, the American Lung Association published this cartoon story about the evil TB germs called tubers (cast in the story as Nazis) and the immune system white blood cells (cast as the Allied forces) in a battle for the lung. The purpose was to educate the public about TB -- but for me, it served as my introduction to pathophysiology and the fascination of human disease.)
On Monday, you will begin the first of many years -- at least 7 -- formally learning an increasingly complex body of knowledge, and you will need to learn continuously throughout your career in order to keep your knowledge base up to date.
At my graduation from residency, our speaker, the late John Moyers, former Head of Anesthesiology said something which I think about every time I am tired, irritated, or distracted when seeing a patient: “When your patient is in trouble, what he cares about most is that you are competent.”
The ubiquitous availability of medical research and opinion on the internet has made our patients more informed, which is all to the good, but has also has led some people to say that the physician’s authority based on knowledge is eroding because medical knowledge can now be accessed by anyone.
However, every practicing physician knows that “just the facts” is not enough. It is rather the ability to integrate all these facts, and, equally as important, to understand what you do NOT know, and to be able to apply all this to the particular circumstances of the individual patient sitting in front of you.
Moral Authority
Moral authority derives from the principle that physicians are expected to act not based on their own needs, but rather on behalf of the needs and best interests of their patients. We are to act as leaders to our patients, giving guidance not just mere advice - in fact, based on our moral authority, we should act paternalistically, or parenterally if you prefer. At first, this may appear to be at odds with the modern emphasis on patient choice and autonomy, but it is not, as long as this paternalism is tempered with respect for the patient’s choices and values.
A famous illustration of the need for moral authority is the story of Franz Ingelfinger, most famous as long time editor of the NEJM, but also an international expert on cancer of the esophagus, an aggressive disease that is difficult to treat effectively. Berger, a Russian psychiatrist, describes Ingelfinger’s dilemma when he himself developed esophageal cancer: “One can hardly imagine a more informed patient than him. After surgery, ... he received from physician friends throughout the country a barrage of well-intended but totally contradictory advice. As a result he and his physician family members became increasingly confused and emotionally distraught. Until somebody wise said to him “what you need, is a doctor.”
What did that mean? That what was needed was someone who could take all the relevant medical facts, assess Dr. Ingelfinger’s individual situation, and then advise and take responsibility for that advice.
Moral authority requires that the physicians work from a place of personal integrity, not just in their work life but in their personal life as well.
Charismatic Authority
In the original meaning, charismatic authority derives from the historical confluence between medicine and religion; between physicians and priests.
That combination may at first seem irrelevant, or even inappropriate, in these modern times.
In fact, it is both relevant and appropriate.
The modern basis of Charismatic Authority has nothing to do with religion per se, but rather with the reality that life and death may be on the line at any moment, and there is no way that any physician, or even medical science, can know all that is relevant; thus, in a real sense, the sick person must relate to the physician with faith, and the belief that the physician can help. Beyond this, charismatic authority leads many patients to bring issues to their doctors from all parts of their life, not just their health -- think, for example, of how often Ann Landers recommends to readers: “talk to your doctor” about problems of all sorts.
This is an awesome responsibility -- and one that should lead the physician to feel, not arrogant, but humbled.
Every practitioner has had priest-like experiences -- it can be a bit eerie the first time it happens, when you realize that people really do see you as more than just a person providing medical care.
Here is a very small example from my own practice:
Just three weeks ago a woman, in her late 50’s and postmenopausal, came to my clinic to review her laboratory tests. We had found a small ovarian cyst several months ago, and I had ordered an ultrasound for follow up to be sure it was stable, and thus unlikely to be cancerous. The ultrasound actually showed that the cyst had gone away. When I saw her name on the schedule that day, I thought, with irritation, “Why is she coming in -- we could have done this by phone or with a letter. This is a waste of my time.” I went to the room, and quickly told her the good news that the test had been normal, and that no more tests were needed.
She did not look particularly happy with this news, and then she said, “ I need to tell you some things.” Over the next 15 minutes or so, she went on to tell me that her husband had died of cancer 5 months ago, her granddaughter was shortly thereafter diagnosed with a severe psychiatric illness, and her brother had just developed advanced, disabling chronic obstructive lung disease. She had no friends or family to talk to, and she did not feel she could still be sad. She cried. I listened. That was all she needed that day.
A characteristic you must develop to fulfill the mandate of charismatic authority is empathy - not just for the patient’s illness, but also for their whole being.

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