Abraar Karan: Medicine’s power problem

Every doctor, by virtue of being in a position of relative power, runs the risk of misusing it, says Abraar Karan

abraarIn January 2016 a powerful white male doctor sexually assaulted a black female patient at one of the most prestigious academic hospitals in the US. It happened right in the emergency room, a place she came to hoping for care. When the case went to court and the doctor pleaded guilty, many questioned how this could have been possible.

The doctor in question was a nationally recognised star in his field. A friend of mine happened to be in medical training at that institution when the assault occurred, and he too was shocked. “What was he like?” I asked. “He was incredible,” my friend said. “Every resident liked working with him. He expected a lot from you, but he was an all star. You were always excited when you saw that he was on service.”

For some, this would seem all the more surprising, but I had to think that perhaps it was not. The reckoning that came with #MeToo showed us how often power, prestige, and a sense of invincibility are factors that make people feel like they can get away with exploiting others. The US has had many such cases of abuse between doctors and patients—both sexual and other forms—and the NHS in the UK has reported a similar problem with doctors who have “superhero status.”

The reality is that this abuse is not limited to superstar doctors—every doctor, by virtue of being in a position of relative power, runs the risk of misusing it. The superstar cases may be the ones that make the news, but I fear they are the tip of the iceberg.

We know that power in medicine, created and perpetuated by outdated hierarchies, has led to abuse not only of patients, but of medical students, staff, and other healthcare professionals. In a systematic review, it was found that more than a third of medical trainees had experienced some form of harassment or discrimination from more senior doctors. 

Within the specific case I opened with, we can see a number of unfortunate undertones: the gender dynamics, the racial inequities, the quick reflex of some of the medical community to dismiss the patient as having mental health issues or trying to “get back” at the doctor. And we are left with a terrible incident that is representative of many of the things that are wrong with modern medicine.

We have a serious power problem in academic medicine. We have too many doctors with too much power and too little oversight to keep that power in check. While any doctor could harm a patient or colleague, those who are exceptional in their specialties are potentially more immune to the consequences. Many of these so called “superheroes” have achieved astronomical success and fame, some through biomedical research, others as policy scholars, writers, media personalities—the resumes are endless. But as doctors become more powerful, is there a risk that they move further away from the qualities that we would want in our own doctor? 

I previously wrote about how the design of our medical system dehumanises patients. But does the potential for power built into our academic medical enterprise dehumanise doctors as well? Patients come for help—they inherently admit vulnerability and seek care. But do some doctors instead see someone who is exploitable? While in the US, this mistreatment commonly takes more subtle forms—microaggressions being a notable manifestation— elsewhere, it can be more explicit.

In 2015, a journalist detailed the troubling number of reports of women being verbally and physically abused—including pinching and slapping—in Indian delivery rooms, particularly those treating poor patients. As a global health doctor, I have worked in Central America, sub-Saharan Africa, and southeast Asia—and I have noticed similar dichotomies of power and perpetuation of abuse between doctors and patients in almost every setting.

If doctors have the potential to become abusive, why do they do so, and how might we stop it? Some have pointed to the growing epidemic of burnout and depression among medical trainees as a contributor. In one study, researchers found that medical students who were more “burnt out” were more likely to behave unprofessionally and less likely to hold altruistic views on taking care of patients, especially underserved ones. Another study that looked at Turkey reported that between the first and third years of medical school, students became significantly less empathetic. A myriad of solutions to address burnout have been suggested elsewhere—here may be one more reason to adopt them quickly.

Another reason may be that we aren’t selecting the right type of people to be doctors. In the US, medical admission systems are still heavily orientated around test scores, which means you will have a doctor who is great at taking tests. But that doesn’t necessarily translate into what patients usually find important: a doctor who listens, cares, empathises, and treats them as an equal partner. Research has shown that these traits are better captured in what is called emotional intelligence. Some medical schools are shifting towards changing their admissions criteria to better reflect this need, but most have not caught on.

Yet aside from these reasons, we must not forget that power will always run the risk of corrupting those who wield it, especially when there isn’t a system to keep it in check. Instead, all too often we hear accounts of prestigious doctors and academics who have actually been protected by their institutions in the wake of abuse allegations.

The reality is that big name doctors are important to big name institutions. Some bring in large amounts of research grants; others add to the clout and prestige of the place they work. But the people in charge who have the power to do something about abuse need to ask themselves, “Is a patient’s safety not worth more than saving face or protecting research money?”

As a young doctor working my way up the academic ladder, I write this in part to remind myself what not to become. Patients deserve the best doctors, but the best doctors are not always the most famous doctors. When push comes to shove, you won’t care about how many titles are behind your doctors’ name, how many publications they’ve authored, how many research grants they’ve obtained, or how many TV interviews they’ve starred in.

When disease strikes, you will want someone who is at your bedside, treating you with respect and care, and recognising that you are a fellow human being. Doctors who think they are God won’t be able to do this. We don’t need any more powerful doctors in medicine—what we need are good people.

Note: An earlier version of this article was first published in Scientific American.

Abraar Karan is an internal medicine resident at the Brigham and Women’s Hospital/ Harvard Medical School and is currently obtaining a diploma in tropical medicine at the London School of Hygiene & Tropical Medicine. Twitter @AbraarKaran

Competing interests: None declared.

The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.