Professionalization, Monopoly, and the Structure of Medical Practice (Conrad and Schneider)

Explanandum (what is to be explained): How "regulars" successfully organized as professionals, eliminating their competitors and creating a medical monopoly

Before “professionalization” Humoral theory (Hippocrates) dominated European medicine until well into 19th century -diagnosis was impressionistic, often inaccurate, based on patient reports of symptoms, physicians’ own observations of signs of illness (appearance, behavior) but rarely on manual exam of body Medicine not scientific In colonial America, physicians were p/t, also working as clergymen, teachers, farmers, etc In early 19th c, medicine was low status, not an important economic activity

Professionalization professionalization: "the process by which producers of special services sought to constitute and control the market for their expertise" (Larson, qtd. on p. 195) Professions organize to create and control markets American Medical Association (AMA) forms in 1847  The medical profession became functionally autonomous, insulated from external evaluation and largely free to regulate their own performance

Case study in the Creation of a Medical Monopoly: Scientific Medicine's Anti-abortion Crusade Prior to the Civil War, abortion was a common and largely legal medical procedure in America, free of moral stigma Pregnancy was not considered confirmed until "quickening" ("first perception of fetal movement,” p. 196) common law did not recognize the fetus before quickening, an unquickened fetus deemed to have no living soul After 1840 abortion comes increasingly into public view, services widely advertised in magazines and newspapers By 1870, about 1 abortion per 5 live births

Physicians, not religious leaders, led anti-abortion crusade in late 1860s – But WHY? concern about dropping birthrates, esp. among native born, "better classes" to promote professionalization and create a monopoly over medical services they did this by getting states to sanction their competitors ("irregular doctors," e.g., homeopaths, botanical doctors, eclectic doctors, etc.) By 1900, abortion was not only illegal in American society, but also deviant and immoral

Growth of Medical Expertise and Professional Dominance last three decades of 19th c saw great strides in surgical medicine and improvements in hospital care  rise of germ theory of disease  rise of “scientific” medicine

Doctrine of specific etiology: "each disease was caused by a specific germ or agent. Medicine focused solely on the internal environment (the body), largely ignoring the external environment (society)"….this paradigm is the essence of the "medical model" (p. 198)

Flexner Report Flexner Report: published in 1910 under the auspices of the Carnegie Foundation, found the level of medical education in US poor and recommended closing most schools, establishing stricter state laws and tougher standards

Changes in Medical Practice Doctors move from “solo practice” to large corporate practices or employment in hospitals or other bureaucratic organizations Medicine more specialized & more dependent on technology Medicine expanded as a portion of American economy Currently around 1/6th of US economy (Kaiser)

Kaiser Family Foundation Report, Trends in Health Care Costs & Spending (March 2009) According to the Centers for Medicare and Medicaid Services (CMS), the U.S. spent over $2.5 trillion on health care in 2009, or $8,160 per U.S. resident Health spending in 2009 accounted for 17.6% (over 1/6th) of GDP In 1970, U.S. health care spending was about $75 billion, or $356 per resident, and accounted for 7.2% of GDP Health care spending has risen about 2.4 percentage points faster than GDP since 1970 CMS projects that by 2018, health care spending will be over $4.3 trillion, or $13,100 per resident, and account for 20.3% of GDP

"fee-for-service" American medicine has long operated on a "fee-for- service" basis, i.e., each service is charged and paid for separately  more services, more fees, possibly encouraging unnecessary medical care Medicine is one of the few services that can "create its own demand," since patients go to doctors to find out what procedures they medically need

Since the 1930s, a shift to "third party" payments, mainly from health insurance and the government  availability of federal $ without cost controls, leading to “cost crisis” This has also driven the "medicalization" of more and more human problems

“Medicalization: Context, Characteristics, and Changes & The Shifting Engines of medicalization” Ch. 1 in The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders, Peter Conrad

The Original Engines of Medicalization the power and authority of the medical profession social movements and interest group mobilization professional organized action by physicians themselves 1-: in terms of professional dominance, physician entrepreneurs, and medical colonization 2-: groups mobilized to promote a medical understanding of problems like alcoholism, PTSD, and Alzheimers 3-: doctors organized to gain authoritative control over processes such as childbirth, replacing midwives with obstetricians @ this stage, corporate aspects of medicalization were not central to the analysis

Key Changes in Medicine (beginning in the 1980s) erosion of medical authority rise of cost controls increasing commercialization of medicine

Emergent Engines of Medicalization Biotechnology Consumers Managed Care

A. Biotechnology - pharmaceutical industry pharmaceutical industry: changes in FDA regulations allowed for off-label uses of drugs and direct-to-consumer (DTC) marketing of pharmaceuticals, esp. on television -Viagra: the drug industry expanded the notion of ED, encouraging the use of Viagra-like drugs for enhancement of sexual pleasure and relationships -Paxil: a new "anxiety market" was created as shyness & worry were medicalized as social anxiety disorder (SAD) and generalized anxiety disorder (GAD) Biotech: this covers all kinds of medical technologies, from forceps for childbirth to drugs for distractible children

A. Biotechnology – genetics & enhancement genetics and enhancement: thus far, genetics has made its impact mostly in terms of the ability to test for gene mutations, carriers, and genetic anomolies, but research indicates there's a private market for enhancements for children, regardless of the high cost (e.g., the use of human growth hormone for children of short stature) Biotech: this covers all kinds of medical technologies, from forceps for childbirth to drugs for distractible children

B. Consumers 1. consumers have shown they are willing to pay out of pocket for a range of cosmetic procedures, e.g., breast enlargement and liposuction 2. nonprofit consumer groups (like CHAAD and NAMI) have "medicalized underperformance" in promoting the concept of adult ADHD; here, the internet has become a critical consumer vehicle in websites with information, self-exams, and bulletin boards Consumers: as health care becomes more commodified and subject to market forces, medical care has become more like other products and services in the marketplace

C. Managed care Managed care is a method of organizing and financing health care services that emphasizes cost-effectiveness and coordination of care 1. it’s both an incentive and constraint on medicalization: while reducing coverage for psychotherapeutic treatment for mental illness it has facilitated the use of psychotropic medications 2. overall, managed care organizations have increasing influence over what is considered medically appropriate and inappropriate treatment C. Managed care: since the 80s managed care organizations have come to dominate health care delivery, requiring pre-approvals for treatment and setting limits on types of care

D. Medicalization in the New Millennium 1. Today the engines of medicalization are driven more by commercial and market interests than by professional claims-makers in the field of medicine itself 2. Medicalization will continue to shape social norms, as it already has altered attitudes toward breast augmentation and de-stigmatized male erectile dysfunction 3. Gender segmentation, a proven profit-making strategy, will characterize the market for medical care, where medical problems and solutions will be organized on the basis of gender differences 4. Medicalization will expand as an international phenomenon

Selling Sickness: The Pharmaceutical Industry and Disease Mongering Moynihan et al., 2002, BMJ

Summary points: Some forms of medicalization may now be better described as “disease mongering”—extending the boundaries of treatable illness to expand markets for new products Alliances of pharmaceutical manufacturers, doctors, and patients groups use the media to frame conditions as being widespread and severe

Summary points (cont’d): Disease mongering can include turning ordinary ailments into medical problems, seeing mild symptoms as serious, treating personal problems as medical, seeing risks as diseases, and framing prevalence estimates to maximize potential markets Corporate funded information about disease should be replaced by independent information

5 examples of disease mongering (from Australia but familiar internationally) Ordinary processes or ailments of life classified as medical problems Mild symptoms portrayed as portents of serious disease Personal or social problems seen as medical ones Risks conceptualized as disease Disease prevalence estimates framed to maximize size of a medical problem

1. Ordinary processes or ailments of life classified as medical problems: baldness The medicalization of baldness shows clearly the transformation of the ordinary processes of life into medical phenomena

2. Mild symptoms portrayed as portents of serious disease: irritable bowel syndrome The "makeover" of irritable bowel syndrome from a common functional disorder into a “credible, common and concrete disease” with the help of industry-funded "medical education" campaigns

3. Personal or social problems seen as medical ones: social phobia the medicalization of human distress as the psychiatric disorder of social phobia

4. Risks conceptualized as diseases: osteoporosis the medicalization of reduced bone mass—which occurs as people age—is an example of a risk factor being conceptualized as a disease. the marketing of fear: "The construction of the widely used WHO diagnostic criteria is such that large numbers of healthy women at menopause will automatically be diagnosed as having this “disease” because their bones are being compared with those of much younger women” Against a background of controversy over disease definition, poor predictive value of bone density measurement, and heavily advertised expensive therapies offering marginal benefits to menopausal women, corporate backed promotional activities are attempting to persuade millions of healthy women worldwide that they are sick"

5. Disease prevalence estimates framed to maximize size of medical problem: ED advertisements claimed 39% of men suffered from erection problems, but # combined all categories of difficulties, including "occasional" problems and average age of those reporting complete dysfunction was 71

For de-medicalization Key concern is the invisible and unregulated attempts to change public perceptions about health & illness to widen markets for new drugs Author calls for a publicly funded and independently run program of “de­medicalisation, based on respect for human dignity, rather than shareholder value or professional hubris"