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PROFESSIONALIZATION,
MONOPOLY, AND THE
STRUCTURE OF
MEDICAL PRACTICE
(Conrad and Schneider)
EXPLANANDUM
(WHAT IS TO BE EXPLAINED):
How "regulars" successfully organized
as professionals, eliminating their
competitors and creating a medical
monopoly
BEFORE “PROFESSIONALIZATION”
 Humoral theory (Hippocrates) dominated European
medicine until well into 19th century
-diagnosis was impressionistic, often inaccurate, based on
patient reports of symptoms, physicians’ own observations of
signs of illness (appearance, behavior) but rarely on manual
exam of body
 Medicine not scientific
 In colonial America, physicians were p/t, also working as
clergymen, teachers, farmers, etc
 In early 19th c, medicine was low status, not an
important economic activity
PROFESSIONALIZATION
professionalization: "the process by which producers
of special services sought to constitute and control
the market for their expertise" (Larson, qtd. on p. 195)
 Professions organize to create and control markets
American Medical Association (AMA) forms in 1847
 The medical profession became functionally
autonomous, insulated from external evaluation and
largely free to regulate their own performance
CASE STUDY IN THE CREATION OF A MEDICAL
MONOPOLY: SCIENTIFIC MEDICINE'S ANTIABORTION CRUSADE
 Prior to the Civil War, abortion was a common and largely
legal medical procedure in America, free of moral stigma
 Pregnancy was not considered confirmed until
"quickening" ("first perception of fetal movement,” p. 196)
 common law did not recognize the fetus before quickening, an
unquickened fetus deemed to have no living soul
 After 1840 abortion comes increasingly into public view,
services widely advertised in magazines and newspapers
 By 1870, about 1 abortion per 5 live births
PHYSICIANS, NOT RELIGIOUS LEADERS, LED
ANTI-ABORTION CRUSADE IN LATE 1860S –
BUT WHY?
concern about dropping birthrates, esp. among native
born, "better classes"
to promote professionalization and create a monopoly
over medical services
 they did this by getting states to sanction their competitors ("irregular doctors," e.g.,
homeopaths, botanical doctors, eclectic doctors, etc.)
By 1900, abortion was not only illegal in American
society, but also deviant and immoral
GROWTH OF MEDICAL EXPERTISE
AND PROFESSIONAL DOMINANCE
 last three decades of 19th c saw great strides in
surgical medicine and improvements in hospital care
 rise of germ theory of disease
 rise of “scientific” medicine
DOCTRINE OF SPECIFIC ETIOLOGY:
"each disease was caused by a specific germ or
agent. Medicine focused solely on the internal
environment (the body), largely ignoring the
external environment (society)"….this paradigm is
the essence of the "medical model" (p. 198)
FLEXNER REPORT
Flexner Report: published in 1910 under the
auspices of the Carnegie Foundation, found the
level of medical education in US poor and
recommended closing most schools, establishing
stricter state laws and tougher standards
CHANGES IN MEDICAL PRACTICE
Doctors move from “solo practice” to large
corporate practices or employment in hospitals or
other bureaucratic organizations
Medicine more specialized & more dependent on
technology
Medicine expanded as a portion of American
economy
 Currently around 1/6th of US economy (Kaiser)
KAISER FAMILY FOUNDATION REPORT,
TRENDS IN HEALTH CARE COSTS &
SPENDING (MARCH 2009)
 According to the Centers for Medicare and Medicaid Services (CMS), the
U.S. spent over $2.5 trillion on health care in 2009, or $8,160 per U.S.
resident
 Health spending in 2009 accounted for 17.6% (over 1/6th) of GDP
 In 1970, U.S. health care spending was about $75 billion, or $356 per resident, and
accounted for 7.2% of GDP
 Health care spending has risen about 2.4 percentage points faster than GDP
since 1970
 CMS projects that by 2018, health care spending will be over $4.3 trillion, or
$13,100 per resident, and account for 20.3% of GDP
"FEE-FOR-SERVICE"
American medicine has long operated on a "fee-for-
service" basis, i.e., each service is charged and paid
for separately
 more services, more fees, possibly encouraging
unnecessary medical care
Medicine is one of the few services that can "create
its own demand," since patients go to doctors to
find out what procedures they medically need
Since the 1930s, a shift to "third party"
payments, mainly from health insurance
and the government
 availability of federal $ without cost controls, leading to “cost crisis”
This has also driven the
"medicalization" of more and more
human problems
“MEDICALIZATION:
CONTEXT,
CHARACTERISTICS,
AND CHANGES & THE
SHIFTING ENGINES OF
MEDICALIZATION”
Ch. 1 in The Medicalization of Society:
On the Transformation of Human
Conditions into Treatable Disorders,
Peter Conrad
THE ORIGINAL ENGINES OF
MEDICALIZATION
A.
the power and authority of the medical profession
B.
social movements and interest group mobilization
C.
professional organized action by physicians themselves
KEY CHANGES IN MEDICINE
(BEGINNING IN THE 1980S)
A.
erosion of medical authority
B.
rise of cost controls
C.
increasing commercialization of medicine
EMERGENT ENGINES OF
MEDICALIZATION
A.
Biotechnology
B.
Consumers
C.
Managed Care
A. BIOTECHNOLOGY PHARMACEUTICAL INDUSTRY
• pharmaceutical industry: changes in FDA regulations allowed for off-label
uses of drugs and direct-to-consumer (DTC) marketing of
pharmaceuticals, esp. on television
-Viagra: the drug industry expanded the notion of ED, encouraging the
use of Viagra-like drugs for enhancement of sexual pleasure and
relationships
-Paxil: a new "anxiety market" was created as shyness & worry were
medicalized as social anxiety disorder (SAD) and generalized
anxiety disorder (GAD)
A. BIOTECHNOLOGY –
GENETICS & ENHANCEMENT
• genetics and enhancement: thus far, genetics has made its impact mostly in
terms of the ability to test for gene mutations, carriers, and genetic
anomolies, but research indicates there's a private market for
enhancements for children, regardless of the high cost (e.g., the use of
human growth hormone for children of short stature)
B. CONSUMERS
1. consumers have shown they are willing to pay out of pocket
for a range of cosmetic procedures, e.g., breast enlargement
and liposuction
2. nonprofit consumer groups (like CHAAD and NAMI) have
"medicalized underperformance" in promoting the concept
of adult ADHD; here, the internet has become a critical
consumer vehicle in websites with information, self-exams,
and bulletin boards
C. MANAGED CARE
Managed care is a method of organizing and financing health
care services that emphasizes cost-effectiveness and coordination
of care
1. it’s both an incentive and constraint on medicalization:
while reducing coverage for psychotherapeutic treatment
for mental illness it has facilitated the use of psychotropic
medications
2. overall, managed care organizations have increasing
influence over what is considered medically appropriate and
inappropriate treatment
D. MEDICALIZATION IN THE
NEW MILLENNIUM
1. Today the engines of medicalization are driven more by commercial and
market interests than by professional claims-makers in the field of
medicine itself
2. Medicalization will continue to shape social norms, as it already has
altered attitudes toward breast augmentation and de-stigmatized male
erectile dysfunction
3. Gender segmentation, a proven profit-making strategy, will characterize
the market for medical care, where medical problems and solutions will
be organized on the basis of gender differences
4. Medicalization will expand as an international phenomenon
SELLING SICKNESS: THE
PHARMACEUTICAL
INDUSTRY AND
DISEASE MONGERING
Moynihan et al., 2002, BMJ
SUMMARY POINTS:
 Some forms of medicalization may now be better described as “disease
mongering”—extending the boundaries of treatable illness to expand
markets for new products
 Alliances of pharmaceutical manufacturers, doctors, and patients groups
use the media to frame conditions as being widespread and severe
SUMMARY POINTS (CONT’D):
 Disease mongering can include turning ordinary ailments into medical
problems, seeing mild symptoms as serious, treating personal problems
as medical, seeing risks as diseases, and framing prevalence estimates to
maximize potential markets
 Corporate funded information about disease should be replaced by
independent information
5 EXAMPLES OF DISEASE
MONGERING
(FROM AUSTRALIA BUT FAMILIAR INTERNATIONALLY)
1. Ordinary processes or ailments of life classified as medical
problems
2. Mild symptoms portrayed as portents of serious disease
3. Personal or social problems seen as medical ones
4. Risks conceptualized as disease
5. Disease prevalence estimates framed to maximize size of a
medical problem
1. ORDINARY PROCESSES OR AILMENTS
OF LIFE CLASSIFIED AS MEDICAL PROBLEMS:
BALDNESS
• The medicalization of baldness shows clearly the transformation of the
ordinary processes of life into medical phenomena
2. MILD SYMPTOMS PORTRAYED AS PORTENTS
OF SERIOUS DISEASE: IRRITABLE BOWEL
SYNDROME
 The "makeover" of irritable bowel syndrome from a common
functional disorder into a “credible, common and concrete disease”
with the help of industry-funded "medical education" campaigns
3. PERSONAL OR SOCIAL PROBLEMS SEEN
AS MEDICAL ONES: SOCIAL PHOBIA
 the medicalization of human distress as the psychiatric disorder of
social phobia
4. RISKS CONCEPTUALIZED AS DISEASES:
OSTEOPOROSIS
 the medicalization of reduced bone mass—which occurs as
people age—is an example of a risk factor being
conceptualized as a disease.
 the marketing of fear: "The construction of the widely used
WHO diagnostic criteria is such that large numbers of
healthy women at menopause will automatically be
diagnosed as having this “disease” because their bones are
being compared with those of much younger women”
5. DISEASE PREVALENCE ESTIMATES
FRAMED TO MAXIMIZE SIZE OF MEDICAL
PROBLEM: ED
 advertisements claimed 39% of men suffered from erection problems,
but # combined all categories of difficulties, including "occasional"
problems and average age of those reporting complete dysfunction was
71
FOR DE-MEDICALIZATION
 Key concern is the invisible and unregulated attempts to change public
perceptions about health & illness to widen markets for new drugs
 Author calls for a publicly funded and independently run program of
“demedicalisation, based on respect for human dignity, rather than
shareholder value or professional hubris"