Transcript Source: Sinclair S (1997) Making Doctors: An Institutional

SOCIAL AND COMMUNITY
PERSPECTIVES
Medicine as a profession
6th May 2003
Aims
• To explain what is meant by the terms
‘professional’, ‘socialisation’ and
‘professionalisation’
• To contrast the different approaches to
consultation used by orthodox and non
conventional practitioners
• To illustrate an awareness of the ways in
which the medical profession has developed
Introduction
• Why do we need to consider medicine
as a profession?
• Drs differ from other groups of health
service in terms of professional status
• Along
with lawyers
foremost profession
regarded
as
Historical context
• Royal College of Physicians founded 1518.
• You needed:
– an Oxford or Cambridge degree
– to be an Anglican.
• Not very scientific
• e.g by 1790 oral exam in Latin was still the
main entry requirement
• Elite status  not based on scientific
knowledge, but on social background of
doctors.
Doctors as an elite group
• Physicians only catered for the wealthy.
• Apothecaries and barber surgeons
treated the rest.
• Most healing took place domestically.
• Women cared for others in childbirth
and knew how to make potions and
lotions.
Modern clinical medicine
• Began turn 18th/ early 19th Century.
• Associated with the emergence of
hospitals in England.
• 19th Century medicine was very
competitive.
• Few effective cures at this stage.
• Very dependent on wealthy clients and
the quality of bedside manner.
Modern clinical medicine
• Much rivalry and competition in early
part of 19th century.
• Ill-feeling towards each other among
healers/doctors.
• Same situation prevailed in America.
• No unity or collective authority
Attitudes towards medical
profession in early-mid 19th century
• Qualification of “physician” restricted to
gentlemen.
• But there were other healers - e.g. teeth
pullers, bone-setters, itinerant healers etc.
• Occupation of healing was often seen as a
“rattlebag of quacks and rogues”.
• Queen Victoria - did not recognise army
surgeons as “officers and gentlemen”.
Changing times
• Changes in culture, society, science and
technology in mid-19th Century.
• Capture of a body of scientific knowledge.
– anaesthetics
– discovery of tubercle bacillus
– introduction of forceps
• Struggle for cultural authority and social
mobility.
• Begin to see professionalisation of medicine
The professionalisation of
medicine
• Increasing specialisation = increasing
•
•
•
•
interdependence.
1858 Medical Act - gave the GMC power over
registration of doctors.
Led to a monopoly on supply of medical
services.
Control over medical education by the
medical profession.
Restriction of entry led to raising of standards.
Late 19th/early 20th century
• Industrialisation - led to dependency on
strangers  change in relationship
between doctors and pts
• BMA and AMA - medical profession
could present a solid and united front
with a code of ethics.
• Claim to be above commercialism.
Early 20th century
• Growth of medical authority continued
to expand
• Helped by
– development of medical science.
– role as gatekeepers to medicines and
sickness certificates.
• Doctors became better paid.
• Major change: WWI - swept away old
elite systems and gave new
acceptability to the professions.
Why and how did profession
of medicine develop?
• Two approaches:
• Functionalist
• Conflict
Functionalist approach
• Associated with authors such as Talcott
Parsons
• Profession  accorded high status and given
greater financial rewards than other
occupational groups.
• Profession of medicine developed because of
society’s desire to control illness
• Need group with access to technical
knowledge – used in interest of community –
functional for system
Functionalist approach
• Technical knowledge – power and
status (although all illnesses not
controlled)
• Drs’ status legitimised because:
– Practise on the grounds of technical
competence
– Institutionalised expectations of ‘doing
everything possible’ for good of whole
community
Conflict theory
• Reject idea that medical profession
emerged naturally
• Profession developed out of specific
historical process which involved a
power conflict among a number of
different interest groups.
• Medicine not evolve naturally, but as a
result of political struggle between
groups intent on achieving higher status
Conflict theory
• Conflict theorists want to explain why
medicine was successfully in attaining
professional power compared to other
competing groups
• Freidson (1970) sees profession as a
structural position which has to be
attained and maintained
• Freidson identified certain profession
characteristics
Conflict theory
A profession has:
• Specialised Knowledge
– Careful management of knowledge
• Monopoly
Control of numbers, selection and training of
entrants
• Autonomy
– Clinical autonomy: doctors are responsible only to
their patients for diagnosis and treatment, and
only peers can comment on clinical judgements.
• Code of ethics
Importance of the role of the
General Medical Council
• Medical profession regulates itself through
•
•
•
•
•
the GMC.
controls entry to medical register and can
remove practitioners from it.
approves and inspects medical schools.
Based firmly on principle of self-regulation.
Self-regulation itself is based on doctrine of
clinical autonomy.
Now includes lay members.
Medical education
• Medical education = crucial in turning
lay person into professional
• Becoming a doctor not just about
learning facts, but also certain values
and attitudes (Tomorrow’s doctors)
• More than accumulating knowledge
about developing appropriate attitudes
to patients, colleagues, fellow worker
Medical education
• This process known as socialisation:
• process by which culture/values of a
particular society (or group within it) are
transmitted to new incumbents as they
learn to conform with demands and
expectations of the society/group
Medical education
• Medical education involves:
• Lengthy training controlled by
profession
• Recruitment and selection
• First stage of socialisation from lay to
professional = selection
• Appropriate attitudes and behaviour
Medical education
• Formal/Informal curriculum
• Formal: knowledge/tested through exams
• Informal: attitudes beliefs/ performance noted
not formally examined
• May  students concentrating on ‘getting by’
– losing former idealism
• Socialisation and education takes place in
different arenas:
• Front stage/back stage
Source: Sinclair S (1997) Making Doctors:
An Institutional Apprenticeship Oxford,
Berg
Official
Unofficial
OFFSTAGE
Front
Stage
‘Manifest’
curriculum
Lecture.Ward
Rounds/ Exams
Games Field
(rugby/ football)
Theatrical
performances
Lay World
Back
Stage
‘Hidden’
curriculum
Libraries, Hospital
wards
Preparation for
unofficial front
stage activities
Students’ bar
Lay World
Summary
• Medicine’s position of authority and
status evolved over time
• Different ways of viewing professions
position: functionalist/conflict
• Role of medical education
Questions
• Freidson (1970) identified a profession as
having certain characteristics. List these and
explain what is meant by each
• In order to become a medical practitioner new
entrants must acquire certain skills,
knowledge and attitudes. What role does
medical education play in this process?