Negotiating public and professional interests: a rhetorical analysis of the debate concerning the regulation of midwifery in Ontario, Canada

This article investigates the uneasy process of integrating midwifery's alternative, women-centered model of childbirth care within the medically-dominated healthcare system in Canada. It analyses the impure processes of rhetorical identification and differentiation that characterized the debate about how to regulate midwifery in Ontario by examining a selection of submissions from diverse health care groups with vested interest in the debate's outcome. In divergent ways, these groups strategically appeal to the value of the "public interest" in order to advance professional concerns. The study considers the implications of this rhetorical process for re-defining midwifery's distinctive professional identity in relation to other health professions, to the state, and to the women for whom midwives care. Likewise, it suggests the relevance of rhetorical analysis for understanding the discursive formation and re-formation of health models, values, and professions in Western culture.

Doctors in society. Medical professionalism in a changing world

Medicine bridges the gap between science and society. Indeed, the application of scientific knowledge to human health is a crucial aspect of clinical practice. Doctors are one important agent through which that scientific understanding is expressed. But medicine is more than the sum of our knowledge about disease. Medicine concerns the experiences, feelings, and interpretations of human beings in often extraordinary moments of fear, anxiety, and doubt. In this extremely vulnerable position, it is medical professionalism that underpins the trust the public has in doctors. This Working Party was established to define the nature and role of medical professionalism in modern society. Britain's health system is undergoing enormous change. The entry of multiple health providers, the wish for more equal engagement between patients and professionals, and the ever-greater contribution of science to advances in clinical practice all demand a clear statement of medicine's unifying purpose and doctors' common values. What is medical professionalism and does it matter to patients? Although evidence is lacking that more robust professionalism will inevitably lead to better health outcomes, patients certainly understand the meaning of poor professionalism and associate it with poor medical care. The public is well aware that an absence of professionalism is harmful to their interests. The Working Party's view, based on the evidence it has received, is that medical professionalism lies at the heart of being a good doctor. The values that doctors embrace set a standard for what patients expect from their medical practitioners. The practice of medicine is distinguished by the need for judgement in the face of uncertainty. Doctors take responsibility for these judgements and their consequences. A doctor's up-to-date knowledge and skill provide the explicit scientific and often tacit experiential basis for such judgements. But because so much of medicine's unpredictability calls for wisdom as well as technical ability, doctors are vulnerable to the charge that their decisions are neither transparent nor accountable. In an age where deference is dead and league tables are the norm, doctors must be clearer about what they do, and how and why they do it. We define medical professionalism as a set of values, behaviours, and relationships that underpin the trust the public has in doctors. We go on to describe what those values, behaviours, and relationships are, how they are changing, and why they matter. This is the core of our work. We have also identified six themes where our definition has further implications: leadership, teams, education, appraisal, careers, and research. The Working Party's definition and description of medical professionalism, and the recommendations arising from them, can be found in Section 5 of this report. If our recommendations are acted upon, we believe that professionalism could flourish and prosper to the benefit of patients and doctors alike. However, the exercise of medical professionalism is hampered by the political and cultural environment of health, which many doctors consider disabling. The conditions of medical practice are critical determinants for the future of professionalism. We argue that doctors have a responsibility to act according to the values we set out in this report. Equally, other members of the healthcare team--notably managers--have a reciprocal duty to help create an organisational infrastructure to support doctors in the exercise of their professional responsibilities. Just as the patient-doctor partnership is a pivotal therapeutic relationship in medicine, so the interaction between doctor and manager is central to the delivery of professional care. High-quality care depends on both effective health teams and efficient health organisations. Professionalism therefore implies multiple commitments--to the patient, to fellow professionals, and to the institution or system within which healthcare is provided, to the extent that the system supports patients collectively. A doctor's corporate responsibility, shared as it is with managers and others, is a frequently neglected aspect of modern practice. The audience for this report is, first and foremost, doctors. But we believe it should be of equal interest to patients, policy-makers, members of other health professions, and the media. All these groups have a vital part to play in discussing and advancing medical professionalism. This report is only the beginning of an effort by the Royal College of Physicians, together with others, to initiate a public dialogue about the role of the doctor in creating a healthier and fairer society. Medical professionalism has roots in almost every aspect of modern healthcare. This Working Party could not hope to solve all the issues and conflicts surrounding professionalism in practice today. But our collective and abiding wish is to put medical professionalism back onto the political map of health in the UK.

[The new seniors. Sociological and medical aspects]

Medical progress has led to a spectacular increase in life expectancy. The world population is ageing in a context of rapid technological change destabilizing individuals and societies in their values and functions to such a point that it is Leading to a true change in civilization. Seniors have become important socio-economic players with a feeling of prolonged youth and autonomy. Globalization has generated a feeling of insecurity and a constantly growing need for more information. In the face of these changes, adaptation in rhythm ranges, according to the individual, from reticence in its extreme form, the principle of precaution, through fatalistic passivity to opportunistic enthusiasm. In the medical field, patients have access to all modern means of information, and the most well-informed tend to behave more or less consciously as healthcare consumers, modifying the relationship with doctors which may become a service provider-client type relationship. A new relation to the body and with others has appeared with desires and also performance obligations. The difficulties of adaptation to this complex and socially anxiogenic world are expressed by permanent social conflicts and the increasing recourse to individual psychotherapeutic support.

Death brokering: constructing culturally appropriate deaths

Death brokering refers to the activities of medical authorities to render individual deaths culturally meaningful. Social scientists and others agree that mortality provokes existential ambiguity in modern life requiring cultural coping mechanisms. In contemporary Western societies, medical professionals have sequestered the dying in institutions, and have classified the causes of death to explain suspicious death. Over the last decades, the institutionalisation of the dying process has been challenged by social movements and the sudden onset of some deaths while forensic medicine has struggled for professional legitimacy in the borderland between mainstream medicine and the legal system. I argue that medical death brokering persists in spite of challenges because medical experts offer increasingly flexible cultural scripts to render the end-of-life socially meaningful while accentuating death's existential ambiguity. Medical professionals help create the ambiguity they promise to resolve, reinforcing the cultural need for more expert death brokering.

Dynamic professional boundaries in the healthcare workforce

The healthcare professions have never been static in terms of their own disciplinary boundaries, nor in their role or status in society. Healthcare provision has been defined by changing societal expectations and beliefs, new ways of perceiving health and illness, the introduction of a range of technologies and, more recently, the formal recognition of particular groups through the introduction of education and regulation. It has also been shaped by both inter-professional and profession-state relationships forged over time. A number of factors have converged that place new pressures on workforce boundaries, including an unmet demand for some healthcare services; neo-liberal management philosophies and a greater emphasis on consumer preferences than professional-led services. To date, however, there has been little analysis of the evolution of the workforce as a whole. The discussion of workforce change that has taken place has largely been from the perspective of individual disciplines. Yet the dynamic boundaries of each discipline mean that there is an interrelationship between the components of the workforce that cannot be ignored. The purpose of this paper is to describe four directions in which the existing workforce can change: diversification; specialisation and vertical and horizontal substitution, and to discuss the implications of these changes for the workforce.

Behavioral science at the crossroads in public health: extending horizons, envisioning the future

The social and behavioral sciences are at a crossroads in public health. In this paper, we attempt to describe a path toward the further integration of the natural and behavioral sciences with respect to the study of behavior and health. Three innovations are proposed. First, we extend and modify the "stream of causation" metaphor along two axes: time, and levels of nested systems of social and biological organization. Second, we address the question of whether 'upstream' features of social context are causes of disease, fundamental or otherwise. Finally, we propose the concept of a risk regulator to advance the study of behavior and health in populations. To illustrate the potential of these innovations, we develop a multilevel framework for the study of health behaviors and obesity in social and biological context.

Illnesses you have to fight to get: facts as forces in uncertain, emergent illnesses

Chronic fatigue syndrome and multiple chemical sensitivity are two clusters of illnesses that are pervaded by medical, social and political uncertainty. This article examines how facts are talked about and experienced in struggles over these emergent, contested illnesses in the US. Based principally on a large archive of internet newsgroup postings, and also on fieldwork and on published debates, it finds that (1) sufferers describe their experiences of being denied healthcare and legitimacy through bureaucratic categories of exclusion as dependent upon their lack of biological facts; (2) institutions manage these exclusions rhetorically through exploiting the open-endedness of science to deny efficacy to new facts; (3) collective patient action responds by archiving the systematic nature of these exclusions and developing counter-tactics. The result is the maintenance of these very expensive struggles for all involved.

From representation to mediation: the shaping of collective mobilization on muscular dystrophy in France

How, and to what extent, do patient organisations renew traditional forms of social participation and protest? This question is examined, drawing on a socio-historical case study of the Association Française contre les Myopathies--French Muscular Dystrophy Organisation (AFM). The originality of the AFM is that it has not been content to endorse the classic role of representation of people with muscular dystrophy (MD) and their families. It has also articulated and structured different social spaces that allow people suffering from genetic diseases and severe disabilities to be considered as fully-fledged human beings, persons, and citizens within those spaces. Based on quantitative data and methods, this paper aims to characterize this reconfiguration of social spaces that the AFM has undertaken. My contention is that it has given shape to a different form of collective mobilization, one in which the patient organisation is a mediator between different social actors, as much as a patients' representative. It helps a new issue, here MD, to emerge so that the largest possible collective designate it as a general public concern. As we shall discuss, this renews the question of patients' collective identity and citizenship.

Professionalism in medicine: the new authority

Examine some ways that the health care profession could regain lost ground and begin exerting more influence in the marketplace to help offset the pressures from insurance companies, consumers, and the government.

From the doctor's workshop to the iron cage? Evolving modes of physician control in US health systems

As national health systems pursue the common goals of containing expenditure growth and improving quality, many have sought to replace autonomous modes (systems) of physician control that rely on initial professional training and subsequent peer review. A common approach has involved extending bureaucratic modes of physician control that employ techniques such as hierarchical coordination and salaried positions. This paper applies concepts from studies of professional work to frame an empirical analysis of emergent bureaucratic modes of physician control in US hospital-based systems. Conceptually, we draw from recent studies to update Scott's (Health Services Res. 17(3) (1982) 213) typology to specify three bureaucratic modes of physician control: heteronomous, conjoint, and custodial. Empirically, we use case study evidence from eight US hospital-based systems to illustrate the heterogeneity of bureaucratic modes of physician control that span each of the ideal types. The findings indicate that some influential analysts perpetuate a caricature of bureaucratic organization which underplays its capacity to provide multiple modes of physician control that maintain professional autonomy over the content of work, and present opportunities for aligning practice with social goals.

Health care reform in Germany: patchwork change within established governance structures

Under the pressure of health care reform in the 1990s, interactions among the state, sickness funds, and providers in Germany are said to have entered a new era. We examine this new era by assessing both long-term developments connected to German statutory health insurance (SHI) and related short-term developments of the 1990s. Highly institutionalized rules and practices provide little opportunity for abandoning the historical path of two primary factors: the self-governance of SHI and a strong tradition of a semisovereign state. Some opportunities exist for introducing new ideas, rearranging priorities, softening rules, and adding new complex rules and procedures in a fairly fragmented policy-making system, perhaps even because of fragmentation. Yet reforms that depart from the status quo are severely limited by strong legal and administrative traditions and established rules of the game. These restrictions tend to reinforce state intervention, prevent the emergence of consistent and coherent visions of future health policy, and stifle policy innovation and implementation. In sum, reform measures tend to remain well within the priorities established within state and corporatist governance structures.

Plus ça change: health sector reforms in Greece

Changes in the health care sector in Greece since the pathbreaking introduction of the National Health System (NHS) in 1983 have been sluggish. Twenty years after its inception and a series of attempts to reform it, the NHS remains centralized, fragmented in terms of coverage, and quite far removed from its principles of equity and efficiency. Being part of an idiosyncratic welfare state, the health care system is bound to reflect the particularities of Greek society and economy, namely, clientelism, a weak formal-and a thriving informal-economy, the lack of a strong administrative class, a weak labor movement, and strong organized interests. As a result, several ambitious reform plans have failed repeatedly owing to an array of interrelated economic, political, and social factors that channel potential changes toward the trodden path. This constellation creates unfavorable conditions for the introduction and implementation of major reforms.

State autonomy, policy paralysis: paradoxes of institutions and culture in the French health care system

In this article, we assess the recent performance of the French state at containing costs in health care using political science concepts such as path dependency and incentives, which are central to an economic approach. The article focuses on institutional capacities and cultural immobilism and attempts to lay bare the tensions at play in seizing (or not) opportunities for structural change. In particular, we attempt to delineate what constitutes real change in this policy arena (big reforms versus the accumulation of many small policy movements) and to understand the variables at play in the coming together of conjunctures that provide for the big, as well as the underlying structures that allow the accumulation of the small. Except in cases of favorable conjuncture, the analysis bodes very ill for nonincremental reform and, indeed, for significant change over the long term.

A comparison of organized and traditional health care: implications for health promotion and prospective medicine

PURPOSE

To compare organized and traditional health care delivery systems and their ability to meet several major challenges facing health care in the next 25 years.

APPROACH

Analysis of traditional and organized health care systems based on a career spent in organized health care systems.

CONCLUSIONS

The traditional health care system based on independent autonomous physicians is not able to meet the challenges of current healthcare. Stronger integration and coordination, i.e., organized health care delivery systems are required.

Developments in Scandinavian and American medical sociology

This paper examines the similarities and differences in Scandinavian and American medical sociology. First, the issue of medicalization has not been as important in Scandinavian as it has been in American medical sociology. Second, women's health has been less explored in Scandinavian than in American medical sociology. Third, research on social inequalities and health has been a major focus in Scandinavian medical sociology since the 1990s. Fourth, cultural sociology and the poststructuralist perspective have been part of mainstream theory building in European sociology and also European and Scandinavian medical sociology during the past decade, while American medical sociology has been characterized by social-role theory and a quantitative approach.