Knights or Knaves

Societal Perceptions of Physicians

Knights, Knaves, or Pawns?

Sachin H. Jain, MD, MBA

Christine K. Cassel, MD

New England Journal of Medicine

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). A society’s view of human motivation influences whether it builds public policies that are permissive, punitive, or prescriptive.

Le Grand’s observations were drawn from his studies of British social welfare policy and civil servants but could aptly be applied to physicians and their role in the US health care system. Many health care debates—especially those relating to health care financing, quality, and education— implicitly prescribe a view of physicians and their underlying motivations. Depending on the perspective, physicians are either in practice for the betterment of society or their own selfish gain; or they are automatons whose actions are defined more by external rules and regulations.

In this Commentary, we explore the ways in which physicians are variously represented as knights, knaves, and pawns in public discourse and relate the importance of designing policies that match the true motivations of physicians—whatever they may be.

Physicians as Knights

If a society conceives of physicians as ever well-intentioned knights, it places stewardship for the health care system firmly in their hands. Physicians can be trusted to use and deploy resources wisely, minimize waste, and look beyond their narrow individual and specialty interests to protect the system as a whole. Individual physician decision-making and autonomy are given the highest priority. The physician is the ultimate champion of the patient and policies are structured to support the physician’s work. Physicians practice medicine to save and improve lives; any financial gain is secondary. Physicians read medical journals and texts because of their love of learning and a desire to provide the best care to their patients. They perform clinical and basic research to advance science. The role of policy and payment is mainly to get out of physicians’ way and let them do their jobs as professionals and to seek and respect their advice when policy affects health of the public.

Physicians as Knaves

If a society conceives of physicians as knaves” then policy, management, and educational efforts are designed to com- bat and work against physicians, not with them. Physicians are interested in themselves and their financial wellbeing first and their patients second, if at all. Physicians must be given rewards and incentives to motivate them to what is right by their patients and any such schemes would have to be carefully monitored for abuse, fraud, and waste. Physicians learn new techniques and procedures and order tests and studies for personal gain. Any participation in scientific research is driven by self-glorification and narcissism. The health care system works in spite of knave physicians, not because of them. Policies and regulation must guard against their malfeasance, and the public must be protected by regulation and report cards.

Physicians as Pawns

If a society conceives of physicians as pawns, then efforts are applied to building systems to ensure that physicians do what is right for patients because physicians cannot be trusted to do so on their own accord. Left to their own de- vices, physician behaviors are unpredictable. The pawn physician is merely a function of the environment in which he or she practices; accordingly, physicians must be given guide- lines to follow and policy makers and regulators must decide clinical priorities. Physicians may or may not enjoy learning, but they study and maintain knowledge because licensing and board examinations require that they do. If physicians are required to do more laboratory tests, they will; if required to obtain fewer, they will. Place physicians in a particular practice setting and they will adapt to the local culture and expectations. The role of health policy and regulation for the pawn physician is to guide his or her every behavior because he or she lacks individual agency and judgment to reliably do what is right.

Le Grand’s work on post–World War II British social policy found that perceptions of human motivations gradually trans- formed, with the prevailing view of the typical British citizen morphing from knight into knave as the costs of maintaining an expensive welfare state increased.

US perspectives on physicians have undergone a similar transformation with the increasing cost (both to taxpayers and to individual patients) of health care delivery. As physician behavior has been tied to these rising costs and in- creasing scrutiny has been applied to the quality of care de- livered, policy discourse often reflects the perspective that physicians are an obstacle not an enabler to a functioning health care system. Rather than being counted on to exercise their professional ethic to address problems in health care delivery, physicians should be guided to do what is right with an increasing menu of incentive payments (ie, pay for performance or value-based purchasing) or strict regulations. Rather than being counted on to maintain their knowledge and expertise on their own accord, they are subject to periodic examinations to demonstrate continued proficiency.

These views are grounded in evidence of unwarranted variation in care, clear evidence of waste and even fraud, and decline in knowledge over time. The modern US physician is regarded as either a knave or a pawn and is seldom regarded as a knight. But the evidence that has led to distrust of physicians does not apply universally and many physicians still are the knights in the health care system. How can society be sure not to undermine those motivated by professionalism while guarding against those motivated by self-interest?

Not all policy prescriptions have abandoned the view of physician as knight. Prepaid models of health care payment such as accountable care organizations and the patient- centered medical home place responsibility in the hands of physicians—with the idea that physicians will be responsible stewards. In these examples, physicians must be counted on to organize and structure care delivery, responsibly use resources, and measure and improve individual and population outcomes. Still, it is perhaps the knavish conception of physicians that makes these physician-driven models of health care delivery more the fodder of pilot projects and demonstrations than models that are rapidly adopted and widely disseminated.

Le Grand offers an important lesson and warning: it is critically important to understand and get “true motivations” right. Disaster may follow if persons largely of a knavish quality are treated as knights; but the same may be true for “policies fashioned on a belief that people are knaves if the consequence is to suppress their natural altruistic impulses and hence destroy part of their motivation to pro- vide a quality public service.” Le Grand further warns that policies that “treat people as pawns, may lead to de- motivated workers . . . again causing adverse outcomes for the policies concerned; while policies that give too much power . . . may result in individuals making mistakes that damage their own or others’ welfare.”

The US public would be wise to heed Le Grand’s advice and carefully consider whether its perceptions of physicians match reality. For their part, physicians must thoughtfully consider whether and how they contribute to the perception that they are knights, knaves, or pawns.