The Consequences of Medical Values

In sum, medical training teaches doctors to value emotional detachment, trust their clinical experience, adopt a mechanistic model of illness, rely on interventions, master uncertainty, and prefer working with rare or acute illnesses. Although each value serves a purpose, each also can work against the provision of high-quality health care. Emotional detachment can lead doctors to treat patients insensitively and to overlook the emotional and social sources and consequences of illness. In addition, it can cause doctors to feel disdain for patients they consider too emo- tional. How much emotion a person shows, however, and how that person does so, depends partly on his or her cultural socialization. In contemporary America, women and members of some ethnic minority groups are more likely than are men and nonminorities to display emotion openly. Consequently, these groups are more likely to bear the brunt of doctors’ disdain.

Meanwhile, the emphasis on clinical experience, although sometimes useful, can lead doctors to adopt treatments that have not been tested through controlled clinical trials and that lack scientific validity, such as treating ulcers (which are now known to be caused by bacteria) with a bland diet. In addition, the desire for clin- ical experience sometimes encourages medical students and residents to perform procedures from drawing blood to doing surgeries, even if they lack sufficient training or supervision or the procedures cause unnecessary pain. Medical stu- dents and doctors are most likely to do so if they can define a patient as “training material” rather than as an equal human being. This is most likely to happen when patients are female, minority, poor, elderly, or otherwise significantly different both from the doctors and from the patients on whom those doctors assume they will someday practice.

Mastering uncertainty is necessary if physicians are to retain enough confi- dence in their clinical decisions to survive emotionally. And presenting an image of authoritative knowledge undoubtedly increases patient confidence and stimulates a placebo effect, if nothing else. At the same time, the desire for certainty—or at least an aura of certainty—also probably contributes to authoritarian relationships with patients. This is particularly problematic when proper treatment really is un- certain. For example, doctors are particularly uncomfortable with patients whose diagnoses are unclear or whose treatment is unsuccessful. Similarly, even though for years evidence indicated that hormone replacement therapy for menopause is dangerous, many doctors—perhaps unwilling to give up their aura of certainty— continue to dismiss concerns about these practices and to recommend them to their patients.