By Dr Tim Senior, GP in Aboriginal health and medical education. Tim is an AMWA member and medical blogger. Follow him on Twitter @timsenior.
I was a bit shocked to discover I might be a hypocrite. Remembering what I’d been taught at medical school about the nature of a profession, and applying this to journalism is what started me worrying. Clearly, I thought, as a profession, doctors needed to maintain control over their own regulation. Yes, we’d listen to patients and interested observers, but ultimately only doctors really understood what it was we did, the complexity of medical decision making, the discussion and minimisation of risk, the way things could go wrong without someone having done something wrong. Ultimately, clinical autonomy, the ability to make judgement calls based on the unique circumstances of that patient at that place and time, was the best guarantee of quality medicine.
Meanwhile, as an interested observer and consumer of journalism, I thought clearly journalists needed to have some system of external regulation, and wasn’t sure how they couldn’t see this. The current system was broken, journalists had too much power, they could write whatever they wanted, push a particular agenda under the guise of free speech.
I realised I was convinced by exactly the same arguments for regulation of journalists as I was arguing against for my own profession. Is that tenable? Are the differences so great that I can tell myself I am no hypocrite? How to resolve this cognitive dissonance?
One of the reasons that everyone has an opinion on doctors and journalists is that everyone thinks they know what they do. Just about everyone sees a doctor at some point and just about everyone sees some news on TV. Both doctors and journalists are endless sources of stories for TV dramas, novels and shocking exposes. However, I know that none of House, Doc Martin or Dr McCoy was ever an accurate representation of my working life, which makes me wonder if perhaps Ford Prefect, Lois Lane or Tintin weren’t enjoyed for their journalistic accuracy.
One of my pleasures, therefore, is hearing from experts in a profession describing what it is they do and how they do it. In General Practice, Iona Heath, a previous president of the RCGP in the UK describes what we do beautifully. Reading “The Mystery of General Practice” for example may surprise you. In the world of journalism, it was done recently by Kath Viner, the editor of Guardian Australia in the AN Smith lecture recently, and published here.
Early in the piece, Viner quotes a description of journalism as “truth teller, sense-maker, explainer.” This was uncannily similar to a description I used in an article for the British Journal of General Practice last year, called “I’m just a sensemaking analyst.” Now primed, I couldn’t stop seeing similarities between the professions of medicine and journalism – and some important differences. Perhaps there are lessons here for us both.
Lesson 1: What do you do when you are a member of an expensive profession no-one wants to pay for?
Viner is not the first to describe how the internet has revolutionised journalism in ways that have just about broken its funding models. Can we afford, are we willing to pay for, good journalism? (Can we afford not to?) She describes the impact and the solution that the Guardian is taking to this, which is to bet that developing a 2 way relationship with the readers is going to be the way forward. By no means is this the only proposed solution. Others include “digital first” strategies, often understood as getting news out there first (with accuracy sometimes taking a back seat); Churnalism, or the printing of press releases as news; advertorial, or sponsored content. These essentially view readers as eyeballs to be sold to advertisers. I’m afraid they will all send me to a well thought out blog post with a speed that would make your advertisers wince! I don’t really want to be treated like a passive idiot. The web allows me to be an active participant in what I read. The fact that I have blogged and commented much more often than I have ever written a letter to the editor is testament to this. But I am not all readers, and what models turn out to work is still uncertain.
For doctors, too, the environment is changing. We have moved from a system of lone doctors managing acute diseases in a series of one-off consultations (which fee for service is quite good at funding) to a system of managing several chronic conditions over time across team members, which fee for service struggles with. This doesn’t even take into account public health, working on the social determinants or health inequalities. Can we afford to pay for health care? Especially in an aging society with increasingly complex needs? And those with most need have least ability to pay.
The current funding model for health encourages the medical equivalent of digital first, churnalism and advertorial. You get paid more by viewing patients as Medicare Revenue Generators – see them quickly, see as many as you can, do as much service as you can. Though this happens, it’s far from universal, and there are many doctors out there who are providing really high quality care. They take an income hit compared to colleagues to do so. Good medicine is clearly more than a commercial activity, and this is exactly how good journalism is described in an article quoted by Viner. Viner and the Guardian have taken a punt that focussing on the relationship with their readers will be what keeps them going. In the same way, despite temptations to focus on diseases, to focus on funding models, a clear focus on listening to patients and what they want will (my own leap of faith) pay dividends. Both journalists and doctors are good at saying they are doing this when in fact they are not.
Lesson 2: How we think about the users of our services is important
I don’t object to being called a reader. After all, I do read. It doesn’t really everything I do when I read something, though. I think, react, put in my own context and ideas. And I might comment, blog or tweet about what I read. And so it seems we need new words to describe the people who read. Viner quotes Jay Rosen calling readers “The people formerly known as the audience.” We have similar discussion in medicine about what we call the people we have always referred to as patients. Are they patients? (They certainly have to wait long enough). We’ve also referred to them as consumers (a term that journalism has also tested) which to me conjures up images of people eating up health (or newspapers) until they are gone! How about service users? Clients? Customers? My current favourite (especially in the community controlled sector) is owners. This might work for both audiences, perhaps especially if the user paid!
These aren’t just word games. The way we think about the people using our services affects the way we interact with them. Patient has the advantage of incumbency and captures the vulnerability of being ill, but it also can lead to patronising or paternalistic care. Customer, on the other hand gives the service user more rights, but makes the interaction much more of a transaction based on the wants (not needs) of the user. And customers usually only get what they are able to pay for. Perhaps someone interacting with journalism is now a co-contributor, a wording extremely similar to terminology used by Julian Tudor-Hart for patients as co-producers of health!
Lesson 3: The relationships are the thing
This seems so obvious. No-one will disagree. But then we will continue to talk about medicine as if it is purely transactional – as if the only thing happening in a doctor-patient interaction is a series procedures. Yes, of course procedures will be done. There will be a blood pressure, and a weight, some “patient education,” maybe a prescription issued. But that is just the easily observable surface. Around all of that is a complex, often emotional, drama, even for the simplest consultation. There are worries, fears, pain, advocacy, values, confidences, support, negotiation, compromise. Whether or not this is done well will determine whether someone returns or not, is satisfied or not, or decides to make any changes or not. Replace one of these two human beings and the dynamic is different, the consultations are different, often very different. GPs have a language for describing, teaching and researching the doctor-patient relationship. We take it seriously. And this means taking rapport, trust and confidentiality seriously. You will find doctors really dig their heels in when there are threats to patient confidentiality – and rightly so. I am always reminded of our attitude on this whenever I hear about journalists’ comparable, and admirable, attitude to protect the identity of their sources – even being prepared to go to jail. And having a source trust you enough to leak something they think is important doesn’t happen on a whim – it occurs with someone they have developed a relationship with, who they trust. These are examples of deeply held professional principles that would be adhered to by just about everyone in the profession. The most obvious component, the leaked document or the printed prescription, is just the surface outcome. Without the underpinning relationship it either won’t happen or will be useless. The mission, though, for both our professions is to describe the importance of the relationship, and the length of time needed for this, as opposed to the products of the relationship. Neither of us have been particularly good at this.
Lesson 4: Really understand what is beneath the numbers – and mix with a dash of intuition
Viner’s piece has a nice description of the way their web metrics are used not as the sole measure but to guide judgement about what to do. There’s no apology for using gut instinct. Likewise in medicine, we’ll often be measured on our quality through numbers which are easy to collect – Blood pressure, glycated haemoglobin as a measure of diabetes control, aspirin prescriptions. This is all good, but doesn’t tell the whole quality story. These measures provide a snapshot of a point in time. But I know patients who don’t want to take any medications, but will take 2 of the recommended 4 or more medications after their heart attack because of a discussion with a trusted expert. That would be marked down as poor care in an audit, but can be chalked up as a success when the context is understood. Doctors object to “Tick Box medicine” for this reason, and there is evidence that this approach harm the essential relationship. And because it is a relationship, not a pure transaction of 2 individuals, there is room for intuition. This is not an excuse for guesswork or poor quality care, but is an acknowledgement that better quality care uses those subliminal signals you can’t explain, but to go with your judgement. Perhaps saying this now, perhaps holding a silence a few seconds longer, perhaps even letting that flash of anger show.
Viner describes this in action using the data of website visits. It is too easy to misuse this data to produce a stream of clickbait about “Our 12 favourite wardrobe malfunctions” or the “4 best Vine videos of Pandas riding bicycles” but I would argue that if this is what you are producing you are failing your readers, and it is no wonder your readers have stopped trusting you.
Lesson 5: Trust is everything
Which brings us to the main difference between the professions of journalism and medicine. Medicine is still a profession that is highly trusted. Even when people criticise doctors in general, they usually make an exception for “their doctor.” And note how possessive that is. People feel a sense of belonging. Perhaps that’s why we have terminology such as “Medical Home.” And it might be anathema to admit it, but perhaps one of the reasons the profession is trusted is that we have statutory regulation. We have to be registered with AHPRA and behaviour that badly threatens the trust we hold gets people temporarily or permanently struck off the register. (I’m not arguing it’s a perfect system.) It means I can write here as a citizen journalist, but no professional journalists could do a bit of amateur doctoring. (Sorry!) This level of trust, across the profession as a whole and for individual doctors that you meet is what keeps the system running. There is so much information and marketing out there, that people seek out the guidance of a navigator. It doesn’t matter what job that person has – if they seem knowledgeable and trustworthy people will use them as a guide. Which brings us back to journalism. Surely, that role of navigator around a complexity of competing facts and opinions is just what journalists should be doing (and some still are). But each time rubbish is printed, our trust is reduced that much further. Which means that when important stories come out we are that much more likely to shrug and say “Well, it might not be true. You can’t trust them you know.” This has been a big year for good journalism, as shown by the Walkley shortlists this year (as well as the Snowdon NSA revelations in the Guardian).
We need good navigators, good sensemakers scattered throughout our society. But these roles are nothing if they are not underpinned by trust. Journalists and doctors have a lot to learn from each other about how we do this, and how we continue to provide an essential service for people, no matter what we end up calling them or whatever our views on statutory regulation.
This blog was first published online at Croakey and the Public Interest Journalism Foundation and is republished with full permission.