Book Review

The History of Medicine

The Changing Medical Profession: An International Perspective

N Engl J Med 1994; 331:818-819September 22, 1994

Article

The Changing Medical Profession: An International Perspective
Edited by Frederic W. Hafferty and John B. McKinlay. 261 pp. New York, Oxford University Press, 1993. $47.50. ISBN: 0-19-507592-7

This remarkable sociological treatise, harking back to Talcott Parsons's perceptive elaboration of the sociology of professions, brings together 21 foremost social historians concerned with health care. Sprinkling in liberal and conservative viewpoints, it grows out of the visionary editorial efforts of David Willis at the Milbank Quarterly.

The first part of the book examines the “proletarianization” and deprofessionalization of medicine. The second part examines medical systems in Canada, the United Kingdom, Australia, New Zealand, France, Greece, the Scandinavian states, the former Soviet Union, Czechoslovakia (before the breakup), and China. A three-chapter summary helps dispel some of the gloom induced by a look at how the state can distort the ideals of patient care. For example, emphasizing the care of the community over the care of the individual in the interest of cutting costs merely ordains the unavailability of complicated care for those considered elderly.

With the Cultural Revolution in China, the book provides a glimpse, thankfully brief, into the abyss. Doctors who are transferred hither and yon, made to sweep floors, and stripped of hierarchical positions; nurses doing surgery and diagnosing: the world of the Morlocks and Elois of H.G. Wells's time-machine future could not be more frightening. Fortunately, with Mao Zedong's death, the Chinese medical system has regained some sanity. Nevertheless, in most countries, bureaucracies have taken over the management of medical practice, leaving the physicians varying degrees of dominance over the content of care and the related decisions.

Readers of The Changing Medical Profession will see how, under the guise of doctor shortages, the number of physicians is increased (by open admissions in many countries, and by increasing the number of schools during the spurious doctor shortage of a generation ago in the United States). In some countries -- Russia and Czechoslovakia, for example -- increasing the number of women in the profession was an economic ploy because the underpaid practitioners in the state system were mostly female, whereas the higher-paid specialists, few in number, were mostly male. What sounds egalitarian appears actually to be an attempt to reduce the status of the profession and turn medical societies into just one more employees' union.

The book recounts how, in countries with governments that have succeeded in subjugating the independence of the medical profession, two-tiered systems have sprung up. A minority of physicians remain specialized and continue to have stature; the majority are in general practice (and in some systems, physicians drive taxis or buses because they are economically better off doing so). I have long believed that the emphasis on general practice is an exercise in nostalgia, wanting to recreate the kindly (though medically impotent) physician of Luke Fildes's painting, Doctor. After reading The Changing Medical Profession, I detect a more malevolent reason for it, because a denigrated status makes the physician, who, after all, masters secrets not known to the general public, more vulnerable to the organizational fiat. Yet it is clear to me, although the book does not address the issue in depth, that complicated forms of technology and the lessons of interactive communication demand a different mix, in which the specialist becomes even more important and the triage system offers, at most, a physician's assistant at the bedside or computer terminal. The fate of competition between traditional means (e.g., acupuncture and qigong in China) and modern Western medicine is instructive: despite the reverses of the 1960s, medicine in China is now predominantly Western, and in Scandinavia and other highly controlled systems, alternative approaches cannot enter because they are not reimbursed.

This book is an eye-opener. The medical systems admired by many of our representatives in government may not lend themselves to being transferred here and are themselves changing because of innate failures. Not only must they curtail services to appear to become more economical but they must also change the role of the physician and emphasize the faceless society over the individual patient, a distortion of the classic approach of the American physician that attracted most to medicine in the first place.

Ominous words like “crisis in health care” disguise the fact that not medicine but political, social, and economic problems are being laid at the door of the complicated medical system we have evolved. The blunt truth is that most of the factors affecting health are outside the control of the medical profession. The problems are social ones. “In many ways, it is helpful to see the medical profession as a coalition of competing factions with a common interest in maximizing the resources invested in health care but perhaps sharp disagreements about distributional issues.” That is, if the medical profession is even given a chance to voice its far-from-hegemonic views. Like the parable of the elephant and the blind men, this book offers analyses to support positions that would otherwise be subjective and unsubstantiated and that can guide a solution to the current national and regional controversies.

George Ehrlich, M.D.
University of Pennsylvania School of Medicine, Philadelphia, PA 19106