Today’s Topic:

Health Care Professionals

Objectives for today Describe the evolution of the medical

profession and medical practices

Discuss the supply of physicians in the United States

Discuss the other major health care professionals

Rise of the medical profession

Medicine is the most powerful profession (at least in America)

How have MDs achieved more power than architects, engineers, or even managers?

Docs haven’t always been so dominant (from Starr)

Romans Physicians frequently slaves, freedmen, or

foreigners 18th c. England

Only persons beneath physicians were surgeons and apothecaries

19th c. America Surgeons in same social class as barbers

What about the rest of the world?

Medical profession not as powerful in other highly developed nations

Former Soviet Union - $ comparable to factory workers

Japan - managers make more $

United Kingdom - $ salaries much lower than U.S. docs

The Rise of the Medical Profession

General characteristics of a profession: Self-regulating Unique body of knowledge High level of training Service orientation Code of ethics

Authority of medical profession (from Starr)

The authority of MDs differentiates them from other professions

Authority is the ability to control others’ behaviors

2 roots of authority Dependence Legitimacy

Derivations of dependence

Knowledge, competence of a professional

Belief that bad consequences will occur if one does not obey professional

Unique reasons we are dependent upon medical profession They have scientific knowledge They make decisions for us

Derivations of legitimacy

Acceptance that you should obey Based on...

Rational, scientific grounds Affirmation by peer group Judgement/advice is meant to do good

When legitimacy is in doubt, dependence almost usually still exists

Cultural and social authority

Social authority: Giving of commands (e.g. when parent tells you what to do; when boss tells you what to do)

Cultural authority: Our views of reality which affect our reactions to commands from others.

Consolidation of medical authority

Greater cohesion Referrals to specialists Changes in pre-industrial America Better transportation Telephones Differentiation of labor

Consolidation (continued)

Standardization of medial education In mid to late 19th c., a lot of sects within

medicine Homeopaths: thought disease could be

cured/caused by drugs; thought that disease caused by a suppressed itch.

Eclectics: thought herbal medicine was best treatment.

Consolidation (continued)

First medical school at Univ. of Pennsylvania in 1765 Doctors only went to school for four years

Abraham Flexner’s report Recommended closure of many medical schools

Now, over 100 medical schools in U.S. Doctors have 8 years of undergraduate education

Medical authority and conversion into economic power

AMA: established in 1846. Hospitals and drug companies dependent

upon physicians as gatekeepers Doctors against national health insurance,

prepaid group practices, and company employment

Physician incomeSpecialty Mean Std. Dev.Internal Medicine $133,346 54,218

Family/General Practice 131,968 55,755

Pediatrics 118,366 54,015

Medical Specialties 162,087 76,778

Surgical Specialties 226,917 91,860

Psychiatry 128,459 52,141

ObGyn 201,526 87,554

All 148,271 72,945

Measuring supply No. of physicians per 100,000

enrollees No. of physicians per 10,000 residents

Supply/pop. ratios do not account for.. Physician productivity Health of the population Physicians who travel around to provide

care

No. of excess physicians (from Wennberg)

780

24403

1283

5074

3469

8385

6706

131065

12871

8406

0 20000 40000 60000 80000 100000 120000 140000

Radiologists

Primary Care

Urologists

Anesthesiologists

Ophthalmologists

OB/GYN

Orthopedic surgeions

All specialists

General surgeons

Cardiologists

Consequences of increased supply

Increased competition, shift in employment Solo practice, fee for service Group practice, capitation

HMOs Staff model Group model Network model IPA

Rural/urban distribution of M.D.s

While there is an oversupply overall, too few physicians in many rural counties

Strategies to increase rural supply

Medical schools have increased output from 1965 to now Assume that graduates will go to rural

areas Oversupply, competition in urban areas

could drive some to rural areas Training in rural areas

Strategies to increase rural supply

National Health Services Corp. Indenture program Physicians often leave after their time is

completed Oversupply, competition in urban areas

could drive some to rural areas Training in rural areas

International medical graduates

Supply has increased in 1990s Why?

Some specialties need more docs Rural locations Teaching hospitals

Osteophathic medicine

Osteopathy is similar to allopathic medicine Reimbursed by Medicaid, Medicare, &

most private insurance Tends to stress joint manipulation and

diet more than allopathic

Physician Assistants (PAs) and Nurse Practitioners (NPs)

PAs work under supervision of physicians can diagnose, manage, treat common

diseases NPs have a similar role

Midwives, family NPs, psych. NPs Emphasize prevention, counseling

Rise of nursing

Early 1900’s, Nurses tended to be social derelicts, past

prostitutes (Rosenberg’s The Care of Strangers)

Today, a respected and large (the largest) health care profession

Professionalization of nursing

Led by Florence Nightingale Argued that only women are caring

enough to be nurses Physicians agreed with this

they didn’t want nurses involved in technical aspects

Nurse training in early 20 c.

Nurse training was a good deal Free room and board Usually sponsored by hospitals (as is still

the case in Japan) Hospitals got cheap labor in return

Hospital & Health Administration

Relatively young “profession” Is it even a profession? Demand, education accompanied

hospital growth

HHA Education

1st master’s degree program University of Chicago, 1934

1st Ph.D. degree program University of Iowa, 1950

MHA predominant degree, # MBA programs increasing

Public health education

Educational cores Epidemiology Health behavior and promotion Environmental health and toxicology Health management and policy Biostatistics

Primary degree: MPH