1. SOCIAL AND COMMUNITY PERSPECTIVES Medicine as a profession 6 th May 2003

2. Aims To explain what is meant by the terms ‘professional’, ‘socialisation’ and ‘professionalisation’ To contrast the different approaches to consultation used by orthodox and non conventional practitioners To illustrate an awareness of the ways in which the medical profession has developed

3. Introduction Why do we need to consider medicine as a profession? Drs differ from other groups of health service in terms of professional status Along with lawyers regarded as foremost profession

4. Historical context Royal College of Physicians founded 1518. You needed: –an Oxford or Cambridge degree –to be an Anglican. Not very scientific e.g by 1790 oral exam in Latin was still the main entry requirement Elite status  not based on scientific knowledge, but on social background of doctors.

5. Doctors as an elite group Physicians only catered for the wealthy. Apothecaries and barber surgeons treated the rest. Most healing took place domestically. Women cared for others in childbirth and knew how to make potions and lotions.

6. Modern clinical medicine Began turn 18 th / early 19th Century. Associated with the emergence of hospitals in England. 19th Century medicine was very competitive. Few effective cures at this stage. Very dependent on wealthy clients and the quality of bedside manner.

7. Modern clinical medicine Much rivalry and competition in early part of 19th century. Ill-feeling towards each other among healers/doctors. Same situation prevailed in America. No unity or collective authority

8. Attitudes towards medical profession in early-mid 19th century Qualification of “physician” restricted to gentlemen. But there were other healers - e.g. teeth pullers, bone-setters, itinerant healers etc. Occupation of healing was often seen as a “rattlebag of quacks and rogues”. Queen Victoria - did not recognise army surgeons as “officers and gentlemen”.

9. Changing times Changes in culture, society, science and technology in mid-19th Century. Capture of a body of scientific knowledge. –anaesthetics –discovery of tubercle bacillus –introduction of forceps Struggle for cultural authority and social mobility. Begin to see professionalisation of medicine

10. The professionalisation of medicine Increasing specialisation = increasing interdependence. 1858 Medical Act - gave the GMC power over registration of doctors. Led to a monopoly on supply of medical services. Control over medical education by the medical profession. Restriction of entry led to raising of standards.

11. Late 19th/early 20th century Industrialisation - led to dependency on strangers  change in relationship between doctors and pts BMA and AMA - medical profession could present a solid and united front with a code of ethics. Claim to be above commercialism.

12. Early 20th century Growth of medical authority continued to expand Helped by –development of medical science. –role as gatekeepers to medicines and sickness certificates. Doctors became better paid. Major change: WWI - swept away old elite systems and gave new acceptability to the professions.

13. Why and how did profession of medicine develop? Two approaches: Functionalist Conflict

14. Functionalist approach Associated with authors such as Talcott Parsons Profession  accorded high status and given greater financial rewards than other occupational groups. Profession of medicine developed because of society’s desire to control illness Need group with access to technical knowledge – used in interest of community – functional for system

15. Functionalist approach Technical knowledge – power and status (although all illnesses not controlled) Drs’ status legitimised because: –Practise on the grounds of technical competence –Institutionalised expectations of ‘doing everything possible’ for good of whole community

16. Conflict theory Reject idea that medical profession emerged naturally Profession developed out of specific historical process which involved a power conflict among a number of different interest groups. Medicine not evolve naturally, but as a result of political struggle between groups intent on achieving higher status

17. Conflict theory Conflict theorists want to explain why medicine was successfully in attaining professional power compared to other competing groups Freidson (1970) sees profession as a structural position which has to be attained and maintained Freidson identified certain profession characteristics

18. Conflict theory A profession has: Specialised Knowledge –Careful management of knowledge Monopoly Control of numbers, selection and training of entrants Autonomy –Clinical autonomy: doctors are responsible only to their patients for diagnosis and treatment, and only peers can comment on clinical judgements. Code of ethics

19. Importance of the role of the General Medical Council Medical profession regulates itself through the GMC. controls entry to medical register and can remove practitioners from it. approves and inspects medical schools. Based firmly on principle of self-regulation. Self-regulation itself is based on doctrine of clinical autonomy. Now includes lay members.

20. Medical education Medical education = crucial in turning lay person into professional Becoming a doctor not just about learning facts, but also certain values and attitudes (Tomorrow’s doctors) More than accumulating knowledge about developing appropriate attitudes to patients, colleagues, fellow worker

21. Medical education This process known as socialisation: process by which culture/values of a particular society (or group within it) are transmitted to new incumbents as they learn to conform with demands and expectations of the society/group

22. Medical education Medical education involves: Lengthy training controlled by profession Recruitment and selection First stage of socialisation from lay to professional = selection Appropriate attitudes and behaviour

23. Medical education Formal/Informal curriculum Formal: knowledge/tested through exams Informal: attitudes beliefs/ performance noted not formally examined May  students concentrating on ‘getting by’ – losing former idealism Socialisation and education takes place in different arenas: Front stage/back stage

24. Source: Sinclair S (1997) Making Doctors: An Institutional Apprenticeship Oxford, Berg OfficialUnofficialOFFSTAGE Front Stage ‘Manifest’ curriculum Lecture.Ward Rounds/ Exams Games Field (rugby/ football) Theatrical performances Lay World Back Stage ‘Hidden’ curriculum Libraries, Hospital wards Preparation for unofficial front stage activities Students’ bar Lay World

25. Summary Medicine’s position of authority and status evolved over time Different ways of viewing professions position: functionalist/conflict Role of medical education

26. Questions Freidson (1970) identified a profession as having certain characteristics. List these and explain what is meant by each In order to become a medical practitioner new entrants must acquire certain skills, knowledge and attitudes. What role does medical education play in this process?