Doctors must understand new realities

(February 18, 1999, Gazette)

By Sharon Gray

A provocative talk on communication by Canada's former minister of health and welfare challenged medical students to open their eyes to the way society is changing.

The Hon. Monique Bégin, didn't hold back any punches as she urged young doctors to broaden their perspective. The title - Working and Speaking with Others: Are Doctors Aliens? - was lighthearted, but the message was serious.

Medicine and hospitals are "rigid, sexist, hierarchical, authoritarian and almost disconnected," said Dr. Bégin in her talk at the medical school Feb. 5. "But to be a good doctor includes a sensitivity to the society around and the way it is evolving."

As a sociologist, Dr. Bégin (who is professor emerita at the University of Ottawa) advised physicians and medical students to learn about a series of new realities that have marked society in recent decades: the consumer culture, feminism, and issues of power and equality.

Consumerism has only just started to have an impact on medicine.

"What patients want in terms of involvement in medical decision-making remains to be mapped out," said Dr. Bégin.

Some systematic work has started on the question; she quoted one study done with women who have breast cancer that showed 22 per cent wanted to select their own treatment, 44 per cent wanted to do it in collaboration with their physicians, and 34 per cent wanted to delegate this responsibility to their physicians. But only 42 per cent achieved their preferred level of control.

The impact of feminism is to question, and often resist, medicalizing women's health. There have been some changes - the issues of violence and abuse are now being studied by family medicine students - but Dr. Bégin said generally only a small number of faculty promote an understanding of gender in their teaching.

When it comes to issues of power and equality, Dr. Bégin said there is a major imbalance in the health care system's power structure.

"It is a very hierarchical pyramid, a vertical organization ... comprised of layers of distinct and closed disciplines. The discipline at the top of the pyramid, medicine, is rather male - all the other disciplines or occupations under it are more than 90 per cent female."

Nurses and allied health professionals are "powerless players" in the health care field and do not participate in the decision-making process which constantly shapes and reshapes our health care system.

"On the other hand, physicians enjoy enormous, almost abusive power in the health care system. For all sorts of reasons, physicians, taken collectively, misuse it most of the time."

Despite the increasing numbers of women entering medicine, women still represent little more than 25 per cent of the profession and most are still junior in their practice.

"Medical women often denounce the misogyny and the limitations of the medical education system, a system perpetuated by a professional power structure in which men continue to occupy the overwhelming majority of leadership positions."

On the positive side, Dr. Bégin was delighted to note that Dalhousie University's new dean of medicine, Dr. Noni MacDonald, is Canada's first female dean of medicine.

The way doctors learn to relate to the rest of the world is a product of their training. Dr. Bégin said that to succeed in the eyes of their peers, medical students are socialized, especially as interns and residents, to be "overly competitive, domineering and single-mindedly focused upon career advancement."

She said that true team work is hindered by the disdain ingrained in medicine of the other health disciplines.

"Nursing's ‘caring ideology' has not yet been sufficiently mapped out as a field of knowledge and research. The other health disciplines, those in the rehabilitation sciences, are usually reduced to simple technical know how."

Why do physicians find it so difficult to deal with others - patients or other health workers - in an egalitarian mode? Dr. Bégin offered three hypotheses, and challenged the medical students to figure out what lies behind behaviours which are in the way of collaboration, partnerships and good doctor/patient relationships.

Perhaps it is a question of efficiency, she suggested. In other words, power relationships are seen as the most efficient way of interacting within an organization. Or it could be a belief in the intrinsic and exclusive superiority of the bio-medical model. Or perhaps it is a traditional, patriarchal view of gender roles which is re-enforced by a male-dominated gender-based health care system - including schools of medicine.

Dr. Bégin's talk opened the 1999 Atlantic Medical Students' Conference on Feb. 5, and was part of the lecture series celebrating the 30th anniversary of the Faculty of Medicine.