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Physicians as Professionals

According to Freidson the medical profession developed as such in the nineteenth century. That is the same century in which Virchow and others defined the biomedical disease concept. So historically as well it is likely that the professionalization of physicians and the formulation of the biomedical disease concept are connected.
What is meant by profession? Briefly, this is how Freidson puts it. Professions are based on two pillars. The first pillar is a qualification in the sense of having special knowledge and ability which are considered superior to that which others in the same field know or are able to do. The other pillar is a state legislated and upheld position of monopoly in that field. So there is a combination of expertise and power. The features of a profession are:
  • the profession itself determines what must be regarded as the correct qualifications;
  • the profession has the liberty to regulate itself but also to regulate other “adjacent” vocations;
  • education and training are determined by the profession itself;
  • the profession determines with which clients it works and manages them itself.
There is a broad variation of fields in which a profession can be autonomous. At the one extreme the state allows itself more or less to be led by the profession and uses its power to support the profession’s values, protect it from competition, and control its employees. At the other extreme the profession is allowed autonomy in knowledge and skills but the state reserves the right to determine its social and economic circumstances, and the way in which the work is socially organized. In this respect, the United States is not too far from the former extreme, and the [former] USSR is not too far from the latter. On the side, note that in the Netherlands the medical profession is shifting from a position similar to that of the United States to one similar to that of the [former] USSR.

So the profession is in a privileged position which features autonomy and monopoly. It is the medical profession which has the right and power to define what illness is. “Medicine may be said to be engaged in the creation of illness as a social state which a human being may assume.” Note the distinction between its demonstrable scientific accomplishments and its demarcation of territory. The latter is much larger than the former. Physicians are made into “moral entrepreneurs” who see illness where lay people see something else and who label as serious what lay people do not take so seriously.

Professional autonomy restricts the autonomy of individual citizens as they are no longer autonomous in the profession’s special field. That is why the value of citizens’ autonomy should prevail over that of the profession, and the profession’s autonomy should be kept as restricted as possible when determining the general good of society, so Freidson points out.

Surely nobody will deny that the biomedical disease concept was the basis for spectacular discoveries regarding illness and its treatment, from a statistical lowering of mortality to the blossoming of medicine. However, in the last decades the public has increasingly criticized the way medicine is practiced and at the same time analysis of the costs versus the benefits is increasingly unfavorable.

Szasz points out that there has been a clear shift in physicians’ functioning during the last century. He describes family doctors of yore as wise, preferably older men, who albeit could not do very much, but intensely sympathized with sick people. Present-day physicians more resemble scientists and experts. They are more often distanced than friendly and more likely to be younger than older. They are efficient and express little sympathy. According to Szasz, dissatisfaction with this “scientific doctor” is much greater than used to be with the “humane doctor.”

Eisenberg as well ascribes the increasing dissatisfaction with medicine to its technicalization. “The professionalization of medicine has resulted in enormous advances. But it has exacted a considerable price in the divorce of what the physician sees as his job from what the patient seeks of him. Professional and lay views of the meaning of health and sickness have drawn too far apart.” He advocates including social and psychological treatments, performed by physicians or others in health services.

Szasz and Eisenberg apparently agree that the expansive development of medicine in our century has the side-effect of a certain estrangement between physicians and patients. However, their reactions to this state of affairs are diametrically opposed.

Van Es et al state that “numerous investigations revealed that the patient wants good, dependable assistance that is humane,” and emphasize the “increasing insight into the relationship between living conditions and the origin and/or course of illnesses and being ill.” If that is so, the conclusion must be that the biomedical disease concept falls short of satisfying patients’ wishes and of providing the scientific frameworks that would make further research in this direction possible.
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