Commentary No. 29, Dec. 1, 1999
"Physicians: Professionals, Businessmen, or Employees?"
Once upon a time, physicians were free agents. They were among the last survivors of the old artisan class: persons who had a skill, ran their own solitary enterprise, and offered their services to the community at large. Up until a century ago, they were still largely trained by apprenticing themselves to a practicing physician. They were respected by their neighbors, and earned a reasonable living, but were seldom wealthy. They related to their patients as friends, counselors, and hopefully persons who could assist others in medical need. They traveled to sick person's homes and brought their implements and medicines with them. Their knowledge was in many ways limited but they knew something.
This no longer describes the physician, neither in North America or Europe, nor in Asia or Latin America. The first great change occurred about a century ago. Medical schools became modern teaching institutions and physicians were only recognized as such if they graduated from one of them. Their technical expertise grew. They became a closed guild and obtained a monopoly on the right to give serious health care. Hospitals became safer and more important in medicine and physicians sought to have access to them for their patients. The physician ceased to be a self-trained artisan and became a higher professional. Collective organizations of physicians came into existence to defend the interests of physicians. States began to control pharmaceuticals, and gave physicians the exclusive right to prescribe the more important drugs and medicines. A few physicians worked full time for hospitals or in armies, but most physicians continued to be independent practitioners, perhaps a little better paid. They still visited their patients.
The world economic expansion after 1945 changed this pattern. The numbers of physicians expanded, but so did the demand, and so did more expensive equipment and pharmaceuticals. Wherever medical care remained private, physicians began to be businessmen. Their office structures expanded, as did their supporting staff. Their earning levels went up significantly. They ceased visiting patients. Patients visited them, and paid more. The politics of physicians went along with their evolving economic role. Physicians resisted government control, and when the political situation of the country led to national health services, they negotiated relative freedom and higher fees with governments. Even with national health services, physicians tended to retain absolute control of the work situation. They decided themselves on the diagnosis and the prognosis of health care. They used their medical judgment to make all the relevant medical decisions.
There were two trends that upset the equilibrium. The first was the sharp expansion of demand. Populations everywhere demanded more health care, and more expensive health care, and some of it (when not all of it) was paid for by collective taxation. This actually made the practice of medicine more and more lucrative. The business side of health care began to escalate. If it was a profitable business, it could be more profitable from concentration, as was true of any other business. Concentration began to occur, in the form of physicians' collectives and of increased services in hospital contexts. Hospitals began to concentrate as chains. This then brought about the most recent transformation.
The story of the United States is the most telling. The structure of health care in the United States has long been the most private, the one with least government involvement of any country in the world. The physicians were the relatively wealthiest in the world. They were also just about the most politically conservative. In the 1990's, the Clinton Administration sought to enact a very mild form of state-aided health insurance, just about the last country in the so-called developed world to seek to institutionalize a right to "universal" medical coverage.
The physicians were strongly opposed to this idea. They claimed it would interfere in their relations with patients. At the same time, everyone was concerned with "rising health costs." A solution loomed on the horizon. Instead of national health insurance, the U.S. Congress encouraged the growth of s-called Health Maintenance Organizations (HMO's), which would be private and which would, it was claimed, by efficiency reduce health costs. HMO's were essentially private businesses, not necessarily run by physicians, which marketed health care. They became more and more concentrated. They had doctors attached to them. The HMO's discovered that one way to reduce costs was to control the health care that was dispensed by the physicians.
All of a sudden, physicians discovered that they had ceased to be free professionals, and had ceased to control their work place. They were now employees, receiving in effect orders from managers. They also discovered that their incomes were reduced, since the fees they were paid amounted to less than the sum of the fees they used to earn by direct billing of patients. Employees are not professionals and they are not businessmen. They are employees.
Last year, the American Medical Association, a notoriously politically conservative group, voted to encourage the unionization of physicians. In November of 1999, the U.S. government labor agency (NLRB) decided that hospital interns and residents had the legal right to unionize. And next year, will the physicians be on picket lines? This has already happened in many countries.
The juggernaut of commodification has hit medical care and is rolling over the artisans. In the 1830's, it was linen-weavers; in the 1990's, it is physicians. The size of medical care structures grows larger and larger, and therefore of course more bureaucratic. De te fabula narratur.
[Copyright by Immanuel Wallerstein. All rights reserved. Permission is granted to download, forward electronically or e-mail to others and to post this text on non-commercial community Internet sites, provided the essay remains intact and the copyright note is displayed. To translate this text, publish it in printed and/or other forms, including commercial Internet sites and excerpts, contact the author at iwaller@binghamton.edu; fax: 1-607-777-4315.
These commentaries, published twice monthly, are intended to be reflections on the contemporary world scene, as seen
from the perspective not of the immediate headlines but of the long term.]
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