Sunday, March 16, 2014
Major and Unremarked Change
The place of the medical profession in society is undergoing
a major, important and largely unremarked change.
The era immediately following the end of World War II might
appropriately be characterized as the Golden Age of Medicine. Nothing happened in health care that was not
subject to the profession’s approval. I
remember that sometime around 1960 polio vaccine became available and we took
our two young boys over to the local school for their free inoculations. Nurses were doing the work but two doctors
were quite obviously in attendance; reminders that it was happening with the
approval of the local county medical society.
At that time, it was common that medical society membership
was a prerequisite for appointment to a hospital’s medical staff, thus giving
the profession effective control over who could practice medicine in the
community. Hospitals ostensibly were
controlled by their trustees, but medical staffs were considered to be
“self-governing” and woe betide any administrator or trustee who interfered in
professional affairs.
The adoption of Medicare in 1965 marked a big change in all
of that. Up until then, the American
Medical Association had been able to block any such thing and so Medicare was
the first health care decision taken by the federal government against medical
advice.
Another marker of change was the quality movement that got
seriously under way in the late 1980’s.
Preventing errors and improving outcomes require support and action by
institutions. The loosely structured
profession with its emphasis on the independence of the individual practitioner
was not able to do it by itself.
A current marker of importance is the growth of salaried
practice, to a large extent by hospitals.
A February 14 article on the subject in the New York Times reported that
“About 60 percent of family doctors and pediatricians, 50 percent of surgeons
and 25 percent of surgical sub-specialists….are employees rather than
independent.” It has also been reported
that the number of physicians employed by hospitals is now greater than the
number who are dues-paying members of the AMA.
The NYT article focused on the economic and clinical
implications of this trend. It did not
address the social consequences, which may well be greater.
