Today’s Topic: Health Care Professionals

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