PERSPECTIVE: Will barbers regain their role as medical practitioners?
Milton Packer, MD
Reproduced with minor modifications from a blog post on MedPage Today1 with permission from Dr. Packer.
Until recent history, people did not seek the expertise of a physician in the hope of a cure. Doctors primarily provided comfort by the compassionate communication of a diagnosis, often accompanied by the symbolic prescription of herbs and salves. The physician acted as a supportive guide to the unfolding of a natural course of events. This approach is embodied in one of Hippocrates’ pronouncements,
In the first millennium of the common era, physicians were in short supply. The talented few lived an elitist existence, typically attached to wealthy or powerful royal families. Famed physicians, such as Galen and Avicenna, were able to formulate ideas and write books, because they were supported by wealthy patrons. The poor, who had no access to physicians, turned to the clergy, who spent much of their time practising medicine. Building on existing relationships of trust, priests could attend to someone’s physical and spiritual needs simultaneously. However, the church believed that spiritual men should not be focused on worldly cares. Thus, during the latter half of the 12th century, it insisted that priests were “expert physicians of souls rather than to cure bodies.”2 The practice of medicine was strictly forbidden, especially when it required cutting or burning.
Where then would a “commoner” go for procedural interventions? Barbers — with their expertise with knives and razors — stepped up to fill the need, by offering a wide range of surgical procedures to their customers. On a given day, they might provide a haircut, an amputation, a tooth extraction, or the application of leeches. All of these filled the barbershop with blood and bandages. When wrapped around a pole, they formed a spiral of red and white stripes. The original barbershop pole with the red and white stripes was born in France; later the United States added a blue stripe for patriotic reasons.
From the 12th century onward, the expertise and practices of physicians and barbers became distinct, leading to a troubled relationship between the two groups. Physicians who received university training believed they had privileged access to specialized knowledge and felt superior to the barbers, who had no specialized education and treated only commoners. To highlight the distinction, physicians insisted that they wear long robes, while barbers could wear only short robes. The practice of long white coats for physicians and short white jackets for barbers persisted into the late 20th century. Top
Surgeons eventually differentiated themselves from barbers in the 17th and 18th centuries, but physicians and surgeons remained distinct specialties for several hundred years. When surgeons eventually co-mingled with physicians at medical schools, they wore long white coats — to emphasize to the world that they were not barbers, but were now part of an elite profession.
The elitism of physicians and surgeons provided great satisfaction to those with a medical degree, but little comfort to patients. From the 1940s through the 1970s, the relationship between doctors and patients was distinctly hierarchical. Physicians presented themselves as the authoritative source of medical knowledge and did not expect to have their recommendations questioned. That is not to say that physicians lacked compassion. Indeed, if a patient could find a knowledgeable and kind medical doctor, the bond between the two was therapeutically powerful. Under these ideal circumstances, physicians could provide both comfort and a cure, and, in return, patients provided gratitude and trust. That trust was the centrepiece of the therapeutic relationship. However, over the past 30 years, much of the trust that grounded the patient–physician relationship has been undermined. Today, physicians often seem determined to spend as little time with patients as possible. The history and physical exam are perfunctory, and questions are frequently swatted away with little time for listening. In response, admiration for physicians has waned and patients have become suspicious of physicians’ motives in prescribing medications or recommending procedures, resulting in low adherence to treatment. Top
Adherence is particularly problematic when people need to take multiple medications on a daily basis for years for an asymptomatic condition, such as hypertension. Hypertension is poorly controlled in the community — particularly in socioeconomically disadvantaged populations that are often also mistrustful of their interactions with the medical profession.
To solve this problem, Dr. Ronald Victor, a hypertension specialist, asked what would happen if we could identify a trusted individual within the underserved community who could be trained to measure blood pressures and provide emotional support for treatment? People would interact with this trusted individual on a regular basis to obtain measurements of blood pressure and reinforce the use of medications.
The solution: the barbershop. The barbershop plays a central role in the social fabric of black men in underserved communities. Men visit barbershops on a regular basis, and each has a relationship of trust with his barber, established through repeated and often personal conversations that transpire during the haircuts. As a result, the barber was perfectly positioned to measure the blood pressure of every client at regular visits, and then immediately connect those with hypertension to specially trained pharmacists to prescribe generic medications on site.
Dr. Victor and his colleagues carried out a cluster-randomized trial to prove that his idea would work.3 They recruited 319 black male patrons with hypertension from 52 black-owned barbershops. In half of the barbershops, men were assigned to the barber-pharmacist intervention, and, in the other half, barbers simply encouraged lifestyle modification and doctor appointments. After 6 months, a blood-pressure level of less than 130/80 mmHg was achieved by 64% of the participants in the intervention group versus only 12% in the control group! Top
Why did the idea work? The men paid attention to their blood pressure and took their medications because the treatment was based on a relationship of trust that transpired in a place of trust. In contrast, their hypertension was not controlled if the men were simply reminded to see their physicians.
The historic parallels of this study are striking. About 1000 years ago, barbers stepped up to provide essential medical care to underserved communities who had no access to academically trained physicians. Now, barbers are stepping up again as trusted members of the community to link people to essential treatments that they would be reluctant to take if prescribed by a physician.
In many ways, the divide between those who provide care and those who need it has not changed over the past 1000 years. Ten centuries ago, academically trained physicians were not interested in treating commoners. In the current era, underserved populations do not trust physicians to care for them, perhaps because they believe that physicians are driven by self-interest. The patterns of disconnect a millennium apart are eerily similar.
1.Milton P. Will barbers regain their role as medical practitioners? MedPage Today 2018;12 Dec. https://tinyurl.com/y463ecjb
2.Fanning W. Medicine and canon law. In The Catholic encyclopedia. New York: Robert Appleton Co.; 1911. https://tinyurl.com/yxhus93e
3.Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, et al. A cluster-randomized trial of blood-pressure reduction in black barbershops. N Engl J Med 2018;378(14):1291-301. DOI: 10.1056/NEJMoa1717250
Note from the editor: This article reinforces the idea that relationship-centred and whole-person care are more important than the older paradigms, patient-centred or physician-centred care, which only focus on one element of the relationship. Dr. Victor’s study also demonstrates two underlying principles of the LEADS framework at work: caring and distributed leadership. Caring is as important in healing as curing, and healing works best within the context of distributed leadership and shared responsibilities.
Milton Packer, MD, is an academic cardiologist in the United States who researches heart failure and is an active medical blogger.
Correspondence may be provided online at MedPage Today: https://www.s4me.info/threads/will-barbers-regain-their-role-as-medical-practitioners.7228/