We will have to expand radically the use of community health aides; to spread medical knowledge to patients and to non-physician health workers; to minimize the social distance between doctors and patients.
The Decline of the Professions and the Doctor-Patient Relationship
To change the health system at all, much less to create a medical system which maximally utilizes self-help and mutual help and which encourages an active rather than a passive role for the patient, will require radical deprofessionalization.
Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.
Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.
Why? Some of it could reflect differences in training. I remember when my wife brought our infant son Walker to visit his grandparents in Virginia, and he took a terrifying fall down a set of stairs. They drove him to the local community hospital in Alexandria. A CT scan showed that he had a tiny subdural hematoma—a small area of bleeding in the brain. During ten hours of observation, though, he was fine—eating, drinking, completely alert. I was a surgery resident then and had seen many cases like his. We observed each child in intensive care for at least twenty-four hours and got a repeat CT scan. That was how I’d been trained. But the doctor in Alexandria was going to send Walker home. That was how he’d been trained. Suppose things change for the worse? I asked him. It’s extremely unlikely, he said, and if anything changed Walker could always be brought back. I bullied the doctor into admitting him anyway. The next day, the scan and the patient were fine. And, looking in the textbooks, I learned that the doctor was right. Walker could have been managed safely either way.
(I will examine the proletarianization/deprofessionalization thesis in greater detail below as it relates to the doctor-hospital relationship.)Parallel to, and often included in the Marxist account, has been the growing feminist literature on medicine.
In the Marxist analysis, the American doctor-patient relationship is conditioned by the "medical-industrial complex" (Ehrenreich and Ehrenreich, 1970; Waitzkin and Waterman, 1976; McKinlay, 1978; Waitzkin, 1986); profit-maximization drives the innovation of technologies and drugs and constrains physician decision-making.
Drawing on, and extending the professional power analysts, the growing school of Marxist sociologists interpreted the doctor-patient relationship within the context of capitalism.
In particular, feminists have focused on the patriarchal nature of the male physician-female patient relationship, documenting the history of medical pseudo-science that has portrayed women as congenitally weak and in need of dubious treatments (Ehrenreich and English, 1972, 1973, 1978; Arms, 1975; Scully, 1980; Mendelsohn, 1981; Shorter, 1983; Corea, 1984; Fisher, 1986; Martin, 1987; Todd, 1989).
There is also extensive work done on the history of exclusion of women from medicine (Walsh, 1977; Levitt, 1977; Achterberg, 1991), and the effects of the growing numbers of female doctors on the doctor-patient relationship.
Though Starr draws on many theoretical sources, he paints a picture of the American doctor-patient relationship as a successful "collective mobility project" (Parry and Parry, 1976), whose contours were not at all determined by the functional prerequisites of society.
Women providers are also better communicators (Weisman and Teitelbaum, 1985; Shapiro, 1990).The growth of studies on cost-containment, and the economistic trend of 1980's social science, led to the rise of methodologically individualistic "rational choice" studies of the doctor-patient relationship.
This control extends beyond the claim to technical proficiency in medicine, to claims of authority over the organization and financing of health care, areas which have little to do with their training.There are now many studies of the way that professional power has been institutionalized in the structure and language of the doctor-patient relationship.
Instead, the economists' model starts from the assumption of a mutual "utility-maximizing" agency contract between the doctor and patient (Dranove and White, 1987; Buchanan, 1988).