1.7 The decline in charismatic authority

Medical power has declined in all four dimensions - moral, bureaucratic, sapiential and charismatic - the last of these being the most subtle but perhaps the most important.

1.7.1 The gift of grace

Charisma, or charism as it is cited in the Shorter English Dictionary, means 'a favour specially vouchsafed by God; a grace; a talent'. Although the term 'charismatic' is sometimes used now as a synonym for an attractive personality, the original meaning applies, or applied, very well to the medical profession, who were seen as healers in society. Before science, healing was a gift of God and Jesus as a healer was considered to have a special gift from God. The doctor as healer, of course, implied that it was the doctor himself (for in those days all were male) who had the healing power, either given by God or deriving from some other source. The work of Michael Balint, which revealed the power of what he called 'the drug doctor', emphasised the importance of the doctor as healer. The Balint Groups of the 1950s did not, however, claim that the power of the doctor was a gift of God. They recognised that it derived in part from the doctor's personality but that it also reflected the faith invested in the clinician by the patient.

1.7.2 The doctor replaced the priest in many communities

The secularisation of western society resulted in a fall from grace of priests. Secularisation is not simply the result of increasing faith in science - other factors, such as increasing population mobility, play a part. What is certain, however, is the decline in charismatic authority of the parish priest, hitherto a figure of central importance throughout the United Kingdom. In the middle of the 19th century the parish priest clearly had more authority than the doctor; by the middle of the 20th century the positions had reversed, although it is hard to determine precisely when the crossing point was reached.

Some doctors complained about this, aware of the fact that they were being brought many problems that would previously have been taken to the parish priest, either because of their moral dimension or because the Church had traditionally managed many problems of unhappiness, which, either presenting directly as depression or presenting in some physical guise, are now taken to the doctor.

1.7.3 Idealistic medical drama inflated the charisma of the medical profession

In the 1950s, A. J. Cronin was a doctor, a graduate of Glasgow University, who achieved fame with a number of novels that had a strong social message, for example Hatter's Castle. Cronin's fame today, however, is based largely on the television series, Dr Finlay's Casebook, which ran from 1959 to 1966, with a new adaptation in 1993. These stories, set in Callendar in Scotland, gave an idealised picture of a dedicated young doctor interacting with his more cynical older colleague, Dr Cameron. Also in 1959 the television series Doctor Kildare was launched, in which the young Richard Chamberlain appeared as an idealised perfect young clinician, again often in conflict with a curmudgeonly older colleague.

1.7.4 Realistic medical drama decreases charisma

Many idealised images of society were portrayed on television in the late 1950s and early 1960s, reflecting the more confident mood in society and the wishes of the media to provide people with escape from the pressures of daily life. Currently-televised medical dramas, for example 'Casualty' and 'ER', are much grittier and more realistic, characterised by:

• doctors expressing doubts about their mission
• nurses challenging doctors
• ungrateful patients
• doctors revealing the human side of their own lives.

These programmes demythologise the healing professions, and by reducing the myths reduce the charisma, a process accelerated by the medical profession itself.

1.7.5 Medicine is demystifying itself

Both the medical profession as a whole, and individual practitioners to a greater or lesser degree, have become more open, following to some extent the general social trend towards informality and openness.

Three manifestations of this are:

1. the clinicians' mode of dress
2. their consulting style
3. their mode of address to patients.

1.7.5.1 Clinicians' mode of dress

In the 19th century, medicine and nursing were dirty businesses, and special dress was needed. Furthermore, it was recognised that it was often necessary to change one's dress after leaving clinical work for both health and aesthetic reasons. As suppurating infections have become less common and disease less often presents at an advanced stage, clinical care has become less dirty, but until the end of the twentieth century clinicians continued to wear the uniforms which were put on and taken off at either end of the working day, like priestly raiment before and after religious services.

In most hospitals, the nurse's cap, which has become progressively less utilitarian and more symbolic, has now been done away with, and nursing clothes are now much less formal in their appearance than the traditional uniform, which was closer to that of the French maid than to that of a technocrat. The sexual connotations of nursing uniforms, of course, also probably accelerated their demise.

For the doctor the white coat represents, among other things:

• a barrier against infection, its scientific justification
• a means of identification, its moral justification
• the healer's pure white mantle, its symbolic justification

For many doctors a white coat is justifiable, both keeping their own clothes clean and providing a reassuring barrier between the doctor's clothes and the patient. However, white coats, although still a symbol of medical authority, are now less commonly worn. Even in general practice the dress code is changing, with a general trend towards informality, and an increasing proportion of male general practitioners no longer wearing jacket and tie for consultations or home visits.

All of these changes diminish the distinction between doctor and patient and contribute towards demystification.

1.7.5.2 Varying styles of consultation

Many doctors have become less formal during the consultation. 'Doctors orders' is a phrase which entered common parlance but whose significance is now reduced, as doctors less commonly give strict 'orders'. Furthermore, clinicians now develop their own consulting styles, with training in general practice encouraging a participative style of shared decision-making.

A study of consulting style in the United States found that patients had different expectations which, unfortunately, were rarely matched by the clinician, with the implication being that each clinician develops his or her own consulting style and delivers it to all patients, whatever the individual patient's preferences may be. This issue will be discussed in more detail but its importance in the current context is that the general trend has been towards informality and openness with the physician trying to demystify the process of decision-making.

1.7.5.3 The mode of address

The patient who has known a doctor personally before the initial consultation, or before joining their list, will continue to use the doctor's first name, but the use of first names by both doctors and patients is increasing and doctors who look after patients on a long-term basis may develop a personal relationship, with the use of first names by both parties. Doctors are now more cautious about calling patients by their first name and less cautious about requesting patients to call them by their first name. This also contributes to demystification.

1.7.6 New healers are emerging

As doctors have become demystified, and have demystified themselves, other healers have emerged to fill the need for healing, and some of the criticism made of modern medicine derives from the fact that a patient may be looking both for the best of modern science and a traditional healer. As doctors in particular have become more like engineers, the patient's need for healing has not been met, causing dissatisfaction with the process of care (even though the patient is receiving the best technical quality), leaving the patient to seek other sources of healing as alternatives to the medical profession.

1.7.7 The charisma of the vulnerable human

The charisma of the remotely impressive doctor of the 20th century was powerful and had some beneficial effects for some patients, but for many the effect was demeaning. The charisma of that type of doctor derived from the reverence in which the profession was held, often augmented by the behaviour of the individual doctor. The diminution of this type of charisma may have been replaced by another type of charisma.

The word 'charisma' is now used to describe the superficial image of a public figure, closer to the adjective 'glamorous' than to the original meaning which referred to certain personal characteristics of the individual. The 21st century clinician, stripped back of the image from which 20th century charisma derived, can offer a substitute - his or her own, honest person, frailties and all. The doctor as superman has been replaced by the doctor as human being, willing to relate to another person - the patient - and the charisma of the human being who is the clinician may be as powerful as charisma derived from the false image.

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