1. Today’s Topic: Health Care Professionals

2. 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

3. 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?

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. Consolidation of medical authority Greater cohesion Referrals to specialists Changes in pre-industrial America Better transportation Telephones Differentiation of labor

12. 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.

13. 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

14. 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

15. Physician income

16. 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

17. No. of excess physicians (from Wennberg)

18. 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

19. Rural/urban distribution of M.D.s While there is an oversupply overall, too few physicians in many rural counties

20. 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

21. 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

22. International medical graduates Supply has increased in 1990s Why? Some specialties need more docs Rural locations Teaching hospitals

23. 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

24. 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

25. 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

26. 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

27. 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

28. Hospital & Health Administration Relatively young “profession” Is it even a profession? Demand, education accompanied hospital growth

29. 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

30. Public health education Educational cores Epidemiology Health behavior and promotion Environmental health and toxicology Health management and policy Biostatistics Primary degree: MPH