Are Physicians (and the Rest of Us, Nothing for Nothing) Knights, Knaves, and/or Pawns? With Larry Bauer, MSW, MEd—Summer Shorts 8

For a full transcript of this episode, click here.

During the recording of episode 409, where Larry Bauer was explaining some really cool and innovative bright spots in the healthcare industry created by physicians, we somehow got off on a tangent about an article in JAMA from 2010—and I was all in. Unfortunately, going all in on a topic that has nothing to do with the actual topic of the currently in progress podcast means one thing; and you probably know by now what that one thing is. Yep … summer short. So, let me unveil for you our last summer short of 2023. In this healthcare podcast, we’re gonna talk about doctors and the societal perception of them as being a knight, a knave, or a pawn.

All of this is from a JAMA article that is entitled, surprisingly enough, “Societal Perceptions of Physicians: Knights, Knaves, or Pawns?” and it’s by Sachin Jain, MD, MBA, and Christine Cassel, MD, and is unfortunately firewalled (but I’ve linked to it anyway).

To get us started here, this is the first sentence of that JAMA article: “The British economist Julian Le Grand suggested that public policy is grounded in a conception of humans as ‘knights,’ ‘knaves,’ or ‘pawns.’ Human beings are motivated by virtue (knights) or rigid self-interest (knaves) or are passive victims of their circumstances (pawns).”

And, yeah, that plays out. Why can’t physicians own hospitals? Well, in somebody’s eyes, docs got a knave rap. How’d that happen? I don’t know. I can make some guesses.

Even if it’s a small percentage of docs doing knave-y money grabs or power-hungry things, there is spillover. We societal humans, after all, like black and white, not gray; so everybody gets painted with the same brush in the same color and policy gets created to control the lowest common denominators.

I loved this conversation with Larry Bauer that follows because it explains a lot of sequelae, if you will, that I couldn’t quite put my finger on the root cause of.

So, in the brief but fast-moving clip of the conversation that follows, Larry Bauer and I chat about docs as knaves or knights. But we don’t get around to pawns, so I did just want to chuck in my two cents here about this third category. I also will say that since I’ve got these three new classifications, I find myself using it to predict actions—to some effect, I might add.

I was chatting with someone recently, and I said something about doing well by doing good and he replied, “Well, how about this? You can do the good, and I’ll focus on doing well by doing well.” Okay … so, that’s a predictive layup.

The harder ones are where people with a lot of press training and social capital do talks about doing good and being knightly, but then you listen to the minutes of their board meetings and, wow, are they focused on revenue maximization … at the expense of patients and their fellow doctors. This happens more often than I would like to see, but then again, I would like to see this happen never.

As I mentioned about eight sentences ago, the category we don’t talk about in this conversation with Larry Bauer that follows—which has also occupied a chunk of my mind space lately—are pawns. As with all of these categories, it’s not just docs who fall into them but everybody else, too. Pawns are super interesting. You might be way ahead of me here and have been thinking about this for years because, on its face, this is obvious. But sometimes there’s truth hiding in plain sight, so I’m not embarrassed to keep talking about this in case it helps you connect the same dots I’ve recently started to connect.

I will state at the outset here that those who I would chuck in the pawn category do not listen to this podcast (neither do knaves). They do not like this show at all. This show forces a level of self-reflection and awareness and, to some degree, accountability about the net net of some of the goings-on that those who don’t want to hear it don’t like at all.

I was reading an article the other day about the “tragedy of organizational decision-making.” Kind of like the tragedy of the commons if you’re familiar with that terminology, but don’t worry about it at all if you’re not. The tragedy of organizational decision-making is that everybody in companies, especially big ones, is making lots of decisions. Tens of thousands of decisions happen in any given company on any given day, but so few then feel accountable or responsible or are even keeping track of the downstream and ultimate impact or consequences of any of the combined actions.

It’s this big machine, and you’ll hear some people say that they are but a cog “just doing my job” with no sight line into patient or member or community or societal impact. Without this context or accountability or ownership, it is so easy to make decisions that take to the extremes what should be a nuanced plan of action. And then we get what we’ve currently got.

Look, anybody who is part of a larger organization has to toe the party line to some extent; but there’s a difference between making informed choices and seeking ways to deliver a net positive for those we ultimately serve and doing things without contemplation. This is one thing that I love about the Relentless Tribe: just how much contemplation happens.

I am still working this out in my own head. I would welcome your feedback and thoughts, but from what I’ve seen so far, what pervades some of this pawn-like thinking might be—and I empathize with this a lot—it could be a feeling of powerlessness. Why bother being a knight, because nothing I do really matters anyway? Sometimes people just throw hands in air and, yeah, a familiar feeling even amongst those of us who try to think things through and have manifestos. So, I get it. But whereas this feeling of powerlessness causes some of us, meaning you and me, to double down on reflection, it may cause others to just quit trying altogether because they think they have a snowball’s chance in hell of influencing absolutely anything.

If it helps you in conversations that you might be having at some point with someone who may be feeling powerless, here’s a quote I memorized: “Great things are done by a series of small things brought together.” That was Vincent Van Gogh who said that. You also have Malcolm Gladwell from his book The Tipping Point, which talked about how many people have to be doing something to reach a tipping point: 12%. That’s doable. If basically 1 out of 10-ish people in any organization becomes a knight, the minority becomes the majority. Or here’s another quote that has some problems admittedly, but it makes a good point if you don’t cognate on it too hard: “If you think you are too small to make an impact, try going to bed with a mosquito in the room.” That was Anita Roddick.

Anyway, I hope that’s inspirational or helpful to you in some way.

You can learn more at the Family Medicine Education Consortium Web site or by emailing Larry at laurence.bauer@gmail.com.

Larry wrote a “Bright Spot” report; check it out here.

Laurence Mahoney Bauer, MSW, MEd, served as chief executive officer of the Family Medicine Education Consortium, Inc., from 1994 to October 2021. The FMEC is a not-for-profit corporation designed to promote collaboration among the academic family medicine and primary care communities in the northeast region of the United States.

He has also served as director of network development for the Center for Innovation in Family and Community Health in Dayton, Ohio, from January 2006. He is an associate clinical professor in the Wright State University School of Medicine, Department of Family Medicine, in Dayton.

Previously, he served at The Ohio State University School of Medicine, Department of Family Medicine, for 4 years as director of organization and faculty development. He served as director of faculty development and behavioral science in the Department of Family and Community Medicine at the Pennsylvania State University School of Medicine in Hershey, Pennsylvania, for 13 years.

Presently, he is an active consultant committed to the creation of a primary care–driven system in the United States. He lives in Hershey. He enjoys pickleball, basketball, and gardening. 

07:36 Are physicians knaves or knights?

10:05 “Most of the people … that [I’ve met], I would actually put under the cap of knights.”

10:21 “By and large, the healing community is quite ubiquitous.”

10:38 What is more important than accountability in the healing community?

13:42 Why is it important to recognize our own biases in how we view physicians and the medical community?

18:10 EP266 with Matt Anderson, MD, MBA.

18:16 Is it “the suits” versus “the scrubs”?

19:08 Why is it important to get doctors on committees and get policymakers on the ground?

You can learn more at the Family Medicine Education Consortium Web site or by emailing Larry at laurence.bauer@gmail.com.

Larry wrote a “Bright Spot” report; check it out here.