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Over time
there have been many discussions and debates concerning whether medical power
and professional dominance is under threat. ‘Medical autonomy is the publicly
accepted control that medical professions exercises over the terms and
conditions of its work. Medical dominance is a relative concept, indicating the
authority that the medical profession can exercise over other occupations
within the health care division of labour, patients or society.’ (Gabe and Monaghan, 2013) If there
is a decline of professional autonomy or dominance in the medical profession it
can take a range of different forms. One aspect will be a change in doctor
patient relationships, other aspects will include medical professions becoming
less autonomous as they will become more controlled from the side of the state,
on the basis of what they actually do and what they have input in, and patients
can then complain to figures higher up in medical structures. Scepticism in
society towards the health care system can also compromise the trust of
patients in physicians thus leading many patients to rely on the internet or seek
alternative medicine. There have been several shifts that explain the reason
for the transformations suggesting a decline in medical power and professional
dominance in contemporary society. However, I think medical power and
professional dominance are both under threat to a certain extent. This essay
will explore whether we are on the professional verge of a decline in the
professional power.

Over the last
few decades of the twentieth century there have been several trends and
transformations in health care. Due to the transformation from modernity to
postmodernity dominant institutions in society that used to keep the balance,
have less influence. It has led to people having more freedom in the choices
they make regarding their culture and identity. Post modernisation has led to new
arrangements of social structures by introducing a state of flux within social
relations. Klein (2010) stated that the NHS is in a ‘permanent state of flux’,
the structures and positions in the system are fluid therefore the pace of change is so fast,
that it is hard to keep up with all the different things happening.  These transformations have  had an effect on the NHS which can make their
service unsustainable. In order for the health service to cope with the
structural changes it has to make a profit off their service whilst also creating
social unity, but this is problematic as all their resources are used up whilst
not being able to accumulate profit.

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The rise of
the new managerialism in the health care system mirrors the bureaucratic state
as it involves the government intervening to ensure development, it disperses
the medical power from the physicians in the centre of the system to managers
on the outside. Hence, resulting in a rising shift of involvement from third
parties who impact the health care system through their funds and organisation.
‘in the UK, the major reforms to the NHS that have been introduced since the
1980s – including the introduction of a more market- driven ethos and structure
have been seen by many as constituting an attack on producer dominance and
professional exemption from external scrutiny. In the USA, the expansion of
for-profit health care corporations, the move to managed care and associated
new financial management of medical practice’ (Gabe and Monaghan, 2013). The
new management has adopted the style of the private care system, so the service
provided to patients depends on how much money is spent, this further
demonstrates the effects of consumerism on the health care system. Those who do
not have the money to pay for private health care may not get the best
treatment or may not be able to afford the services which will lead them to
seek alternative medicine.

Organisational
flux is a regular affair in the health care system as the trends and
transformations shape their policies. There has been a shift in health care
from focusing on disease to the main concern being and maintaining a healthy
lifestyle. ‘From the mid-1970’s, health policy documents began to emphasize the
need to promote good health rather than treat illness and disease’ (Nettleton,
2013). Another shift has been the health and medical care going from the
confines of a hospital to being dispersed through the community. The changes
from traditional to unconventional health care has driven patients to adapt
from the primacy of biomedicine to a plethora of health options. The choice of
alternatives has blurred the lines between medical knowledge experts and the
consumers. This may cause a decrease in professional dominance because they no
longer have influence on how patients are treated and what issues they bring to
the hospitals.

There are
several explanations of why these transformations have taken place and can be
considered as underlying reasons to the demise of professional authority in
medicine. The theories predict how physicians control over the content of their
profession. The de-professionalization thesis focuses on the change in dynamic
between professionals and clients due to patients’ uncertainty of how effective
modern medicine is which have led to patients becoming sceptical. It is an
influential criticism of the developments in health care, it contemplates the
shift in policy from its values of inclusion and citizenship to focusing on
controlling public expenditure (Clark, 2005). ‘sustainability
and transformation plans (STPs) which propose ward closures, cuts in bed
numbers and changes to A and GP care in 44 areas…needs to find
£22bn in efficiency savings by 2020-21…A draft plan circulating among NHS
managers in West Yorkshire reveals proposals’ (BBC News, 2018), doctors do not
have a say in where the savings are made it is down to the managers and trusts
who work for the government. The cuts have led to protests from
patients and welfare workers who are feeling the pressures of the detrimental
savings. It also makes the private sector take responsibility from the public
sector such as formal services doing less and private individuals or families
doing more. The thesis also states a difference in the roles of the professionals;
they have less opportunity to be autonomous, so they may go against their
professional opinion for what may be best for their patients and they have less
will when it comes to treating patients (Clark, 2005). This reflects the
physicians experiencing de-professionalization because they can no longer give
their patients the best service in their opinion due to not having the access they
need to resources, in this case they lose their medical power as they become tools
of the state. Ritzer and Walczak (1988) stated ‘Their power, status, and continuing
control over a centrally important area of human existence lead us to believe
that they will not tumble far down the professional continuum’.

The
Proletarianization thesis, a Marxist notion predicts that eventually the
medical sector will become part of the capitalist system and have no control
over production which will result in the professionals becoming isolated from
their work as they will have no input. The term was exchanged to the
corporation thesis because of the limitations the proletarianization thesis and
‘the word was considered threatening’ (McKinlay and Marceau 2002). As the rules,
procedures and authority are increasingly controlled the professional autonomy
is undermined as they will no longer be in control of things. The Neo-Marxist
perspective explains that as medicine advances and becomes more corporate,
physicians lost some of their professional rights to regulate their service
without the government intervening.  The
government also affected medical work by breaking it into specialist sub
sections. For instance, because medicine’s increased use of new modern
technologies, allows staff who are not medically trained to be able interfere in
the relationship doctor and patient by advertising new techniques as trends or
new products, also these staff can also control these technologies without the
doctor being there. This makes patients seem like clients of the NHS or trusts
that manage the doctors rather than being the doctors’ own responsibility and being
able to develop intimate relationships. Therefore, physicians cannot be seen as
professionally dominant due to them working for the organisations and not being
self-employed. McKinlay and Marceau (2002) argued that the Marxist theories suggest
that the capitalist development causes the reduction of professional rights
like the right to set salary showed medicine was producing capital for the
state. The Proletarianization thesis was seen as a flawed argument so it was
revised because as the corporate world becomes more and more influential
medical doctors become reduced to employees meaning they would be deprived of
their access to means of production. It was a one-sided theory, so it was
adapted to the corporation thesis. The Corporation thesis is more suggestive as
the cause of the changes than proletarianization. However, it is problematic
because it is not useful in countries where health care is provided by the
state for example medical autonomy is changing in places that have their health
care funded by the state.

Other
health care occupations have been thought to challenge medical dominance. For example,
nurses have been developing their clinical skills and growing in order to allow
their roles to cover other medical responsibilities that are parallel to
doctors, such as being able to prescribe medicine. This is also a similar case
to physiotherapy or pharmacy. From personal experience patients are being
referred and encouraged to go to pharmacists first to be treated and diagnosed,
the experience is comparable to an appointment at a general practice. It
creates a gap in the doctor patient relationship as the doctor no longer
becomes an important contact but rather a last resort. Also, it makes medicine
more available to patients which undermines the need to have doctors when it
has become easy to approach a counter and purchase medication. According to the
proletarianization thesis this is an example of the health sector surrendering
to the capitalist movement to separate the medicine from their work as doctors
to make profit.

However,
this does not necessarily mean professional dominance is under threat, it just
represents a working hierarchal structure to society and within the health care
system. Considering that doctors are the main authority figure it often
reported and the case that they are overworked and constantly busy it only
makes logical sense to delegate to relieve the pressure. Cooper et al (2011) indicated
in their study the confidence that patients have in doctors to oversee the
prescription process and have a pivotal role in ensuring the correct clinical
competence ‘supplementary prescribing involves the doctor in the initial
diagnosis’. It doesn’t threaten medical dominance if anything it enhances it
allows nurses and pharmacists have the confidence to refer back and ask
questions, ’empowered them to discuss medication with doctors and question them
about how they made prescribing decisions’ (Bradley et al 2007). Doctors still
remain as the primary figures to diagnose and the medical knowledge bearers.

The rise of
consumerism also influences medical power, there have been broader shifts in
the climate of medicine and the emergence of the more consumerist context. The
choice of patients is now prioritised in health care which gives them the
chance to choose between different doctors and different medical approaches.
Complementary and alternative medicine today views the body holistically and
suggests that illness is caused by our psychological state, spiritual and
social environment being disrupted. The new medical movement to focus on living
a healthy lifestyle means patients will often to choose to go for alternative
medicine as it allows them focus on restoring balance and repairing their body
rather than focusing on an illness and dealing with symptoms. This is
especially true for patients who may have a chronic illness but do not want to
spend their lives managing or concentrating on its effects as it viewed as the medical
practice’s inadequacy to treat them. Thus, leading to patients taking matters
into their hands and seeking an additional helping hand, this shows how willing
patients are to challenge the medical expertise which provides them with more
hope. This can once again destabilise medical power because if they alternative
medicine is able to benefit patients who had been turned away by physicians it
creates a public scepticism towards the efficacy of the health system. ‘CAM and
biomedicine are in an economic political and cultural struggle by the medical
profession attempt to maintain a monopoly’ (Saks 2003). The struggle can cause
a shift from biomedicine dominating the health system to equally sharing with
complementary and alternative medicine due to the increased interest by
patients. ‘2002,
about 62% of U.S. adults used some form of CAM in the past 12 months’, Barnes
et al 2004 argue that the results found in their study related to patients
confirming results from CAM are surprising as there is a lack of evidence to
support the efficacy and safety of these therapies. However, the effects of it
could be due to many reasons such as individual differences or the placebo
effect which suggests treatment will work as long as the patient believes it
will work.

The internet
has become a form of empowerment for patients due to the bureaucratic
regulation on the system it has allowed expert knowledge to become more
accessible to everyday civilians. Reducing the knowledge gap between the professionals
and patients presents a challenge to the medical power as they no longer view
the professionals as a more knowledgeable other. They feel as though all the
answers they need can be found on the internet. A majority of people go to the
internet first when they experience some symptoms, sometimes this can be the
answer for example when they conduct their search on websites or forums
accredited by professionals or run by them. If this was the case, there would
be no issues but many of these sources on the internet are controlled by lay
people and the information is not completely credible. This then causes
patients to believe their condition is either more serious or less serious than
it is, the doctor will tell them the opposite of what they think, resulting in
tensions to grow. This is also an impact of changing lay perceptions and knowledge,
as the patients increased use of a broad
variety of secondary sources on the internet, promoted by health care
institutions has led to more critical patients who are better informed to make
better informed decisions. This will put the professional dominance under
threat as patients can view themselves coping with out doctors because the
internet can diagnose and provide treatment instructions.

An
additional challenge to medical power is due to a loss in trust from patients
in the health care system and in the professionals that work for the system. Associated
with the rise in consumerism, patients are encouraged to become complaisant in
trusting medical expertise, this explains patients moving away from
institutions such as the NHS to private health care because they assume paying
for a product or service and the reputation will ensure higher quality care. Moreover,
the decline in trust has also been caused by numerous malpractice allegations, Dixon-Woods,
Yeung and Bosk reported in 2011 the role of medical scandals ending
self-regulation. Scandals involving bad doctors were nothing new, they were all
similar in content, for example patients being murdered by doctors, or being
sexually abused. Some offences by the doctors were not even reported due to the
high status of the doctors and patients being afraid of backlash from society.
Therefore, trust has to be re-built, because these cases have caused trust in
the medical sector to be shattered, especially in a time of a social media peak
doctors cannot afford further transgressions as it will reach masses of people
all over the world.  A scandal in one
country will be enough to affect trust of the health care system in other
countries. On the other hand, Calnan and Rowe (2008) conducted a study and
found that there is a lack of evidence to indicate a decline in trust toward
health care professionals. They reported that studies from the UK and USA show
trust is still high for doctors but vary depending on the type of illness, how
big the risk is on the patient and their previous experience with health care.
They concluded that trust in health care as a whole is lower than in doctors
individually.

Is medical
power and professional dominance currently under threat?  I’ve concluded from the literature and various
texts that the health care system has surpassed the biggest impact of all the
trends and transformations that may cause a threat. Although many changes are constantly
happening, it is only under threat to a certain extent. Society will remain reliant
on the healthcare based on the knowledge that the treatment used by the health
care has been empirically test and can objectively prove their treatments have a
positive effect on diseases. Even though the health care system has become more
regulated it ensures welfare workers are professional in all they do and limits
the possibilities of scandals occurring. As long as physicians continue to
rebuild trust with patients and maintain relationships patients will seek less
alternative methods to curing their illnesses. On the other hand, doctors may need
to accept that they are no longer the primary drivers due to the rise in
consumerism, new biotechnology and third parties’ involvement.

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