Medisinens gullalder

For omkring 30 år siden ble det i USA tydelig at individuell autonomi hadde ført til stor variasjon i hvordan legene behandlet pasienter med lik sykdom, og til unødige undersøkelser, innleggelser og medisinsk og kirurgisk behandling. I slutten av 1960- og begynnelsen av 70-årene kom det stadig flere rapporter om overforbruk av helsetjenester. For legene ble etterkrigstiden en gullalder, de kunne behandle pasienter og skrive regninger som de ville, og stadig kom det nye og revolusjonerende behandlingstilbud. For pasientene var nytten imidlertid noe blandet, mange prosedyrer førte til unødige infeksjoner, feil, nye sykdommer, endog til unødige dødsfall.

En sentral publikasjon i denne perioden var den amerikanske sosiologen Eliot Freidsons bok Profession of medicine, som kom første gang i 1970 (2), fulgt av Professional dominance: the social structure of medical care (3). Freidson gav en detaljert beskrivelse av hvordan legeprofesjonen i USA har påvirket og dominert de amerikanske behandlingssystemene på en måte som ikke bare har vært til pasientenes beste. Han satte spørsmålstegn ved hvordan de profesjonelle dydene ble praktisert, og var særlig opptatt av hvordan legenes organisasjoner handlet strategisk for å sikre medlemmenes rettigheter. Freidson mente bl.a. at fordi en profesjonsorganisasjon var avhengig av kontingentinntekter, kunne den ikke risikere for mange misfornøyde medlemmer. Dette og andre forhold gjorde at en slik organisasjon rett og slett ikke kunne ha den avstanden til sine medlemmer som var nødvendig for å kontrollere kvalitative og etiske sider ved medlemmenes virksomhet. Tradisjonelt har amerikanske leger vært opptatt av høflighet, service, respekt og tillit, mens det ikke skulle settes spørsmålstegn ved deres profesjonsutøvelse. Freidson definerte profesjonalitet som autonom virksomhet, men overså at profesjonsautonomi, praktisert på individuell basis, kunne true kvaliteten.

Pengene overtar

I sentrum for gullalderutviklingen stod universitetssykehusene. I USA vokste disse raskt til akademiske medisinske sentre og videre til store akademiske helsetjenestekomplekser som ofte satte fortjeneste foran befolkningens behov. Parallelt med Freidsons studier kom det en detaljert rapport om de akademiske sentrenes imperiebygging i New York City. I The American health empire beskrives hvordan lokalsykehus i fattige områder ble overtatt av sentrene, nedlagt eller omorganisert, og hvordan fattige minoritetspasienter ble benyttet i forskning og utdanning (4). Entreprenører og imperiebyggere surfet på gullalderbølgen, og var lite opptatt av profesjonsetikk og kollektiv autonomi til beste for pasientene. Denne historien blir også fortalt, med litt mer eleganse og forsiktighet, i Kenneth Ludmerers bok Time to heal (5). I andre land har man gjort andre erfaringer, men spørsmålet blir også der i hvilken grad en liknende dynamikk mellom kollektiv og individuell autonomi har ført til urimelig store variasjoner i kvalitet og kostnader, til unødig hospitalisering og subspesialisering og til imperiebygging rundt universitetssykehus.

Et eksempel på hvordan pengene blir viktigere enn etikken kan være hva en skotsk lege fortalte fra sin tid som student på et universitetssykehus i USA. Selv med sin sparsomme erfaring kunne han se hvordan spesialistene bestilte alle mulige prøver og gjorde alle tenkelige inngrep hos pasienter som kunne betale. Men da han diagnostiserte en pasient med akutt appendisitt og rekvirerte operasjon, diagnostiserte veilederen hans at pasienten ikke hadde forsikring og bestilte drosje til ham, mens han lo av den naive utenlandske studenten som ikke visste hvordan medisin skulle praktiseres i USA.

Akademiske medisinske imperier og det som ble kjent som «wallet-biopsy» (lommeboksbiopsi) er ekstreme eksempler på en profesjonsdominans som i USA har fått utvikle seg nesten fritt, uten offentlig regelverk eller likhetsideologier. Har liknende ting funnet sted i andre land? I hvilken grad har makten der konsentrert seg om store akademiske sentre og subspesialiserte inngrep hos 1 % av befolkningen?

Også utenfor universitetssykehusene har profesjonsdominansen hatt sin innflytelse på amerikansk helsevesen. Leger slo seg sammen i aksjeselskaper og startet nye spesialklinikker og sykehus der hovedmålet var å tjene penger. De henviste pasientene til sine egne klinikker, og fikk dermed dobbel inntekt, men også dobbel interessekonflikt (6, 7). Investorer begynte å interessere seg for helsesektoren. I begynnelsen av 1970-årene fant de at dette var et område med mulighet for høy fortjeneste og liten risiko. I 1980 skrev den anerkjente redaktøren av New England Journal of Medicine, Arnold Relman, et innflytelsesrikt essay: The new medical-industrial complex (8). Han viste hvordan legenes domener etter hvert ble invadert av investorer og kapitalister. Det han imidlertid ikke erkjente, var at legene selv langt på vei ønsket kommersialiseringen velkommen, kanskje med unntak av akuttmedisinerne. Legene så ikke tydelig sin egen aktive rolle i dette spillet. Enmer grunnleggende kritikk av legeprofesjonen kom fra en kanskje uventet kant. I 1975 skrev jesuittpateren og samfunnsviteren Ivan Illich Medical nemesis: the expropriation of health (9)og føyde dermed ordet iatrogenese til helsepolitikkens vokabular. Basert blant annet på en gjennomgang av ledende medisinske tidsskrifter mente han å kunne dokumentere en epidemi av sykdom og skade forårsaket av legene selv, gjennom overdreven prøvetaking, medikamentforskrivning og unødige kirurgiske inngrep og sykehusinnleggelser. Legenes virksomhet hadde i liten grad bidratt til den fordoblingen i forventet levealder som hadde funnet sted siden 1900. «Den smerte, fortvilelse og forkrøpling som er resultatet av medisinske intervensjoner, kan måle seg med sykdom og skader forårsaket av trafikk, industri og krig, og gjør medisinsk påvirkning til en av vår tids raskest voksende epidemier» (oversatt av OGAa).

Det dreier seg ikke om en epidemi av menneskelig svikt, mente Illich, men om konsekvenser av vanlige, høyteknologiske medisinske inngrep. Enkeltstående tilfeller av menneskelig feil blir i komplekse, høyteknologiske sykehus overskygget av et systemsammenbrudd som følge av en ukontrollert medikalisering. Illich fant at kliniske studier i sentrale internasjonale tidsskrifter viser en økning i invalidiserende ikke-sykdommer, et resultat av at tilstander som ikke er sykdom, er blitt gjenstand for medisinsk behandling (sosial iatrogenese). Hverdagen er blitt medikalisert. Ifølge Illich finner det også sted en «farmasøytisk invasjon», der legene går på akkord med sitt kliniske skjønn og lar seg påvirke til å forskrive medikamenter fra de firmaene som gjør dem tjenester, gir dem utstyr eller betaler reiser til seminarer og konferanser.

Både Illich og hans bok vakte internasjonal oppsikt. I USA tok enkelte ledende personer i det medisinske fagmiljøet påstandene hans alvorlig, som et varsku til akademisk medisin og dens tendens til overdreven medikalisering. Flere innså at medisinen kunne benyttes til sosial kontroll, ikke minst innen psykiatrien, og at legene hadde en tendens til å definere alle ubehagelige menneskelige opplevelser som patologiske og behandlingstrengende.

Som en motvekt til befolkningens økende krav til kjappe terapeutiske løsninger etterlyste Illich mer selvtillit, inkludert selvdiagnostisering og selvbehandling. Mange av hans tilhengere som var leger ville dog ikke gå så langt, det ble sett på som uforsvarlig. Men Illich satte utvilsomt fingeren på noe, og i tiden som fulgte kom det stadig mer litteratur om medisinens begrensning og det økende antallet pasienter med årelange lidelser som følge av medisinske inngrep. Omtrent på denne tiden kom boken Our bodies, ourselves (10) ut på et kvinnedrevet forlag i Boston. Dette er en håndbok i selvomsorg som inkluderte detaljerte instruksjoner og illustrasjoner for å vise hvordan kvinner kunne undersøke underlivet selv – man trengte ikke gjøre seg avhengige av medisinen og gjennomgå ydmykende undersøkelser. Andre bøker fulgte, ofte skrevet av leger. Interessen for livsstil, helsekost og alternativ medisin økte. I dag er påstandene til Illich dagligdagse, men tendensen til «profesjonell patologi», fortsetter, så boken hans kan med fordel hentes frem igjen. I New York annonserer ortopediske kirurger med at middelaldrende kvinner og menn bør få seg nye kneledd dersom resultatene på golfbanen begynner å dale.Internasjonal farmasøytisk industri lar sine legemiddelkonsulenter fortelle legene at sjenanse og manglende orgasme bør oppfattes som psykiatriske lidelser, og tilbyr medikamentell behandling (11). I 2000 mottok amerikanske legere 7,2 milliarder dollar i kontanter og gaver fra legemiddelfirmaer, mens industriens representanter i tillegg brukte 6,3 milliarder dollar på å besøke alle leger flere ganger i året for å få dem til å forskrive de rette medikamentene.

Gullalderen over

Kort etter at Medical nemesis var blitt bestseller, kom oljekrise og økonomisk tilbakegang, og helsetjenestebetalere, dvs. offentlige myndigheter eller helseforsikringsselskaper, begynte å klage over økende kostnader. Bygging av nye sykehus og legespesialistutdanning ble begrenset, stykkpriser og totalbudsjetter ble i økende grad kontrollert. Primærhelsetjenesten ble gjenoppdaget som den kostnadseffektive ryggraden blant alle subspesialitetene. I de fleste land var slike omstruktureringstiltak effektive, og utgiftsøkningen flatet ut. Presset for å begrense kostnadene holdt seg utover i 1980- og 90-årene.

Trykket var ekstra stort i USA, fordi forsøk på kostnadsbegrensning vil være mindre effektive i et system basert på frivillig helseforsikring – den enkelte betaler vil ikke være interessert i å begrense fellesskapets kostnader. Samtidig har motkreftene mot profesjonsdominans vært svake. Dermed toppet kostnadskrisen seg i et «kjøpernes opprør» (12). Arbeidsgiverne og Kongressen, som de største betalerne, begynte å oppføre seg som virkelige kjøpere. De stilte spørsmålene: «Hva får jeg egentlig for pengene mine?» «Trenger denne pasienten egentlig sykehusinnleggelse?» «Trenger denne pasienten virkelig å ligge en dag til på sykehus?» Etter hvert utviklet det seg tre typer løpende kritiske vurderinger (utilization review)fra betalernes side: prospektive, for å vurdere om en innleggelse eller en operasjon virkelig var nødvendig, løpende, for å se om pasienten kanskje kunne skrives ut eller behandlingen avsluttes litt tidligere, og retrospektive, for å finne hvilke sykehus som var de mest kostnadseffektive. Ekspertene i dette nye fagfeltet fant f.eks. at prisen for samme rutineoperasjon kunne variere med en faktor på 2 – 3 i samme by. Man utviklet også metoder for å beregne praksismønster for spesialister. De fant f.eks. at noen kardiologer la inn langt flere pasienter enn andre eller opererte oftere. Hvorfor, spurte kjøperne, skulle de bruke de dyreste sykehusene eller spesialistene med de dyreste praksismønstrene?

Fremvekst av «managed care»

Nye organisasjoner og praksismåter ble kalt «managed care». Gradvis var det «accountability» (etterrettelighet) og ikke «autonomy» (autonomi) som ble stikkordet. Dette innebærer en ny form for profesjonalitet: En profesjonell er en som mestrer en verdifull, avansert fagkunnskap og ferdigheter, og som anvender dette på klienter (eller pasienter) etter en anerkjent og målbar standard. I 1980-årene brukte General Motors mer penger på de ansattes helseforsikringer enn på det viktigste materialet for virksomheten, stål. Men man begynte å undre hvorfor de samme kvalitetskravene som ble stilt til stålet eller de øvrige bilkomponenetene, ikke også ble stilt til de helsetjenester de betalte for. I over et tiår hadde de forgjeves forsøkt forskjellige samarbeidsstrategier for å få legene til å begrense kostnadene. De akademiske medisinske sentrene mente at arbeidet deres var for viktig til at man skulle bry seg om hva det kostet (5). Mot slutten av 1980-årene var det imidlertid mange som ikke brydde seg om hvordan kostnadene ble kuttet, bare det ble gjort. Store arbeidsgivere sluttet å ha egne administratorer for sine helseforsikringsopplegg, de gikk over til «managed care»-planer. Uwe Reinhardt har beskrevet hvordan store selskaper leide «managed care»-organisasjoner til å eliminere helsetjenestekostnader (13).

Legene var sjokkert over veksten i denne virksomheten og den begrensingen i behandlingstilbud og honorarer den førte med seg. Sosiologene McKinlay & Arches beskrev dette som «proletarisering» (14), og da de skjønte at dette var et fyord blant legene, endret de terminologien til «korporatisering» (15) av legeprofesjonen. Selv om disse forfatterne er kritiske til det amerikanske kapitalistiske samfunnet, ble deres karakteristikker av den nye legen som «samlebåndsarbeider» eller «slavearbeider» i en «managed care»-organisasjon, raskt grepet av legenes organisasjoner. Dette nye bidraget til sosiologisk analyse av legerollen førte til en oppblomstring av nostalgiske strømninger blant legene: Hvis de nå ikke greide å beholde sin tradisjonelle status som hyggelige, selvstendige og autonome profesjonsutøvere, herrer i eget hus, så ville de bli fastlønnede funksjonærer i store, byråkratiske helsekonserner som bare var opptatt av produksjon og fortjeneste. Noe liknende ville skje på universitetene, de ville bli tvunget til å rekruttere kvinnelige studenter og studenter med minoritetsbakgrunn, med offentlige stipender og lån. Og unge leger ville bli tvunget til å praktisere der det virkelig var behov for dem.

Den som praktiserer som lege i Norge, eller i andre land med fastlønnede sykehusleger, ser umiddelbart hvilket unyansert og til dels feilaktig vrengebilde av legerollen som McKinlay & Arches analyse fremprovoserte. På grunn av de private forsikringsordningene har legenes frihet til å bestemme hvilke diagnostiske og terapeutiske prosedyrer som bør benyttes, vært mindre i USA enn i de fleste andre land siden lenge før fremveksten av «managed care». Dessuten var de amerikanske legene absolutt ikke bare uskyldige ofre i den nye helsetjenesteindustrien, de var i stor grad med på oppbyggingen og styringen av den. Begrepene proletarisering, korporatisering og profesjonsdominans passer kanskje som beskrivelser på en bestemt periode, som ironisk nok var omtrent tilbakelagt da begrepene kom. Begrepene har imidlertid begrenset nytte i analysen av hva som har skjedd med de amerikanske legene de siste 30 årene. Vi trenger et skjema som setter legene inn i en større sammenheng, både i tid og rom. Tabell 1, som viser aktuelle krefter og motkrefter, er et forsøk på dette.

Tabell 2 viser de forskjellige aktørene, deres verdier og hvilke visjoner de har for en god helsetjeneste. Legeprofesjonen har lenge hatt som sin viktigste målsetting å utvikle best mulig sykdomsbehandling og samtidig styrke legenes prestisje og makt. I dette ligger, i alle fall i USA, en visjon om en helsetjeneste tuftet på privat praksis, kontrollert av leger, med privat betaling, henvendt til syke mennesker. I sentrum for et slikt system finner vi de medisinske akademiske sentrene, omkranset av spesialklinikker, og lengst ute i periferien allmennlegene. Folkehelsen har ingen plass i en slik visjon av den ideelle kliniske virksomheten. Det er i et slikt system en lang periode med profesjonsdominans har skapt dagens ubalanse. Men hvem representerer de andre aktuelle kreftene, og hvor bør motkreftene settes inn? Staten og andre store betalere, som forsikringsselskaper eller arbeidsgivere, er selvsagt interessert i at befolkningen skal være så frisk og vital som mulig, til lavest mulig kostnad. Disse aktørene er derfor mest interessert i folkehelse, forebygging og egenomsorg. Så følger behandling, med vekt på primærhelsetjenesten. Her er legen sentral, men det er naturlig å begynne med opplæring av pasienter, ufaglærte og faglærte omsorgsarbeidere, og etter hvert mer spesialiserte yrkesgrupper, med leger og legespesialister til slutt. Det er sløsing med ressurser når en pediater med 11 års spesialistutdanning fra Yale behandler en banal ørebetennelse.

Den nye legen: Åpenhet og ansvar

Moderne informasjonsteknologi har langt på vei gjort det mulig å åpne legevirksomhetens lukkete rom. Systematisk registrering av praksis gir ofte legen mer informasjon om hvordan han praktiserer enn han selv er klar over. Tidlig i 1980-årene begynte noen av de største amerikanske helseorganisasjonene (HMO) rutinemessig å sammenlikne hvordan forskjellige leger behandlet samme sykdom, og man fikk etter hvert legene til å kommer frem til et felles behandlingsopplegg, basert på dokumentert kunnskap. Dette er essensen i den nye profesjonaliteten. Vi er optimister og ser for oss en ny legeprofesjon som er i stand til å nyttiggjøre seg den enorme mengden ny kunnskap og de nye mulighetene og samtidig ivareta tradisjonelle profesjonsdyder. For å gjenopprette den kvalitet, åpenhet og tillit som har forvitret gjennom de siste 25 årene, er det nødvendig å snu den gamle profesjonaliteten opp ned, som vist i tabell 2. Den nye legen baserer seg på kvalitetsmål og retningslinjer utviklet av kliniske forskerteam, med rom for klinisk skjønn der det er nødvendig. Det sentrale er etterretteligheten (accountability), det vil si alltid å kunne dokumentere hva som gjøres og hvorfor. Jo mer man fraviker fra det som er standard prosedyre, desto viktigere blir det å dokumentere. Det lukkede roms tid er forbi. Den nye legen gjenoppretter legeprofesjonens intensjon om å hjelpe pasientene og samfunnet ved å maksimere helse og funksjon. Derfor er den nye legen opptatt av forebygging, pasientopplæring, primærhelsetjeneste og samfunnsmedisin – sykehusmedisin og subspesialisering kommer i annen rekke. Den nye legen delegerer så mange oppgaver som mulig til andre, og arbeider gjerne i tverrfaglige team.

Staten spiller en viktig rolle. Den har ansvaret for å opprette nasjonale institutter for klinisk kvalitetsutvikling, finansiere resultatorientert forskning, støtte systematisk metodevurdering og andre offentlige helseoppgaver.

Man kan si at profesjonaliteten blir gjenfødt gjennom å imøtekomme kjøpernes krav om kunnskapsbaserte prosedyrer og bedre resultater. Forskerteam ledet av leger, akademiske sentre og spesialistforeninger er nå opptatt av å finne hvilke intervensjoner og protokoller som er mest effektive. Det blir bygd bro mellom universitetsklinikker og den befolkningen de skal betjene (17). I lokalsam-funnene lærer pasientene stadig mer om egen helse fra åpne kilder med medisinsk informasjon, fra bøker eller fra Internett.

Denne prosessen har resultert i to nye elitegrupper blant legene: På den ene side de som er eksperter på å håndtere elektroniske kunnskapsbaser og kan sette sammen protokoller, behandlingsskjemaer og kunnskapsbaserte retningslinjer for sine praktiserende kolleger (kunnskapsatletene), på den annen side de som velger å bli ledere for en «managed care»-organisasjon, en helseorganisasjon eller et sykehus. Dessuten viser kliniske, kontrollerte forsøk, ledet av leger, at sykepleiere og hjelpepleiere er like nøyaktige i gjennom-føringen av en rekke primærhelseoppgaver, de følger protokollene minst like godt som legene (18). Sykepleiere kan faktisk gjøre en god del av det arbeidet som i dag gjøres av legespesialister. Sammen med opplæring av pasienter og andre hjelpere betyr dette en helsetjeneste med bedre og mer pålitelig kvalitet til en lavere kostnad, f.eks. gjennom tverrfaglige team i kommunene.

Leger som klamrer seg til den tradisjonelle profesjonsrollen, føler seg truet både ovenfra og nedenfra. Men leger som ønsker den nye legerollen velkommen, blir med på å utvikle en teambasert, åpen og ansvarlig helsetjeneste for det neste århundret.

I Norge er vi kanskje noe nærmere den nye legerollen enn i USA. Men selv om også vi ser en tendens til at grenspesialistene har urimelig mye makt, har vi likevel en helsetjeneste med tyngdepunktet utenfor sykehusene, i alle fall på papiret. Mange av de oppgavene som er nevnt i listen over, har hos oss vært initiert og drevet frem av Legeforeningen eller andre legedominerte institusjoner. Men det gjenstår mye. For eksempel ser det ut til at fastlegeordningen i sin nåværende form svekker primærlegens mulighet til å drive forebyggende arbeid eller til å delta i tverrfaglige team i kommunene. Heller ikke i norske sykehus er legene flinke teamarbeidere, og forholdet til sykepleierne er unødig komplisert. Som i alle land sliter også norske leger med å nyttiggjøre seg ny informasjonsteknologi, både på registreringssiden og på kunnskapssiden. Men mulighetene er flere enn noen gang. Vi har lite å tape og mye å vinne.

From Autonomy to Accountability

Societies grant the profession extensive powers, to cut into people’s bodies and to inject them with beneficial poisons, because its members promise to use such powers to heal or ameliorate the effects of illness, injury, disability or suffering. These powers are framed by forms of accountability, to an oath and ethics, to licensure, to legal sanctions and to clinical standards of scientifically based interventions. As Aasland notes, three classical features of professionalism are altruism, the quest for excellence and the management of poorly performing clinicians (4). A particularly British slant adds that in return for monopoly protection and financial support, the state can rely on the profession «for the covert rationing of the available public-health care resources» (5). These arrangements are all built on trust, by patients and the state of the profession, but also trust by the profession of the state and patients to appreciate the limits and constraints under which professionals work.

Historically, the professional associations were granted autonomy to develop standards and assure their realization, in part because their members controlled a valued body of complex, vital information and because society had to trust them to maintain standards. The cultural dimensions of autonomy depend on powers granted by the populus and patients, and the structural/legal dimensions of autonomy depend on powers granted by the state. This means that autonomy is a constructed reality, a political and institutional fact that physicians often forget. Autonomy is not autonomous. Both sets of dimensions are based on trust, respect and deference as substitutes for accountability.

The problem with the social compact of professional autonomy has been that not only did the profession as a whole assume autonomy for itself, but so did each individual practitioner. The latter seriously limits the former, the ability of the medical associations to carry out their mission to maintain standards and hold individual physicians accountability to the «professional standards» that they were supposed to uphold. Thus, if «professionalism» refers to the autonomy of individual professionals, it cannot be the foundation of true professionalism (6). Rather, the asserted independence of individual practitioners undermines the autonomy and trust which society bestows on a profession as a whole to hold its individual members accountable. Few professionals seem to realize that their personal insistence on autonomy underlies the modern «crisis of professionalism» that has been experienced in many countries. For that crisis consists of the organizational, economic and clinical consequences of professionalism based on individual autonomy with minimal accountability. The dynamics of individual autonomy and the crisis of usurped professionalism is a story worth telling.

The «Golden Age of Medicine»

During and after World War II, scientific and clinical advances enabled doctors to treat a wide range of fatal or debilitating disorders. Patients revered them and they had a free hand to practice medicine as they thought best. «This was truly the golden age of modern medicine,» Aasland notes, «a period where everything seemed possible» (4). But in the 1960s, Beecher’s article and the thalidomide affair documented how medical hubris could wreak havoc on the lives of trusting patients and how professional arrogance led to abuses. In the 1980s, it became clear that individual autonomy had led to large variations in how individual clinicians treated patients with the same kinds of disorders, and to unnecessary hospitalization, surgery, tests and prescriptions (7, 8). Reports of excesses appeared in the late 1960s and early 1970s.

Many practitioners regard this postwar period as the golden age of medicine, because they could practice as they liked. But unrestrained growth in utilization, variation and charges also made this an age of gold for doctors and hospitals. Its benefits to patients were mixed with excessive procedures that induced unnecessary infections, accidents, diseases, and death. Dr. Robert McCleery, for example, organized law students under Ralph Nader to produce a report in 1971 that detailed the low quality of clinical work and injury to patients by ordinary physicians (in contrast to those celebrated in the press at the great medial centers) and the very limited ability of medical societies and state boards to do much about it (9). In 1972, Senator Abraham Ribicoff, who had been Secretary of Health, Education and Welfare, published The American Medical Machine and described its relentless ability to generate bills. «The 1960s and 1970s will be remembered as the years when the sky was the limit in medical costs and nobody seemed to make much headway controlling them,» he wrote (10). In Tulsa, Oklahoma, he found, medical debts accounted for 60 percent of all personal bankruptcies. In same year, Senator Ted Kennedy published his critique, In Critical Condition, based on testimony from citizens at hearings his committee held across the country (11). One listens in to patients bewildered about what their insurance policies covered and shocked at what expenses they did not cover. A wave of similar books followed. As Hernes wryly notes, the doctor, as the patient’s agent may have interests of his own, «possibly some that are in conflict with those of the principal…» (12)

A landmark study of this «golden age» was Profession of Medicine (13) by Eliot Freidson in 1970 and his companion volume with the more thematic title, Professional Dominance: The Social Structure of Medical Care (14). Surprisingly ahistorical, these works nevertheless described in detail the structural dominance of the profession in the United States and the resulting pathologies. Freidson concluded that an organized profession could not discipline itself effectively, in part because professional associations rely on dues and officers are elected, which limits a professional association’s ability to monitor or discipline its members. In other ways as well, they do not stand apart enough to serve as an inspectorate. Rosenthal documented the reasons why and foreshadowed the acute crisis of Britain’s General Medical Council and the intervention by the state to take over professional functions. Professional disciplinary bodies tend to respond slowly to evidence of even egregiously incompetent or abusive doctors, reluctant to discipline, secretive and protective in their non-disclosure to the victims or the public (15, 16). The tradition of professional courtesy, the emphasis on trust and respect, and the insistence on autonomy all assume that quality and practice are above question. Ironically, Freidson himself grounded his concept of professionalism on autonomy as its core, even though it did not sit well with his observations about individual autonomy as a barrier to professional quality. This led me to conclude years ago that accountability is the core attribute of professionalism and autonomy has been a substitute or a delegated form of accountability because systemic assessment of clinical work was not possible until the 1970s (6).

At the heart of the golden age of medicine were medical schools and their teaching hospitals, which in the Untied States grew rapidly to become academic medical centers and then academic health care complexes. Parallel to Freidson’s studies was a closely observed report on the aggressive empire building of academic medical centers in New York City (17). The American Health Empire described how they took over neighborhood hospitals and clinics in low income areas, closed them or reconfigured them, and used poor minority patients as «material» for clinical research or practice-teaching. This history has been described with more grace and circumspection in the later chapters of Kenneth Ludmerer’s Time to Heal (18). Other countries have quite different histories, but the question for them is whether similar dynamics of professional elitism led to fiefdoms of subspecialty medicine being built around medical schools and teaching hospitals and led the profession away from its core societal mission to maximize the well-being of populations, toward the excessive use of hospitals and subspecialty medicine and toward the large variations in quality and cost that results from individual autonomy?

Academic medical empires and what became known as «wallet biopsy» are extreme manifestations of professional dominance, unrestrained in the United States by a missing societal framework of service or concerns for equity. A Scottish doctor recently recounted his elective rotation as a student at a teaching hospital in South Carolina, where even in his untrained state he could tell that the specialists were ordering every test conceivable and performing every procedure possible on patients who could pay. But when he diagnosed a patient in the emergency room as having acute appendicitis and ordered surgery, his supervisor «diagnosed» that the patient had no insurance and ordered a taxi, laughing at the naivete of an overseas student who did not know how medicine is really practiced in the United States.

Outside of academic medical complexes, the pathologies of individual autonomy and organized professional dominance became increasingly apparent in the unfettered world of American medicine. In the 1970s, U.S.physicians incorporated their practices and turned them into businesses. Specialists pooled their earnings (known as «profits» in other lines of work) to build surgi-centers, specialty clinics, diagnostic centers and even for-profit hospitals. Then they referred their patients to them for scans, tests, or ambulatory surgery, thus doubling their profit streams but also their conflicts of interest (19, 20, 21). Outside investors began to take notice. They realized by the early 1970s that health care was a field with high profit margins and almost no rise. For-profit medicine took off. In 1980, Arnold Relman, the revered editor of the New England Journal of Medicine, published an influential essay, «The new medical-industrial complex» (22). What he failed to note, however, was that the medical profession had welcomed corporations into every other aspect of medicine except acute clinical services; so that the shock seems to have been that investors and capitalists moved into the one remaining sector. Physicians usually overlook their active role in creating the medical-industrial complex and the role of entrepreneurial physicians in commercializing hospital and specialty care.

The crisis of professionalism can be dated from the debates provoked by Freidson’s two books or from the international best-seller, Medical Nemesis: the Expropriation of Health (23) by Ivan Illich. He added «iatrogenesis» to the vocabulary of health policy as he documented from leading medical journals an «epidemic» of «doctor-made» sickness and injury from over-testing, excessive prescribing, unnecessary surgery and hospitalization. Illich concluded that «The pain, dysfunction, disability, and anguish resulting from technical medical intervention now rival the morbidity due to traffic and industrial accidents and even war-related activities, and make the impact of medicine one of the most rapidly spreading epidemics of our time» (p35).

This «epidemic» of medically inflicted damage, Illich observed, is not due to malpractice but to routine high-tech interventions. Occasional human error had been replaced with «system breakdown» in complex technological hospitals, he maintained. Medicalization was rampant. Drawing on clinical studies in major medical journals, Illich concluded that «Disabling non-diseases resulting from the medical treatment of non-existent diseases are on the increase,» (p.37 – 8). Thus society was inflicted with social introgensis, or the creation of medicalized life, in which everyone sees him- or herself as having a disorder.

Central to this process was the «pharmaceutical invasion» (70 – 75). Doctors allowed their clinical judgment to be compromised by prescribing the drugs sold by the companies who bought them favors or equipment or luxurious trips to seminars, where they could brush up their professional skills (24). Today, this commercialization of clinical judgment constitutes a deeper and more pervasive threat to professionalism than the «new medical industrial complex» of hospital and health care corporations.

Illich called for self-reliance, including self-diagnosis and self-treatment, and an end to the addictive craving for a therapeutic «fix». Many within the medical profession are not willing to go that far, and yet they need to discuss how even the best of medical interventions in the Golden Age produced millions of patients with long-term disabilities and chronic disorders. Illich provided a coherent account of why the medical profession was in trouble, how high error rates were built into its practices and hospitals and how doctors were becoming appendages to pharmaceutical companies. He described how all this was making patients dependent and weak, rather than more independent and strong, and why self-help and more natural forms of self-care were growing as an international social movement. Twenty years later, the Institute of Medicine caught up with one part of Illich – the systemic nature of medical errors in hospitals – but did not recognize the obvious links to professional autonomy or the commercialization of clinical judgment by an army of highly trained drug reps bearing billions in gifts (25).

Meantime, the Boston Women’s Collective published Our Bodies, Ourselves (26), a handbook of self-care that included detailed instructions and drawings to show women how to examine themselves without putting themselves in a position of dependency and perhaps humiliation by being examined by a doctor. A number of other books began to appear, such as home guides for self-diagnosis written by physicians. The movement for health foods, healthy living, and alternative medicine developed. The development of the internet has greatly increased the range of medical and technical knowledge available to people. As Hernes notes, «professions that before had a near monopoly of knowledge, in the future will be challenged – and provoked – more and more often by those who can access information they cannot themselves produce.» (11)

Significant advances since Illich wrote have increased the capacity of clinical interventions to improve and extend the lives of patients. Today, advances in clinical medicine are credited with about one-quarter to one-third of gains in reduced morbidity, mortality and disability since Illich wrote his diatribe (27, 28, 29, 30). At the same time, his themes have developed so fully into movements of organic, wholistic and alternate forms of health and care that his seminal works are largely forgotten and unread. The professional pathologies he identified, however, continue. The global pharmaceutical companies are medicalizing shyness and less-than-orgasmic sex as psychiatric disorders for which they offer chemical cures. Physicians are being coached by drug reps on how to prescribe chemical adjustments so that everyone feels good, is social gregarious and has great sex, every day of the year. No wonder a Jesuit, concerned about personal character and the soul, became alarmed. Massive addiction to prescription drugs is developing in the United States, such as Oxycontin, Percodan, Vicondin, MS-Contin, Demerol, Ritalin, Dexerdine, Valium, Xanax, Activan and their brand-name equivalents (31). All are approved and written by physicians, who each year in the United States have billions spent on them by representative from each of the large firms to bend their «independent» professional judgment towards the new, high-profit variations within each drug class (32). Would professional doctors not refuse to see these salesmen and take their gifts? This was a major recommendation by David Rothman in a recent analysis of medical professionalism (33).

The Revolt Against the «Golden Age»

As the early critiques of professional dominance became best-sellers, the oil crisis and recessions of the 1970s occurred, and payers (usually governments and insurance pools) sounded the alarm about rising medical costs. They staged what could be called a Buyers’ Revolt. They took measures to control the building of more hospital beds, the training of specialists, the fees they charged, and the overall budgets (34). Primary care was rediscovered amidst all the attention on sub-specialties as the cost-effective bedrock of any health care system. In most countries, these measures worked and medical expenditures flattened out. Nevertheless, the perceived pressure to hold down costs persisted in the years following and throughout the 1980s and 90s.

These developments made clear that a larger and more historically dynamic concept than «professional dominance» was needed, one that centered on the relations between a given profession and the state, patients, insurers, and other major institutions such as employers. The concept of countervailing powers emphasizes these differing agendas and values of stakeholders and the changing balances of power over time (3). From this historical and comparative perspective, professional dominance represents one long historical period in which the organized medical profession had extensive control, not only over its work but over other professionals working in the field, over terms of financing, over political policies, and over the institutional contexts of professional work. But behind such stability are accommodations to different stakeholder values and what Salter calls «competing discourses» (5). These are illustrated in table 1 that characterizes the values major stakeholder groups.

There are four major domains in which countervailing powers interact and where professions aim to exercise control (35). The strategic domain involves basic decisions by governments or sometimes large oversight institutions about the goals of the health care system, the structure of its institutions, the distribution of power, and the supply of beds or specialists. The economic domain involves decisions about budgets and terms of payment. The administrative domain involves the management and coordination of services. And the clinical domain involves defining and controlling the nature of clinical work, its quality, and issues of delegation or coordination. Recognizing these four domains allows one to map and measures the strengths and vulnerabilities of a given profession. It clarifies how much more precarious was the seemingly impregnable dominance of the medical profession in the United States, because its strategic, economic and administrative dominance was largely de facto, not as institutionalized as they are in countries with universal health care coverage and a unified set of regulatory bodies.

Nowhere were the pressures for cost containment from countervailing powers greater than in the United States, because nowhere else were the efforts to hold down costs less successful than in a voluntary system with thousands of payers who could not serve as a countervailing power to professional dominance. Doctors and investors easily circumvented such efforts. Thus the cost crisis came to a head in the buyers’ revolt (36). Employers and Congress, as the largest payer of all, revolted and started acting like buyers. They asked questions like, «What am I getting for my money? Does this patient need to be hospitalized? Does that patient need to stay another day, or can she be discharged today?» Thus the three kinds of «utilization review» (UR) began: prospective review of whether an operation or hospital admission needed to be done, concurrent review of hospitalized patients to see if they could be discharged today rather than tomorrow, and retrospective review of hospital records to see which hospitals were more cost-effective. Experts in this new secondary industry found, for example, that charges for the same routine operations varied by 2 – 3 fold among hospitals in the same city. UR experts also developed ways to do comparative profiles of specialists. Again, they found that some cardiologists admitted far more patients with the same problems than others, or operated much more. Why, the newly awakened buyers ask, should they contract with the most expensive hospitals or the specialists with more costly patterns of care?

What American physicians fail to realize is that the medical profession in almost every country with a national health care system of one kind or another gains seats or even majority control in national institutions that shape the health care system’s strategy, economics, institutions, and administration. The political influence of professional associations still matters, but it takes place around a solid institutional base of professional power. Once the buyers’ revolt and the drive for cost containment began, it quickly exposed the deeper consequences of professional autonomy: continued use of ineffective procedures, unreliable uptake of new effective procedures according to individual taste, variable and sometimes poor quality, and variable expenditures treating the same patients. Thus professional power in the clinical, strategic and administrative domains had to be challenged.

The Rise of Managed Care and the Crisis of Professionalism

The tools and new organizations dedicated to reducing variations and costs developed gradually into what came to be called «managed care». By degrees, accountability, not autonomy became the watchword. This implies a new concept of professionalism as mastering an esoteric and valuable body of knowledge and skills and appluing them to clients (or patients) using measurable standards. General Motors by the 1980s spent more on the peripheral employee benefit of health care than on the core material for its products, steel. Executives wondered, «Why should the same expectations of high, consistent quality and good value that we sought in a manufacturer for its steel, or gear boxes or other components not apply to the clinical medicine they were paying for?» For over a decade they had tried various co-operative efforts to get the medical profession to help restrain costs, but to no effect, and academic medical centers thought they were too important to be concerned with cost containment (37). By the late 1980s, many became fed up and did not care how costs were contained so long as the job was done. Large employers began to shift away from hiring mere administrators of their health plans to contracting with «managed care plans». Uwe Reinhardt has captured best the feeling of major U.S. payers when he describes how they hired managed care companies like bounty hunters to go out and «shoot down» health care costs. No questions asked: bring in the ears (reduced costs), and receive a handsome reward (37). These organizations selected cost-effective medical groups, hospitals, laboratories, and other providers. They bargained down discount rates. They applied the relatively crude tools of screening and utilization review and set limits on mental health and other services that could get out of hand.

From the perspective of physicians, the buyers’ revolt felt like an assault, and doctors experienced a loss of control over medical decisions, over referrals, over the organization of medical services and over funding (38). An American pathologist interviewed in 1997 said, «There is way more fear and paranoia in the physician community than there was 20 years ago…way out of proportion to the changes that have actually taken place.» An internist explained, «…[P]atients are yanked from place to place by their insurance programs….Loss of control over one’s practice [is the biggest change], so that more and more of the day is potentially consumed by non-patient care, and yet the amount of time you’re required to spend on patient care remains the same…» A growing number of physicians have simply refused to cooperate at all and discovered life goes on: «What I did two months ago was resign from all HMOs and at this point, and in the future, I will not accept any HMO patients and I think it will be harder financially, initially, to practice medicine, but in the long run, I think I’ll be able to do a better job, take better care of my patients.» Since 1997, he has been joined by so many thousands that managed care has been declared «dead» and the 30 by 60 foot billboard on my way to work by the largest HMO plan in the nation declares, «Specialty care without referrals.»

Bounty hunting was the crude American form of managed competition, an elegant theory developed by Alain Enthoven to overcome the multiple ways in which health care does not meet the basic requirements for viable markets (39). It became an international movement, promoted by global consulting firms and imposed by the World Bank and other funders as a condition for economic aid (40, 41). Competition, the theory held, could be used to drive out wasteful practices if it took place in a system that had universal coverage, risk-adjusted budgets, good comparable measures of performance and a number of other safeguards against competing plans simply selecting lower-risk patients or skimping on quality.

Margaret Thatcher was an early enthusiast and transformed the NHS into a market system that had most of the safeguards deemed necessary by Enthoven (42). But Americans, in their bandwagon style of «solving» social problems, embraced Enthoven’s rhetoric while ignoring most of his tough conditions for managed competition to reward efficiency and service, rather than cream skimming and quality skimping. As his model predicted employers and government programs hired bounty hunters (for-profit managed care corporations that made money by paying less for clinical services) without bothering with universal coverage, risk-adjusted contracts, or other «details» (43).

International assessments of managed competition have found that most countries drew back from their initial enthusiasm, because they came to realize that implementing markets could raise transaction costs, increase management costs, create service dislocations and increase inequalities (44). But the concept is still very alive, and it is important to realize that even in its most complete form, managed competition has several hidden flaws and unpleasant surprises (45).

The Crisis in American Professionalism

The growth of managed care corporations and their wholesale efforts to rein in utilization and charges shocked the medical profession. McKinlay and Arches captured the feeling in the United States when they wrote about the «proletarianization» of the medical profession (46). The keen reception of this thesis, and its revision with only a word-change to «corporatization» a few years later (47), is remarkable because of the arguments set forth. First, in this account of how professional autonomy has been destroyed, clinical standards are described as «encroachments on autonomy,» and medical directors running their departments are characterized as «enslavers». Second, the authors claim that the «high degree of bureaucratization» is the central means by which physicians «become enslaved» and have to conform to encroachments on their autonomy in order to ascend the bureaucratic hierarchy. Third, this bureaucratization, they state, «is being forced on medical practice as a consequence of the logic of capitalist expansion.» But it was the leading subspecialists of the medical profession caused hospitals to become increasingly large, complex and thus bureaucratized in the decades after World War II. As they ran their services as profit centers, incorporated their practices and became investment partners in hospitals or clinics, they were the capitalists. It was the rich professional rewards of higher status and larger fees that spurred the development of the specialty-medical complex, not the greed of outside capitalists.

Third, McKinlay and Arches describe medical schools as «being forced to recruit proportions of minorities and women», and the government as imposing student scholarships and loans. The professional autonomy of the post-World War II era led to biased recruitment of predominantly white, middle- and upper-income males, and efforts to redress these inequalities are seen as infringements on autonomy. Inducing or requiring young physicians to practice in underserved areas, rather than in the more affluent and settled areas where their predecessors set up practice is also depicted as an infringement on autonomy. Efforts to rein in the escalating charges by physicians is described as encumbering them with regulatory legislation. In sum, when the «capitalist» bureaucracy is not «de-skilling» specialists and putting them on a wage of $2000 – 4,000 a week, legislators are impinging on physicians’ rights to recruit white, male candidates from affluence families and practice among their own kind.

Finally, the argument for proletarianization or corporatization equates subspecialty training with Marx’s characterization of how capitalists de-skilled craftsmen by dividing their skills into little steps on assembly lines. «The modern physician is first taught and then subsequently exhorted, to make greater use of technology…with a maximal use of the very latest and most sophisticated biotechnology,» the authors write in Luddite horror (1985: 168), a strange equating of superskill with no skill. Salaries, regardless how high, are considered to be evidence of proletarianization. The autonomous doctor sends out his own bills. The worry, then, is that this thesis is so popular, based on the authors’ celebration of a Norman Rockwell image of the solo practitioner from the 1940s and 1950s.

The Crisis in British Professionalism

In the UK, the challenges to professionalism took different forms. In a somewhat analogous way, the government as the payer went through a change in consciousness to act like a buyer or purchaser driving for better value. The British government has been often characterized as a «democratic dictatorship», because its ministers and cabinet are so secret and their power to get their agenda through Parliament is so great. The profession was shocked when the Government (as it is Capitalized in the UK) unilaterally made several changes in the 1990 GP contract that began to make GPs more accountable for what they did. The increased powers given to hospital executive teams and the elimination of any independence from political control steadily chipped away at the fiefdoms which consultants had enjoyed since Bevan had persuaded them to join him in creating a national health service, by giving them their own firms, beds and budgets in 1948 (48). Some long-time observers commented that Thatcher’s real goal in revolutionizing the NHS was to «get to the consultants and make them accountable». To appreciate the depth of institutionalized autonomy which Thatcher, or any conscientious leader trying to purchase cost-effective services for a population faces, consider that all the specialists have life-long sinecures, all GPs have a separate contract «outside» the NHS and nearly all of the hospitals became statutorily independent; so that in some ways none of the major players are actually within the health service that leaders are trying to manage. Conversely, those in charge of the NHS have no place to go except to these quasi-autonomous professions, resulting in what Klein characterizes as «anarchic syndicalism.»

But it has been the government of Tony Blair and New Labour that have most deeply challenged the traditional professionalism of autonomy, by establishing national standards for clinical performance based on the best prevailing evidence, and by making changes that bring both GPs and consultants more fully into the NHS as a corporate body of rationalized services. The state announced that «clinical quality would be integrated with the normal systems of NHS accountability. Medical self-regulation is no longer regarded as sufficient guarantee of high-quality health-care provision and there is to be a comprehensive, management-led system of clinical governance to set, monitor and, where necessary, correct clinical standards» (4).

Rare Cases of Gross Incompetence

This drive for a modern NHS with high national standards has been painfully advanced by a string of national scandals about incompetent and arrogant senior consultants – the paragons of the medical profession – causing serious injuries and even leaving the hospital while their patients bled to death. Such has been the language used in front-page news in every part of the country for weeks on end. The questions raised have been systemic: how could such doctors remain undetected for so long? How could they continue injuring, exploiting and killing patients for years? All the answers center on professional autonomy and an arrogant «club culture» that covers up a colleague’s mistakes and punishes any nurse, administrator or fellow doctor who tried to «make trouble.»

The vast majority of conscientious, hard-working doctors are horrified, if anything more horrified than the public, by these terrible acts. For they know that these few doctors discredit the entire profession and with it the trust on which professionalism is based. Patients can become wary. Yet how to respond is complicated, as well portrayed by Marilynn Rosenthal’s in-depth study of incompetence in medicine (15). First, uncertainty pervades clinical practice, complicated by the limits of what even competent practitioners can know and by the information they are given. Thus practitioners are necessarily fallible and mistakes will happen.

I did the wrong treatment. I made a mistake. She died. Was that incompetence? Where do you draw the line? …Perhaps it’s possible to find if there is a pattern of mistakes. (senior GP)

It becomes unacceptable when they don’t learn from their mistakes. It could happen to anyone once, maybe twice, but no more. (regional director of public health)

Depending on people, especially professionals, to admit that they are making mistakes or are incompetent in their life’s work, however, seems unrealistic. In addition, professionals believe that only fellow specialists can judge their work, and fellow specialists have a strong tradition of (and good personal reasons for) not criticizing each other. As a result, an oncologist told Rosenthal, «There is nothing formalized. At the end of the day, there are differences of opinion. In the courts you see equal experts disagree.»

Do Not Forget Ledward

All eyes are now on the massive Bristol report (49), and indeed it has wider and deeper implications than previous reports, as shall be described. But the Bristol report is about the rarified world of a tertiary center that should have never been one, and thus its prominence can draw our attention away from much more common problems in the ordinary hospitals filled with ordinary consultants that are documented in the report on the gynecological surgeon, Rodney Ledward. Presumably he too is a rare exception to the competent hard work of consultants, though there are clear signs that others are now out there, manifesting the systemic problems identified in the Ledward report (59). First, the report itself took place because so many women felt that the GMC’s investigations were too focused on medical and professional issues and did not address a wider range of practices by this surgeon which they document and describe. They include

These constitute a chauvinist, caste syndrome whose principal victims are women. The massive Bristol report and current reforms echo some of harrowing detail found by the three women and one man who carried out the report on Ledward, but not all of them. The Ritchie Report needs to be revisited and its lingering issues addressed. Besides addressing the club culture, as the Kennedy Report does, what should be done about the caste culture? To what degree can surgeons and others cover up their mistakes because of poor tracking systems? And if we suppose completely competent surgeons and consultants who still have a chauvinist elite attitude that treats women with disrespect, is that acceptable professional conduct?

By the summer of 2001, British experts assured me that the ways in which Rodney Ledward had inflicted wounds and damaged many women over many years, while dismissing their concerns and keeping them in the dark, could no longer happen. Then Mr. Neale, another gynaecological surgeon, was found guilty of numerous surgical blunders that kept occurring over 14 years. Worse, the General Medical Council of the BMA was warned of him as early as 1985, and he had been struck off the medical register in Canada before that for incompetent surgery. One wonders why he was allowed to operate at all, and if allowed, not supervised carefully? Again, a courageous group of women, fighting against the institutional barriers of their own health care system, pressed for a wider investigation and response.

In the fall, the BMJ reported that still another «…consultant surgeon who left five women dead and seven more injured was accused before the General Medical Council this week of performing operations for which he had no training or experience and of misleading patients’ families about the botched outcomes» (51). Patients liked him because he was enthusiastic. After one patient lost 17 litres of blood during an operation, he told the family that she had «bled a little.» She died two hours later. Where was the Royal College or GMC in all this? Do royal colleges set quality standards but then no stand behind them? Why have they not established good data and tracking systems on clinical performance long ago?

From Autonomy to Accountability

The crisis in British professionalism took a significant turn between the investigation by the GMC in 1996 – 97 of dead and damaged babies in the Bristol unit. Reflecting traditional professionalism, the GMC as the disciplining body was not allowed to assess incompetence or deficient performance, only «professional conduct.» While no one doubted grave performance problems, the only question investigated by the GMC was whether the three doctors had violated norms of professional conduct, by failing to examine their own results critically and draw appropriate conclusions about their skills (52). That is to say, disciplinary action presumed a model of individual autonomy and the reliance on individuals to monitor their own performance, without any jurisdiction over poor performance itself. Again, the royal colleges are supposed to play a crucial role here assuring patients and the public of high quality, but they use techniques which independent investigators, like Rosenthal, have judged to be ineffective.

By the time of the Kennedy report on the Bristol tragedy, even professional bodies were no longer willing to rely entirely on the professional conduct of autonomous doctors to review their work critically and act accordingly. One headline summed it up: «End of Doctor Knows Best» (53). Incompetence is now judged as well as professional misconduct. The GMC has been broadened in a number of other ways so that it responds more quickly and has much more lay input. Accountability has replaced autonomy. Yet accountability itself requires a significant amount of autonomy, so one might say more precisely that accountable autonomy has replaced unaccountable autonomy.

The scope of the Kennedy report extends to the organization of subspecialty services as a whole. It details why the Bristol Royal Infirmary should not have been designated as a supra-regional center for cardiac pediatric surgery in the first place by the Royal College of Surgeons. Once designated, there seems to have been little follow-up to be sure that it quickly met the high standards of tertiary medicine. Once it started running in its hobbled way, its funding depended on staff not exposing its problems and weaknesses. The inquiry team was «shocked» by the dilapidation of the facilities, the lack of adequate equipment, and the shortage of experienced clinical staff.

These findings raise serious questions about what Rudolf Klein calls «a basic flaw in the design of the NHS: the disjunction between ends and means» (54). Chronic underfunding by the Treasury has meant inadequate equipment and staff and is «the enemy of excellence». It has created a culture of «getting by», of «mend and fix» and resigned passivity of board members. Most of the causes of the Bristol tragedies, Joan Higgins reminds us, were identified over and over in more than 30 similar inquiries since the 1960s (55). The Kennedy report also raises question about how regional and national subspecialties are defined and developed. The answers probably lead one into a complex warren of parties with control but not responsibility and others with responsibility but not control. Will matters get worse with the creation of PCTs as the crown jewels of professional medicine fall between cracks?

These questions lead to an insightful passage by Rudolf Klein on «contributory environmental factors [to poor performance]…outside the control of the surgeons, such as inadequate diagnostic information, the lack of a dedicated team and a split site…» (56) If surgeons and others perform below par under such circumstances, is not the NHS or Parliament liable for the poor results? This is certainly the question in the United States. If an HMO or other health plan engages too few subspecialists or too few diagnostic machines per 10,000 enrollees to meet their needs in order to minimize costs, so that medical problems result from lack of access or from delays, is not the plan liable? If sub-specialists cannot get the tests and procedures done they think are necessary, then the cause is the system in which they work, not their own competence or dedication. The NHS is just such a plan, the world’s largest single health plan, which has deliberately trained and staffed nurses and doctors in nearly every specialty at levels well below what the international community has judged adequate, and has deliberately provided modern equipment at equally inadequate levels.

Societal Foundations of Professionalism

This analysis leads us to the institutional and financial structures in which professional work takes place. If doctors are granted near-complete autonomy, lifetime contracts, no financial risk for how they treat patients, and almost no accountability or data gathered on their performance, then many will act as if they are in a selective club and can do as they choose, because indeed that is de facto what professionalism means. Put another way, professionalism may be in part what the profession says it is, but in the end professionalism is what society and state regulations say it is. One cannot say that different systems make different doctors, but a sociological perspective notes that different institutional and legal frames and different cultural contexts shape what doctors do, how they feel, and what is considered to be professional practice (3).

Likewise, in the United States, if physicians (the term Americans prefer to «doctor») practice in a highly corporatized, voluntary service, where nearly all parties at all levels organize policies, plans and services to maximize revenues and profits (or «surpluses) and leave uncovered or untreated problems to others, or to no one, then «professionalism» gets defined within that institutional and financial structure. One’s fiduciary relationship to patients and moral obligations to treat the sick may be somewhat deeper than that of a restaurant manager’s to her patrons, or a tour guide’s to his group members, but not too much more. Thus, when the state feels compelled to pass a law in the United States requiring that emergency rooms must at least stabilize anyone who comes in, regardless of ability to pay, because of evidence that they first perform «wallet biopsy» and tell the ambulance driver to take the unstable patient somewhere else if she cannot pay, the state is defining a lower limit to professional behavior. Even then, this rule to prohibit certain commercial decisions sits uneasily – who is to pay the high costs of stabilizing uninsured ER patients? – and evidence keeps appearing that ERs are still discriminating against patients who cannot pay.

The same sociological framework applies to other health professionals. If a state allows nurses to prescribe some drugs, or many drugs, then that is part of what «professionalism» means for those nurses. Conversely, if a state does not allow nurses to prescribe any drugs, then that too characterizes «professionalism» for those nurses. In the British case, if society and the state trust the profession to monitor and discipline errant members through an elected body like the General Medical Council, then that is part of «professionalism» until shortcomings lead to new arrangements. Likewise, when the public becomes so outraged at the failures of the GMC, and consultants express «an outpouring of anger» by voting «no confidence» in their GMC, as they did on 29 June 2000, they are moving the goalposts and defining the professional inspectorate of the profession as «unprofessional.» And when the Government writes and passes into law the Reform and Professional Performance Act, which will supervise the regulation of the health professions from outside of them, then it is redefining what professionalism is and how it works.

Creating a New Professionalism

This analysis provides a different and sociological perspective on «professionalism» that dates back to Talcott Parsons’s first essay on the subject in 1937 (57). What is striking about current efforts to establish good, reliable quality is that the state and other countervailing powers such as patients’ groups and employers are helping the profession redefine what good professionalism means. For these parties all need good professions. They can no more eliminate them than a profession could function without clients or the state. They are in effect rescuing the medical profession from its own internal limitations to assure patients and payers that they are getting good, effective, evidence-based medical care. These efforts imply that patients and payers have come to take over some of the responsibility of the organized professional bodies to assure good, accountable and reliable services at fair value.

A further implication is that the outcomes of quality services matter more than the input of diplomas. Good training is fine, and recertification helps assure everyone that providers are up to date; but the bottom line is the quality of services and results. The computer revolution has enabled clinical researchers to develop measures of what takes place inside the black box of physicians’ practices (58). Thus autonomy is no longer needed as a substitute for accountability, and clinical profiling can tell a doctor more about how he practices medicine than he can tell himself. By the early 1980s, some of the leading HMOs were routinely comparing how their physicians treated the same disorder and having them talk through the differences to more uniform, evidence-based practices. Surrounding such efforts are large gray areas where evidence-based quality is not clearly defined and subtle judgment based on good training and experience are vital. And the range of uncertainties, as Fox (59) has shown, will be as large if not larger in the years to come.

A critical role is being played by the state, even in the free-enterprise USA. It has established national institutes of clinical excellence, funded comparative research on outcomes and supported Cochrane centers and other public health efforts. For example, as the largest buyer of medical services in the United States, Congress has taken over core responsibilities of the profession towards patients and society, which the organized profession rarely carried out (60). They include:

One might say, as Freidson (61) suggested, that professionalism is being reborn, by responding to the demands of payers for evidence-based procedures and better outcomes. Physician-led research teams, academic medical centers, and specialists societies are now dedicating themselves to identifying which interventions and protocols are most effective. This process involves two professional elites, physicians who are experts in developing clinical protocols, care pathways and evidence-based guidelines for their rank-and-file colleagues, and physician-leaders who oversee clinical governance and practice management for a managed care organization, a health authority, or a hospital. But the agenda is being driven by politicians, patients and payers. Further, institutional bridges are being built between medical schools and the profession and the communities they serve (62). In those communities, patients are learning more and more about their health conditions from open publication of medical information and research in publications and on the internet.

Another implication of the new professionalism is that if a certain range of services can be done as well, or better, by providers who cost less to train or cost less to employ, then there is no reason not to use them. Appropriate substitution and delegation are in, pulling rank is out. Physician-led clinical trials have shown that nurse practitioners, and even physician’s assistants with less than two years’ training are as accurate in doing primary care as are doctors and follow protocols more reliably (63, 64). Nurse-specialists can do much of the work now done by Board-certified subspecialists. When combined with patient education and the training of carers, this means that health care of a higher, more trustworthy quality can be delivered at less cost, using community-based health care teams. Doctors who cling to traditional professionalism feel threatened from above and below. But doctors who embrace the new professionalism feel liberated (39).

The new professionalism turns traditional professionalism on its head in order to restore quality, value and the trust that has been shaken over the past quarter century. The new professionalism is based on accountability to measures of quality based on clinical research, and guidelines developed by teams of clinical researchers who constitute a new elite for practitioners. The new professionalism reaffirms the profession’s purpose to serve patients and society by maximizing well-being and functioning. It focuses first on prevention, patient education, primary care, and community-based management of health problems, with sub-specialty medicine and hospitals as back-up. It recognizes that skill-based practice means that delegation and substitution to nurses, physicians’ assistants and trained health workers in the health care team should occur when possible. This is illustrated in table 2.

By these steps, the crisis in professionalism has led not only to an exposure of inherent weaknesses in the traditional model based on autonomy, but also to a more positive performance-based model of professionalism rooted in accountability. Quality is defined, not by one’s degrees but by performance measured against standards based on evidence and consensus among experts in the field. Teamwork, just as in «morning report» and «grand rounds», helps add the judgments of others to one’s own about ambiguous cases. Quality also gets defined in terms of health gain or increased functioning or relief of suffering, though ambiguities are rife here too.

The old professionalism excused itself from this focus with the famous phrase, «The patient died but the operation was a success.» The new professionalism understands that technically skilled operations may not save a patient, but it does not rest its case there. It asks questions like, «Could the problem have been detected earlier, or treated earlier, or even prevented altogether?» The bottom line for the new professionalism is that the patient died, even if the surgeon’s skill is admired. Thus, the new professionalism is more than replacing autonomy with accountability. It represents a paradigm shift in defining the nature of professional work as improving the health and well-being of both individual patients and whole panels or populations of people for whom professional teams are responsible. The old «sub-professional» activities, such as prevention, screening, early detection, education, teaching self-management and developing community-based support systems for the millions of patients with chronic problems, become paramount.

Institutional Conditions for the New Professionalism

The crisis in professionalism has inspired leaders to define what professionalism «really» means and call for renewal. Wynia and colleagues, writing from the ethics division of the AMA have called for a professionalism of service and selfless dedication that seem unrealistic in a highly commercialized health care system (65). Rothman, in a tough-minded article that emphasizes the corrosive influence of pharmaceutical companies on training and professional independence, concludes that «professionalism must become a vital part of American medicine today» (66). Yet he is not sure how this might happen, especially since «physicians have avoided the admittedly tough question of how professionalism is to become central to their thinking and behavior.»

More recently, Rosemary Stevens invoked the American medical profession’s «long (if neglected) history of public service» and calls for «good scenarios for constructive empowerment» and new public roles (67). She dismissed concepts of conflict or countervailing powers as «tired and in some ways meaningless». But the historic «public service» agenda she describes in the private American system, of improving scientific standards and medical education, improving patient safety, and enhancing the quality of the doctor-patient relationship^{70: 333}, is the agenda of private practice and professional autonomy that led the profession into its modern crisis and to health care being corporatized. Of course, the public has benefited from these, but the countervailing corporate powers and obstacles to developing unified public roles are daunting. Thus she advocates «reinventing professional idealism in the market» (italics in original) and reviving the profession’s charity tradition to ensure needed care to every member of the society, but these are private roles that have proven to fail as substitute for public ones. What kind of professional idealism is possible in competitive markets needs to be spelled out. Charity is public service within a private market but quite limited when compared to public service roles in health care systems with universal funding and a strategic goal of improving the health of communities and the population.

Sir Donald Irving, across the ocean, argues that professionalism is «at the heart of doctors» relationships with patients and the public» and that quality is at the heart of professionalism (68). He then calls for open, frank dialogue about «what really went on» when a few incompetent, abusive or criminal doctors were allowed to keep damaging patients for years. He calls for a joint commitment by the professions (plural), the public, the Government and managers to «embrace wholeheartedly and unequivocally the practice and habits of continuous quality improvement.» Irving is even more frank and tough than Rothman about the mistakes of the past, but he is also more specific about how to develop a new professionalism based on accountable quality – national clinical standards, a national system of clinical governance carried out by healthcare teams, regular updating and revalidation of clinical skills and a «regulatory framework of professional values and standards» that is professionally led. Further, all four parts of the UK are bringing lay persons into policy making and on to health care boards. In short, the public British system is moving from central ministerial control to more regional or local lay control, yet still within firm national frameworks of finance, quality, accountability and professional control.

Similar reforms are not possible in the United States. The reason that even the best American minds cannot define a clear way forward is that the institutional conditions for the new professionalism are lacking in the United States but exist in Norway, the UK and many other countries. As Irving acknowledges, many of the best ideas and techniques come from America; yet its lack of some kind of universal health care and competitive commercial markets make cream skimming, selective marketing, and claims of being «the best», as evidenced by proprietary information you cannot see, far more profitable. American health plans and industry leaders talk about «healthy communities» and «improving population health», but in reality they compete for market share in any given area, and the easiest way to improve the bottom line is to attract healthier groups and leave other plans stuck with less healthy groups. «Population» means enrollees in a health care corporation for that year, with a 10 – 20 percent turnover per annum. There are a number of notable and noble community programs developed by major providers, like a local hospital, or by insurers; but they can only be quite modest in scope and are often run by the marketing department to enhance the institution’s image (69).

These qualities or characteristics lead us to the heart of the new professionalism, a basic shift from responding to the demands that bring patients in, to treating symptoms and salvaging what one can, to identifying needs and addressing causes in patients as part of a community-based or population effort over time to maximize health and well-being. No one articulated this better than Julian Tudor Hart in his call for «a new kind of doctor» (70, 71). Noting that «the worst combination is a large number of doctors with a marketed system of care,» Hart emphasized the need to be paid and staffed to be responsible for a community’s health, a doctor «who combines clinical skills with the skills of population medicine, is able to lead a team of health workers with sensitivity and imagination, and is loyal enough to patients to stay in one place and see the job through to the end» (72). This need is made more urgent by the growing inequality and relative poverty within affluent countries as well as between nations. Westin (73) along with others has led clinical research that documents large increases in visits to GPs and referrals to specialists when people become unemployed. Markets work poorly to address the costs of relative poverty and causes of reduced vitality in a nation’s population because clinical medicine fails to meet the basic criteria for viable markets at almost every point (74). Commodifying medicine and stressing clinicians leads to errors and less effective relations with patients and thus less effective management of their health problems (75).

The new professionalism that is emerging in various countries logically requires a population and community approach in order to raise overall health status and maximize people’s ability to function in society. It finally catches up with the old finding that clinical medicine makes only a modest contribution to health status and is largely a repair service for patients after they have broken down. The state and other large payers, like insurers or employers, are primarily interested in a healthy, vital population and workforce at least cost. Thus, they start with a focus on public health, prevention and self-management of health conditions. Clinical care comes next, with an emphasis on primary care, followed by secondary and tertiary care. Physicians are vital here, but the natural emphasis is on teaching and devolving skills, first to patients and their carers and a variety of health educators and helpers, then to a wide variety of professional nurses, and finally to general physicians, specialists and subspecialists. Consumerism and commercial efforts to increase demand have no place here. They simply inflame demand and drive up costs. Yet of course they are rampant in the United States, and the global pharmaceutical firms are intent on extending consumerist health care to the rest of the world.

Kindig, a visionary American physician and student of Donabedian, has pulled the entire argument together for how to purchase population health (2). In so doing, he provides a blueprint for a new professionalism that Stevens and Rothman seek. Yet Kindig’s master plan runs into the same problem as Stevens and Rothman: reforms like purchasing so that population health gain is achieved can only happen here and there in the United States, if at all, without the level playing field that Enthoven and many others have described of universal coverage, population-based purchasing, national standards of quality based on interprofessional teams, and a fair system for compensating clinicians for treating patients. But countries in Europe and elsewhere that have the institutional conditions for helping the new professionalism to flourish. In an era of chronic disorders and subtle contributors to health status stress, diet and loss of community, a partnership with patients and communities is essential, because improving health status depends on them.

Challenges to the Accountable Quality Agenda

The new professionalism and its accountable quality agenda have implications and challenges that need to be confronted. Here we shall deal briefly with three:

Are We Ready to Pay?

Accountable health care finds things out that are not being done. That is good, but it increases costs. The international movement to improve quality, including the «discovery» by «the greatest health care system in the world» that it is unnecessarily killing «the equivalent of two jumbo jets crashing every day» and now is said to have a very serious quality problem, is expensive (25). Establishing quality standards and enforcing them, largely around serious medical conditions and their treatment, adds cost. Tudor Hart’s and Kindig’s vision of accountable quality focused on the integration of public health and primary care could be less costly; but the high-profile, high-fashion policy focus is on quality in subspecialty and hospital care, where very sick and frail patients will always pose challenges to «quality». Even safety is an issue in the safest hospitals in history; but does anyone want to stand up and say they think safety is not a worthy issue? The technology of accountability itself has become a secondary industry. All if these efforts are worthwhile, but there is a disconnect between headlines or articles on improving quality and ones on ever-rising costs. One does not see them linked in headlines such as, «Health Care Costs Rise As Higher Quality Pursued.»

Medical technology and treatment are expensive and always increase faster than the general economy. There are few medical advances that save money directly, and nearly all of them either create or perpetuate conditions of chronicity. Granted, people live longer as a result and perhaps with fewer symptoms and suffering; but these improves are not a measurable benefit. Aside from getting people back to work, better medicine is economically all cost and no benefit. Further, prevention is getting more expensive, thanks largely to pharmaceutical firms offering pills in place of changing life styles. Some of their largest, multi-billion dollar blockbusters are for invisible and unfelt risks such as hypertension and cholesterol. Imagine how bizarre this would seem to most of the world’s poor, who focus on getting adequate food this week. When health workers urge them to change unhealthy habits because they will shorten their lives in 20 or 30 years, they think these workers do not know what life is like this week. On a larger scale, economic inequality and relative poverty continue to increase in most countries and between countries. This is the single greatest cause of worsening health conditions but is off-limits for health care.

The Doctor as Double Agent?

Mandating clinical guidelines within a budget is a good example of forcing doctors, nurses and managers to act as double agents, serving patients whom they put first and meeting a long list of quality/service targets, while staying within an inadequate budget. Fudging, lying and hiding are inevitable consequences, as evidenced a series of scandals in the UK, where they are not seen as Catch 22s of systemic contradictions (76).

Marc Rodwin, in his analysis of accountable health care in the United States, identifies four components of accountability: control, responsibility, answerability, and responsiveness (77). You cannot be accountable unless you have control over the service, and you cannot be accountable unless you are designated as responsible for it. To be answerable is to have to explain performance, and to be responsive is to be prompt in answering for lapses in services and doing something about them. Traditional professionalism might be characterized as having control and then deciding how responsible, answerable or responsive you wanted to be. Recent reforms aim to make clinicians much more answerable and responsive and also responsible; but as noted earlier, without adequate supplies, trained personnel, equipment or budgets, they cannot be held accountable for what they cannot do.

In his review of HMOs and health plans, Rodwin notes several accountability problems that apply to other countries (20, 77). First, health plans have conflicting goals, such as clinicians being employees or even stakeholders in the delivery system versus having a fiduciary relationship with their patients. Second, health plans control costs by controlling the supply, range and availability of specialists. But limiting these makes it more difficult to meet standards of accountable quality. Third, US health plans limit what they cover, a issue that now arises often in other nations, though on a much smaller scale. Fourth, Rodwin found US plans hide from patients what they do not cover, what is undersupplied, and what the costly options are for treating serious problems. Fifth, case managers for serious and chronic patients are paid to keep costs down. Double agency pervades.

Constructing Quality Chaos?

Accountable quality is fine, but there can be too much of a good thing, to the point of demoralizing staff, draining funds and harming quality. Alan Maynard portrays a brave new world of ««experts» who wander about telling other people how to do «it’ better» (78). People’s jobs and salary raises are tied to «performance» which too often focuses on activity rather than outcomes, causing distortions and compromises in patient care. Complaints about contradictory quality assessments are rife, and behind the confusion «lies a world of plot and intrigue» between competing inspectorates for power and funds (79). One hopes it will all be straightened out, but for the moment a proportion of clinicians are so fed up that they have decided that they only way to stay sane and do good work is to ignore all the quality checks and targets.

To conclude, despite these challenges, the new professionalism addresses the problems of traditional professionalism and provides a healthy future for the medical and other health professions. In a system devoted to population-based health gain, it provides a solid basis for the «new kind of doctor» that Tudor Hart envisioned. Its emphasis on evidence-based service allows more delegation, substitution and team-based services and will provide better services at lower costs at the same time as it provides a solid basis for professional work. The new professionalism restores the social compact with society and refocuses professionals on serving the needs of people in society. It restores trust and assures patients that doctors are working for them and to high standards. But its development remains hobbled by historic and entrenched institutions, economic arrangements and priorities.