One fascinating concept within the study of how doctors conceptualize their work is the concept of “disease prestige.” As the name suggests, the basic idea is that there’s a general hierarchy in which some diseases are seen as more, well, prestigious than others. One Norwegian sociologist, Dag Album, has for a long time been surveying how doctors in Norway rate different diseases in terms of prestige, and in a new paper in Social Science & Medicine, he and two other researchers show that over the decades, there’s been a fairly stable — and rather telling — hierarchy.
The authors used data from three studies of Norwegian physicians, conducted in 1990, 2002, and 2014, in which the physicians were asked to rate 38 categories of diseases on a prestige scale from 1 to 9, based on how they felt health professionals viewed the disease-category in question. In all three surveys, there was stability at the top: Leukemia, brain tumors, and myocardial infarctions (heart attacks) were the top three in all three surveys, though the order switched around. At the bottom were fibromyalgia, depression, anxiety, and cirrhosis of the liver. So what does this tell us about how doctors think? The paper offers some fascinating theorizing, some based on the authors’ own past work: Based on interpretation of the survey results, extensive reading of the literature, qualitative interviews and informal conversations with physicians from several specialties in connection with ethnographic field work in a gastro-surgical ward, Album and Westin (2008: 186–7), suggested three sets of prestige criteria – or “deference entitlements” (Shils, 1968: 106) – that seem to structure disease rankings. The first is related to the disease and its typical trajectory.
Non-self-inflicted, acute and lethal diseases with clear diagnostic signs, located in the upper part of the body, preferably the brain or the heart, are typically awarded high prestige. The second set of criteria is related to the typical treatment of the disease. Disease categories associated with active, risky and high technology treatment leading to a speedy and effective recovery are awarded high prestige. The third set of criteria is related to the typical patient with the disease. Disease categories associated with young patients, patients who accept the physician’s understanding of the disease, and whose treatment results do not involve disfigurement, helplessness or other heavy burdens, are awarded high prestige (see Album and Westin, 2008; Johannessen, 2014 for more in-depth discussions). Part of what appears to be going on here is that doctors view as prestigious those conditions which help them look good.
Research from one of the paper’s co-authors, Lars E.F. Johannessen, for example, “shows how physicians value narratives in which they are portrayed as ‘masculine and extraordinary lifesavers’, reflecting deep-rooted heroic tales of Western culture.” Overall, physicians seem to “value disease categories associated with acuteness and drama over those considered chronic and mundane.” From a doctor’s point of view, some conditions are more interesting and fun and exciting to treat than others. Diseases with a long, chronic trajectory, and/or which don’t affect those vital north-of-the-equator organs, and/or which don’t allow for miraculous-seeming medical interventions can be a real grind to deal with. Unsurprisingly, the researchers think these beliefs could have deep ramifications for the practice of medicine: We believe our findings have implications beyond the evaluation of disease categories.
Prestige criteria such as acuteness, lethality and curability are likely to influence how physicians evaluate other elements of their profession, such as colleagues, departments, hospitals, patients, procedures, specialties, technologies or wards. In other research, we have seen a clear similarity between the ranking of diseases and specialties (Album and Westin, 2008). This suggests that the disease prestige hierarchy illustrates fundamental evaluative tendencies in medical culture. These evaluative tendencies are likely to have widespread ramifications in medicine. For instance, prestige has been shown to be a relevant factor for students’ choices of medical specialty (Aasland et al., 2008; Azizzadeh et al., 2003; Creed et al., 2010) and for informal priority setting in intensive care units (Halvorsen et al., 2009). More generally, we should pay more attention to how disease prestige can exert subtle, symbolic influence on physicians.
[The renowned French sociologist Émile] Durkheim (2008/1912) has shown that symbols can exert a significant emotional force on those holding them to be sacred, and we can hypothesise similar effects resulting from shared and taken-for-granted ideas about the “importance” of a particular disease category – not only in the clinic but also in boardrooms and budget meetings. Further research into the connections between disease prestige and decision-making is strongly encouraged. Now, it’s important to remember that since these surveys involved Norwegian doctors, it may be the case that in the U.S., physicians see things differently. I wasn’t able to dig up any disease-prestige surveys administered to American doctors — this really is a niche specialty of Album’s that he’s been working on for years — but I’ll update this post if I come across anything (if you Google search terms like “disease prestige,” you’ll see just about all the relevant links pointing back to Album’s research).
This is still a really useful way to examine critical questions about which diseases garner the most attention, funding, and talented young physicians, though, since these decisions are not made on a purely rational basis. Again: Doctors are human.