Over timethere have been many discussions and debates concerning whether medical powerand professional dominance is under threat. ‘Medical autonomy is the publiclyaccepted control that medical professions exercises over the terms andconditions of its work. Medical dominance is a relative concept, indicating theauthority that the medical profession can exercise over other occupationswithin the health care division of labour, patients or society.’ (Gabe and Monaghan, 2013) If thereis a decline of professional autonomy or dominance in the medical profession itcan take a range of different forms. One aspect will be a change in doctorpatient relationships, other aspects will include medical professions becomingless autonomous as they will become more controlled from the side of the state,on the basis of what they actually do and what they have input in, and patientscan then complain to figures higher up in medical structures. Scepticism insociety towards the health care system can also compromise the trust ofpatients in physicians thus leading many patients to rely on the internet or seekalternative medicine.
There have been several shifts that explain the reasonfor the transformations suggesting a decline in medical power and professionaldominance in contemporary society. However, I think medical power andprofessional dominance are both under threat to a certain extent. This essaywill explore whether we are on the professional verge of a decline in theprofessional power.Over the lastfew decades of the twentieth century there have been several trends andtransformations in health care.
Due to the transformation from modernity topostmodernity dominant institutions in society that used to keep the balance,have less influence. It has led to people having more freedom in the choicesthey make regarding their culture and identity. Post modernisation has led to newarrangements of social structures by introducing a state of flux within socialrelations. Klein (2010) stated that the NHS is in a ‘permanent state of flux’,the structures and positions in the system are fluid therefore the pace of change is so fast,that it is hard to keep up with all the different things happening.
These transformations have had an effect on the NHS which can make theirservice unsustainable. In order for the health service to cope with thestructural changes it has to make a profit off their service whilst also creatingsocial unity, but this is problematic as all their resources are used up whilstnot being able to accumulate profit.The rise ofthe new managerialism in the health care system mirrors the bureaucratic stateas it involves the government intervening to ensure development, it dispersesthe medical power from the physicians in the centre of the system to managerson the outside. Hence, resulting in a rising shift of involvement from thirdparties who impact the health care system through their funds and organisation.’in the UK, the major reforms to the NHS that have been introduced since the1980s – including the introduction of a more market- driven ethos and structurehave been seen by many as constituting an attack on producer dominance andprofessional exemption from external scrutiny. In the USA, the expansion offor-profit health care corporations, the move to managed care and associatednew financial management of medical practice’ (Gabe and Monaghan, 2013). Thenew management has adopted the style of the private care system, so the serviceprovided to patients depends on how much money is spent, this furtherdemonstrates the effects of consumerism on the health care system. Those who donot have the money to pay for private health care may not get the besttreatment or may not be able to afford the services which will lead them toseek alternative medicine.
Organisationalflux is a regular affair in the health care system as the trends andtransformations shape their policies. There has been a shift in health carefrom focusing on disease to the main concern being and maintaining a healthylifestyle. ‘From the mid-1970’s, health policy documents began to emphasize theneed to promote good health rather than treat illness and disease’ (Nettleton,2013). Another shift has been the health and medical care going from theconfines of a hospital to being dispersed through the community. The changesfrom traditional to unconventional health care has driven patients to adaptfrom the primacy of biomedicine to a plethora of health options.
The choice ofalternatives has blurred the lines between medical knowledge experts and theconsumers. This may cause a decrease in professional dominance because they nolonger have influence on how patients are treated and what issues they bring tothe hospitals.There areseveral explanations of why these transformations have taken place and can beconsidered as underlying reasons to the demise of professional authority inmedicine. The theories predict how physicians control over the content of theirprofession. The de-professionalization thesis focuses on the change in dynamicbetween professionals and clients due to patients’ uncertainty of how effectivemodern medicine is which have led to patients becoming sceptical. It is aninfluential criticism of the developments in health care, it contemplates theshift in policy from its values of inclusion and citizenship to focusing oncontrolling public expenditure (Clark, 2005). ‘sustainabilityand transformation plans (STPs) which propose ward closures, cuts in bednumbers and changes to A and GP care in 44 areas…needs to find£22bn in efficiency savings by 2020-21…A draft plan circulating among NHSmanagers in West Yorkshire reveals proposals’ (BBC News, 2018), doctors do nothave a say in where the savings are made it is down to the managers and trustswho work for the government.
The cuts have led to protests frompatients and welfare workers who are feeling the pressures of the detrimentalsavings. It also makes the private sector take responsibility from the publicsector such as formal services doing less and private individuals or familiesdoing more. The thesis also states a difference in the roles of the professionals;they have less opportunity to be autonomous, so they may go against theirprofessional opinion for what may be best for their patients and they have lesswill when it comes to treating patients (Clark, 2005). This reflects thephysicians experiencing de-professionalization because they can no longer givetheir patients the best service in their opinion due to not having the access theyneed to resources, in this case they lose their medical power as they become toolsof the state. Ritzer and Walczak (1988) stated ‘Their power, status, and continuingcontrol over a centrally important area of human existence lead us to believethat they will not tumble far down the professional continuum’.TheProletarianization thesis, a Marxist notion predicts that eventually themedical sector will become part of the capitalist system and have no controlover production which will result in the professionals becoming isolated fromtheir work as they will have no input.
The term was exchanged to thecorporation thesis because of the limitations the proletarianization thesis and’the word was considered threatening’ (McKinlay and Marceau 2002). As the rules,procedures and authority are increasingly controlled the professional autonomyis undermined as they will no longer be in control of things. The Neo-Marxistperspective explains that as medicine advances and becomes more corporate,physicians lost some of their professional rights to regulate their servicewithout the government intervening. Thegovernment also affected medical work by breaking it into specialist subsections. For instance, because medicine’s increased use of new moderntechnologies, allows staff who are not medically trained to be able interfere inthe relationship doctor and patient by advertising new techniques as trends ornew products, also these staff can also control these technologies without thedoctor being there.
This makes patients seem like clients of the NHS or truststhat manage the doctors rather than being the doctors’ own responsibility and beingable to develop intimate relationships. Therefore, physicians cannot be seen asprofessionally dominant due to them working for the organisations and not beingself-employed. McKinlay and Marceau (2002) argued that the Marxist theories suggestthat the capitalist development causes the reduction of professional rightslike the right to set salary showed medicine was producing capital for thestate. The Proletarianization thesis was seen as a flawed argument so it wasrevised because as the corporate world becomes more and more influentialmedical doctors become reduced to employees meaning they would be deprived oftheir access to means of production. It was a one-sided theory, so it wasadapted to the corporation thesis.
The Corporation thesis is more suggestive asthe cause of the changes than proletarianization. However, it is problematicbecause it is not useful in countries where health care is provided by thestate for example medical autonomy is changing in places that have their healthcare funded by the state. Otherhealth care occupations have been thought to challenge medical dominance.
For example,nurses have been developing their clinical skills and growing in order to allowtheir roles to cover other medical responsibilities that are parallel todoctors, such as being able to prescribe medicine. This is also a similar caseto physiotherapy or pharmacy. From personal experience patients are beingreferred and encouraged to go to pharmacists first to be treated and diagnosed,the experience is comparable to an appointment at a general practice.
Itcreates a gap in the doctor patient relationship as the doctor no longerbecomes an important contact but rather a last resort. Also, it makes medicinemore available to patients which undermines the need to have doctors when ithas become easy to approach a counter and purchase medication. According to theproletarianization thesis this is an example of the health sector surrenderingto the capitalist movement to separate the medicine from their work as doctorsto make profit.However,this does not necessarily mean professional dominance is under threat, it justrepresents a working hierarchal structure to society and within the health caresystem. Considering that doctors are the main authority figure it oftenreported and the case that they are overworked and constantly busy it onlymakes logical sense to delegate to relieve the pressure. Cooper et al (2011) indicatedin their study the confidence that patients have in doctors to oversee theprescription process and have a pivotal role in ensuring the correct clinicalcompetence ‘supplementary prescribing involves the doctor in the initialdiagnosis’.
It doesn’t threaten medical dominance if anything it enhances itallows nurses and pharmacists have the confidence to refer back and askquestions, ’empowered them to discuss medication with doctors and question themabout how they made prescribing decisions’ (Bradley et al 2007). Doctors stillremain as the primary figures to diagnose and the medical knowledge bearers.The rise ofconsumerism also influences medical power, there have been broader shifts inthe climate of medicine and the emergence of the more consumerist context. Thechoice of patients is now prioritised in health care which gives them thechance to choose between different doctors and different medical approaches.
Complementary and alternative medicine today views the body holistically andsuggests that illness is caused by our psychological state, spiritual andsocial environment being disrupted. The new medical movement to focus on livinga healthy lifestyle means patients will often to choose to go for alternativemedicine as it allows them focus on restoring balance and repairing their bodyrather than focusing on an illness and dealing with symptoms. This isespecially true for patients who may have a chronic illness but do not want tospend their lives managing or concentrating on its effects as it viewed as the medicalpractice’s inadequacy to treat them. Thus, leading to patients taking mattersinto their hands and seeking an additional helping hand, this shows how willingpatients are to challenge the medical expertise which provides them with morehope.
This can once again destabilise medical power because if they alternativemedicine is able to benefit patients who had been turned away by physicians itcreates a public scepticism towards the efficacy of the health system. ‘CAM andbiomedicine are in an economic political and cultural struggle by the medicalprofession attempt to maintain a monopoly’ (Saks 2003). The struggle can causea shift from biomedicine dominating the health system to equally sharing withcomplementary and alternative medicine due to the increased interest bypatients. ‘2002,about 62% of U.
S. adults used some form of CAM in the past 12 months’, Barneset al 2004 argue that the results found in their study related to patientsconfirming results from CAM are surprising as there is a lack of evidence tosupport the efficacy and safety of these therapies. However, the effects of itcould be due to many reasons such as individual differences or the placeboeffect which suggests treatment will work as long as the patient believes itwill work.The internethas become a form of empowerment for patients due to the bureaucraticregulation on the system it has allowed expert knowledge to become moreaccessible to everyday civilians. Reducing the knowledge gap between the professionalsand patients presents a challenge to the medical power as they no longer viewthe professionals as a more knowledgeable other. They feel as though all theanswers they need can be found on the internet.
A majority of people go to theinternet first when they experience some symptoms, sometimes this can be theanswer for example when they conduct their search on websites or forumsaccredited by professionals or run by them. If this was the case, there wouldbe no issues but many of these sources on the internet are controlled by laypeople and the information is not completely credible. This then causespatients to believe their condition is either more serious or less serious thanit is, the doctor will tell them the opposite of what they think, resulting intensions to grow. This is also an impact of changing lay perceptions and knowledge,as the patients increased use of a broadvariety of secondary sources on the internet, promoted by health careinstitutions has led to more critical patients who are better informed to makebetter informed decisions. This will put the professional dominance underthreat as patients can view themselves coping with out doctors because theinternet can diagnose and provide treatment instructions.Anadditional challenge to medical power is due to a loss in trust from patientsin the health care system and in the professionals that work for the system.
Associatedwith the rise in consumerism, patients are encouraged to become complaisant intrusting medical expertise, this explains patients moving away frominstitutions such as the NHS to private health care because they assume payingfor a product or service and the reputation will ensure higher quality care. Moreover,the decline in trust has also been caused by numerous malpractice allegations, Dixon-Woods,Yeung and Bosk reported in 2011 the role of medical scandals endingself-regulation. Scandals involving bad doctors were nothing new, they were allsimilar in content, for example patients being murdered by doctors, or beingsexually abused. Some offences by the doctors were not even reported due to thehigh status of the doctors and patients being afraid of backlash from society.Therefore, trust has to be re-built, because these cases have caused trust inthe medical sector to be shattered, especially in a time of a social media peakdoctors cannot afford further transgressions as it will reach masses of peopleall over the world. A scandal in onecountry will be enough to affect trust of the health care system in othercountries. On the other hand, Calnan and Rowe (2008) conducted a study andfound that there is a lack of evidence to indicate a decline in trust towardhealth care professionals.
They reported that studies from the UK and USA showtrust is still high for doctors but vary depending on the type of illness, howbig the risk is on the patient and their previous experience with health care.They concluded that trust in health care as a whole is lower than in doctorsindividually.Is medicalpower and professional dominance currently under threat? I’ve concluded from the literature and varioustexts that the health care system has surpassed the biggest impact of all thetrends and transformations that may cause a threat. Although many changes are constantlyhappening, it is only under threat to a certain extent. Society will remain relianton the healthcare based on the knowledge that the treatment used by the healthcare has been empirically test and can objectively prove their treatments have apositive effect on diseases. Even though the health care system has become moreregulated it ensures welfare workers are professional in all they do and limitsthe possibilities of scandals occurring. As long as physicians continue torebuild trust with patients and maintain relationships patients will seek lessalternative methods to curing their illnesses.
On the other hand, doctors may needto accept that they are no longer the primary drivers due to the rise inconsumerism, new biotechnology and third parties’ involvement.