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. 

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