Theories and the Rise and Fall of the Medical Profession
The modern profession of medicine stands among the powerful, if not the most powerful, of occupational groups in contemporary society. Medicine and its practitioners are the arbiters of life and death; of possibilities realized, possibilities reclaimed and possibilities dashed; and of evaluations of “normal” and “abnormal.” The expansion of medicine’s claim over more and more life spheres has been chronicled and criticized (see Olafsdottir, Conrad, both in this volume). In contemporary society, we turn to physicians to understand what we do, what we should eat, and whether we should punish or treat those who step outside society’s norms. And, despite claims that the power of the medical profession may be waning, no viable alternatives have come forth to replace the allopathic system. Even “complementary alternative medicine” (both indigenous and New Age) has been absorbed, transformed, or otherwise brought under its jurisdiction.
KeywordsSociological Theory Complementary Alternative Medicine Scientific Medicine Carnegie Foundation Germ Theory
The modern profession of medicine stands among the powerful, if not the most powerful, of occupational groups in contemporary society. Medicine and its practitioners are the arbiters of life and death; of possibilities realized, possibilities reclaimed and possibilities dashed; and of evaluations of “normal” and “abnormal.” The expansion of medicine’s claim over more and more life spheres has been chronicled and criticized (see Olafsdottir, Conrad, both in this volume). In contemporary society, we turn to physicians to understand what we do, what we should eat, and whether we should punish or treat those who step outside society’s norms. And, despite claims that the power of the medical profession may be waning, no viable alternatives have come forth to replace the allopathic system. Even “complementary alternative medicine” (both indigenous and New Age) has been absorbed, transformed, or otherwise brought under its jurisdiction (Astin et al. 1998).
In this chapter, the rise of the modern medical profession to this position of power and prominence will be traced through a recounting of sociological theories. This history can be crafted as a story that begins with the glorious and inevitable march of progress, moves to the inside of an aspiring profession, increasingly considers the other social actors, contexts, and processes that enabled the medical profession, and ends, at least to this point, with the full constellation of other institutions and organizations that have the potential to support or encroach on its boundaries. This recounting may take on the flavor of a “grand narrative” with all of its strengths and flaws (see Klein 2004). However, as a sociology of knowledge, it reflects the dominance of the theoretical ideas of the times in which these theories were fashioned. Perhaps more importantly, it reveals a story of incorporating more and more aspects of context that come together to shape the profession’s fate. As Nobel Laureate and political scientist Elinor Ostrom (2009) advised us, understanding the whole of a complex phenomenon requires understanding the interaction of specific structures, forces, and processes. I argue that each theory set took on an explanation of critical parts of the complex interactions that constructed the privileged status that the profession of medicine holds. Together, they provide a thorough understanding of the rise to power but, as yet, an incomplete understanding of its present and future.
To this end, and at the risk of being ethnocentric, I will focus primarily on the American case. Much of the work has been done on the U.S. This is perhaps not surprising, as the U.S. is the country where the medical profession achieved the greatest power and, despite concerns over its future, continues to have a degree of control over aspects of its work never achieved in other societies. The American case represents an integral part of how “professions” came to be defined, and its comparison with other countries allowed a separation of what is essential to professional status and what is not.
Clearly, the modern nation state exerted influence in determining the exclusive jurisdiction of allopathic medicine vis-à-vis other systems of medicine (e.g., the initial support for traditional Chinese medicine under Mao and the Communist Party in China; Unschuld 1992) and the extent to which the allopathic system was privately or publically owned and funded (e.g., as part of welfare state in the United Kingdom and the Nordic countries; Berlant 1975; Porter 2001). Just as critically, political power shaped the nature of colonial medicine in Africa (e.g., Lyons 1988) and Asia (Brown 1979), where allopathic medicine was used as a tool of colonial dominance, and in the public systems in the Soviet Union or Chile, where state socialist ideologies explicitly addressed class-based inequalities in the provision of care (Waitzkin 2011). Thus, almost right from the beginning, Freidson (1970a) marked the critical division between the profession’s power over the content of its work (e.g., diagnosis, treatment) in contrast to control of the terms of its work (i.e., the socio-cultural arrangements under which physicians provided services). Yet, to provide an overview of the complex story of how sociological theories of the medical profession engaged and even stood at the forefront of altering larger theoretical trends and foci (e.g., the shift from concerns with the rise of professional power to debates of over its decline) in sociology, training the analytic lens on one country facilitates feasibility.
Sociological Theories of the Medical Profession in Historical Context
All theories—from medical science to mainstream sociology to the Marxist critique—agree on five fundamental and interrelated factors. Understanding these similarities provides an essential foundation upon which to lay out sociological theories focused on the U.S. profession of medicine. First, medicine is one of the “big three” occupations that has clearly and unambiguously staked a claim as a “profession.” Despite the rather ubiquitous current use of the term to apply to any number of occupations, only medicine, law, and clergy have a special and privileged position based on unique expertise. Whether that claim was/is justified or “natural” becomes part of the theoretical history. What is also clear is that, as Freidson (1970b) noted, in contemporary society medicine appears to “trump” other professions in terms of power (e.g., determining if an individual can or cannot be tried for a crime depending on their assessment of mental status).
Second, while a special role for healers has existed in every known society and the precursor to the modern physician was established during the Middle Ages, what we now think of as a “physician” (i.e., an allopathic and science-based practitioner) only came to prominence at the beginning of the twentieth century in the U.S. and somewhat earlier in European countries (e.g., roughly the 1860s in Germany; the 1880s in Great Britain; Hollingsworth 1986). Third, science, specifically the “Great Break” (i.e., Germ Theory + Anesthesia + Antisepsis), marked the beginning of the modern medical profession. Despite knowledge of anthrax in ancient societies, French, German, and British scientists around 1860 first documented that this disease was associated with a rod-shaped, blood born body (later called a bacillus; see Turnbull and Shadomy 2011). This is widely considered to be the initial step in the development of the germ theory of modern medicine, the dominant paradigm separating modern physicians from all sorts of other healers. Combined with the development of anesthesia (Pernick 1987) and the call to use antiseptics (Haller 1981), the germ theory represented a major departure from the hot/cold, elemental theories and bloodletting practices of physicians of the day (Freidson 1970b; Lindemann 2010).
Fourth, physicians in the late nineteenth century were not held in higher esteem in their communities than were practitioners of other healing traditions, including homeopathy, midwifery, and folk healing. With their medical bag holding mainly purgatives, opium-based medicines (e.g., laudanum), and tools for blood-letting, even the great physicians of that time (e.g., Benjamin Rush in Philadelphia) offered little that was unique. Because of the harsh and even lethal effects of existing therapies, the public held little regard for medicine and especially hospitals, considering them only as a last resort and “a place to die” (see Warner 1986 on the “therapeutic gloom” of the period). Fifth, in the U.S., all theories point to the Flexner Report of 1910, commissioned by the Carnegie Foundation for the Advancement of Teaching, as sealing the fate of the U.S. health care system and the profession of medicine. Given its fundamental interest in education, the Carnegie Foundation hired Abraham Flexner to visit existing medical schools, many of which were proprietary. School administrators opened their doors, anticipating the private foundation funding that might come from their participation. However, much to their surprise and dismay, Flexner took a strong stance on the viability of and support for only the few, newly established medical schools, such as Johns Hopkins, which adopted a scientific curriculum based on the German university. He argued that all other schools should be closed, and they often were. The Flexner Report rippled through the existing landscape of medicine, and discussions of its role and stakeholder motivations are interpreted differently in theories of the rise of the profession, as we shall see below.
Phase I: The Initial Foray—Looking “Inside” to Unique Characteristics
With medicine’s own histories detailing the Great Break, and the victories in World War II serving as the staging platform, sociologists and their colleagues from history, political science, anthropology, public health, and other disciplines sought to understand the modern profession of medicine. They rejected the “Great Man” theories of medicine (e.g., Walsh 1907) in favor of looking to the characteristics of modern practice and practitioners that separated them from other occupations in the medical arena and joined it with the other great professions of law and religion. But even before American sociologists focused their analytic lens in this direction, Sir Alexander Morris Carr-Saunders and Paul A. Wilson in England wrote The Professions (1933). Carr-Saunders, initially trained as a natural scientist, turned his attention to many social problems, including eugenics (which he supported). In this classic treatise, the focus was squarely on the obligations of professionals and their duty to serve others, seeing this as a “higher calling.” What distinguished professions from other occupations were those characteristics that are still seen as the hallmarks of the professions—a specialized body of expert and esoteric knowledge, long formalized (not apprenticeship-based) training in universities, and the establishment of a professional association which oversaw licensing criteria and the development/enforcement of a code of ethics.
In a more abstract way, then, Parsons followed Carr-Saunders and Wilson in articulating those characteristics that separated the profession from other occupations. First, the profession of medicine is characterized by an achievement orientation. Entry into the role is based on technical competence acquired during a long and rigorous training period. Through formal schooling, physicians acquire the knowledge, skill, certification, and confidence to attend to illness. In essence, physician roles come not from skills handed down or inherited along family lines; rather it is a learned profession. Second, the role of the physician is functionally specific. Unlike the more generalized role of healers in premodern societies, physicians are to limit their profession and practice to their scientific training and expertise. They do not serve as “wise men” whose role encompasses understanding and solving all social problems. Third, physicians are expected to approach their work with affective neutrality. Illness is cast as an objective problem and patients must be dealt with in a professional and scientifically neutral way. Finally, the profession of medicine’s role is characterized by a collectivity orientation. Physicians are obligated to put the welfare of patients above all else, especially personal and financial interests. Thus, the profit motive is not central to their work, and the exploitation of sickness for personal gain is strongly prohibited. Parsons specifically contrasted medical work and “commercialism,” seeing the latter as the “most serious and insidious evil with which it has to contend” (1951: 435).
Phase II: The Construction of the Profession—Physicians as Self-interested, Proactive Actors Requiring Political and Public Support
Pioneered by Eliot Freidson (1970a, b), this second phase is defined by the concept of professional dominance. Freidson rejected the notion that the power and prestige of the profession of medicine was somehow naturally conferred. As with his concept of the “sick role,” Parsons’ version of the “professional role” came to be seen as an ideal type in the Weberian sense. In contrast, Freidson and those who followed in this tradition conceptualized one brand of healers in the heterogeneous medical marketplace of the 1800s as actively and consciously working together to create a special status. Science-based medicine offered a striking departure from previous attempts at healing and promised better living by bringing medicine under the canopy of science (Rosenberg 1987). Science was the “hook” upon which allopathic physicians seized to set themselves apart.
Along with Jeffrey Berlant (1975), Magali Sarfatti-Larson (1977) and others, Freidson made clear that this was not an inevitable march of progress nor the only path to a modern profession of medicine. Rather, physicians were determined actors who, through American Medical Association (AMA) leadership, developed a centrally defined political agenda, characterized by the “trappings” of professionalization (e.g., codes of ethics) and an organization of resources to separate themselves from other medical and folk practitioners of the time.
Freidson saw the list of unique characteristics of the professions from earlier theories as deliberately crafted by emerging allopathic physicians to lay claims to preeminence, autonomy and self-regulation. Thus, sociologists in the professional dominance tradition delineated the processes by which occupations actively struggled to become professions. To use Magali Safartti-Larson’s term, the “professional project” of aspiring middle-class men was to establish a new view of the body (as machine), disease (as based on the germ theory), and appropriate in-house training of and standards for practitioners (in lab-based, university-attached medical schools; codes of ethics).
Phase III: Synthesis Embedded in a Cultural Twist: The Social Transformation of American Medicine
Importantly, however, he documented that early attempts to gain exclusive licensing privilege by allopathic physicians had failed. It was not enough to have physicians organize and court state legislators; rather, a larger cultural shift had to occur to allow both powerful groups and the public to grant the profession its privileged status. The Progressive Era, which he calls America’s Cultural Revolution, created a growing willingness to rely on the specialized skills of strangers and replaced the commonly-held skepticism surrounding “expertise” that had characterized earlier political and cultural eras in the U.S.
Rejecting earlier views that were more idealistic, optimistic, and positivist, Starr drew from the second wave of sociological (Freidson 1970b) and historical (Rosen 1983) theories but combined them with newer theories of states, markets, power, and authority. He did not see the success of the profession’s claims for political support as inevitable, and he dismissed earlier notions that political pre- or proscriptions would “take hold” and translate directly into popular acceptance. Rather, a cultural change, inspired by the new industrial age, allowed for the growth of cultural authority and its conversion into the control of markets, organizations, and governmental policy. Cultural authority engendered trust, compelled obedience, and fostered legitimacy, thereby increasing public acceptance of and dependence on the scientific profession of medicine. Without this larger shift, and only in this context, did the American public become willing to embrace physicians as experts and institutionalize the scientific model as preeminent.
Standing Outside Mainstream Sociological Arguments: The Marxist Alternative
Nevertheless, this theoretical approach brings neglected structural understandings to theories of the rise of the profession. For example, Navarro (1978, 1983, 1993) cast the primary objective of the long training in education not as necessity, but as a way to perpetuate social roles within privileged social classes. And, in Medicine Under Capitalism (1976), he argued for and presented data on the pervasive control that members of the corporate and upper middle classes exert on policy-making bodies of U.S. health care institutions. Berliner (1983, 1985) and others went further, arguing that the great philanthropists of the early industrial era recognized the potential benefits for their own class-based interests in funding the scientific-based medical profession. Their massive donations provided not only goodwill as they amassed their wealth at great fiscal and health cost to the working classes, but also put in place an ideology of disease and a rationale for treatment that was compatible with the logic of industrial capitalism.
But it was not until the work of E.R. Brown that a political economic story of the rise of the American medical profession was articulated. Celebrated by some, ignored by most, Brown (1979) documented the role of the private philanthropy of the capitalist “robber barons” in establishing the American medical profession in Rockefeller Medicine Men. He argued that the Flexner Report essentially served as a medical system blueprint for the “captains” of industry and their administrative “lieutenants” who would serve their vested interests. This was accomplished through donations made by their philanthropic foundations.
The Flexner Report 1910 was commissioned, funded and carried out by the Carnegie Foundation, whose interests surrounded education. Arguing that all proprietary medical schools were of exceedingly poor quality and should be closed, the Flexner Report prompted other philanthropies, most notably the Rockefeller Foundation, to fund the economic foundation of the modern medical care system. This included but was not limited to building university-based medical schools that embraced the same techno-scientific model that underlay industrial capitalism. Foundations provided the resources to set up the expensive laboratories and large, technologically equipped hospitals that scientific medicine required.
Philanthropists tied their donations to requirements that changed both the face of medicine and higher education. To receive funds, for example, universities were required to appoint physicians as “faculty,” not an accepted or welcome practice at the time. By situating medical education in the university, the class-based profile of the modern physician was set. Practicing physicians who were female, working-class, from communities of color, or who were trained primarily through apprenticeship or attendance at proprietary medical schools were disenfranchised as they failed newly instated licensing exams based on the scientific model. Aspiring practitioners from other healing traditions or from lower social ranks, however defined, found their entry to university-based medical schools blocked by educational or financial requirements.
Comparing the U.S. and Great Britain, Hollingsworth (1986) showed how powerful class divisions played out as different nations solved the problem of financing their emerging modern systems of medicine. He looked not to scientific imperatives, but to “the social relations in which medical systems are embedded and the influence of power relationships on the structure of national medical systems” (1986: xiii). Ironically, he showed that the greater level of stratification within the early allopathic British medical profession (i.e., those affiliated with the prestigious voluntary hospitals vs. general practitioners) resulted in a weaker social movement by practitioners, a stronger working class voice, and a fiscal role for the state to assure access that was clearly absent in the U.S.
In sum, those in the political economic tradition saw the newly wealthy philanthropists as purposively using their resources to reinforce and legitimate the dark side of industrial capitalism, including deflecting issues of health, disease, and treatment away from larger social issues and the damaging effects of industrialization (e.g., see Arnove 1982; Berliner 1983; Hollingsworth 1986; Waitzkin 2011). Unlike mainstream work on the rise of the profession of medicine, these accounts tend to cast physicians as either conspirators or puppets. Current work continues this discussion; for example, asking whether managed care pressures physicians to be “double agents,” both protecting patients from the profit motive of for-profit health care while having to attend to its bottom line (e.g., Waitzkin 2000).
Phase IV: Synthesis Embedded with a Network Twist: Elaborating the Internal Mechanisms of Professional Change
Curiously, Starr explicitly rejected Marxist accounts of the rise of the profession (see Pescosolido and Martin 2004). However, professions do not “bring money to the table.” As experts, they rely on their ability to persuade others of the value of their knowledge and services. By their very nature, they are dependent on economic resources that “society,” whether individuals or organizations, are willing to provide. Aside from the Marxists, the sociological story of the profession of medicine minimizes the role of money, resulting in a “shock” that accompanied discussions of the health care crisis of the late 1980s. Neither the public, nor the profession itself, was prepared to shift the discourse and see issues of financial support take center stage in dealing with health, illness, and health care reform (Mechanic 1983).
As sociological theories moved from “ideal type” to “professional project” to “cultural shift,” historians, sociologists of science, and critical sociologists came forward to document that the rise of the medical profession was linked to very limited empirical proof of scientific medicine’s efficacy (McKeown 1979; McKinlay and McKinlay 1981) and to a simultaneous, often contentious struggle of both science and medicine for legitimacy (Gieryn 1999; Wailoo 2004). Laboratories, autopsies, and vaccinations were not welcomed nor accepted by the public. Debates and resistance were commonplace; utilization rates were low (Warner 1986). Physicians, as applied practitioners of little regard, were not embraced by scientists and, even within the ranks of aspiring physicians, there was skepticism about a blanket adoption of the scientific approach.
All sociological theories saw the middle class promulgating a strong belief in medical science, reforming medical education under the scientific paradigm, and working against practitioners, patients and patrons from other social classes to impose their views. But it was Brown (1979) who reminded us that homeopathy was the preferred medical sect of upper class physicians and patients. He documented how J.D. Rockefeller himself insisted that homeopathy as well as allopathy be supported by his donations, only to be overridden by middle class, philanthropic managers who came to control the Rockefeller Foundation.
Following on this, Jack K. Martin and I argued that unearthing the actual dynamic processes and interactions that created the conditions for the Flexner Report, modern medical education, the construction of medical infrastructure, and the public use of services was necessary (Pescosolido and Martin 2004). Following Frenk and Duran-Arenas (1993), we saw professional dominance (monopoly) and sovereignty (consulting status) as two fundamentally different processes that did not flow in the same way as previous theories contended. A larger cultural shift, the Progressive Era, inspired the real actions of real people in the middle classes, and in turn, produced a much later and more gradual cultural shift among the broader public. The transfer of resources from the upper to the middle classes constrained the actions of individuals in all social classes.
Constructing Professional Dominance. From the mid- to late nineteenth century an ideological shift, turning on the progress of science for the “betterment” of society, took place among the emerging middle classes. A middle class of managers grew as a result of the transition to industrial capitalism. The elite of this class formed a network of administrative leaders across formal social institutions (e.g., politics, education, law) that acted to mobilize resources (i.e., money, licensing laws, and curricular change) in support of the aspiring profession of scientific medicine.
Existing mainstream theories give more than a fair share of the credit to the concerted efforts of middle class physicians and politicians to establish the modern profession of medicine using science as the vector of differentiation. However, it took those physicians, in concert with the middle class administrators in philanthropic foundations and higher education to negotiate, cajole, coerce, and collaborate to underwrite the wholesale construction of a new medical marketplace in the U.S. Physicians engaged in a simultaneous struggle for dominance and sovereignty in line with other entrepreneurial projects of the rising middle class (e.g., the creation of the modern university; Hollingsworth 1986; Ludmerer 1985; Markowitz and Rosner 1973; Stone 1997).
Following the Marxists, we saw traditional explanations underplaying the role of the enormous transfer of resources from private philanthropy to the modern profession of medicine and the modern university (see also Stone 1984). American industrialists of this period endowed the profession generously, but their money was directed by the visions and efforts of the middle class managers of their foundations, university presidents, and newly configured hospital boards. These middle-class elites, particularly members of other aspiring professions, all shared the ethos of scientific progress solving social problems, whether in business, medicine, education, or the larger society. Together, they re-engineered society by reshaping societal arrangements and resources to benefit this model, including establishing the dominance of scientific medicine. In the U.S., unlike the U.K., the reconstruction of the medical marketplace was accomplished almost exclusively with private monies, setting up a private system that offered no social safety net to individuals in times of sickness, as the Marxists noted.
Cultural shifts and professional organization offer far more elegant accounts of the rise of scientific medicine than the crass details of how money drove the transformation of institutions and set the terms of medical care in the U.S. All theories agree on the importance of the early foundations’ economic contributions, but they part on the motivation of the capitalists, dubbed the “pseudo-aristocracy” by some (e.g., Larrabee 1971: 228, 242). The influence of the foundations has been told as a story of either redemption (e.g., Starr 1982) or conspiracy (Berliner 1985). However, this story can be told with less effort, as the overlap of ideological views between industrial capitalism and the scientific model, as changes in philanthropy which saw middle class managers hijack resources to their own visions of “doing good,” and as the frustration of the “robber barons” losing control of decision making in their own foundations.
The Marxists were right in seeing the deliberate and powerful influence of industrial capital; ironically, they conflated ownership and control of the means of production. With the wealth of the industrial capitalists, the managerial class held the authority to control where the charitable contributions went, changing the objective and symbolic conditions of healing. In doing so, they often subverted the wishes of the financial elites. They shaped an ideology based on their class position and activated their network ties to transfer enormous sums of money to produce the visible symbols of scientific medicine (e.g., new hospitals, ambulances, emergency rooms) which came to pervade the modern landscape of healing. They created the idea of medical schools attached to universities, against the will of most faculty; legitimated the scientific medical professor as a member of the faculty; and funded the building of the first great medical schools and hospitals in the U.S. In turn, these faculty trained the new breed of physicians and wrote the examinations that their students were well prepared to answer, but all others would fail.
In sum, this transformation resulted in what Sarfatti-Larson (1977) calls a monopoly in cognitive superiority. The middle class shared an ideological stance, believing they had the “right” answer for continued progress despite disagreement among the ranks of practicing physicians and the upper class elites (Rothstein 1972). Presidents of universities, foundation officers, and elite members of the scientific medical profession activated their network ties to the mutual benefit of modern institutions fashioned under the scientific model. The building of large, impressive scientific medical schools and their associated complexes, as well as the transformation of hospitals from centers of last resort to “modern temples of science,” embodied the cultural authority of scientific medicine. Thus, professional dominance was both reflected and reified in a huge, built environment accompanied by public relations campaigns stressing the miracle of science (Stevens 1999) that emplaced the cultural authority of scientific medicine. Local philanthropic foundations throughout the country followed the lead of the most visible foundations in funding local scientific medical schools and in building new hospital and clinic facilities where the new allopathic physicians would hold appointments (Pescosolido and Martin 2004). This process of mimetic isomorphism (DiMaggio and Powell 1983) differed mostly in the details across the U.S. and dramatically diverged only where market conditions were extreme (e.g., see Starr 1982 on Kaiser-Permanente).
Understanding Public “Acceptance.” The establishment of professional dominance dwarfed all competitors, eclipsing alternative sources of care. Most theories of the profession see the public as being “convinced,” while Marxists see services as either denied or coerced (e.g., Waitzkin 1970). In reality, these theories paid little attention to what transpired among the majority of individuals in the community.
That is, theories of the rise of the profession of medicine share the absence of an explicit theory of how individuals use, or do not use, medical care services. Even Freidson’s (1970a) lay referral system theory, emphasizing individuals’ network structures and cultural content, did not connect markets to help-seeking. Nor did he bring this theory to bear in his theory of the medical profession. In the same work (Freidson 1970a), both sociological theories of patient and physician status and roles are explicated but remain as separate social processes. While sociologists and other social scientists contextualized how individuals respond to illness in terms of the context of their local lives, the first generation of utilization theories (i.e., how individuals use medical care) did not consider the larger market context of medical care. Similarly, theories of the professions did not weave together how the actions of individuals played into or against scientific medicine’s professional project. Implicitly, mainstream sociological theories of the medical profession appear to reflect the importance of beliefs in health care decision-making (e.g., Rosenstock’s 1966 Theory of Health Beliefs). In some way, fervor for the scientific approach was disseminated to and embraced by the public.
However, a consideration of, essentially, a second generation of theories on how individuals come to use the formal health care system brings a different version of the achievement of “consulting status” to light (see Pescosolido 1991). Whatever their ideological bent, these newer sociologically-based utilization theories emphasized how geographical and financial availability shape which “services” can be accessed, and how “choices” are made (e.g., Andersen 1968, 1995). In other words, the financial and social organization of medical systems looms large in individuals’ use of services. Both what exists and what individuals perceive in terms of available services matter. Further, financial accessibility enables individuals to use some geographically available services. With the coming of third party payers (private insurance in the 1940s and public programs such as Medicare and Medicaid in the 1960s; see Quadagno 2004), the services of modern physicians were covered while those from most other providers were not. In these theories, the sole focus is on the use of modern physicians, hospitals, and clinics in the allopathic tradition.
Bringing this understanding of utilization to theories of the rise of the profession provides a missing link in understanding sovereignty. The social re-organization of medical care, engineered to achieve professional dominance, both preceded and produced the public “choices” for modern medical services (Pescosolido and Martin 2004). The shift in cultural authority from the working and lower classes that would give the profession its sovereignty would follow from, but not cause, the establishment of dominance. Freidson “consulting status” did not have to be “earned” through demonstrated success; individuals did not have to be “convinced;” and Starr’s sovereignty was not a natural outcome of the larger cultural shift in the Progressive Era. Rather, the public use of modern medicine was constructed by actively redirecting resources that changed the calculus of individual decision-making for medical care. Under conditions of illness, shifting options for medical care, and theories that conceptualize individuals seeking a solution that is only “good enough” (Pescosolido 1992), sovereignty was subtly coerced, even if welcomed, by constraining the public’s options. The role of the new institutions and practitioners overshadowed and, over time, changed public beliefs and values because they signaled the closing off, or at least limiting, of the pathways individuals could travel to “treatments.”
Thus, a two-step process occurred in which physicians’ monopoly was established through the efforts of middle-class elites, which in turn guaranteed an eventual, inevitable change among the general public. Dramatic institutional changes in the community ensured the general public’s acceptance of scientific medicine in the later twentieth century. First, professional dominance dramatically altered the ideology and symbols of healing at the community level, ultimately leading to a shift in both objective and cognitive conditions. Second, these conditions shaped the public’s use of the new scientific medical services under theories that conceptualized geographic and fiscal accessibility as crucial. Later developments in the U.S. (e.g., the widespread acceptance of private health insurance after World War II, the passage in 1965 of Medicaid and Medicare) reinforced the public’s sole use of allopathic medicine by refusing reimbursement of practitioners of other systems. Thus, the public’s use of health care represents a bargain struck between the offerings of providers of different healing systems and the preferences of individuals (Pescosolido 1992, 2006). No other medical tradition or “paraprofessional” in modern medicine, to use Freidson’s term for other occupations in modern medicine, comes close to the “functional strength” or “structural superiority” (Lee 1982) of science-based medicine in the U.S., or for that matter, in any Western nation.
The power of individuals has been conceptualized only more recently as an active force, as social movements organize the resources and influence of specific groups (e.g., Brown 1995). Ironically, not all of these stand in opposition to the profession; rather, they demand more voice, access, and influence in contemporary medicine. Perhaps not as surprising, those movements that draw from the middle classes are more successful in leveraging philanthropic support and disseminating its influence throughout society (e.g., Epstein 1996 on HIV; Sulik 2010 on breast cancer).
Phase V: The Theoretical Shift from a Concern with the Rise of Professional Power to Its Demise
By the 1980s sociologists no longer concerned themselves with theories of the profession of medicine. Indeed, by 1989, there was a concern that medical sociologists had lost interest in the health care system and its practitioners as a whole (Mechanic 1989). Those who continued to focus on the profession turned their attention from understanding the rise of the profession to considerations of its “fall” from power. Specifically, sociologists targeted the three D’s: deprofessionalization, decline, and distrust (Pescosolido 2006).
Deprofessionalization, in Marie Haug’s (1976) view, represents a loss of prestige, power, and trust. It derives from rising levels of education among the citizenry and from increased reliance on technology and medical algorithms that have demystified medical care. Decline looks to external factors that erode support for the profession and to intrinsic factors related to physician supply and shrinking American Medical Association (AMA) membership (McKinlay and Marceau 2008). Earlier, McKinlay (1982) referred to proletarianization as the inevitable fate of physicians who, like all other workers in a capitalist society, would eventually be stripped of the control over their work through corporatization and bureaucratization. Lastly, distrust stems from the rapid privatization of medical care and the growth of managed care (Mechanic 1983). Distrust undermines expectations that medical institutions and providers will act in accordance with the interests of individuals, and calls into question physician credibility, allegiance to altruistic motives, efficacy in medical encounters, and ultimately, treatment outcomes (Pescosolido and Boyer 2001; see Wolinsky 1993 for a review).
Much of this discussion proceeded without empirical evidence but with statements about flagging public support and confidence. The evidence, however, was equivocal. In fact, a pair of analyses using the same data came to opposite conclusions. Both documented “erosion” since the percentage of Americans who have a “great deal” of confidence in medicine had dropped since the 1970 though not in a consistent fashion. These data from the General Social Survey also revealed a statistically significant rise in the percentage of Americans who report having “hardly any” confidence in medicine. But the interpretation differed. Whether the jump from about 5 to 13 % of the general public giving a “no confidence” vote is troublesome to the status of the profession of medicine, as Schlesinger (2002) argued, was not obvious to us given the absence of any viable alternative (Pescosolido et al. 2001).
Clearly, there has been a non-trivial disenchantment with medicine in the public eye. However, placed in larger cultural and organizational context, the fate of the profession appears to be not much more than a general concern with whether the glint of the modern industrial age has tarnished and the “American Century” is over (Pescosolido and Rubin 2000). Our further analysis of public beliefs in “physician authority” between 1976 and 1996 revealed that the increase in negative responses appeared to represent a shift from the “don’t know” category, not a shift from positive to negative opinion (Pescosolido et al. 2001).
Arguably, then, the profession of medicine no longer has quite the luster that McKinlay and Marceau (2002) believed it had during “the golden age.” From the beginning of the concern with professional power, Freidson (1970a) made two important points that seem to be lost in the “Three D’s” debates. First, in no country, even the U.S., does medicine achieve a complete monopoly (e.g., chiropractic in the U.S. was never banned in all states). Second, to return to a point made earlier, it is control over the “content” of medical work (i.e., diagnosis, prescription, authority over ancillary professions) that is key to professional dominance, not control over the “terms” of medical work (i.e., the socio-cultural arrangements). As long as the profession is relatively free of technical evaluation and control by other occupations in the medical division of labor, intrusions that change the socioeconomic terms of modem medical work do not significantly change medicine’s professional character. Of course, the distinction is not pristine. Utilization review, cost controls, enormous financial settlements for medical malpractice, and formularies that allow physicians to prescribe some drugs but not others, all bespeak a demise of the extensive powers once given to physicians, particularly in the United States. And, the profession of medicine was stunned as early as 1972 when Congress passed a law allowing Medicare to cover chiropractic services (Pescosolido 2006).
In the end, Freidson (1993) was “unimpressed” with contentions and evidence on the fall of the profession of medicine. Similarly, Mechanic (1991) suggested that even with less autonomy, contemporary societies still support the dominant medical paradigm, the centerstone of the profession’s status and roles. However, in this context, both Freidson and Mechanic supported the new theoretical work of sociologists who shifted their focus from issues of rise and fall to “maintenance.”
Phase VI: Re-embedding the Medical Profession in Society in the Face of Crisis—Systems Thinking Returns
In 1983, Gieryn set the stage for understanding professional dynamics following ascent to preeminence. Focusing on science, not medicine, he argued that there will always be skirmishes at the borders of professional turf. Professional boundaries are “drawn and redrawn in flexible, historically changing and sometimes ambiguous ways” (Gieryn 1983: 781). Theories of the profession of medicine followed suit, laying out the full complement of organizations, actors, and groups that hold the potential to support, or, increasingly, encroach on its boundaries. Thus, ironically like Parsons’ (1951) original theory, the medical profession is embedded in the whole of society’s institutions.
Similarly, the theory of countervailing powers “locates professions within a field of institutional and cultural forces and parties” (Hafferty and Light 1995; Light 2000; Mechanic 1991; Timmermans and Oh 2010). This explicit focus on institutional pillars suggests that the relative strength of the profession vis-à-vis other sources of fiscal and cognitive support has produced a weakened, but not less dominant, profession. On a larger scale, others theorize that the underlying, relative power in medicine has shifted from a logic of professions to a logic of institutions in controlling the terms of medical work (Quadagno 2004; Scott et al. 2000). Some segments of the profession aspire to be free of commercial and institutional concerns, while others see direct ownership as the only protection from outside incursions. This reflects and reinforces larger cultural change. The resulting tensions, both within and at the periphery of medicine’s jurisdictions, hold the potential to reformulate the terms of professional autonomy, dominance, and sovereignty. Private, unfettered, fiscal support for the profession of medicine in the U.S. has been replaced by a clear managerial perspective from private insurance to government programs that now cover the bulk of medical costs (Pescosolido 2006).
This review of sociological theories of the profession of medicine reveals theories mirroring both the growing sophistication of sociology and the growing complexity of contemporary society. In the end, whether the medical profession, as we know it, stands or falls is inextricably tied to dominant social forms and processes, including the class structure that Waitzkin (2011) and others continue to bring to our attention. In “The Continued Social Transformation of the Medical Profession,” Timmermans and Oh (2010) return to concerns about the role of money in professional status. Reviewing “tensions” and accepting the Phase V conceptualization of the medical profession as “one stakeholder among many stakeholders vying for market share and power in the health care field” (2010: s94), they conclude that the profession is resilient, continuing to adapt and change at the margins.
Our voice, as sociologists, in understanding jurisdictional boundaries and skirmishes involving the profession of medicine is critical, but not central in current debates. This is problematic for the discipline, the subfield, and for social change. Without continued sociological attention melding mainstream sociological theory and substantive expertise in medical sociology, our own understanding of society, the profession of medicine, and the fate of individuals’ health and health care will be impoverished. Now more than ever, our theorizing has to be reenergized, new data need to be collected, and those data have to be interpreted in larger context. The debates about the future of primary care that McKinlay and Marceau (2008) and Timmermans (2008) began, the dialogue on expropriation and transformation of complementary and alternative medicine (CAM) that Wolpe (1985) initiated, and the fate of the profession in light of larger societal changes represent challenges to sociological theory.
Every society fashions its own medical social contract. Even if we experience a shift of the magnitude that parallels the one that accompanied the industrial age, for better or worse, medicine and its practitioners will be reconstituted in light of social resources, cultural context, and social cleavages. Yet, the critical ingredients will be the same, in the abstract, as we have seen here—cultural landscape, professional solidarity (or not, as AMA membership continues to slide), competing practitioners inside and outside of the scientific medical paradigm, and ownership and control of resources that will be shaped by and through networks of power. What is crucial, and what will vary, will be the specific nature of societal negotiations that constructs a medical marketplace. Further, the decisions will remain the same: Will health care be a right or a privilege? Who will “own” and “control” the health care system? In particular, how much of a role will the State play in granting or assuring professional dominance of the full complement of healing practitioners? If the boundaries of the nation state become more porous, or less salient, as Giddens (1990) suggests, what legal or political institution will step in its place? The answers to these questions are vital in shaping the profession, the nature of medical work, and the health of populations.
Parsons’ (1951) initial statement stands: All societies create institutional roles for patients and providers. For sociology to understand social institutions, the life chances of individuals in them, and the intimate connections between the two, health and health care continue to present an essential window into social life. Theorizing and bringing empirical examination to bear to grasp the structure, culture, and impact of these roles remains a central sociological task.
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