Said Shahtahmasebi, Ph. D.

Some commentators have suggested that the social status of doctors has been eroded which has led to a commensurate decline in the quality of care that they provide. The irony is that the social status of doctors has not changed, they are still in the top social class. What may have changed are the doctors’ own perceptions of themselves and their role in the context of technological changes which in turn have changed public attitudes and expectations. First, there is no evidence to support a causal relationship between social status and quality of care. Second, quality of care is determined by the quality of the health care system. Third, quality of care is dependent on the quality of the education and training system. Fourth, the health care system is governed by socio-political economic and socio-environmental processes such as public attitudes, and expectations. Public attitudes and expectations, like other processes, are dynamic and change over time.

There is no denying that a major factor in influencing attitudes and expectations is information. And advances in technology giving rise to the information superhighway have brought information into the home. In the early stages of the information technology era a change in attitudes is much more likely.

On one level, information technology has allowed information to be disseminated to the public. The knowledge that was once special and a privilege of doctors is now in the public domain. So as access to information has improved over time through media and technology, it has to some extent devalued in the public mindset the association between ‘doctors’ and ‘special knowledge.’ In other words, the assertion that ‘Doctors possessed special knowledge’ does not have the same meaning as it had pre the information superhighway. This change does not equate to doctors losing their social status.

Over and above the improvements in accessing information, there have been changes to the health care system, and doctors’ behaviour. For example, doctors having to apply business models to formulate and deliver care have changed public perceptions of doctors and the quality of care. Such a change would have had an impact on the doctors’ own perception of their role and effectiveness in health care provision. Furthermore, improved access to information means a greater exposure of the public to other issues such as junior doctors’ hours, burn out and lawsuits against doctors. It is plausible that these changes have influenced the perceived image of doctors that doctors are human after all. This is not to say that doctors did not experience this change. Viewed from their perspective, the perceived attenuation in the association between social status and quality of care may well be the effect of change on doctors.

Doctors’ social status has not changed but their image in the public mindset at the point of delivery of care may have. This effect coupled with a social expectation of a health care system may influence the subjective view of quality of care as assessed by (i) patients, and (ii) doctors – social status is a red-herring. On the other hand it is possible that it is the doctors’ own perception of their role and the quality of care they provide has changed. In other words, they may be feeling that they are competing in knowledge with their patients and that their care may be questioned more frequently by patients. Improved access to information, at least in part, has empowered the public to do the once unthinkable and question their doctors and seek a second opinion. The feedback effects may be negative on the doctors but positive and empowering on the public which is very different to a decline in the social status of doctors.

The main issue that should have been raised here is that whether, in this age of information technology, medical training is good enough to prepare doctors (and in general health professionals) to deal with an altogether different generation of clients who are more ‘informed’ than their predecessors.

‘Health’ is a human behaviour and therefore health care delivery is a dynamic social process which requires a holistic approach. The issues of quality, efficiency, effectiveness etc. will not be addressed by a medical or business model alone; they may in fact add to the complexities of the health care system. Interested readers are also referred to the article “Sustainable Health Care?”

This is a commentary on the article, “The social status of physicians and the quality of health care” by Leo Sher, M.D. published on our website, www.internetandpsychiatry.com