ch. 11 The Profession of Medicine

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ch. 11 The Profession of Medicine af Mind Map: ch. 11 The Profession of Medicine

1. American Medicine in the Nineteenth Century

1.1. Regular Doctors: the forrunners of contemporary doctors

1.2. Irregular Practitioners: Midwives, patent medicine makers, botanic eclectics, etc.

1.3. Allopathic Doctors: Sometimes treated illness with drugs elected to produce symptoms opposite to those caused by the illness.

1.4. Homeopathic Doctors: Treated illness with drugs that produced symptoms similar to those caused by the illness

1.5. By the second half of the 19th century, most doctors responding to the public's support for irregular practitioners and fear of heroic medicine, had abandoned their most dangerous techniques.

1.6. Irregular Practitioners: Midwives, patent medicine makers, botanic eclectics, etc.

1.7. Irregular Practitioners: Midwives, patent medicine makers, botanic eclectics, etc.

2. The Rise of Medical Dominance

2.1. American Medical Association (AMA): incepted in 1847, worked to restrain the practices of other health care occupations.

2.2. Professionals realized a lack of science could doom their fields.

2.3. Older occupations (such as midwives and herbalists) lacked the social status/power/money needed to fight against doctor's lobbying.

2.4. The Flexner Report and its Aftermath

2.4.1. Flexner Report: Written by Abraham Flexner and commissioned by the nonprofit Carnegie Foundation at the AMA's behest. Shocked the nation with its descriptions of the lax requirements and poor facilities at many medical schools.

2.4.2. Improved the quality of health care available to the American public and paved the way for later advances in health care.

2.4.3. Only two medical schools for African Americans and one school for women survived.

2.5. Doctors and Professional Dominance

2.5.1. Professions have 3 characteristics 1. The autonomy to set its own educational and licensing standards and to police its members for incompetence or malfeasance. 2. Technical, specialized knowledge, unique to the occupation and learned through extended, systematic training. 3. Public confidence that its members follow a code of ethics and are motivated more by a desire to serve than a desire to earn profit.

2.5.2. Professional Dominance: Freedom from control by other occupations or groups and the ability to control any other occupations working in the same economic sphere.

3. The Threats to Medical Dominance

3.1. Medical Dominance: High level of professional dominance by doctors.

3.2. The Rise of Corporatization

3.2.1. With the initiation of medicare and medicaid, the potential for profits in health care expanded tremendously, leading many for profit corporations to enter the field.

3.2.2. Corporatization: The growth of corporate medicine.

3.2.3. Managed Care Organizations

3.2.4. Practice Protocols: Establish treatment guidelines aimed at providing the best, but also the most cost effective, treatment for different conditions.

3.3. The Rise of Government Control

3.3.1. Diagnosis-Related Groups (DRG): Established preset financial limits for each diagnosis for hosptial care under Medicare.

3.3.2. Resource-Based Relative Value Scale (RBRVS): Designed to control spending on doctor's bills.

3.4. The Decline in Public Support

3.4.1. Shift from fee for service medicine towards insurance paid medicine.

3.4.2. Fewer relationships with primary care doctors.

3.4.3. Rise of the internet gives consumers access to their own medical literature.

3.5. The Decline of the American Medical Association and Countervailing Powers.

3.5.1. Only 28% of doctors now belong to the AMA

3.5.2. Insurance and pharmaceutical industries have become far more powerful.

3.5.3. Countervailing Powers: Various powerful groups and institutions fighting for control over a given arena such as health care.

4. The Continued Strength of Medical Dominance

4.1. The dominance of doctors relative to other health care occupations still remains largely intact.

4.2. Americans still consider medicine a highly prestigious field and still strongly trust their doctors.

5. Medical Education and Medical Values

5.1. The Structure of Medical Education

5.1.1. Residents: Doctors who are continuing their training while working in hospitals.

5.1.2. 80% of students who enter medical school obtain debt.

5.1.3. Tremendous time costs.

5.2. Ethnicity, Sex, Class and Medical Education

5.2.1. Most are from upper middle class families

5.2.2. Asian Americans are significantly overrepresented.

5.2.3. Increasingly more women (even though men still outnumber women)

5.2.4. There is a lot of sexism involved in the politics of medicine.

5.2.5. High concentrations of women in pediatrics, radiology, and pathology.

5.3. Learning Medical Values

5.3.1. Medical Norms: expectations about how doctors should act, think, and feel.

5.3.2. Emotional Detachment

5.3.3. Professional Socialization: the process of learning the skills, knowledge, and values of an occupation.

5.3.4. Clinical Experience Evidence Based Medicine: Medical care based on a thorough evaluation of the best available scientific research

5.3.5. Mastering Uncertainty Learn how to cope with the inability to know absolutely everything.

5.3.6. Mechanistic Model See the body as a machine and disease as a breakdown.

5.3.7. Intervention

5.3.8. Emphasis on Acute and Rare Illness Acute Illness is considered more interesting than chronic illness

5.4. The Consequences of Medical Values

5.4.1. The problems are stronger during training than after experience. Detachment, Rigidity, lack of observing social situations.

6. Patient-Doctor Relationships

6.1. Power and Paternalism

6.1.1. Power is greatest 1. When patients are completely incapacitated by coma, stroke, or the like 2. When doctors'cultural authority is much greater than that of their patients.

6.1.2. Courts will often favor the doctor's decisions over patient's wishes

6.2. Ethnicity, Class, Gender and paternalism

6.2.1. Doctors are not immune to stereotypes about minorities, women and lower class individuals.

6.2.2. This can result in ethnic and gender differences in diagnosis and treatment.

6.3. Paternalism as Process

6.3.1. Doctors typically dominate discussions

6.3.2. Doctors can reinforce their dominance by the simple tactic of referring to the patient by first name but expecting patients to refer to them by their title

6.3.3. Doctors typically present two treatment options by showing heavy bias towards one or another.

7. Reforming Medical Training

7.1. Throughout the US medical students and professors are working to implement innovated programs for itnetgrating more patient centered perspectives into medical curriculum.

7.2. Cultural Competence: The ability of health care providers to understand at least basic elements of others' cultures, to recognize the impact of their own cultural identity and biases on their interactions with clients and thus to provide medical care that better meet their clients emotional as well as physical needs.

8. American Medicine in the Nineteenth Century