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In 1987, my now-retired—UCLA, Emerita—wife of 50+ years, Dr. Cunningham, received her PhD in English from UC Santa Barbara. The Commencement was attended by her Irish family (I almost said Irish Catholic family but that, practically speaking, would be redundant.) After the formal awarding of her degree, she—the first PhD in her family—descended the ceremonial stairs and, suffused with pride in her remarkable achievement, came to us. As she reached us, her older sibling, a Conservative, brayed, Yes, but you’re not a real doctor. He meant, Too bad you’re not an MD instead of a—pick one: non-productive, useless-to-society, low-wage-earning, ivory-tower dwelling, fatuity-spewingPhD.

I love my BIL (Brother-In-Law)—he’s just my BIL—but that was jackassery of a high order. Over the intervening 35 years, he has changed; he would not today make the same comment. Though he remains Conservative—even his remains will remain Conservative—he has attended JA meetings, done the work, and is now a recovering jackass (although as JackAnon regularly reminds families, recovering jackasses are recovering forever). And though his sister, my unreal doctor, has forgiven, she will never forget (see above, Irish). I on the other hand am a New York Jew whose traditions accommodate neither option.

Conservatives are not alone in making this spurious distinction. Americans in general believe MDs are real doctors while PhDs are, if not entirely fraudulent, at best academic. In Great Britain and other places, health care practitioners with medical degrees are referred to as Mister or Miz, deserving of respect, but not of adoration. Here we’ve been inculcated to pay homage to MDs, and they—the real (i.e. the non-academic) doctors—on their part expect to be adored. Unlike in Great Britain, here they are always addressed, even outside their offices, as Doctor and are accorded many perks, often including the ultimate American perk, preferential parking.

The over valuing of MDs and the concomitant undervaluing of PhDs result from the successful efforts of the single most effective professional guild in American history. No, I’m not talking about the NFL Players Association or even the LAPD police union. I’m talking about the American Medical Association. Founded in 1847, the AMA is the oft-imitated-but-never-equaled model for all professional organizations that have followed. Since its inception, it has been extraordinarily effective at lionizing those who practice medicine. (Maybe if they keep practicing, someday they’ll get it right. Rim shot!) In its 175 years, the AMA has successfully established MDs as real doctors and lofted them into an American arisdocracy. (There are stories of NBA players pretending to be MDs just to get a few extra perks.) It has secured for its members special legal status—the doctor-patient privilege that is so unlike the English Professor-student privilege; and, by lobbying legislatures to permit monopolistic practices—i.e., reserving to its members the exclusive concession to write prescriptions—it has fabricated a structure of deference to, and fertilized fecund fields for augmenting the finances of, its members.

Unfortunately for the rest of us, while the AMA was relentlessly working to enrich the lives and incomes of its members, it was hijacking our nation’s health care delivery system. AMA-driven boosts in its members’ prosperity and well-being have come at the expense of fair and reasonably priced medical services for America’s patients.

To accomplish this elevation of privilege (those who know computer security terms will recognize the malware metaphor), the AMA leveraged—brilliantly, from a marketing perspective—traits ingrained in both human behavior and the American character. It successfully exploited our many-thousands-of-years-old fascination with, and need to believe in, the pronouncements of oracles, those seemingly exalted, often somewhat distracted, beings who present as having either special pull with the gods or special access to the mysteries of the universe. Or both. Over time, Americans have come to relate to real doctors as though they—the real doctors, not the Americans—were oracles, as though they—the real doctors, not the Americans—had access to arcane secrets unavailable to the rest of us.

(Thanks to the Internet, this is no longer true; nearly everything a real doctor knows is, for anyone with access to a computer, a few clicks away. I recently asked a real doctor a question; for the answer she turned to her computer and navigated to the Mayo Clinic’s website. Sure, it’s important to know how to apply that information, but that’s true also for electricians, mechanics, and plumbers.)

To further bolster their oracular cred, medical professionals use mostly Latin and Greek terminology. This is intended to—and does—reinforce a patient’s sense that real doctors speak a magic tongue. In addition, the AMA has long conspired with the pharmaceutical industry to gate keep not only life-saving, but also pain-reducing, weight-controlling, hair-growth-enhancing, prostate-shrinking, mood-elevating, and sex-life-encouraging compounds. (Until their patents run out, those drugs are given weird names to burnish their mystery, make their prescribers seem even more oracular, and justify high drug prices. Only something very valuable could have so few vowels.)

As to leveraging the American character in pursuit of its income-enhancing goals: the AMA has long decried what it has opted to call socialized medicine, by which it means any law, policy, idea, myth, whisper, or typo that, if implemented, might tend, in even the slightest possible way, to risk the merest possibility of undermining its members’ potential income. In 1949, as a part of his Fair Deal, President Harry Truman called for universal health care. Frantically decrying socialized medicine, the AMA, working with Republicans, thoroughly anesthetized that idea. (Commie-baiting remains a favorite tactic.) The AMA conflated patriotism, capitalism—although, come to think of it, for Republicans, those are already conflated—anti-intellectualism, oracular awe, and health care. And Americans bought into it, yet another example of people being manipulated into decisions that are against their own best interests,

The symbol of the medical profession is the Caduceus.

Those snakes, of the genus AMA, are boa constrictors.

My long-lingering irritation about my BIL’s real doctor remark stemmed—and stems still—not from his feeling over-shadowed and in a sibling-rivalry-tinged moment trying to throw some shade back; nor from the fact that he saw an MD’s potential earnings as more valuable than a PhD’s potential contributions to her field. MDs do make more money than his sister ever would. My irritation stems from this: Of the many advanced degrees that entitle people to call themselves doctors, an MD is among the—if not the—least academically rigorous.

It is not that I think people don’t have to work hard for their MDs. Of course they do. But getting through med school is—sorry—mainly memorization; it is learning long lists of muscles, bones, glands, nerves, joints, conditions, diseases, and statistics (which their patients inevitably become); along with lists of incantatory pharmaceutical names and their side- and after-effects. Med school is difficult in the sense of tedious. But earning an MD is simply not as onerous as earning a PhD is for scholars in unreal disciplines like Astrophysics, Quantum Mechanics, English, Comparative Literature, Microbiology, or …. Earning an MD requires a good memory, the willingness to train and use it, self-discipline, time, and an adequate supply of uppers.

Earning a PhD in an unreal field of study requires not only memorizing long lists of arcane terms and formulas, but also reading thousands of books about obscure, complicated subjects; and racking one’s brain to understand hair-splitting distinctions and obscure, abstruse, abstract theories that are, more often than not, written in foreign tongues and conveyed via awkward translations that render the writing and the theories even more opaque. Frequently these books and theories are the writings of long dead scholars who, though they may have been brilliant, lacked basic communication skills.

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All this preparation is then followed by years of original research involving thousands of hours hunching over ancient texts, or performing thousands of experiments, all of which must be scrupulously documented. Then the results must be carefully compiled. A book-length dissertation must then be written, then vigorously defended. All this must be done while the PhD candidate endures years of endless, mind-numbing classes, seminars, and conversations discussing esoterica about which no one else in the world cares. Or values. And all this must be done while navigating academic politics. No one seeking social affirmation need apply. And at the end, there’s little hope of finding a job in one’s field.

Having seen what my wife and others endured to earn their PhDs, I have no patience for people who have the complacent, ignorant, jackass-inine attitude that MDs are real while PhDs are unreal. The only thing that is unreal about a PhD is the effort it takes to earn one. Here is a crude comparison (subject, of course, to self-serving spin from the disciplines involved): Medical school attrition varies between 14-18%. Attrition at law schools—where coursework is far more abstract and cerebral than at med school and where, unlike at med schools, classes are graded on harsh curves (please see the following paragraph)—varies from 20-25%. In comparison, attrition among PhD candidates hovers steadily around 50%. (I do not discount the rigors of post-MD medical residencies—they are brutal, multi-year hazings that, were they conducted by fraternities or sororities, would get participants prosecuted. But medical residencies, like longer but less physically demanding pre-tenure gauntlets, occur post-degree, and I am comparing degrees. Yet even counting the rigors of a residency, earning a PhD is, simply, much more difficult.)

Re harsh curves ahead: Have you ever wondered why we don’t hear about real doctors graduating first in their med school classes? It’s because, while law and STEM schools grade on harsh curves, most med school classes are pass-fail. And just as a driver’s license candidate who fails the written portion of the exam gets to retake it, MD hopefuls get to retake failed classes.

Think about this the next time you’re told your next possible appointment with a real doctor—who may have been near the bottom of his or her class; there’s no way to know—is six weeks out; then the week—or day—before, he/she cancels/reschedules; then, when the long-awaited day arrives—by which time your condition is either much better or much worse—you’re kept waiting 45 minutes; then are seen by a PA who gets your name wrong.

[Once, when we lived in north Florida, I was at a real doctor’s office. Searching for a bathroom, I wandered unescorted through the back-office warren and passed a couple of chatting nurses. Not realizing I was there, one said to the other, He’s leaving for golf. Tell everyone waiting he’s been called away on an emergency surgery. (And yes, I do know there are wonderful, caring real doctors. In fact, my own real doctor is wonderful and caring—and I’m not saying that just because I have an upcoming appointment for a pre-mortem, which, for people of my age, is what a physical is called).]

The honorific doctor has a long history—about a thousand years—beginning as an academic title accorded those having earned university-conferred PhDs. Coming from Latin, it was an acknowledgment of advanced learning, a nod of respect to dedicated scholars. It is only relatively recently that it has become associated with health care practitioners and much more recently—around 1847—that it began to lend arisdocratic prestige to MDs while throwing shade on those earning other, far more difficult to achieve, degrees. (There are exceptions: No one has a problem calling him Dr. Kissinger (he’s a tough, gruff guy who speaks with a German accent); or Dr. Phil (he’s on TV); but Dr. Biden? Jill falls well within our American tradition.)

So given that they’re actually less learned, why do MDs get to be publically called doctor—and given all those perks—while PhDs are publically demoted and mocked as pretentious and vain for wanting to be called by an honorific that was incredibly hard-earned, particularly when compared with the difficulty of earning an MD?

The AMA.

In one sense, the AMA’s task wasn’t all that difficult because humans in general, and Americans in particular, were primed for what the AMA did, which was leverage differentiation. In Marketing and Economics, differentiation—sometimes called product differentiationis the process of distinguishing a product or service from others, to make it more attractive to a particular target market. In this case, the target market was America and its riches

Differentiation is critical to the success of any marketing venture. The concept was pioneered by the early Christian Church, which needed to differentiate their product from Judaism: They do Sabbath on Saturday? We’ll do ours on Sunday. Theirs are rabbis? Ours are priests. Rabbis marry? Our will give up sex. (Well, I know, but that’s an entirely different essay.) Synagogue? Church. Hebrew? Latin.

Examples from modern commercial marketing are numerous: Dove is not soap, it’s one quarter cleansing cream. (What is cleansing cream exactly? Is it anything like soap?) Colgate-Palmolive now markets dozens—literally dozens—of different Colgate toothpastes, each of which is a product very much like another product that’s been on the market for many decades and which has often been called toothpaste. Some manufacturers buy or create different brands of the same product, giving consumers the illusion of competition. The real purpose is to give manufacturers more supermarket shelf space and a larger share of a particular market. Consumer product differentiations are almost always distinctions without difference.

Manipulating our deep-seated need to differentiate is not hard because we come pre-wired. Differentiation is deeply ingrained in the human psyche: them/us, foe/friend, toxic/healthy, quicksand/solid, dangerous/harmless, peanut/plain. Its roots are entwined in every moment of every perception. It’s how we survive.

An insidious use of differentiation is to foster fierce loyalty to a false distinction. To put that another way, its intent is to make a spurious distinction seem real. Them/us can be relatively benign—my Rams are tougher than your Chargers—but turned to the dark side it can subvert. As we see coming from the right, them/us can be used to more sharply define cultural divides that, because they resonate with foe/friend, can prod otherwise well-meaning people to acts of previously unthinkable political and/or physical violence. A frightening example is the January 6th attack in the name of patriotism on the capitol; anyone who has ever wondered why people rioting in the name of justice will destroy their own neighborhoods will gain some insight by comparing these.

The AMA’s most effective use of differentiation was to create specialists. The next time you wait six weeks for an appointment; then are granted access to the inner sanctum and placed in solitary for forty-five minutes of meditation on your sins; then are finally blessed by the distracted presence of the oracle; then feel grateful that the oracle listens not-all-that-attentively to your concerns; then anxiously await while the oracle pretends to consider your plight, contacts and communes with the keepers of secret knowledge, then tells you’ll need to see a specialist, thank, the AMA.

Then call Dr. Cunningham, a real doctor who knows how to do research.