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Social studies of the medical profession involve the analysis of medicine as an occupation. The emphasis lies not on the technical discoveries of medicine or on the biographies of great physicians but on the ways in which the production and application of knowledge in helping prevent, cure, or care for illness is a social activity. Social science studies of medicine are historical and structural and not only cross-sectional and psychological. To understand medicine we need to explain its historical development. This research paper focuses on medicine in the English-speaking world.
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1.1 Medicine as a Profession
The traditional professions have a history rooted in the guilds of the Middle Ages (Krause 1996). In the nineteenth century the professions promised a mode of work which provided an alternative to the deadening factory systems of the day. Today bureaucracy and profession are contrasting work principles, the former characterized by hierarchy and routine, the latter by autonomy and self-direction.
In the 1930 to 1960s and in comparison to ‘ordinary’ occupations, the professions were viewed as having unique attributes including an esoteric body of knowledge, a code of ethics, and an altruistic or community orientation. Yet studies of speciﬁc professions, including medicine, indicated that they were not as rigorously self-regulating, ethical, or ‘community oriented’ as their doctrines asserted. By the latter part of the twentieth century the professions were seen as exploiting their power to reduce competition, to secure higher incomes, to entrench their task monopolies, and to protect as much as correct or discipline, their own miscreants. The core of professional identity came to be deﬁned as control of the content of work and professionalization as a strategy for attaining and maintaining control over a set of tasks (Freidson 1970, Larson 1977). Social studies of medicine reﬂect this increasing skepticism about professional altruism (Saks 1995).
1.2 A Heterogeneous Profession
To speak of ‘the medical profession’ is to ignore the profession’s internal and international variation. Within particular countries there are dozens of medical boards, associations, and regulatory agencies. Public health and curative medicine have divergent aims and somewhat competing philosophies. Physicians work in a variety of organizations and settings which diﬀerentially shape their work and orientations. Internationally, medicine ranges from doctors using basic medical equipment to highly skilled experts employing complex computer-assisted procedures. It encompasses practitioners who routinely accept bribes to high status doctors catering to elite clients. While some countries or regions have a physician oversupply, others need more physicians. Internationally, the ratio of physicians relative to population ranges from two (in Chadd, Eritrea, Gambia, and Malawi) to over 400 per 100,000 population (Cuba, Georgia, Israel, Spain, Ukraine). Globalization has, however, been accompanied by an almost universal reverence for highly technical medicine to which elites around the world want access. Doctors are generally of high social standing.
2. Historical Development
In the second half of the nineteenth century medicine was fragmented and fractious, composed almost entirely of males and faced with a variety of competitors from midwifery to homeopathy within pluralistic healing systems. Many laypersons thought they knew as much about health and illness as physicians. While anesthetics and aseptic techniques had helped to improve surgical procedures, medical therapies generally were not far removed from the bleeding, blistering, and purging prevalent earlier.
By the middle of the twentieth century, in less than 100 years, medicine had risen from its previously lowly position to one of social and cultural authority (Starr 1982). Medical power was considered to be legitimate and justiﬁed. Physicians controlled key health care institutions and were the acknowledged experts in what constituted disease and what should be done about it. In mid-century, unlike in earlier times patients generally beneﬁted rather than suﬀered from visiting a doctor. Medical education was lengthy, rigorous, and science and technology based. Entrance into medicine was highly prized and competitive. Physicians had high status, unprecedented autonomy and authority, and high incomes. Medicine was dominant within health care (Freidson 1970, Larkin 1983, Starr 1982, Willis 1983 89).
At the end of the twentieth century, ever more complex instruments permit a new gaze into and through the human body. Innovative therapies and technologies are announced daily. Treatments promise to make even cancer more like a chronic illness than an acute fatal disease. The amelioration of symptoms is important.
The major trend for medicine has thus been that of an increasingly scientiﬁcally sophisticated, powerful and eﬃcacious profession. There are, however, dissenting views. Medicine has possible iatrogenic eﬀects on the individual, the institutional, and the social level (Illich 1975). Powerful technologies and pharmacologies often have negative side eﬀects. Medicine still is more eﬀective at treating injuries and trauma and acute disease than it is at curing the rising tide of more chronic diseases in aging populations. Medicine individualizes the social causes of illness and may rob the public of the inclination to view themselves as responsible or competent regarding their own health. The proliferating use of antibiotics creates more deadly drug-resistant organisms. Ever-more aspects of life are viewed as posing a threat to health rather than accepted as a normal part of life. Analyses indicate that more doctors and more health care are not the major factors leading to the improved health of populations (Evans et al. 1994, McKeown 1979). Medicine is criticized both for being too scientiﬁc and not ‘humane’ and for not being scientiﬁc enough in testing its own procedures. The profession is accused of self-interest in its attempts to hinder, prevent, or shape the establishment of health care systems designed to ensure more equal public access to health care.
2.1 Medicine, Central and Powerful yet Challenged
Medicine is always part of, rather than ‘above’ society. In the nineteenth and early twentieth centuries medicine was overtly, sexist reﬂecting the patriarchal social structures of the time. Women patients were viewed as fragile victims of their own uteruses (Ehrenreich and English 1973). Before and during World War II, the profession in Germany actively displayed anti-Semitism and physicians took part in the Holocaust. Under state command economies, medicine frequently, as in psychiatry, served the purposes of the state in oppressing or subduing citizens. In Europe and North America, medicine early on was eugenicist and, in many jurisdictions, physicians sterilized the mentally ill or retarded. Later, tranquilizers used by doctors to treat depression in women also served to ‘adjust’ women to what are now perceived as oppressive social roles. Given the tendency to reﬂect the interests, values, and regulatory regimes of the era in which it is embedded, medicine can be seen as part of the movement to control and regulate populations (Lupton 2000).
Medicine is part of the movement towards medicalization, the tendency to view human phenomena, not in terms of right or wrong, but in terms of health and illness. Yet the medical profession is not the only source of such medicalization. Health care is the source of proﬁts within a rapidly expanding medical– industrial complex. Nonprescription drugs and food supplements are as popular as prescription drugs. The drug industry is one of the most powerful drivers of the health ﬁeld and its research directions and applications.
We are living in a ‘risk society’ (Beck et al. 1994). Almost any activity now carries with it an assessment of the possible threat to health and safety that it contains. In a secular and materialist society, human life is not viewed as preparation for an afterlife but as an end in itself. There is a desperate desire to delay death, avoid or control risks, and to appear and be, young and vigorous, or at least not old and decrepit. In all of these areas medicine has something to say.
Nevertheless, seemingly at the height of its powers, and with new genetic discoveries promising much more in the coming decades, medicine faces challenges from all those whom it had previously controlled or inﬂuenced, from patients to governments (Haﬀerty and McKinlay 1993). In what follows, the historical rise of, and contemporary challenges to, medicine are traced through a brief analysis of medical knowledge, education, practice, and discussion of ‘the rise and fall’ of medicine.
Medical knowledge and medical power are intimately related. Control over the production of knowledge as well as credentialism are methods whereby medicine has attained and maintains control over health care.
The profession administers the production of knowledge in medical schools or health science complexes. Physicians are the guardians of access to patients and to prescription drugs, crucial aspects of the research endeavor.
Yet, doctors in the eighteenth and nineteenth centuries claimed authority, not on the basis of science, but because of their gentlemanly status. This authority was underwritten by attendance at elite universities and knowledge of classical learning. Medicine was a male middle-class enterprise. Ever-increasing educational requirements served to discourage, or weed out, working class and minority groups.
In the nineteenth and twentieth centuries medicine asserted authority because of its association with the rapidly rising prestige of science. Medicine was one of many groups claiming to be using science to improve human well-being. But this was a particular kind of medicine. A medicine based on individual biology and the germ theory gained ascendance over a public health medicine focused on the social roots of illness in poverty and poor living conditions.
Recent developments have undermined the authority of medical claims to expertise. New forms of knowledge challenge these professional underpinnings. In the late twentieth century nonphysician experts question the eﬃcacy of particular medical procedures. New corps of clinical epidemiologists and others, often at the behest of governments, are busy formulating what works and what does not. Even clinical work can be routinized through medical guidelines or protocols.
In the application of medical knowledge to practical problems, the essence of what it means to be a profession, medicine develops interests not necessarily pregiven by medical knowledge and not necessarily congruent with the needs or interests of patients, the public, or payers (Freidson 1970). To serve its own interests medicine in many countries opposed ‘state intrusion’ into health care or attempts to make access to care more equitable (Haﬀerty and McKinlay 1993). The current ‘rationalization’ of health care has weakened the links between medical knowledge and medical authority both regarding medical control over health care systems and over clinical work (Gabe et al.
1994, Haﬀerty and McKinlay 1993). Economists, planners, and managers claim more expertise in health care policy than physicians. State or corporate involvement in health care systems, new modes of payment, ﬁnancing of equipment, insurance company scrutiny, for-proﬁt health corporations, state protocols, and clinical guidelines shape what doctors do in their day-to-day work.
The relationship between medicine and the social sciences has itself changed. Once medicine used the social sciences to accomplish its own tasks. Typically, social scientists were asked to help understand why some patients did not ‘comply with’ medical regimes. Now, social science has begun to undermine medical authority through challenging the biomedical paradigm, through its focus on medical power and selfinterests, and for its support of the view that health is determined more by social factors than it is by health care. Social science analyses were once ‘in’ medicine but are increasingly now ‘of’ medicine.
The foundations of medical knowledge are being challenged by new views of science in which knowledge is viewed as being socially constructed or determined rather than science directly reﬂecting ‘nature.’ There are now claims that medicine is ‘constructing’ the body rather than simply ‘discovering’ it (Lupton 2000). Biomedicine is not viewed as scientiﬁcally neutral but as a truth claim in contests over power. From this perspective the profession is also conceived as part of state attempts to control populations through implicit methods of ‘surveillance’ and of inculcating norms of behavior through various medically approved ways of thinking and acting (Petersen and Bunton 1997, Turner 1995).
4. Medical Education
In the late nineteenth and early twentieth centuries university education became the oﬃcial certiﬁcation of professional standing. Medical training changed from a rather haphazard process, given in some countries in proﬁt-making schools, to a scientiﬁc education, most often accomplished in public universities (though in some countries the most prestigious schools were in private colleges and universities). The Flexner Report in the United States in 1910 reﬂected the triumph of the new biomedicine and was important in making university education more scientiﬁc and laboratory based, on the German model. Dozens of schools were closed and exclusionary tactics and credentialism raised the status of the profession, controlled competition within, and helped reduce competition without (Larson 1977).
By the mid-twentieth century medical students generally took four years of education followed by internship and perhaps another three or four years of specialist training. Usually the ﬁrst two years were science based with clinical training being introduced over the subsequent years. Throughout the century the power of the universities and medical schools or the state over medical education increased and the direct power of the profession over curriculum and even the number of students being trained decreased.
Medical students are now more diverse in background. Jews are no longer overtly excluded or ostracized and, beginning in the 1960s, women formed an increasing proportion of the medical school population. Other minority groups are still not equitably represented among medical students and practitioners but now as much for class reasons as because of race or ethnicity.
Early social science perspectives had held to the view that what physicians did in their practices was a reﬂection of the training they had undergone. By contrast, in the 1970s it became accepted wisdom that the behavior of physicians was more a reﬂection of the work situation in which they practiced than it was of their educational experiences (Freidson 1970). Medical students were being socialized into the role of the medical student rather than into the role of the physician. They learned how to study, how to be emotionally detached from patients, how to tolerate clinical ambiguity and, in their confrontations with their clinical teachers, to become adept at presenting themselves as knowledgeable and competent. Medical students are now collectively less passive. In some countries interns and residents have organized into associations and unions to improve their conditions of study and work and their pay.
5. Medical Practice
From the earliest times doctors practiced by themselves within markets. In the eighteenth and nineteenth centuries doctors faced competition both from other physicians and from ‘other’ healers ranging from midwives to bonesetters. The use of physicians was a last resort and hospitals were largely a place for the poor to die. In any event few could aﬀord physician fees. With improved perceived eﬃcacy and the rise of a market for health care, physicians emerged as the pre-eminent free-enterprise professionals and adopted a corresponding individualist ideology. In the 1930s medicine was still largely based on solo practice. But within half a century there was a major transformation of medicine from physicians as petty bourgeois entrepreneurs catering to patients in the domestic sphere to physicians as part of a mass health care market treating patients in oﬃces or in the new ‘health factories.’ In most Western countries spending on health care now ranges around a mean of about 9 percent of national GNPs. Worldwide, however, health care expenditures varies widely, from 2 percent of GNP (in low GNP countries) to over 14 percent (the United States).
As part of the movement towards the welfare state, the provision of medical care became a public concern. Internationally many forms of payment mechanism and system developed, from health care systems as in Britain to national health insurance (e.g., Canada) to more private systems (e.g., the United States) or to mixed forms (e.g., Australia, Germany). These systems inﬂuenced what physicians did, and where, for how much, although in somewhat diﬀerent ways (Haﬀerty and McKinlay 1993, Johnson et al. 1995). Today increasing proportions of physicians are paid by salary or capitation rather than the traditional fee-forservice, although in some places such as in Eastern Europe, this trend is reversed. Though medicine resisted the intrusion of state or corporate power or tried to shape it, everywhere there is more external control than there was previously over the nature, conditions, and quality of practice.
Medical autonomy is being undermined in both private and publicly ﬁnanced or organized systems. In the most predominantly private system, that in the United States, privately owned provider organizations control the day-to-day work of doctors in the name of proﬁt or saving costs. In publicly ﬁnanced systems, once some form of control over physician costs had been instituted, the state tends to leave purely ‘clinical’ matters in the hands of the profession. Yet general health care policies, such as the almost universal controls over the use of technologies or over payment mechanisms, do have a profound impact on what individual physicians do at the clinical level. Nevertheless, medicine in more private or more state run systems is subject to diﬀerent constraints.
The heart of professional standing is self-regulation, yet, within the market and outside of it, by competition, by corporate ﬁat and or by state regulation, medical practice is subject to more surveillance and regulation. There is a deepening division in many jurisdictions between the function of representing the profession and that of licensing and regulation. Organizations with the latter aims, even if still largely controlled by physicians, are more constrained by public or governmental input, direction, or representation than they were previously. Professional selfregulation, the core measure of professional standing and autonomy, is never complete and is always qualiﬁed.
Physicians are a cohesive and closed group, dependent on colleagues for patient referrals, for recommendations, and for mentorship though now competing for patients. There is competition in some big city markets for patients, and, in various stateadministered systems, there is physician unemployment. Perhaps as a result of competition, for the ﬁrst time in the United States in 1994 the average income of physicians dropped. Internal fragmentation made more diﬃcult the eﬀorts of medical elites to mobilize the profession to face the political, economic, and social challenges of the late twentieth and early twentyﬁrst centuries.
The last third of the twentieth century witnessed the rise of neo-liberalism and globalization accompanied by attacks on the role of the state and the decline or transformation of the welfare state. Health care systems became more controlled, rationalized, and privatized. The interests of medicine are no longer necessarily congruent with the forces which led to welfare state decline. Business and states are in an implicit or explicit coalition to control health care costs hence the work of physicians. Medical practice has thus historically moved from a situation of patronage, in which clients controlled physicians, to one of collegiate or colleague control in a medically dominated system, to one in which doctor–patient relationships are mediated by (public or private) third parties (Johnson 1972).
5.1 Understanding Changes in Medicine
What do developments in the last century and a half tell us about the medical profession? There is more agreement regarding the general trends than there is about how to understand these. Medicine rose to power in the nineteenth and early twentieth centuries. By the mid-twentieth century, medicine was dominant in health and health care, controlling the content of care, patients, other health occupations, and the context within which medicine is practiced (Freidson 1970). Other health occupations were absorbed, subordinated, limited, or excluded from the oﬃcial health care system (Willis 1983 89). Powerful within health care systems, medicine had important eﬀects on the societies in which it was embedded.
Today, however, medicine faces challenges from all those with whom it interacts. Patients use unorthodox forms of healing and herbal medicines, demand particular forms of care, and complain about or sue physicians. Health care occupations, many of them ‘female’ occupations, from nursing to physiotherapy chafe under medical control, seek autonomy, and chip away at the borders of the medical monopoly through credentialism, claims to a unique knowledge, and through political bargaining. A proliferating variety of forms of unorthodox healing, from shiatsu to chiropractic, claim legitimacy (Cant and Sharma 1999). States and corporations come to shape medical work. The impact of a technologically sophisticated medicine on human well-being or the health of nations is not as clear as it once appeared. Moreover, just when medicine is facing external challenge it is weakened by internal fragmentation by specialty and gender and by a developing hierarchy between an academic and research elite and practitioners. The major issue for social science analysts has thus become to understand a historical trajectory of rise, consolidation, and challenge or possible decline of medical power.
A common-sense explanation for medical power is that medicine became authoritative as it gained in scientiﬁc knowledge and became more eﬀective in curing disease. However, while improving eﬀectiveness, or at least the perception of such eﬃcacy, was important (doctors have to be sought out by patients), historians have noted that medicine became cohesive and dominant before it became more eﬃcacious. Eﬃcacy based theories of the rise of medicine also have diﬃculty explaining recent weakening medical power (though changing disease patterns are important).
Many social science analyses of medicine have been descriptive narratives loosely based on a simple interest group perspective and have focused on interprofessional relationships. Freidson’s emphasis on medical dominance in the 1970s stimulated broader debates about the reasons for the rise of medical power. Pluralist interest group theories, or forms of closure theory (Murphy 1988, Witz 1992) which stress medicine’s own struggles as part of a ‘system’ of professions, contrast with structurally oriented theories which emphasize the rules within which interest group struggles occur (Abbott 1988, Murphy 1988, Navarro 1986, Witz 1992). Closure theory describes the strategies of demarcation of occupational boundaries and of exclusion used by medicine in attaining and maintaining its dominance over other health occupations. By contrast, structural theories claim that medical power is fundamentally anchored in the congruence of its interests and ideologies with those of dominant elites, classes, and the state. Biomedicine became predominant partly because its individualist oriented explanations drew attention away from the social causes of disease. In general a focus on medical ‘agency’ views medicine as imposing biomedicine on society, while structural analyses focus more on the ‘selection’ of a particular type of medicine by prevailing structures of power.
5.2 Is Medical Power Declining?
Has the social and cultural authority of medicine declined since the medical dominance thesis was ﬁrst proposed? Most analysts acknowledge that medicine is being challenged, particularly since governments, as part of the rise of welfare states, are viewed as ‘intruding’ on medical power within health care. A few theorists argue that state involvement in health care actually crystallized medical power in place (Larkin 1983) or that medicine as a corporate entity retains its power externally although individual practitioners may have lost some of their autonomy to medical elites. But the consensus is that medical power is not what it once was.
The terms proletarianization or corporatization (McKinlay and Stoeckle 1988) depict trends inﬂuencing medicine as similar to those that aﬀected workers in the nineteenth century as skilled workers became employees and their work came to be managerially controlled, if not routinized and fragmented. Medicine, previously an autonomous and dominant profession, has become subject to state, corporate, and bureaucratic imperatives. Although the proletarianization thesis applies more closely to the United States with the major instance the corporate micro-management of physician work, still, state or corporate rationalization of health care everywhere involves more control over what physicians do and how they do it. Deprofessionalization refers to the decreasing distance, in knowledge or education, between doctors and patients or the rise of consumerism generally (Haug 1975).
It may be that all of these diﬀerent perspectives reveal something about medical power, although referring to somewhat diﬀerent levels of analysis and or to diﬀerent aspects of medical power. The proletarianization thesis most clearly applies to medical work; deprofessionalization to medical knowledge; and social closure to inter-professional struggles. Proletarianization is the most general concept since employment status and managerial control as part of a general process of the corporatization and bureaucratization of care can aﬀect most aspects of medical dominance. For example, current reforms of health care almost inevitably involve pressure for a reorganization of interprofessional relationships within the health care division of labor in the name of eﬃciency, potentially leading to a weakening of the medical monopoly.
The notion of professionalization as a strategy of control over a particular work domain, which includes as a key component professional autonomy and selfregulation, implies continual struggles over such control. State and private interests now coincide in viewing medical power as a barrier to a reorganized and less costly health care. In this sense, both the rise of medicine to a dominant position and its current possible decline can be viewed in terms of the congruence or incongruence of its interests and ideologies with class and state forces external to health care. Medical power, as both Freidson and Navarro in their diﬀerent ways have pointed out, is always contingent on its ﬁt within the power structure of the societies of which it is a part.
Analyses of medicine have been given recent impetus both by world events and by new social science perspectives. Economic globalization and the rise of an emphasis on markets in health care have brought a new urgency to attempts to understand the role of medicine. For example, might a return of health care markets bring a revival of medical power? It seems unlikely to do so because market oriented governments regard the professions as unneeded market monopolies and health markets are themselves constraining. If some physicians in some countries beneﬁt from neo-conservative or even ‘third way’ policies, their gains are somewhat accidental and contingent. Medicine no longer has the power to deﬁne the health agenda.
Explanations for the changing nature of medicine are also caught in the debates between agency and structural determination which pre-occupy the social sciences. The notion of diﬀering levels of analysis, individual and group actions within particular changing social structural conditions might provide a way out of this dilemma. New perspectives in the social sciences may help bridge or transcend these dichotomies (Scambler and Higgs 1998). For example, notions from Foucault of power as enabling and not simply repressive may change our views of doctor–patient power conﬂicts (Petersen and Bunton 1997). Social constructionist views that biomedicine is simply one among a number of diﬀerent and presumably equally valid ways of viewing the world and the body may fundamentally alter traditional views of science and knowledge. Theories about the eﬀects of globalization on state autonomy, class structure, and professional powers may prove important (Coburn 1999) as might attempts from critical realism to view agency as operating within structures. Certainly, any perspective on contemporary developments has to come to terms with the broader economic and political changes, many of these towards more market oriented economies and societies, which are sweeping the world. Such analyses, however, are more promises for the future than current accomplishments.
Medicine is like other forms of work and subject to many of the same general pressures. Physicians are both active in shaping and reproducing particular social structures yet the profession cannot escape being subject to such structures. Most recent social studies of the medical profession are oriented to its power, to changes in that power and evince an increasing skepticism to professional claims of altruism. The focus is on the self-interests of the profession and its changing accommodation with external powers. This view contrasts with perspectives which emphasize the many individual (Norman Bethune in China) and collective (Medicine Sans Frontieres) acts of heroism and self-sacriﬁce of physicians or groups of physicians. The social science emphasis on self-interests and power is a little onesided, medicine is not only self-interested. Moreover, a health care controlled by private corporations, managers, or the state may presage a worse future for patients than one in which medicine, or at least individual physicians, retain a relative autonomy from external powers.
Medicine rose during a particular period of industrial capitalism and ﬂourished, perhaps had its ‘golden age’, during the period of the development of the welfare state. In that milieu medicine could partially reconcile both service to others and its own selfinterests. We are today in a new era, one which promises a greater emphasis on individualism and on markets. Thus, medicine, as the societies of which it is a part, is currently in the midst of profound changes, the ramiﬁcations of which are as yet unclear. At the center of societal and individual concern and interest yet challenged by others as to its pre-eminence. Embedded within a huge industry much of it driven by the desire for ﬁnancial gain, and enmeshed with state bureaucracies with their own imperatives. Medicine is revered yet envied, sought after but viewed with skepticism, scientiﬁc yet saturated with self-interests and motives not pregiven by its science or service, with many potentially altruistic practitioners yet apparently mercenary organizations. The challenge for medicine is to fulﬁl its service to others in an era of proﬁt seeking. The social sciences focused on medicine face the task of providing an understanding of medicine more adequate for contemporary transformations and contradictions.
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