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February 3, 1999

Rejuvenating the Symbols of Medicine

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JAMA. 1999;281(5):479. doi:10.1001/jama.281.5.479-JMS0203-6-1

I took the greatest interest in his doctor's bag, a miniature black suitcase, fitted inside to hold his stethoscope and various glass bottles and ampules, syringes and needles, and a small metal case for instruments.—Lewis Thomas, The Youngest Science: Notes of a Medicine Watcher

We bestow symbols on the things we value. We top the spires of our churches with crosses, wear wedding rings on the left third finger, and fly our country's flag on national holidays. Symbols not only help us identify easily with the object of our attention, but also give us something concrete on which to pin our feelings. Symbols give us an ideal, a goal, a vision of ourselves.

The same is true in medicine. From the beeping ECG monitor to the once-ubiquitous black doctor's bag, television and books are full of such imagery. These symbols dramatize the respect physicians receive from our society, as well as the mystery people ascribe to the healing art.

Such symbols also celebrate the high standards that, to its practitioners, are medicine's thrilling challenge and awesome responsibility. Working in health care provides daily reminders that many physicians deserve high praise. However, there is another reason why physicians and patients alike portray doctors in a flattering light: when the oxygen mask is descending and the thiopental is flowing in, it is comforting to think that the green-gowned surgeon is more knowledgeable and more skilled hands than your average by-stander. And it helps to feel a bit that way if you are the one with knife in hand. But there is more at play here than idolizing physicians: these lofty ideals instruct us. They link us to the great tradition of physicians before us and provide a beacon to lead us through the trials of medical training and practice.

In recent decades, high social status and even higher salaries have brought doctors an enhanced public visibility that has inevitably made the disparity between our expectations and the actuality of doctors' human nature more obvious than anyone likes. Putting aside physicians' more mundane shortcomings, it is still all too easy to recall examples of some physicians' quackery, indiscretion, and greed. Clearly these few have ignored medicine's ideals altogether. Add to this mix the frighteningly rapid changes in the financing and delivery of health care, and you have all the ingredients for a large-scale backlash against physicians.

This backlash has brought with it a new set of less flattering symbols. Images of slick black BMWs and the patient's 15-minute visit with a brusque stranger have gained their place among medical icons. They reflect the unfortunate reality that high social status has brought with it ostentation and that some of us have allowed profit to interfere with caring for patients.

Despite the kernel of truth in such caricatures, dedicated and brilliant people populate our hospital halls who should not be spuriously stripped of the respect they deserve. Thus the healing profession is under siege, from within and without. We have among us doctors who care too little for their patients, and we exist in a skeptical society that is too ready to cast aspersions on an honorable profession.

So how do we reclaim the symbols of medicine, both to give our good doctors their due and as a way of showing future physicians what medicine should be? The fight must be conducted at the bedside and in the political arena.

Importantly, we should recognize that the worth of medicine lies not in its public image but in the good done for patients. Physicians heal people, and the more we become businessmen and public relations representatives, the more we compromise this vital function. Certain danger awaits once a physician enters the public relations fray. Any blatant campaign to rejuvenate the positive values of medicine could appear contrived, especially when people already worry that medicine and its practitioners have become superficial. If physicians minister attentively to their patients, as they have for millennia, then we will continue to deserve the trust of our patients. This is nothing new, just something important to remember in an age when we may be tempted by salary or misdirected ambition to abandon this time-honored practice.

Epidemiology teaches us that poverty and violence and a host of other social ills are as pathogenic as the metabolic derangements and infectious micro-organisms we treat every day. Thus, in order to provide the kind of complete medical care that will regain our patients' trust, we should wed caring bedside medicine with activism aimed at redressing such social afflictions.

Society's symbols reflect its values. By staying true to a clear vision of comprehensive patient care, doctors will ensure that their great profession remains a valued and respected part of society, one that lives up to its proud history and lofty symbols. These symbols dramatize the respect physicians receive from our society, as well as the mystery people ascribe to the healing art.

Reviews of books and other media are available on the MSJAMA Web site at http://www.ama-assn.org/msjama.