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Toward the new pattern of medical practice.

Since the initiation of Medicare and Medicaid almost 30 years ago, medical practice has been undergoing continuous change. However, the nature of both our federal political system and our largely private economy discourages sudden, radical change, so it has occurred step by step, with no single step being decisive. The result is that while no one can doubt that change is occurring, neither the decisive force behind it nor its direction are clear. In the case of the President's coming proposals, we can be sure that the political process will prevent the submission of a truly sweeping plan and that Congress will modify whatever is submitted to it. Change in this as in past plans will be incremental, making it difficult to anticipate its long-run consequences for medical practice. While we are moving away from the old pattern of practice, it is difficult to tell what new pattern is emerging.

The Old Pattern of Medical Practice

The pattern in the United States that people still recognize as the norm reflects the vanishing past. (The details of the pattern I describe refer primarily to the United States, where primary care physicians are not sharply separated from specialists and are not excluded from hospitals. In most other Western nations, the division between hospital (specialist) and community (primary) practice is much sharper, and in some (e.g., Germany), specialists are not permitted to provide primary care.) Essentially, this is individual economic and clinical freedom practiced within a protective framework of exclusive licensing. It has the following characteristics:

* Practitioners set up their offices with their own capital as self-employed proprietors who largely work alone.

They work within a market in which licensing gives them a virtual monopoly over the right to provide basic health services.

* They are paid on a fee-for-service basis directly by their patients, their income depending on the number and class of patients they serve and the number and type of services they provide.

* The success of their practice depends on personally attracting and satisfying individual patients. While many specialists depend on colleagues for referring patients, they too work alone in their own offices.

* Competition between practitioners is limited (but not prevented) by an etiquette that discourages overt or public criticism of each others' performance, establishes minimum fee schedules, and restricts advertising.

* Practitioners have considerable freedom to diagnose and treat their patients as they personally see fit. Solo practice itself provides some of that freedom.

* The freedom is reinforced by the absence of any authoritative standards by which to judge the quality of their work (medicine being considered more art than science).

Trends in the United States

Key elements of the old pattern have been changing for some time. The rise in importance of the hospital after World War I was the first major change, followed by the development of private and later public third-party payment. Consider these trends in the United States (these trends are, by and large, stronger in the United States than in other Western nations.):

* A decline in self-employment.

* Practicing in organizations or groups rather than alone.

* Obtaining patients through association with organization such as HMOs or through contracts with publicly or privately financed third-party payers.

* Dependence on payment by powerful public and private third parties rather than by individual patients.

* An increase in competition between practitioners through legal challenges to traditional etiquette.

* Development of authoritative national standards of clinical practice.

* Overt, formal evaluation of clinical practices by employers, third-party payers, peer review committees of colleagues, and clinical superiors (e.g., chiefs of services).

Current Prophecies of the Future Pattern

In light of these trends, most observers agree that the old pattern of independent, individual practice is vanishing, but they differ considerably in their prophecies of what the new pattern will be like. Among those who use analytic theories and go beyond deploring the loss of the "Good Old Days," the most extreme prophecy stems from the Marxist theory of history, which presumes that capitalism has an inherent tendency to reduce the cost of labor (and so increase profits). This is achieved by redesigning work to be simple and standardized, which eliminates dependence on skilled and therefore relatively scarce and expensive workers while also making work easier to supervise and control. Because workers do not own the means of production, they are dependent on employers for their income and must simply follow orders. Lacking any specialized skills, they become interchangeable from one job to another. The contention of those influenced by this theory of "proletarianization" is that physicians, who previously owned the means of production by virtue of being self-employed, are becoming dependent employees whose work will eventually be wholly controlled by their employers.(1)

A somewhat less extreme prophecy is based on the theory of the great German sociologist, Max Weber, who saw the history of the West under capitalism in terms of the increasing "rationalization" of human institutions-the continuous drive toward efficiency and order through the application of rational planning and techniques of control. Though it hardly ignores economic factors, this view places more emphasis on the way human affairs are organized and controlled. It emphasizes the drive toward predictability and accountability through the development of formal rules or standards for supervising and controlling performance, and of formal administrative hierarchies by which responsibility and accountability are allocated. The trend for American medicine to be practiced in organizations rather than "solo," the increasingly powerful position of public and private third-party payers, and the development of authoritative standards and formal methods for reviewing and controlling clinical decisions figure strongly in the predictions of those influenced by this theory.(2) Some use the term "corporatization" to characterize the end result, in which practicing physicians become cogs in an elaborate administrative machine, obliged to follow standardized rules of clinical procedure and subject to fairly extensive supervision by administrative superiors.(3)

Both theories assume loss, or at least serious weakening, of the professional status of medical practitioners-what some call the "deprofessionalization" of medicine.(4) In my own criticism of those theories,(5) however, I point out that they pay little or no attention to a critical characteristic of medicine that has not changed and is not likely to change in the future--its monopoly of practice and its authority over health-related knowledge. Furthermore, they analyze medicine as if it were merely a collection of licensed practitioners, overlooking the fact that it is a corporate body that includes professional associations, training and research institutions, government agencies, practice organizations, and members who play specialized roles in them. And, like many nostalgic observers, they mistake the vanishing pattern of the past, which is merely one historic form of professionalism, for professionalism itself.

Those observations lead me to project a rather less extreme and determinate future for medical practice. On the one hand, I see an ongoing reorganization of the profession, with physician-administrators and physician-researchers gaining considerably more authority than they had in the past and with practitioners losing much of their capacity to control their individual practices. While the practitioners of the profession have less freedom than in the past, some members retain the authority to establish technical standards for the conduct and evaluation of individual practice and others the authority to administer those standards. Thus, the corporate profession remains the ultimate source of control over work.

This reorganization of the medical profession is a precondition for the development of a distinctly new pattern of practice in the future. A new pattern has not yet emerged, though, because the distinct orientations and interests of researchers, administrators, and practitioners have not yet stabilized, nor has private and public health care policy. The pattern that eventually develops will emerge not only from the political and economic forces that establish policy, but also from the ways that the medical standard-setters and physician executives influence and implement that policy.

It is highly unlikely that the norm for the future practice of medicine in the United States will be clearly and definitely established by the plan that President Clinton proposes and Congress finally legislates. However, some movement toward a new pattern should be visible in the way legislation attempts to structure the creation and application of quality standards as well as the administration of health services. Even more important for the future pattern, though, is the way the medical authorities choose to formulate standards and the way physician executives choose to administer their practice organizations.

The Critical Role of Discretion

What issues are central to the development of a truly new pattern of medical practice? Many writers believe that employment in large practice organizations that establish bureaucratic procedures to order their affairs is the key to setting the future pattern--at least in the United States. (This prophecy is for the United States, where, of all industrialized nations, the trend toward employment in large practice organizations is strongest.) That certainly establishes a distinctly different flamework for practice, but, because there are so many different forms of employment and so many different forms of administrative organization, the gross fact of employment in large organizations tells us too little. What is critical is whether or not that framework sustains professionalism in medical work. And a critical element of professionalism is freedom to exercise a considerable degree of discretionary judgment.

The freedom to use schooled and experienced judgment to deal with individual cases is the antithesis of bureaucratization and proletarianization. Insofar as work is addressed to individual and therefore idiosyncratic cases, discretionary judgment by its nature takes precedence over statistical probability and cannot be guided by detailed rules of procedure. It must be remembered, however, that professional freedom does not mean individual freedom to practice however one will. Rather, individual judgment is subject to evaluation and, if necessary, correction by professionally accepted standards. The critical question for the future is whether or not coming changes in the organization and administration of health care will sustain and strengthen the freedom to use discretionary judgment during the course of work. Broad policy changes will have effects of their own on professional freedom, but the most important effect is likely to stem from the way the emerging professional elite of clinical standard-setters and administrators choose to implement policy.

The Choices of Standard-setters

What perspective will researchers, academics, and other medical authorities take when they participate in the formulation of standards? Will quality standards be formulated in such precise detail that few if any exceptions in approved procedure will be permitted for most diagnostic categories? To do so results in what some call "cook-book medicine," which is analogous to the industrialization of medical work.(6) Will the emphasis be on treatment by the statistical norm without more than lip service to the possibility (and varying statistical probability) that an individual case deviates from the norm? Or will significant leeway be allowed for treating many diagnostic categories, leaving a variety of alternatives open to clinical judgment of the individual case?

Part of the answer to these questions lies in the intellectual position of the standard-setters themselves-- namely, the degree to which they are inclined to believe that medicine is more an art requiring judgment than a science requiring strict conformity to procedure, and the degree to which their vision of practice is clinical rather than actuarial,(7) with patients conceived as individuals rather than populations and their illnesses conceived concretely rather than abstractly. Of course, the way they respond to the inescapable pressure to control costs is also important. But they have alternatives. They can be committed to formulating standards that control costs before the clinical encounter, which considerably reduces the discretion of the practitioner, or they can allow sufficient leeway in their standards so that practitioners must consider the concrete case with which they are confronted when taking cost into account.

The Choices of Administrators

Whatever new policies are established, and however standards are formulated, the physician executives of programs and practice organizations must serve as mediators between practitioners, standard-setters, and the health care system. Physician executives of practice organizations such as HMOs are in an especially important position, for, unlike all other administrators in the system as a whole, they are confronted with the immediacy of daily practice. Their choices are perhaps the most critical for developing the future pattern of practice because they link daily health care with the larger system. Because they are accountable to both practitioners and the larger system, the question cannot be which they choose to serve but rather the particular balance they strike between them.

The position they choose to take on two issues is especially important for the future pattern of medical practice:

* The method of exercising control over the quality of care,

* Working conditions in which discretionary judgment can be effectively employed.

Considerations of cost and efficiency are inevitably involved in each of these issues. Whether health care is financed and ultimately governed by private or public capital, the cost of providing it must be controlled. In the case of private capital, profits and/or growth must be assured to investors; in the case of public funds, costs cannot exceed what the public is willing to give up in taxes and premiums.

If physician executives regard themselves primarily as agents of investor-owners or the public purse and only secondarily as proponents of clinical practice, their effort to contain costs must inevitably involve limiting services on a technically justifiable basis. The easiest and most effective way of doing this is to pursue a policy that supports the use of technical standards based on statistical findings to monitor the work of practitioners, while discouraging both clinical judgments arguing exceptions and on-site peer review of concrete individual cases. This position would drastically transform the pattern of practice by restricting the physician to the minor exercise of discretionary judgment within a largely preformatted practice. The autonomy of physicians would be reduced to that of the middle-level manager in commerce and industry. They would be truly deprofessionalized.

If, on the other hand, physician executives choose to take the side of clinical practitioners exercising conscientious concern for individual patients, they would argue against the use of such standards and instead work to create effective qualitative review of clinical decisions. Because such peer review takes a considerable amount of time away from the direct provision of services, it is more expensive and less predictable than the strict administration of authoritative decision-rules created by researchers and medical authorities far from the consulting room. Furthermore, neither actuarially oriented standardsetters nor economists are likely to consider it effective or efficient. In order to sustain qualitative peer review and the support of discretionary professional practice, therefore, the physician executive must be prepared for continuous struggle against the economizing and rationalizing forces that prefer formal, bureaucratic methods of control.

Another element that is critical to the very possibility of exercising discretionary judgment is the physician's case load. For industrial workers, a "speed-up" requires performing routine actions more rapidly. A large case load for a professional, however, requires changing the actions themselves. In the management of a large case load, individual cases are more likely to be evaluated statistically and treated without much attention to the possibility that they deviate from the norm. When there is an overly heavy case load, it is probably more desirable that practitioners follow externally established, detailed standards for procedure rather than invent their own short-cuts, but, in either case, the distinctive freedom of professional work to adapt to the individual case is lost. Should physician executives in practice organizations fail to resist the build-up in case load that often accompanies economizing efforts, they will be encouraging the deprofessionalization of medical work.

Physician Executives and the Pattern of the Future

Physician executives are the critical links between the political and economic forces that are changing the practice of medicine. Theirs cannot be a passive task. It requires active effort to translate policy into concrete administrative procedures and practices that organize medical work, and there are many alternatives to choose from. Furthermore, their duties include actions to alter established policy, for they are expected to report to policy makers and governing boards on the difficulties of implementation and on the success or undesirable consequences of particular policies. In doing so, they must choose which issues to emphasize and they must sometimes actively resist the policies promulgated by their governing boards and the more remote bureaucrats who formulate the rules for the system.

The way physician executives administer their organizations and the position they take toward their governing boards and health policy reveal their conception of medical work. That conception is likely to be a far more important factor in setting the new pattern of practice than the broad parameters of financing, coverage, and the like on which so much attention is focused today. It is the choice of alternatives within those parameters that is critical to medical practice, and it is the physician executive who plays an important role in selecting, advancing, and defending one alternative or another. If they conceive of medical work as the application of detailed standards of procedure to patients classified by formal diagnostic categories, they will bring about an industrial revolution in medicine and deprofessionalize practitioners while industrializing patients. If instead they conceive of medical work as the artful use of complex knowledge and skill to serve the needs of individuals within the new economic and political framework that is slowly developing in the United States, they will bring about a new form of practice that preserves the disciplined freedom that distinguishes truly professional work.

References

1. For examples of this literature, see Oppenheim, M. "The Proletarianization of the Professional." Sociological Review Monographs No. 20:213-27, 1973 and McKinlay, J., and Arches, J. "Towards the Proletarianization of Physicians." International Journal of Health Services 15(2):161-95, 1985.

2. See, for example, Ritzer, G., and Walczak, D. "Rationalization and the Deprofessionalization of Physicians." Social Forces 67(1):1-22, Sept. 1988.

3. See, for example, McKinlay, J., and Stoeckle, J. "Corporatization and the Social Transformation of Doctoring." International Journal of Health Services 18(2): 191-205, 1988, and Starr, P. The Social Transformation of American Medicine. New York, N.Y.: Basic Books, 1982.

4. For example, Haug, M. "Deprofessionalization: An Alternative Hypothesis for the Future." Sociological Review Monographs No. 20:195-211, 1973.

5. See Freidson, E. Medical Work in America. Essays on Health Care. New Haven, Conn.: Yale University Press, 1989, pp. 178-224. For an appraisal of professional institutions in general, see Freidson. E. Professionalism Reborn. Cambridge (UK): Polity Press, 1994.

6. The standards and administrative policies I discuss here are already in use but do not yet predominate. For their implications, see Feinglass, J, and Salmon, J. "Corporatization of Medicine: the Use of Medical Management Information Systems to Increase the Clinical Productivity of Physicians." International Journal of Health Services 20(2):233-52, 1990. The question for the future is the extent to which they become the norm.

7. For an example of actuarial thinking, see Dawes, R., and others. "Clinical Versus Actuarial Judgment." Science 243(4899):1668-74, March 31, 1989.

Eliot Freidson, PhD, is Professor Emeritus of Sociology, Faculty of Arts and Science, Department of Sociology, New York University, New York, NY.
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Author:Freidson, Eliot
Publication:Physician Executive
Date:Nov 1, 1993
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