Medical 12

Copyright 2012 by Pearson Education, Inc. All rights reserved.

Chapter 12

The Physician in a Changing Society

Medical Sociology Twelfth Edition

William C. Cockerham


Introduction

Public attitudes toward the medical profession have shifted away from unquestioning acceptance of physician authority

Dissatisfaction with rising costs and the failure to provide quality care for all Americans

Organization of medical care has changed dramatically, reducing authority of physicians


Social Control of Medical Practice

Arguments for autonomy of medical profession: Physicians themselves established the medical

standards enforced by governmental regulating agencies

Laypersons are generally unable to judge technical performance

The physician is a member of a self-controlled collectivity performing a vital function for societys general good



Arguments against autonomy of medical profession:

Laypersons do judge technical performance, regardless of whether they are competent to do so

Autonomy granted to the medical profession is granted conditionally

Assumed that physicians will resolve significant issues in favor of the public interest



Arguments against autonomy of medical profession: Rules of etiquette among colleagues restrict the

evaluation of work and discourage the expression of criticism Technical errors more likely to be forgiven by colleagues

than moral errors

Incompetent and dishonest doctors may still be subject to sanction Malpractice suits and government review boards


Countervailing Power

Countervailing power Describes how a particular group may be only one of

several groups in society maneuvering to fulfill its interests

Suggests that the medical profession is but one of many powerful groups in health care

The medical professions control over its market faltered as these countervailing powers established powerful positions as well and ended the professions monopoly


Government Regulation

The federal government has implemented several measures to control costs and improve quality of medical care: Professional standards review organizations

(PSROs) Established by the government and composed of licensed doctors who determine if the services rendered for Medicare and Medicaid patients are medically necessary, meet professional standards of quality, and are provided as efficiently and effectively as possible


Government Regulation

Diagnostic related groups (DRGs) Schedules of fees placing a ceiling on how much the government will pay for specific services rendered to Medicare patients by hospitals and doctors

Initiated efforts to reform the health care delivery system


Managed Care

Refers to health care organizations that manage or control the cost of health care by:

Monitoring how doctors treat specific illnesses

Limiting referrals to specialists

Requiring authorization prior to hospitalization

Represent a significant reduction in the authority of doctors to make referrals and choose modes of treatment


Managed Care

Have the potential to reorganize health care into a stable, reliable, and less costly form that emphasizes preventive care

But may disrupt doctor-patient relationships and deeply reduce doctor fees without providing quality managed clinical care


Managed Care

Physicians play a variety of roles in such organizations Double agent because they must look out for

interests of both company and patient

Gatekeepers by limiting access to more expensive medical procedures and care by specialists

Patient advocates in working to convince case managers and other bureaucrats that more expensive care is warranted in a case


The Coming of the Corporation

The past decades have seen the emergence of numerous health care and health-related corporations E.g., for-profit hospitals and free-standing

emergency centers

These facilities minimize their expenses through an emphasis on the efficient use of resources

Generally aimed at more affluent patients who can pay for services, usually with private health insurance


The Coming of the Corporation

For the physician, health care corporations:

Provide jobs, offices, staffs, equipment, hospital privileges, and perhaps even a salary guarantee

Represents a loss of autonomy

Less control over the timing and pace of work, closer scrutiny over mistakes, and less control over decisions on policy, hospital budgets, capital investments, personnel appointments, salaries, and promotions


The Changing Physician-Patient Relationship

Three changes have particularly impacted the doctor-patient relationship: 1) Shift in medicine away from the treatment of

acute diseases and toward preventive health services

2) A growing sophistication of the general public with bureaucracy

3) Development of consumerism, which has led to more of a provider-consumer association between doctors and patients


The Deprofessionalization of Physicians

Deprofessionalization A decline in power which results in a decline in the

degree to which professions possess, or are perceived to possess, a constellation of characteristics denoting a profession

Occurring as result of the changes discussed Increasing government regulation

Managed care reducing physician authority

Physicians becoming employees of corporations

Increased consumerism on the part of patients


The Deprofessionalization of Physicians

Government policies emphasizing greater control over health care and the rise of the profit orientation in medicine identify a trend in medical practice away from substantive rationality toward greater formal rationality Formal rationality

The purposeful calculation of the most efficient means to reach goals.

Substantive rationality A process of making decisions with an emphasis on ideal

values


The Evolution of the Organization of Medical Practice

Dominant pattern becoming one in which most doctors are employees

Accompanied by a general evolution in the health care delivery system toward greater size and complexity

Represents a major shift in the organization of American health care delivery

Solo, self-employed, fee-for-service doctors are no longer the norm

Medical 12

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