Hardly able to see straight, Dr. Monique Waznicki flops into an empty chair behind the main desk in the Special Care Nursery. She scans The Board and decides that the nurses can hold things together while she chases down a consult call she has into a cardiac specialist.  And maybe she can get a coffee from the Starbuck’s Outlet at the same time! On her way out the door she thinks “everyone is still pretty distraught from the death of the baby in room #4.  If only the mother had seen someone earlier, so her Diabetic problems could have been treated earlier … the baby would have been smaller, and none of this would have happened.  It was all so sad and so un-necessary”!!

Seconds later, Sheena Inston, the shift head nurse, comes looking for the good doctor:

Damn, she’s disappeared again. . . . I need to work out the new budget cuts with her but she’s never around for that kind of stuff, she’s always dumping the management stuff on me and I’ve got my own clinical responsibilities. None of these physicians understand the union contract issues or get involved with the budget discussions. But God help you if you don’t get their signatures on everything! They’re never around for the discussions and the planning, they just show up at the end and yell … or even worse, they willy, nilly change everything, and all the planning and partnering with everyone else goes down the tubes. . . I hate being yelled at . . . Some of the docs are decent human beings but the majority are prima donnas.

Sheena smiles grimly to herself and declares under her breath: “wait until Dr. Waznicki sees what ‘they’ are going to do this time … there’s going to blood on the floor for sure over these cuts!”

Why is Dr. Waznicki so worn out and why is Sheena Inston so angry about Dr. Waznicki and many of the good doctor’s colleagues? And do Monique and Sheena keep trying so hard and why is there so much agreement among these professionals regarding budgets, paperwork and realities of contemporary health care. We would suggest that both Monique Waznicki and Sheena Inston are members of a single organizational culture, yet also members of two warring subcultures. Furthermore, we propose that this culture is in trouble and that it is quite understandable that both Monique and Sheena are tired and frustrated.   

Rise and Fall of the Professional Culture

To understand Monique and Sheena we must first acknowledge that the professional culture has been the most powerful and influential of the four cultures in North American health care, and has played a central role in the history of North American medicine since Colonial times. We must also acknowledge that this culture is now in trouble and under enormous pressure to change, with some justification. There are minor horror stories interwoven with overall stories of successful treatment.

It is too easy to doctor bash with stereotypes and blame the professional culture for the problems in the health care system. The aristocrat and narcissist archetypes (see Chapter Two) can all too readily be applied in times of transition, when anxiety is high among both health care recipients and practitioners. We must, therefore, first offer praise for the exceptional work done by health care professionals in the United States. The archetypes of helper, mother, father and caregiver are more appropriately applied to most physicians and other health care professionals than are the archetypes of aristocrat or narcissist.

Every day in the news and on TV we hear yet another story about how physicians, nurses, emergency room technicians and a host of other players, act out their parts to save people’s lives—especially during the COVID-19 era. Yet there are problems. As one senior surgeon put it: “it used to be fun to be a physician but not anymore … today, for instance, we can’t relieve the tension in the operating room by cracking jokes because it may violate the harassment policy. Medical malpractice insurance is just killing us. . . . and there is no way to spend adequate time with patients and at the same time go to all the meetings they want us to go to. I told my kids to go into something else, being a doctor is just too stressful and pressured.”

The professional culture may be dominant but the people in it are paying an enormous price for that success. Enormous success and profound wounding characterize this culture. The culture of the health care professional lies at the heart of the contemporary health care system. The wounding of health care professionals and the response of these professionals to being hurt is key to the ultimate transformation of the system. Physicians and nurses and a host of other clinical professionals have worked out methods for delivering high quality patient care. Unfortunately, the methods that they have developed are now exacting huge personal, professional and financial costs and are no longer sustainable. The key to transforming the entire health care system lies in helping these people find other ways of working together to deliver the care that is needed. Only then will we have a healed and whole health care delivery system.

In this chapter, we first describe the creation of a powerful professional culture in North America. This history yields many insights that can help us better understand much of what exists as a core part, both good and bad, in the American health care systems. This history can also provide us with some clues as to how we might somehow find our way out of this morass. The public is demanding change from this culture as a key part of re-working our health and healing systems. New perspectives and new roles are emerging, yet the best parts of the old culture must be preserved. The changes that this culture makes (or doesn’t make) will have a major impact on the possibility of creating revitalized health systems so that patients can be served even more successfully.

Canada and the United States traveled along the same path for the first two hundred years of their history. The professional culture in both countries still embodies the same health practices and standard-setting bodies. Communality in educational curricula enable nurses and physicians to still fly back and forth across the borders with ease. In order to make sense of this shared culture we will travel back in time to the founding of the New World by the Puritans and other early colonists. We’re moving back to a very different time in North American history.

Preconditions for a Professional Culture

We must first realize that in general, the Colonial era in Western civilization is typified by unclear boundaries and undifferentiated states. Even after Europeans discovered the continent, The First Nation (Native American) peoples still occupied most of it with their multitude of beliefs and health care practices. It took two hundred years for the Europeans to establish their colonies and grow sufficiently large in number to change the character and history of the North American continent. The professional culture got its start out of the chaos of this settlement phase. Order was established through the enforcement of two primary values: pragmatism and elitism.

Pragmatism

The elements of the Colonial world were not sorted into neat piles and organizations did not play tidy roles in this pioneering society. Rather, everyone did a little of everything and various societal categories, such as vocation, institutional roles and clear definitions of rights and responsibilities, were not yet firmly established. People were struggling to stay alive and forge a livelihood in this hostile New World. They devoted little time to making things clear and consistent. Whatever worked was employed, regardless of role or credentials. This is the essence of New World pragmatism.

Initially, the North American colonists focused on the establishment of economic, political and societal structures on the new continent. They were understandably less concerned about medicine, education, culture or the other less hard and less practical aspects of life. There were very few trained physicians, so many of those who had any training at all found themselves in great demand. They tended to travel around as itinerant healers, much as in the case of the itinerant preachers who wandered around the North American countryside. There were essentially four kinds of people providing medical treatment during the Colonial era: academically-trained, upper class physicians, surgeons who received their training (as tradesmen) through apprenticeships, apothecaries who compounded and dispensed drugs, and minister-physicians.[i]

The first of these four types was uncommon in Colonial North America. There were not enough physicians who were trained academically to go around. As a result, other so-called professionals took on the job of ministering to the sick. Ministers were particularly likely to provide these services, not only because they were in the business of service, but also because they were usually among the best informed individuals with regard to such health matters as birth, disease, accident and death. They were intimately aware of these personal matters as they took place in their community.

Elitism

The counterpart of New World pragmatism is New World Elitism. A professional in North America relies as much on elitism as she does on pragmatism. Whether she is a physician, lawyer or architect, the North American professional has access to specialized knowledge that is not available to other members of her community. Her profession is revered and she is among the elite in North American society.[ii] Traditional medicine in the New World was assigned primarily to the wealthy—the elite. Like education and law, medicine was not considered a right of the poor, but rather a privilege of class.  Many of the men who provided health care during the colonial period were renaissance men.

Broadly educated men, like Benjamin Franklin, were often among those in the Colonial communities most concerned about medicine. They became knowledgeable about and applied medical knowledge as a function of their more general role as well-read gentlemen and leaders of their communities. Many of the people who could read and write during the Colonial period packed a few home remedies in their baggage when traveling to the New World. Many educated people—such as ministers, lawyers and judges, and city officials—often had extensive libraries that included books on medicine, as well as such topics as religion, science, and agriculture. At the time, books were the primary sources of knowledge and those colonists who could not only read and write, but also owned books were among the most influential and powerful in any community. We thus see the beginning of the professional culture in North America and the emphasis on access to knowledge as a key component of this culture.

This elitism in North American medicine was sustained by the restrictive conditions of medical training in both the US and Canada. The British and French protectors of America and Canada placed health care at the bottom of their list of priorities. They were primarily concerned with the financial solvency of the North American colonists, as well as with regional and national defense. They provided little medical training for Americans or Canadians. As a result, North Americans were on their own to start their own medical schools and obtain funding for these new medical training programs. Because formal, traditional medical services were in short supply, they were made available only to those who could afford them. Furthermore, because there was little outside (i.e. English) support for programs to train new medical professionals, indigenous New World medical training institutions had to be established.

Even today, physicians and other health care professional are influential and respected in large part because of their access to information that is not available to the common lay person. Those Americans and Canadians who were practicing crude medicine during the Colonial period tended to have power in part because they alone had access to books about medicine. In many ways their power is reminiscent of the power held by Catholic priests in Italy prior to the reformation. The priests had power in part because the common people could not read Latin and therefore had to rely on the priests for an interpretation of the Latin bible. Colonists similarly had to rely on those who possessed and read learned books.

Many of us probably think it is inevitable that professionals are always among the elite in any society. This is simply not the case. Paul Starr has observed that physicians during Roman times were often slaves or recently freed men.[iii] Alternatively, they were foreigners. In either case, they had little status in society. Similarly, during the Middle Ages in Europe, the physicians held little status and surgeons were placed at an even lower level, given that they worked with their hands and were considered not much more than butchers (being in the business primarily of cutting off limbs and draining blood). Much greater status was often given to a group of traveling medical specialists who repaired hernias, removed bladder stones and performed other difficult medical operations.[iv]

Similarly, in Eighteenth Century England, the time of New World colonization, physicians remained on the margins of society. Along with the surgeons and pharmacists (then called apothecaries), British physicians were always scrambling for a buck and were beholden to the upper class for financial support and protection. More recently, we can look to the former Soviet Union. Soviet physicians earned less than most Soviet industrial workers. This is probably why so many Soviet physicians were women. They didn’t have any status.

North America was different. Professionals, and physicians in particular, soon occupied positions of high status in society. Because the elite of North American society, the well-read and well-bred, initially had almost exclusive access to accepted notions about medicine, medicine was founded in America as an elite profession. Thus began the pull between elitism and service to the under-served in North American medicine—a pull that is particularly evident in the tensions that exist between the professional culture and each of the other three cultures.

Elitism and Populism

There were, of course, many other healers in Colonial North America, and we will be discussing them when we turn to the alternative culture in North American health care. These nontraditional healers represent the polar opposite of elitism in New World culture. They represented New World populism and reliance on the natural and local wisdom of North American communities. They also represented a New World emphasis on giving power and information to the common people and serving those who are under-served. New World populism flies directly in the face of the elitist emphasis on keeping information and power in the hands of elite professionals.

Ironically, during the Colonial period in North America the elite often had less access than the poor to folk medicine (which were often more effective than traditional medicines). At the same time, the poor were less likely than their European counterparts to live in squalor and unhealthy urban environments.[v] While their living conditions could never be considered either clean or healthy (using present day standards), the poor were often better prepared to deal with their ailments than were the wealthier North Americans, who tended to rely on traditional and ineffective physicians.

This has always been a curious factor in the history of New World medicine: while the elite in North America had little faith in the abilities of these professionals, they used them extensively. Furthermore, the elite saw no reason to make these services (at some cost) available to the poor and dispossessed—who were probably predestined anyway (from a Calvinist perspective) to sin and degradation in this life and to an eternity of damnation afterwards.

Professionalization of Health Care

Medicine as a profession in North American began a slow but steady progression in the Eighteenth Century. As in the case of the other emerging New World professions, medicine began to become a profession by initiating apprenticeships, degrees and licensing, leading inevitably to the restraint of trade.[vi] Apprenticeships were first set up during the colonial period in North America as a means of training young men for the medical profession. Up to the middle of the Eighteenth Century, physicians had received little formal training, having learned informally from an experienced practitioner or on their own. They were accepted in their community not because of specific training, but because of their reputation for competence and success. By mid-century, a few established physicians began offering courses. Typically, these courses were concerned with specialized topics, such as human anatomy.

The processes of licensing were not easily established in North America. By the start of the American Revolution, almost fifty people had received some sort of degree that enabled them to practice medicine. Yet, there was no formal license. As with the other professions, medicine tried to license practitioners and attempted to restrain the practices of those who were not licensed. But they were not successful until the Twentieth Century. In part this was because the apprenticeship programs simply did a better job of training practitioners and of guaranteeing quality than did formal academic education or licensing laws. In many ways this same problem still exists regarding the preparation of medical practitioners in the Twenty-First Century. Academic goals are still often at odds with the goals of medical education. Licensing procedures still reflect this ambivalence about appropriate preparation for the profession of medicine.

Deeper and somewhat less rational opposition to licensing came from outside the medical profession. This opposition was quite effective. By the mid-1770s only two states enacted medical licensing laws (New York and New Jersey) and these proved to be neither popular nor enforceable.

While elite Colonial North Americans were angry about the quality of health care they were getting, there was a backlash from several groups every time physicians or concerned members of the general public tried to impose a strict licensing law.

First, there have always been those who believe that democracy and an egalitarian spirit are incompatible with any practice that brings about social distinctions and the prohibition of professional practice. These Jacksonian populists tended to oppose any restraint-of-trade that could drive up medical costs and restrict access to medical services. This group was also caught up in an important dimension of the New World dream—namely, the freedom of choice. These economic libertarians firmly believed in a free market in all areas, including medical practice. They believed that when freedom reigns supreme, new and highly innovative practices appear and are soon rewarded. Outmoded practices will prevail and go unchallenged when medical practices are restrained—even though they are ineffective.

Ironically, in many ways the economic libertarians of the Nineteenth Century foresaw the recent discrediting of medical practices and the late Twentieth Century call for a more open marketplace regarding health care practices. In many ways, as the populists warned us, training and licensing are nothing more than justifications for restraint of trade. Once licensing was required, physicians could begin to define what is and is not acceptable medical practice and what is the scope of medical practice that should be subsumed under the license.

Advocates were another group favoring an open market and opposing medical licensing over the years. However, they had more vested interests, given that they provided, used or at least supported alternative modes of health care. Many Colonialists were hesitant to restrict the use of nontraditional treatments as long as traditional medicine could not demonstrate that it was better than anything else!

The Modern Era

As American societies began to prosper and become more respectable in the world community, a new professional class emerged that in many ways took the place of the class structure that dominated most European societies of the Nineteenth Century. Along with law and the ministry, medicine was one of the first professions, and until the present day, medicine has exemplified (along with law) the culture of the professions.[vii] While the Colonial era saw the emergence of a fledgling medical profession, the Nineteenth Century and early Twentieth Century witnessed the full-blown expansion of this profession. The medical profession moved into the heart of the North American character. It created a dominating organizational culture that would determine the norms, values and aspirations of the health care community for many years to come.

The professional culture has played a powerful role because it represents, in some essential manner, the basic nature of the North American culture during the Twentieth Century. North American society is built on professionalism. More specifically, the professional culture was dominant in North American medicine during most of the Twentieth Century for three reasons. First, it struck a chord with Twentieth Century values, building as it did on the marvels of science and technology, and filling a gap left by the decline of community in North American society. Second, the professional culture established a critical alliance with the managerial culture.

This Grand Alliance served as the base for the massive expansion in medical facilities, the emergence of a very large scale health care insurance industry, and the restructuring of American higher education to accommodate the health care education needs of our society. Third, the professional culture successfully lobbied for restrictions in provision of health care services, via the licensing laws. This in turn, created a scarcity of qualified health care providers and led to a significant increase in the income generated and control exerted by these health care professionals.

To fully understand and appreciate this vigorous North American support for the professional culture, we must delve into the character of North American society during the first part of the Twentieth Century. This character has remained quite powerful and was only challenged during the second half of the Twentieth Century, with Vietnam, Watergate, urban riots and other exemplars of the decline in values, standards and community in American society. This early Twentieth Century character is encapsulated in four words: science, technology, optimism—and money.

Science and Technology

Our story begins with the love affair that has existed for many years between North America and scientific discovery. As a new world where old ideas are critically examined and discarded if not practical, North America has always been supportive of science and the applied technologies that emerge from scientific investigations. When medicine began to take on the trappings of science and disowned its roots in the arts and philosophy, Americans and Canadians became enamored with its potential, pragmatic power.

In many ways the solidification of traditional medicine and the medical profession began with the technological and scientific breakthroughs of the turn of the Twentieth Century. We find that the resistance of many physicians to the scientific discoveries of the Nineteenth Century, including immunology and nutrition, melted away by 1890, leading to vast changes and improvements in the quality of care being offered patients. As Lawrence Henderson noted many years later, “somewhere . . . between 1910 and 1912 a random patient, with a random disease, consulting a doctor chosen at random had, for the first time in the history of mankind, a better than fifty-fifty chance of profiting from the encounter.”[viii]

The power of science and technology was further enhanced by the alliance that was temporarily established at the turn of the Twentieth Century between the newly formed professional culture and the mature advocacy culture. Representatives of the advocacy culture effectively lobbied for local, state and federal funding of research projects that substantially increased our knowledge of both disease and cure. Ironically, most of these funds initially went to support agricultural research.

Apparently, legislators were more interested in the health of farm animals than human beings. The major human-based research achievement of the late Nineteenth Century and early Twentieth Century that could be attributed to the professional/advocacy alliance concerned the elimination of yellow fever. The federally-funded Reed Commission provided invaluable leadership in the treatment and eradication of yellow fever, not only making possible completion of the Panama Canal, but also setting a precedence for later medical initiatives of comparable scope (e.g. mass production of penicillin and polio vaccine).

Less than twenty years later, the professional culture was to shift its primary alliance from the advocacy culture to the managerial culture, though still seeking public dollars for science and technology in conjunction with members of the advocacy culture. Even today, members of the professional and advocacy cultures form short-term and often uneasy alliances when seeking public support for funds to find the causes and cures for a wide range of diseases, ranging from alcoholism to AIDS, from smoking to unwanted pregnancies—and now to the current and probable pandemics crippling our world. The early Twentieth Century alliance between the advocacy and professional cultures was clearly based on the love affair between the American people and what Donald Schon once labeled technical rationality.[ix] The breakthroughs in science and technology during the early Twentieth Century were viewed as clear signs of our capacity to eliminate all disease and pain and the accompanied (though often unacknowledged) elimination of all anxiety regarding health and life.

Optimism

The American fascination with science and technology is matched by the New World’s obsession with an optimistic life perspective and, in particular, with optimism regarding health as a major societal value. Whereas European society was infused with a deeply rooted acceptance of suffering, fate and psychological stoicism, North American society was infused with an equally as deep commitment to overcome adversity, free will and psychological pragmatism.

In North America, science and technology hold the answers, not religion, philosophy or the arts. Mankind is destined to overcome adversity and to master nature. Medical science fits neatly into this New World optimism. Nature is conquered not only by moving west, but also by moving inward against nature (disease, germs) through purification of water, pasteurization of milk, immunization against germs, and even transplantation of organs. We overcome pain and suffering through use of drugs. We triumph over depression and psychosis through use of medication and electroshock treatments.

Because North Americans seem to need heroes, it was not surprising that physicians and nurses, as representatives of the professional culture, were often singled out for recognition as the best that our world can offer. Medical researchers such as Jonas Salk or author/physicians such as Benjamin Spock received extensive media exposure. They conveyed an image of the caring doctor who happens to also be the inventor of a life-saving drug or the conveyer of new, and potentially disturbing, ideas about how to raise children. Doctors could get away with saying just about anything. They would be believed (or at least accepted)—and would come to represent many powerful archetypes (healer, scientist, caregiver and champion in particular). Whatever the medical barrier, North American pragmatism (based in science and technology) will overcome and triumph, eventually eliminating the ultimate foe, death, itself.

While New World admiration for science and technology, and North American optimism have always been dominant, these cultural characteristics reached their zenith following World War II. The Allied Forces had defeated Fascism precisely because of their ability to produce many weapons, to make rapid use of new technologies (including, ultimately, the Atomic Bomb) and the spirit and energy of their fighting forces.

United States citizens in particular thought they were invincible. The rest of the world grudgingly came to believe in the American myth as much as Americans did. North American medicine stood at or near the head of the line regarding the achievements about which both Americans and Canadians were proud. North Americans could read daily about the latest wonder drugs and other miracles of modern medicine. Here was evidence that life was getting better. Here was proof that this was already, as Henry R. Luce called it, the American Century.

The United States was not only a victor at the end of World War II, this country was also riding on the wave of economic prosperity. As a result, USA citizens could afford to be worried about their health, having eliminated fears about employment or being conquered by an alien, Fascist government. North Americans began getting regular medical check-ups and became more concerned about chronic diseases (such as cancer, heart attacks, strokes, obesity and mental illness) than about either infectious diseases or physical injury.

These more subtle and complex medical problems were products of a more affluent society. People lived long enough to encounter chronic diseases. These problems could only be addressed by the best and brightest of North American medical researchers and physicians. While medical miracles might heal a cripple or clear out a tubercular lung, they weren’t going to work with these new diseases. Those that controlled this domain (namely, the medical professionals) were certainly not going to let the treatment of these new problems be left in the hands of anyone other than anointed professionals.

Medical professionals also began to define other societal problems in medical terms and went on, in an expansionist spirit, to claim ownership of these redefined problems. Alcoholism became a disease rather than a moral problem or character flaw, just as sexuality was now in the hands of physicians who defined what is and is not deviant. In most cases, this expansion of the medical profession was welcomed and proved to be beneficial to society. Physicians brought major social problems into the light. Both the moral and social stigma was removed. Physicians had a field day. Suggestions made by medical researchers and physicians were rarely subject to the critical review given suggestions made by members of the lay public.

Medical professionals often hid behind the screen of scientific objectivity and neutrality. They also stuck up for one another (part of the sense of collegiality that is central to the professional culture) and didn’t allow unqualified critics to voice their opposing opinions. The advocacy culture was being seduced by the power of the professional culture. Health care advocates could have informed members of the medical profession about what is needed and what is of highest priority and opened forums for debate regarding appropriate medical treatments. Twentieth Century advocates instead often joined with members of the professional culture in encouraging the medical profession to prescribe to society what it needs. Medical professionals could then deliver services that relate directly to these prescribed needs.

The interplay of professionalism, technology, optimism, and science powerfully and positively changed the delivery of quality patient care. On the whole, these strategies were successful up to the early 1970’s. Like anyone who has found a successful receipt for doing something, physicians and other health care professionals, when confronted with choices, reached for what had already worked and applied even more of it. This overuse of science, technology, and a dependence on professionalism began to seriously distance physicians and others from the patient. The public began to question the emphasis on impersonal technology and began to complain about their distant and expensive dependency relationship with physicians. Many members of the media and political figures reacted to this growing discontent by tolerating and even perpetuating a kind and level of doctor bashing that had not been seen for many years.

Money and Medicine

We can’t ignore a second characteristic of Twentieth Century North America, namely it’s love affair with money. In part the dominance of the professional culture during the past century comes from this emphasis on money, especially as it was sought and used by physicians. It is important to note that practicing physicians declined in number between World War II and the early 1980s. Until very recently, physicians have been very much in demand and, typically, have had no problem filling their appointment schedules with people who pay substantial fees per hour for the services they provide.

Whereas the average physician in 1930 saw about fifty patients a week, physicians of the 1950s saw more than one hundred patients. This scarcity of physicians was in part attributable to the diversion of some medically trained practitioners to teaching and research as well as hospital administration. In addition, medical schools became much more restrictive in their enrollment requirements, thereby reducing the number of students graduating each year. By the mid-1950s, there were so few medical students graduating from American medical schools, that many hospitals had to hire graduates of foreign medical schools in order to meet their medical staffing needs.

While hospitals could solve their staffing problems with foreign physicians, this did not solve the problem of scarcity among private practitioners. Most North Americans were not comfortable in going to a foreign physician and other physicians were reticent about referring to physicians who graduated from medical schools that did not have to comply with North American standards.

Anytime you have a scarce resource, this resource tends to be valued and, if this resource is a person, it generates power. A monopoly (such as Standard Oil during the first part of the Twentieth Century) or high-status institution (such as Harvard University) can charge almost anything it wants for a necessary product (gas) or service (education). Similarly, physicians were able to charge virtually any amount they wanted, knowing that their client (patient) had no other recourse. The alternative culture had been knocked out of business, just as Standard Oil’s competitors had been forced to either close or join with Standard Oil. No one wanted to confront either the wisdom or power of the physician, for he held all the cards.

By the 1960s, three different models of the medical professional had solidified in North American society. Each of these possessed a different type of economic power. First, there were the highly affluent physicians in private practice. Most of these worked in the now firmly established suburbs. They lived off fee-for-service and health care insurance. More than the other two groups, these physicians were always in demand and could do pretty much what they wanted. They were able to find both financial security and the autonomy that is so critical to the professional culture. They were dependent, however, on the support of their medical colleagues, in terms of referrals, staff privileges at local hospitals, and protection against malpractice claims. These physicians provided the core of the protectionist wing of the professional culture, holding most of the power in the American Medical Association. They increasingly provided the base as well for the protectionism to be found in areas of medical specialization. These private practitioners often moved away from general practice in favor of medical specialization.

Physicians who worked full time in medical schools and large urban hospitals exemplified a second model of medical practice. Training, education and, in particular, research were of greatest importance to these physicians. While they were always in search of grants and governmental support for educational programs, these physicians held the greatest amount of professional autonomy. They also held the greatest amount of unexamined power over their patients. While people who went to a private practitioner could change doctors (even if this means being placed on a waiting list), patients in hospitals were typically at the mercy of those who treated them. They became objectified as clinical material. The intimate details of their life and body could be discussed publicly with resident students and other researchers. In many ways, this second model represents the epitome of the professional culture, particularly when not balanced by the countervailing perspectives of the other three cultures.

The third model is the least powerful of the three—but has becoming more prominent during the 1990s. This model is exemplified by those physicians who worked in rural or inner-city settings or in state-supported institutions. Those who continue to work as general practitioners or family physicians also exemplify this model. Until recently, we would often find foreigners occupying these positions. Physicians who align with this third model rarely received the kind of money or find the degree of financial security that was to be found in the other two models. However, in recent years this third model has become the beacon for many physicians and other health care professionals who are increasingly displeased with the professional culture, and who are turning to (or returning to) either the advocacy culture or the alternative culture.

As advocates, these Model Three physicians want to provide better treatment to under-served populations, hence they work in the inner city or in rural migrant labor camps. Or they want to join with (and learn from) nontraditional practitioners and turn to nonwestern subcultures in our society. A family physician in Fresno California works alongside a native healer when treating Vietnamese patients; a generalist in Vancouver, British Columbia works with a shaman when treating Native American (First Nations) clients. More traditional colleagues sometimes view these medical professionals as fools or quacks. At best, they are viewed as impractical visionaries. Yet, this third model may be the only one of the three that remains viable during the Twenty-First Century.

Money—who makes it and how it is made—is a major source of internal wounding in the professional culture. Huge disparities exist between the extremely well-paid specialist surgeons, and the nurses and other allied health staff who must listen to their stories about conference junkets, expensive cars, private schools for their children, and stock purchasing strategies. These health care professionals want some of what the physicians have. They know they contribute in a major way to good patient care, as do the physicians. Rewarding physicians at such extreme levels has driven up the aspirations of everyone else—and given the health care system the financial indigestion from which it is currently suffering.

Health care has become an industry and there are now many stakeholders who want to make money out of the economic pie that has been developed.  Somehow many people have lost sight of a key ethical issue that medicine has tried to address throughout its existence: who said it’s acceptable to make money off the pain, suffering and vulnerability of the sick and the injured?  People are willing to pay a great deal for their health. In fact, the leading cause of personal bankruptcy in the United States is unpaid medical bills. Many people (the ill and injured, those who pay insurance premiums, and those who fund managed care systems) have pumped money into the system but more people (stockholders, inventors of wonder machines, pharmaceutical companies, and a host of health care professionals) are taking money out.  It is a situation that can’t be sustained and most health care systems around the world are heading toward bankruptcy. Major transformation is an inevitable consequence.

The Hierarchical Context: Organization, Licensing and Education

More than anything else, North American society has embraced and supported the professional culture through support for various organizations, enactment of licensing laws and funding of educational programs. At the heart of all three of these culture-sustaining agencies is an emphasis on hierarchy, exclusion and status. Initially, there was a great deal of resistance among Colonial North Americans regarding not only the licensing of physicians, but also the formation of exclusive medical societies. This probably was a result of the early New World suspicion of anything that looked too organized (other than church). These restrictions and organizations represented the very thing they were trying to escape when they left the Old World. Colonial physicians essentially struck out in their efforts to organize the profession of medicine. North American physicians were much more successful in organizing their profession after the Colonial period, when Americans moved beyond mere survival to building a new nation with new values and new aspirations.

There were more than 400 medical societies in America by the early 1870s. The leaders of these societies sought to preserve and expand the influence of traditional medicine. As in the case of virtually all professions, physicians made medicine a profession by obtaining medical licensing laws. Licensing probably only took place during the first half of the Twentieth Century because orthodox medicine finally was widely accepted as a handmaid of science and technology, and because so much time and effort was going into the infighting among various sects and factions within the health care community. Licensing was, in essence, a de facto referee, ensuring that everyone played by a certain set of rules when challenging alternative approaches to medicine.

This shift from diversity of medical practices to the establishment of a specific and limited set of conservative medical practices was not precipitated by greater clarity regarding the causes and cures for disease. Rather it was precipitated by the ongoing need for public reassurance regarding health and the search for legitimization in a world of pain and anxiety. In many ways, medical societies, licensing laws and an emphasis on medical education was intended not so much to improve the quality of care as to reinforce certain archetypes (particularly helper and scientist) This, in turn, increased professional credibility and reduced patient anxiety. As Duffy notes, “the work of the [Nineteenth] physician was no abstract intellectual endeavor. He was dealing with suffering and dying human beings and was desperately seeking some way to provide relief and save lives.”[x]

The physician of this era had little claim to legitimacy, having done little to demonstrate superiority over competing claims from members of the alternative culture (many of whom were women and ethnic minorities). Controlling and narrowing the channels of entry into practice was crucial to solving the problem of overcrowding of physicians which was perceived as endemic in the late Nineteenth Century and has persisted in a cyclical fashion to the present. When physicians are plentiful, laymen have more choice and control, incomes remain low, and competition for patients inhibits internal unity. Thus, the control of supply, often masked as improvement in standards, is a crucial contingency in forging professional dominance whereas this culture exists in a health care system.

The physician turned in both America and Canada to the one primary source of power that he held in the community. This was economic power and the accompanying ability to control the health care marketplace through enforcement of licensing laws. Furthermore, in conjunction with this emphasis on licensing came widespread concern and attention in the medical community to medical training and education in preparation for the licensing exams. Thus, medical education became a priority of physicians. Rather than sending their young men to England, Germany and France for a proper education, Americans and Canadians began building their own medical educational institutions. There was still travel to Europe, but now it was for specialized, advanced training.

Establishing schools and upgrading the content and length of training was a key step in professionalization among both American health care workers. Private diploma mills proliferated during the late 19^th Century.[xi] As a result, in order to establish credibility and respectability, many of the established American medical schools became affiliated with universities. The circle of entrants was limited to those of higher social class origins. University affiliation ultimately upgraded and standardized the quality of training; during the last decades of the Nineteenth Century, however, there were continual struggles in the United States between the medical schools and the practicing professionals to control curriculum and entry to the profession.[xii]

While the new medical schools were often affiliated with collegiate institutions (which had degree-granting capabilities—an important factor in establishing the credibility of this newly-emerging profession), they tended to remain only loosely tied to these institutions and, in essence, retained autonomous status. This autonomy remains even today. Other accouterments of a profession were further developed by American medicine: the establishment of domestic medical journals, codes of ethics and the early, rudimentary practice of evaluating the outcomes of specific medical practices (leading eventually to the discrediting of many heroic practices).

The Profession of Exclusion

The professional world of early- and mid-Nineteenth Century medicine in both America and Canada was composed almost exclusively of males from Northern European origins. Some medical schools and hospitals were staffed by and directed toward the concerns of women; however, these were under-funded, sectarian and usually short-lived. Males and females were soon differentiated by status and function in North American medicine through the creation of two separate (though interdependent) professions: physician and nurse. If women were interested in medicine but didn’t want to become nurses, they could serve in some auxiliary function (of lower status) as medical technicians or hospital administrators.

The other route was alternative medical practice. Women were more likely than men to continue practicing alternative medicine, even after men had organized their aggressive opposition to these practices. This occurred partially as a result of the exclusion of women from medical school, but also as a result of their long history of providing alternative medical practices, such as mid-wifery, or herbal therapy, and other forms of healing that were often labeled home remedies, or, worse yet, witchcraft. Women were often chastised, shunned or even burned at the stake for their distinctive efforts to heal other people.[xiii]

Ethnic minorities were also systematically excluded from the medical profession during the modern era in the United States (and to a lesser extent in Canada). For African-Americans, separate but equal was more of a fiction than a fact. Black physicians had inadequate access to medical technology. There was inadequate support staff and hospitals were left in very poor condition. The one bright note was the strength of an alternative medical culture in the Black community. Much as in the case of women, when Blacks were excluded from the traditional professional culture, they turned to the alternative culture and continued to support practices that were preventative and natural in form and focus.

In trying to make sense of this racism and sexism in American medicine, we must remember that professionalism is sometimes misused as a vehicle for restriction of trade. Anything that distinguishes haves from have nots will be employed and justified by some professionals, especially during times of transition and anxiety. The reasons for making this distinction don’t have to be rational, for ultimately one’s status as a professional and the dependency that has been fostered regarding this status are not very rational. Professions exist—or at least the professions of health care exist—partly and perhaps primarily to reduce anxiety. They reduce the fears associated with being ill, with being out of control, with being in pain.

Medical traditionalists colluded with their anxious patients in perpetuating positive archetypes (helper, caregiver—even mother and father) and either discouraging negative archetypes (aristocrat or narcissist) or assigning negative archetypes (such as witch and clown prince) to those who offered alternative medical practices. While this reassurance may be helpful to some patients, it can also be a source of wounding for many healers who reside among the have nots.

Quackery: Pragmatism versus Social Status

The most important task facing the new health care professional during the Colonial period was the clarification of boundaries between traditional and alternative practices. Traditional practitioners found a powerful label to assign to the latter: quackery. While the term, quack, was frequently used during the Colonial period (and would continue to be used until the present day), it took on particular force during the last part of the Nineteenth Century. The traditional medical establishment became more firmly established and stabilized, thereby enabling the traditionalists to come to a more consistent and shared agreement about what is a quack.

There was some dampening of the struggle between the medical traditionalists and non-traditionalists after the Civil War, in large part because the traditionalists had essentially won the battle, having served admirably and with considerable success in treating wounded soldiers. The tension re-emerged during the modern era, however, and perhaps will inevitably exist, for a profession is defined in large part by what it does not accept and by those who are not allowed to call themselves members of this esteemed group. The status of a profession is established and maintained through exclusion. If everyone can be a professional, then it loses its mystery and power.

On the one hand, the concept of quackery was alien to the North American spirit of egalitarianism and pragmatism. It was not easy to get the term, quack, to stick, given the New World proclivity to seek practical solutions to problems and to readily dismiss labels and categories that are not based on concrete demonstrations of worth and pragmatic value.[xiv] A quack is only a quack if his medical treatment plan doesn’t work. The word delivered on high from a medical authority is simply not of much relevance to a people who are trying to conquer a wilderness or to an individual patient who is ill and seeking a successful treatment plan.

The medical establishment thus needed some help in establishing itself as something to be distinguished from quackery. It turned to the other half of the strange New World paradox. Americans are not only egalitarian and pragmatic. They are also elitist and enamored by social status—never fully trusting that they are as good as those from more established cultures in the world. They are pragmatic, yet they are unrealistically enthralled with celebrities. Those of the New World believe that everyone is created equal–yet they devote many pages in their newspapers and magazines to the description and analysis of the rich and famous. The medical establishment benefited from this ambivalence at the turn of the Twentieth Century and in many ways continues to benefit from it at the start of the Twenty-First Century—particularly in the United States.

If traditional medical practitioners could not demonstrate pragmatic superiority over competing alternative practices, then they could at least wield economic and political power. The medical profession sought to establish itself at the turn of the Twentieth Century by becoming more selective and by building the refinement of manners into the medical education curriculum. Throughout the history of North American medicine, this strategy has proven to be successful. Physicians have always been most successful when they come from the respected and affluent ranks of their community. Respect arises from social position and personal qualities rather than medical acumen.[xv]

By the end of the Nineteenth Century, the better medical schools were in the business of preparing gentlemen-physicians to assume leadership in the field. Whereas, medical students during the 18th and most of the 19th Century were “too stupid for classics, too immoral for the pulpit, and too dishonest for the bar,”[xvi] they were attracted in the late Nineteenth Century and early Twentieth Century from among the best and brightest. Stricter licensing laws made traditional medicine a much more lucrative profession than it had been during the earlier years in the United States. Licensing in a profession increases potential income which in turn increases attractiveness leading to increased social status and an even greater emphasis on licensing and exclusivity. This self-reinforcing cycle is to be found in all the professions in North America, leading to the emergence of a powerful and distinctive professional culture. Only during the final two decades of the Twentieth Century do we find a decline in the social status of professionals.

Enforcing Standards and Restricting Trade

Two major events ensured the firm establishment of the medical profession in the United States. A report on medical education in North America was prepared in 1910 by Abraham Flexner for the Carnegie Foundation for the Advancement of Teaching. This report represented a culminating point for the medical profession. In fact, it is often cited as the clearest and most powerful statement regarding the professions in North America.[xvii] The Flexner report represented and helped to sustain the emergence of a strong, even dominating, medical profession in the USA and the firm establishment of an attendant professional culture. In essence, the Flexner report was written in response to the proliferation of medical schools during the Nineteenth Century.

While this proliferation signaled the rich diversity of perspectives on medicine that were present in the late Nineteenth Century, it also represented a less admirable proclivity among Americans. They wanted to make a fast buck off marginal training programs that provide credentials but little else of value to either the student or society.[xviii] Furthermore, the proliferation produced a hierarchy among medical practitioners in America. Medical professors (usually graduating from European universities) are situated at the top. Physicians from reputable American medical colleges (usually affiliated with universities) occupy the middle ranks. A large number of physicians from second- and third-rate medical schools fill the bottom ranks.[xix] While this social-professional hierarchy continues to exist in the late Twentieth Century it has taken on different characteristics, centering primarily on area of specialization rather than pedigree of medical degree—though pedigree continues to be important, especially with regard to initial employment.

Flexner (who was not a physician) based his report on personal visits to 157 medical schools in the United States and 8 in Canada. Flexner discovered highly variable quality among these medical schools, most of which were proprietary and very lax with regard either to entrance requirements or quality of education and training. Faced with this proliferation of schools and variability in standards,

Flexner introduced short factual summaries and evaluations of each medical school in America, specifically with regard to five criteria: entrance requirements, size of teaching staffs, financial status, laboratory facilities, clinical resources.[xx] Each of these five criteria was to have a major impact on medical education for many years to come. The Flexner recommendations pushed many of the less prestigious and financially tenuous medical schools out of existence. They were simply unable to meet the implied criteria of quality that were embedded in the report. Black medical schools were particularly hard-hit. Of the seven Black medical schools in existence at the time of the Flexner report, only Howard and Meharry survived.[xxi]

The longer-term consequences of the Flexner report was a significant increase in the cost of medical education—both because it is costly to comply with the criteria and because much of the competition was taken out of the medical education business. The remaining medical schools had more applicants than open slots, hence had to worry very little about pricing themselves out of the market. The newly graduated physicians bore the dramatic increase in medical educational costs until such time as the federal government began to subsidize medical education. Physicians, in turn, passed on the costs of medical education as well as the high costs of medical equipment to their patients.

Other medical support personnel also began to receive high-price training, education and certification. Patients, insurance companies and other third-party payers absorbed these costs. It was not hard to pass the costs on to patients and third-party payers, for there was not only a shortage of medical schools, but also (as a result), a shortage of qualified physicians. The American medical profession had smartly (even if unintentionally) set itself up to be a high status, high pay, high security vocation.

A few good physicians were graduating from a few good medical schools in the United States. Those who did not graduate from a medical school were discounted, either because they were not good enough to enter medical school or because they were nontraditional (i.e. quacks). Americans often assumed that alternative medical practitioners were nontraditional simply because they were not good enough to get into medical school. They were right in some instance, but in many instances their assumptions were incorrect. The medical profession did little to correct this falsehood, reinforcing the negative and menacing stereotypes and archetypes associated with quackery and alternative practices.

For many years following the Flexner recommendations, the medical profession held a monopoly on medical practice and was able to keep prices, status and job stability up by restricting the number of practitioners in the field. Ironically, Flexner himself became a critic of his own work during the later years of his life.[xxii] He observed that his report didn’t improve the quality of medical education and training being offered in the United States. It helped traditional physicians create a monopoly and thereby reduce the access of poor people and ethnic minorities to appropriate and high-quality health care. Like many other social reformers who have been highly successful, Flexner realized that his work was very influential not so much because it appealed to the greater social good, but because it met the personal (and sometimes selfish) needs of those in charge.

In the wake of Flexner, American medicine began to look very scientific, very technical—and very respectable. The hegemony of this new scientific medicine, practiced by a closed, elite circle of men, was complete. The medical profession and the professional culture became dominant. As we will see, that dominance was to remain in place until the last decade of the Twentieth Century. What allows this dominance to go on? And what led to the decline of this culture during the 1990s? The answers to these questions reside partially in the origins of the other three cultures, to which we turn in later chapters.

Varieties of the Professional Culture

As is the case with the other three cultures of health care, the professional culture is by no means homogeneous. Within medicine for instance, a large group of subspecialties have grown up, each of which attracts people with specific interests and personal qualities. Oncologists (cancer specialists) differ dramatically from cardiologists (heart specialists). Furthermore, within medicine they compete with one another for scarce dollars to carry out their beliefs about treating patients and doing research. Their internecine fights can become quite ugly. In addition, a host of other allied health professions are a part of this culture. This includes Nursing, Pathology and Laboratory Medicine, Medical Genetics, Medical Imaging (radiology and ultrasound), Occupational and Physical Therapy, parts of Nutrition and Foods Services, Pharmacy, Psychology, Respiratory Therapy, Research, Social Work, Spiritual Care. The list goes on and on.

All the allied professions represent work that was at one time done by physicians. These specialties emerged over the years, as medicine redefined its roles and identity. Medicine remains in control of the touching of patients and is the referent group for the entire professional culture.  Ameba-like, the boundaries and relationships among all these parts of the professional culture are constantly shifting and changing.  This culture (and the other three cultures) often creates an external, unified enemy to keep the various subcultures from destroying each other. Any of the other three cultures will do nicely.

Specialization, Mystique and Control

The general mystery of any profession can be sustained only so long. Eventually, subcultures and specialties must emerge that have their own special language, techniques and technologies, organizations, licensing laws, and educational programs. As in the case of all division of labor these specialties are necessitated in part by the growth of the profession, by the demands for increased knowledge and expertise to operate in any one domain of the profession, and by overall increase in the complexity and demands of society. Specialization, however, is also a conservative response that preserves the mystery of the profession, thereby opening the door for projected archetypes and, in turn, helping both the professional and client master their anxiety.

Specialization began to emerge in North American medicine during the middle of the Nineteenth Century. Urban physicians began to limit themselves to diseases of the lungs, eye and ear, or even mental illness. Surgery also soon became an exclusive practice. Specialties became more prominent as medicine became more complex. This complexity, in turn, was driven by the success of medicine during the Nineteenth Century. Expectations regarding medical knowledge rose as people began to rely on physicians for cures, and as physicians began to define themselves as professionals (and alternative practitioners as quacks). Knowledge was expanding at an exponential rate in not only medicine, but also related fields, such as biology, physiology, chemistry, X-ray technology and electronic instrumentation. The general practitioner could no longer keep up with all the newly emerging techniques, nor with the rapidly expanding field of medical knowledge.

With increasing specialization came an even greater mystique regarding the ability of medical specialists to cure. Even something as natural and non-pathological as childbirth soon became the exclusive domain of one area of medical specialization: the obstetrician. Claiming a specialized knowledge that only a certified physician with specialized training can possess, the obstetrician soon drove most of the remaining midwives out of business or underground. This represented a major triumph of the professional culture over the alternative culture. This meant that childbirth was defined not as a natural event, but rather as a medical problem—an illness, if you will.

This specialization also meant that children were born not at home, but rather at a hospital. This occurred not because better treatment could be provided at the hospital. In fact, the opposite has often been the case. A hospital that is home to many ill people, some with infectious diseases, is not a very good place to give birth to a baby. Children were no longer delivered at home because childbirth was now in the hands of specialists who only operated in hospital settings. It is only in the hospital that obstetricians had access to specialized instruments and support personnel that were now, for the first time in history, indispensable to the practice of delivering a baby.

The End of Home Visits

The mystique of physicians also grew out of and was accelerated by the shifting of medical services from the patient’s home to the physician’s office, clinic or hospital. As late as 1940, many physicians made their living by going from house to house, meeting the needs of their patients. Before the invention of the automobile and telephone, and before the urbanization of America, this meant that physicians spent most of their time in transit, using on horseback. Their business was not very lucrative, for they typically could see no more than six to eight patients per day. Furthermore, they were often inaccessible (there being no cellular phones installed on Nineteenth Century horses) and often found out that someone was ill by being tracked down in route between calls.

With the advent of the telephone and automobile, physicians could be much more productive and their practices became profitable. Still, the physician could never make much money by leaving his office. Hence, when he finally gained stature as an esteemed professional, who is in great demand, the physician began asking patients to come to his office for their medical appointments, except in the case of major medical emergencies. Office visits could be justified by mid-century based on the physician’s need for access to sophisticated medical technology and specialized medical assistance that were now located not only in hospitals, but also in the physician’s office. A physician could not bring equipment or his nurse to his patient’s house.

Office visits greatly expanded the potential earning power of the North American physician. A physician could see many more patients each day when they came to his office and could eliminate many costs associated with travel. Some of the increase in income was offset by the increased costs associated with leasing or owning a large, nicely appointed office, hiring office staff, and establishing complex billing and appointment procedures. Still the new system made great economic sense for the physician as long as he was in short supply and patients had no other options in terms of either traditional or alternative health care.

With patients required to come to the physician’s office, the mystique of the professional medical culture further increased. Patients would dutifully wait for their appointment, thumbing through magazines, watching fish swim around in fish tanks, and listening to pre-recorded music. The physician’s time was clearly more valuable than the time being spent by the patient in waiting for her appointment. Furthermore, the patient had no option, given that she would have to wait in any other doctor’s office as well—unless, of course, the doctor wasn’t very good and had few patients, in which case they were to be avoided at all costs. Somehow, the wait further affirmed the physician’s competencies and demand-value, while also building the patient’s dependency on this busy professional and evoking the archetype of the caring but very busy father—who is never to be interrupted and for whom one must dutifully wait.

With the elimination of most house calls, the hospital also became more important for both physicians and patients. No longer were physicians addressing emergencies primarily by attending to the stricken patient at their home. Rather, as soon as possible (by ambulance if necessary) the patient was taken to a hospital for intensive, high-tech treatment, guided by their physician, in cooperation with the hospital staff. The sovereignty of the physician is critical in this regard. Patients were able to retain their close, dependent relationship with their physician even when this meant office visits rather than home visits, and when it meant checking into a hospital rather than being treated at home. Given the impressive display of technology and specialized expertise at the modern hospital, the patient’s dependency and attendant archetypes are even more fully realized during times of serious illness when anxiety is particularly strong.

The Broadening of Control

There is no doubt that physicians are the referent group within the professional culture. They fought for the right and have for years taken legal responsibility for the treatment of the patient. This puts physicians in a position of dominant leadership. They decide who will do what tests, by when and what the various other health care clinicians will do. They refer their patients to renowned specialists and orchestrate the response of the rest of the players in providing care. For this they receive patient respect and trust, high salaries, and status and power in decision-making. The downside is that they, like many other people in leadership positions, are legally accountable for any mistakes that get made or problems that occur. They get sued when patients perceive that their care has been faulty or inadequate.

Patients who have paid enormous sums of money to physicians may not want to believe it. After all it would increase their levels of anxiety! However, the practice of medicine is still not perfect. Physicians are aware, like many other people in leadership positions, that they are increasingly dependent on all the other team members to do their jobs well. The days when the physicians knew every job and could be in complete control are long gone. This loss of control can be incredibly stressful. Issues around power and decision making are dominating many medical agendas. It took years to become the dominant healing profession and discussions about shifting its power base are usually quite contentious.

Historically, as they grew in number and developed their identity and power, physicians suppressed quacks, improved training within their own ranks, and brought patients to their offices, clinics and hospitals. Physicians also gained dominance over and restricted the activities of other health occupations at the margins, through use of three strategies: subordination, limitation and exclusion.[xxiii] Limitation is the primary strategy that physicians used when interacting with other established and respected fields of medicine, whereas a strategy of exclusion was deployed, with some success, in dealing with the various schools of alternative medicine. Physicians weren’t able to exclude or subordinate other established fields, but they could limit these practices.

The negotiations that took place between physicians and pharmacists during the late Nineteenth and early Twentieth Century exemplify the use of limitation to restrict existing medical services. Pharmacists were among the first to come under the control of physicians. Traditionally, pharmacists served as counter-prescribers, suggesting drugs to customers who approached them with medical problems. Pharmacists functioned as primary care healers, particularly for the poor and for those in areas without doctors. Indeed, there was a considerable overlap in functions between medicine and pharmacy since most doctors in the Nineteenth Century and early Twentieth Century dispensed their own drugs.

The drive of physicians throughout North America to become professionals elicited a struggle to control the pharmacy throughout most of the Nineteenth Century. The medical associations sought to obtain legislation giving them the right to regulate training and practice in the pharmacy; however, pharmacists were apparently strong enough to ward off these efforts.[xxiv] Nevertheless, pharmacists soon struck a tacit bargain with medicine; they gave up counter prescribing in return for an agreement by doctors not to dispense drugs. Bans on counter-prescribing were written into the pharmacists’ codes of ethics. By the early Twentieth Century, pharmacy’s subordination to medicine was complete.

Physicians have also restricted most of the paramedical occupations (e.g. physiotherapy, occupational therapy, medical labs and medical imaging) through the use of subordination strategies. These paramedical occupations have been easily subordinated by physicians because they operate within the official medical division of labor, are relatively new, and were born in the hospital under medical control. Physicians controlled these paramedical occupations from the start. Typically, clinical occupations only remain relatively independent of physician control if they have a history of independent practice outside the hospitals and if they are comprised primarily of men. Many of the paramedical occupations tend to be populated by females, are hospital-based and are created under medical tutelage—a recipe for subordination.

The Nature and Purpose of Nursing: The Culture of Care

Nursing as we know it today began in urban hospitals that were intended for the poor. While mothers and wives provided most of the nursing at home, there was a slowly emerging role to be played by women as professionals who were paid for their nursing services to the sick. In North America they quickly came to provide these services in hospitals. In the early Nineteenth Century religious orders such as the Sisters of Charity were actively involved with care for the poor and ill especially in Southern states. The Catholic Church formally organized many of the early nursing services in North America.[xxv] The advent of the Nightingale Era bought reform and organization to the practice of nursing. These reforms were accelerated. Florence Nightingale’s experiences during the Crimean War are well documented, as is her post war influence on the practice of nursing—especially the provision of sanitary conditions and formal training for nurses, and the development of nursing theory.

The concept of professional nursing emerged very slowly. Not until 1870 did formal schooling become an important part of nurses’ training.[xxvi] As in the case of physicians and surgeons (in particular), nurses gained recognition (and grudging respect) as professionals only after they began to tend the causalities of war. The Civil War in the United States brought about the organizing of nurses in order to put into practice the recommendations of Miss Nightingale. Many dedicated women (and some men) volunteered as nurses, including Louisa May Alcott, Walt Whitman, Clara Barton and Dorthea Linde Dix. Miss Alcott and Mr. Whitman went on to notable literary contributions.

Clara Barton became known as the founder of the American Red Cross. Dorthea Linde Dix became the first Superintendent of Female Nurses of the Army. Early nursing schools in the North America followed the Nightingale recommendations. However, confusion existed as to the primary purpose of the schools. Were these schools intended to educate nurses or to provide better nursing in the hospitals? For financial reasons student nurses became a source of cheap labor in the hospitals and standards were lax due to the tremendous growth of nursing during this time. Hospitals came to view nursing schools as both a source of income and means of controlling costs.

Nursing has always served a peculiar, yet critical, role in the USA health care system. Nurses clearly are professionals; however, they serve not only in the role of health care providers, but also health care administrators. They often bridge the gap between the professional and managerial cultures—and even at times between both of these cultures and the cultures of advocacy and alternative health care. Public health nurses have been particularly effective in building a bridge between the advocacy and professional cultures. They have played a central role in public health for many years. Nurses have also bridged the alternative and professional cultures through their fundamental concern for community and patient care: “Whatever helps the patient.” (feminine, mid-wifery tradition). Nurses are usually more open to and willing to provide linkages with the alternative culture than are physicians, provided the alternative procedure relates directly and tangibly to quality of patient care.

More recently, nurses often take on more formal administrative roles as directors of clinical services and assessors of health care quality. They have often played the other members of the professional culture (physicians, lab people, radiologists, etc.) off against members of the managerial culture (human resource analysts, financial officers, purchasing representatives) and vice versa. It is fascinating to watch a nurse tell a physician she can’t do something because of budgetary restrictions, and then two minutes later tell the manager of finance that the same thing must happen because if it doesn’t it will affect patient care. In today’s changing environments, as both physicians and managers learn each other’s languages, nurses are finding that their interpretation skills are somewhat less needed than before. They have to get to the decision-making meetings to represent their own interests and this directness is new for them.

In many ways, the nurses in contemporary health care have established their own hybrid culture: the culture of care. It builds on the animating and reassuring archetypes of healer and caregiver as well as the even more compelling archetype of mother. While some of the animating and reassuring archetypes of professional health care are not gender-specific (e.g. healer and caregiver), others are very specific to the roles traditionally played by men and women—mother and father being the most obvious. And it is specifically in these two fundamental archetypes that the traditional distinctions between physicians and nurses are most clearly drawn.

Nurses have both benefited and suffered from their alignment with the mother archetype. This theme plays out in several different forms throughout this book. Nursing has from the first been primarily a profession for women. During the early years, women volunteered as nurses and found their way into the world of health care by making an offer that no one could refuse: “I will do the dirty work and ask for nothing in return. You [the physician] can get all the glory. I will back you up with quiet, yet competent support.” Just as the wife and mother during the early years of the industrial era remained at home to provide domestic services, so the nurse served as the handmaid to the physician and gained power initially through being subservient to the physician.

During the early years of health care in North America, the professional culture interwove notions of patient care with professional standards and expertise. With the creation of the profession of nursing during the Nineteenth Century, these two functions split apart. The technical expertise, status and prestige went with the physicians. The caring went with nursing. These were clearly gender-based distinctions. Traditionally, men in the medical professions were concerned with finding the origins of illness. They were scientists and philosophers who were talking about evil ways (sin), pollution. They were anatomists (“the operation was successful though unfortunately the patient died.”) and made use of heroic treatments (bleeding).

By contrast, women were the actual healers. They were not so much concerned with the advancement of knowledge—but were rather concerned with healing the individual patient. Nurses were thus conservative in their treatment, but also more likely to make use of natural (alternative) treatments. Women provide the healing touch. This is the recovery aspect of the medical treatment process. The male/physician cuts up the patient. The woman/nurse nurtures the patient back to health. The doctor doesn’t hang around for the slow, healing process nor does he stick around for the slow, inevitable process of aging. The doctor pops in occasionally to check up on the patient’s progress and gives the nurse more orders. Women stay. Men move on. These are very primitive stereotypes. They have played out for many years in North American health care.

The Professionalization of Nursing: “I See and Am Silent”

Nurses are one of the largest groups of predominantly woman careerists in the United States. As such they are a distinct entity in the professional culture of medicine. North American nursing has historically been not just a vocation, but also an avocation that has been largely gender related. Nursing began in the United States as informal unpaid labor that was done by women to provide for and ensure the health and welfare of others, a reflection of the domestic roles and values of the time. In pre-industrial North America, the woman’s role in the family and community was to provide the basic conditions for health and to offer assistance in recovery from illness.

As the nature of work changed, women replicated this role in the workplace, translating their domestic skills into paid occupations. Medicine exploited these social pre-dispositions and continues to do so to some extent today as a means of regulating and controlling the necessary work of nursing and providing for the direct care of patients. The repercussions of the industrial revolution, which broke down skills into simple repetitive tasks in order to employ the cheapest workers, were soon felt in health care. The institutionalization of health care had serious implications for women’s role in medicine. Once independent practitioners, they were denied training and were thus relegated to a subservient position with the medical profession.

For nursing and many other clinical professions, the lure of professionalism became irresistible. An ideology surrounding professionalism proved to be a great incentive for many women. This ideology was founded on a very powerful and binding agreement. In essence, status was promised to the nurses by the medical profession and the university community in return for certain educational and behavioral requirements. As with other professions who have tried to separate from medicine, nurses have continually struggled to be professional. The professionalization of nursing has been accompanied by a shift in the language being used by nurses and the stories being told about the contributions being made by nurses to the health care system: “See, we have knowledge too.” “We also went through difficult education and training that is academically-creditable. We no longer just acquire experiences.” These struggles have led to improvements in nursing education standards but not to improvement in their working conditions, their power, their job security or their wages.

Both the interplay between technology and the exploitation of feminine role expectations are evident in the history of nursing education in North America. In the early Twentieth Century, in part as the result of the effects of war, nurses were organized and trained. The Spanish American War had demonstrated improved results from trained nurses and the American Red Cross persuaded the government to form the Army Nurse Corps in 1901. Public health nursing also developed during the early Twentieth Century and contributed heavily to an improved standard of living in urban environments. A study resulting from a conference sponsored by the Rockefeller Foundation called for two levels of nursing: practical nurses and university-trained nurses. Nursing schools and professional associations for nurses began to develop and establish standards for training and levels of nursing care.

It is instructive to look at what happened in the education of nurses in the United States. The teaching of nurses was strongly influenced by the subservient orientation of Florence Nightingale. The nursing curriculum teachings not only defined the proper relationship with the medical profession but also defined authority relationships throughout the entire hospital hierarchy. The most astounding example of the attempt to socialize the quality of passiveness among the new nurses is the motto chosen for the first school of nursing: “I see and am silent.”[xxvii] The student nurse was in an exploitative situation: lower-class women were drawn into low-paid, hard work by the promise of respect and upward mobility in this new profession of women.[xxviii] In fact, the educational recommendations of Florence Nightingale were used to facilitate the use of nurses as a source of cheap labor for hospitals. Because they were chronically short of money, hospitals realized the advantages of forming nursing schools—much as they discovered the cost advantages of residential training for physicians. In both cases, hospital administrators were delighted to obtain highly skilled, yet inexpensive labor.

A hospital’s reliance in both countries on student nurses as their work force meant that there were very few institutional positions for graduate nurses.[xxix] Private employment fluctuated according to the economic trends. The large number of trained nurses coming from other countries constantly aggravated the problem of unemployment. They migrated under the impression that they could readily find work. Central registries were established at the turn of the century by nurses in the larger American cities to regulate the supply and demand of private nurses.[xxx] The waiting lists for these registries were very long. Nurses could wait as long as six weeks between cases. This made it difficult for them to have real careers. Instead, because of this pattern of work, many women found themselves giving up on the idea of a family, barely making enough money to live on, with an impoverished old age at the end. It was dismal to say the least.

The Three Roles of Health Care Professionals

Three primary medical professions emerged during the Grand Alliance: (1) medical scientist (physician-as-scientists), (2) clinician (physician-as-clinician), and (3) nurse (nurse-as-clinician).

Each of these three functions also relates to one or more of the prevalent archetypes in our society. The medical scientist is the scientist, while the clinician and nurse related directly to the archetypes of healer and caregiver. Given the traditional male designation of most clinicians, these practitioners also tended to align with the father archetype, while the traditional restriction of women to the nursing role tended to lead this role to be equated with the mother archetype. These archetypes infuse each of the three roles with considerable power that has at times been used in a positive manner and at times in a highly destructive manner (especially during the battles waged between these three roles).

Traditionally, the patient-care orientation of the nurses was a distinguishing characteristic and served as the primary source of their authority and credibility. Physicians who served in a clinical role were also in the business of treating individual patients. However, these professionals gained authority and credibility not through the quality of their concern for the specific care being given to their patients, but rather (as in the case of the physician-as-scientist) through the knowledge they possess and apply in the treatment being given their patients. Put in cruder terms, the physician-clinician didn’t sweat the little stuff (patient care), but instead sweated the big stuff (diagnosis and selection of treatment plan).

Conversely, the direct contact of physician-clinicians with patients was a distinguishing characteristic and served as the primary source of their authority and credibility—at least as set in contrast with the physician-scientist. For many years, young physicians made a choice early in their career regarding their movement into medical practice or medical research. The high-status choice was usually research. Yet, the clinician had the opportunity as nurses do, to see medicine-in-action. They have been privileged to experience the healing touch and the impact of a caring bedside manner. If they are sufficiently open and aware they have also experienced the mystery and power of other types of healing relationships: mid-wifery, prayer, the forgiveness of a psychologically-wounded spouse—even the willingness of a family member to let go so that one’s patient can die with dignity. These experiences are less often available to many scientist-physicians. Hence, these men and women may command fewer insights regarding the real processes of health and healing.

There are several major sources of conflict within the professional culture that relate directly to these three fundamental roles. Furthermore, changes are now occurring in each of these three roles and in the relationships established among these them. These changes have often either further precipitated conflicts that already exist among these three roles or created new conflicts as a result of shifts in status, power or formal authority. These conflicts are very painful for health care professionals, and it is often only the threat of an outside enemy (usually the managerial culture) that distracts the professional warriors from these internecine battles.

The Clinician and Scientist: Art or Science

The most visible battle among physicians concerns the roles of scientist and clinician. This conflict is often framed around a fundamental (and probably unanswerable) question: Is medical practice an art or a science?  When first emerging and seeking creditability, many of the professions in America were dependent on the sciences. Not only did the sciences provide tools and technologies for major breakthroughs in many professions (for example, medicine, engineering, psychology and architecture), it also provided the specialized languages and inaccessible findings that made and kept these professions mysterious and ultimately highly elitist. Yet, the alliance between the professions and science was not forged without considerable cost. In the case of medicine, science often came to mean impersonal treatment, the dominance of machines over people, and the loss of personal care in favor of large medical factories (hospitals) that were required for the purchase and use of capital-intensive investments (equipment, technical staff, maintenance and so forth).

Two strong subcultures emerged within the medical professional community, one of these subcultures being identified with science and the technology of medicine, the other subculture with clinical practice and the art of medicine. These two subcultures were not always in agreement during the Nineteenth Century. In fact, as is the case with the subcultures of the other three cultures, the subcultures are often only at peace with one another when the overall culture is under attack. Thus, today we often find an alliance between science and medicine as the primacy of the professional culture is under siege. Yet, during the Nineteenth Century and at many points during the Twentieth Century, the scientist-physician and the clinical-physician had profound disagreements.

During the Nineteenth Century, the scientists and clinicians clearly needed each other. The clinician, in particular, needed the scientist. The new profession of medicine was dependent on science for its credibility. The training, education and certification of physicians (as opposed to alternative practitioners) was distinctive and creditable because it was supported by the newly emerging and freshly esteemed field of biology and new mathematical applications known as statistics. Put quite simply, doctors went nuts about numbers. They looked for any mode of quantification that would help them look appropriately scientific and professional.[xxxi]

Not only could these new scientific tools be used to improve medical practices, they could also be used to demonstrate (crudely) that traditional medicine is effective. With an increasing number of patients being seen in (and confined to) hospitals, there was also an increasingly accessible population to observe (for example, the course taken by various illnesses) and study (for example, examining specific treatment effects). Postmortem examinations were becoming more acceptable and more common, providing a substantial empirical basis for the study of anatomy and fatal pathologies.

Yet, during the Nineteenth Century, many practicing physicians (who viewed their profession as an art as much as a science) remained quite skeptical about the newly emerging discoveries from the worlds of bacteriology and physiology. The clinicians either saw little connection between the scientific findings and their own daily practices, or they were threatened regarding the implications that could be drawn from these findings. Bacteriologists, for instance, presented results that pointed to the important preventative effects of immunology. These results also pointed, at least, indirectly to the important role of medicine in preventing rather than just curing diseases. Such a role was clearly not in keeping with either the training or primary interests of many physicians who were just beginning to be recognized in their local communities for their miraculous cures and treatments for diseases that already existed.

Obviously, at a conscious level, physicians of the Nineteenth Century were just as concerned about prevention as other members of society. Yet the remarkable resistance of many physicians to research results that were quite compelling to other members of the scientific community, suggests some underlying sources that were not altogether rational. In general, those physicians who had the most to lose from the new findings—that is, those that were marginally educated, defined themselves exclusively in terms of their profession, and relied on medicine for their livelihood—were most resistant.

Those physicians who were broadly educated, had some independent wealth, and led a life beyond just medicine, were among those most amenable to the new scientific findings. Medical scientists, on the other hand, often failed to recognize the value of holistic and humane treatment of patients. Emphasizing specialized and atomized knowledge, the medical researcher often forgot that there is a living, breathing patient behind the research that they are conducting. They ignore the fact that medicine is both an art and science.

Science has won the day in medicine by the start of the Twentieth Century, as it did in virtually all other fields of human endeavor in Western civilization. Like many other professions, physicians wanted to appear very up-to-date and scientific. They also found that their use of scientific-sounding language and scientifically based models of the human body played well to an adoring audience. The archetype of scientist during the era of the Grand Alliance was further enhanced by the support given to this archetype by the management culture.

While clinicians would often resist any suggestion that there needed to be an economic justification for their work, scientists had a long history by this time of tying their work, and in particularly their technological advances, to economic benefits. Thus, while medical practitioners have continued to decry the loss of the art of medicine, the science of medicine has held sway during most of the Twentieth Century and has served as a cornerstone for the dominant professional culture in medicine. It was only in the last decade of the Twentieth Century that science fell into some disrepute. Medical science has been called into question with regard to such matter as ethics, relevance of specific research, and the absence of a holistic, integrated perspective with regard to the human body.

Two Clinicians: Physician and Nurse:

When one carefully examines the three-fold categorization of medical professionals (scientist, clinician, nurse), it soon becomes evident that actually there are two clinicians. There is the physician as clinician and there is the nurse as clinician. The nurse had immediate touch with the patient. The physician as clinician is somewhere between the nurse and scientist. The physician, serving in this intermediate role, remains a little bit aloof—a bit distant from the patient—but not as aloof or distant as the scientist. Nurses, as a group, tend to have opinions about doctors that relate directly to this three-tiered model. The more rigid and scientific the physician the less are nurses likely to identify with them. The less patient-focused the physician, the more nurses tend to discount their contributions.

The nurses don’t really mind their role as assistants to physicians. It is important, however, for nurses to perceive the physician they are assisting as someone who truly cares about their patients. If the doctor identifies himself as a clinician first and foremost, if his way of identifying himself to the other sub-professions and patients is centered on the caring function, then most nurses are very willing to work collaboratively with him. They would much rather work with him than with physicians who view themselves primarily as researchers or as technical specialists.

The nurse/clinician is the most conservative of the three types of medical professionals. She preserves old practices, the tried and true, with her emphasis on the quality of care and service to the individual patient: “We have a way of doing things here.” “This is no time to play around with the health of a patient by trying something new and untested!” In the complex dynamics of contemporary health care organizations, nurses often resist change in medical practices. They are often being forced, as the front-line staff, to accommodate the changes in treatment that are now being driven by both economics and technology.

As a group, nurses often tend to resent having to implement a new treatment program, whereas many physicians are quite zealous about trying something new and different. At the other extreme, the physician/scientist is most open to, and is actually often seeking out, new techniques and the use of new scientific knowledge and technology. He loves new equipment (often perceived as the latest toy by the skeptical nurses) and different ways of doing things, hence is best equipped to deal with the new technological and economic challenges of contemporary medicine.

The physician/clinician lies somewhere in between these two extremes. She is pulled toward both the old and new. She is attracted on the one hand toward patient care and is respectful of the tried-and-true ways of doing things that have always worked in the past and are known to her patients. She leans toward Marcus Welby and good old homespun wisdom and medicine. On the other hand, the physician/clinician is a medical specialist, a professional who should always be looking to further perfect her skills and expand her knowledge. She must always be acquainted with new tools and must link her practice to the latest concepts and procedures, the latest advances in science and technology. This is her professional obligation.

By way of their orientation and education, physician/clinicians feel responsible for being current. This is a critical part of their self-ascribed responsibility. They look at new ways of doing things, in part because there is an expectation in the general public that modern medicine will find a new and better way of healing people (new vaccines, new treatment programs and so forth). This is part of the price that physicians pay for their alignment with compelling (and healing) archetypes. Thus, when it comes to medical practices, the nurse/clinician is most likely to be the force for continuity, whereas the physician/clinician or, even more, the physician/ scientist becomes a force for change.

Things are quite different when considering the attitudes of each of these three types of medical professionals with regard to changes in the structures, policies and procedures of health care organizations. Nurses often serve as bridges between the physicians and health care managers. They are the ones in the past who were the administrators—the practical people. They were really the original health care managers. So, in some ways, nurses are more aligned with the changes now taking place than are physicians and often become organizational innovators. With regard to organizational functioning, the physician/clinician often acts more in the role of resistor and recalcitrant than does the nurse.

Struggle for Control

Over the years, physicians have employed many strategies to retain influence and even control over the health care enterprise. Many physicians focus on expert power—the ability to influence by dint of technical expertise and detailed knowledge of a patient’s medical history. As we have noted throughout this chapter, other physicians have sought to control health care through less admirable strategy, making primary use of position power and reward/punishment power rather than expert power in their attempt to retain control. Particularly during periods of transition and anxiety, these often-threatened physicians have often sought to restrict trade (via licensing laws) rather than improve their own performance and modify their own practices. They have also tried to restrict the practices of nurses through subordination. These efforts to subordinate have met with mixed results over the years and have played a critical role in defining the distinctive character of contemporary medicine.

Nursing represents the largest and most influential of the medical sub-groups that physicians have attempted to subordinate. At times nurses have been willing to play a subordinate role to physicians, especially when their own role in medicine was being threatened by outside forces. Many contemporary nurses are unwilling to be subordinated to physicians. Furthermore, they can’t turn to physicians for support given that the physicians themselves are under fire.

Rather, nurses must bridge the gap between the professional and managerial cultures by providing support and protection for the physicians. Actually, this role is not new for nurses. It is only more intense and imperative, given the circumstances of managed care. From the early years of North American medicine, nurses have defined the working relationships between the male-dominated professional culture and the other three cultures of health care, in which women often played a much more public and influential role.

The uneasy alliance between physicians and nurses began many years ago. It was often reinforced by shared antipathy regarding one or more of the other cultures. Traditionally, both nurses and physicians tended to view both the alternative and advocacy cultures as their shared enemy. Both cultures were to be defeated and eliminated. They unified against these sworn enemies even though they also often viewed each other as an enemy. Much as in the case of men and women who sometimes hate each other, yet remain together in a marriage as intimate enemies, the physician and nurse have needed each other, yet have often been annoyed about the very existence of this interdependence. In this dilemma we find a major source of wounding among contemporary healers.

The New World of Health Care

In this chapter we have attended to the historical roots of our professional culture in health care. In the later chapters of this book (Seven and Eight) we will be turning to more contemporary times. We feel compelled, however, even at this early point, to point to several implications of our professional culture heritage for contemporary times. Clearly, we are entering an era in which management and technology have come to dominate health care. Clinicians are now valued less and are not necessarily paid more than other professionals in our society. This shifting status begins to impact on self-esteem and perceptions of self-worth. Why are clinicians beginning to be paid differently? “Perhaps because administrators can get away with it!”— a plaintive declaration offered by some members of the professional culture.

Physicians made a very good salary for a long time, not primarily because they were clinicians, but because they were related to the scientific community and technology. Nurses tended to make low salaries not only because they were women and possessed less specialized expertise, but also because they were clinicians and caregivers who were not linked closely to the scientific community. Thus, many physicians were playing on both sides of the street. They were clinicians, but they were also scientists/technicians who held the magic. That blend is what made them economically powerful during the modern era. The physician’s strength came from being both intimate with their patient and knowledgeable about their patient—two perspectives that no one else possessed.

Insurance companies in the United States now possess substantial knowledge about patients. They have computer databases. With a high degree of resentment in their collective voice, physicians are now inclined to say: “I have a nurse telling me I can’t do this. This nurse who is sitting at a computer terminal in Providence Rhode Island is telling me that I can’t give Mrs. Smith the test and the medication that I want to give her. And I’m a physician and I have all of this education and experience! And some nurse [or even worse, some insurance company employee maybe not even a trained health care professional] is dictating how I practice medicine [based on that computer bank of knowledge]!” Physicians often resent being second-guessed.

An argument could be made that the physician possesses the same knowledge as the computer in Rhode Island and that the shifts in sources of knowledge and control is really nothing more than an irrational power struggle. Who is more right? Who is more righteous?

In many instances, physicians are becoming more like nurses in contemporary health care systems. Managed care administrators and insurance company decision-makers now possess the broad knowledge (demographics and all). Physicians now argue that they possess, along with the nurses, the local knowledge of specific patients. The physician can’t keep up with everything that is going on. Sometimes, a nurse is actually more fully informed regarding the overall status of the patient than is the physician, through her role as bridge between the professional and managerial cultures and specifically between the physician and managed care administrator. This new condition alienates the physician from power, for he is no longer keeper of the wisdom. Nurses and physicians have also become more alike with regard to standards of practice.

Certain protocols are now approved, and certain protocols can’t be used under managed care. In the past physicians controlled these protocols. Doctors experimented with new techniques and procedures. They were on the cutting edge, especially if they viewed themselves as physician/scientists. “That’s why they drew the big bucks!” declares the irate and somewhat defensive physician. Now the insurance companies appear to be giving orders to physicians, just as the physicians once gave orders to their assisting nurses. In the past doctors freely said to nurses: “Clean the wound three times a day. Give the medication four times a day. Make sure the patient gets this amount of fluids.” Now, a doctor often must follow a protocol dictated by the insurance company when he writes his orders. He can do less than the protocol requires, but he can’t do more.

Conclusions

The last years of the Twentieth Century were all about change for the helping professions in both the United States. At the heart of the struggle lies the issue of leadership. As long as the physicians (the referent group) carried out most of the work they were legitimately in charge of the system. But as the system has become more complex, it took more and more work for physicians just to stay up on the science and technology of their practice. They settled for parceling out the work but managed to use a variety of influencing strategies to stay in control. Medicine was most successful with this during the flowering of the era of the Grand Alliance, after World War Two.

As more people could be helped, more people were touched, and the system grew much larger. Physicians had less time for more obligations and delegated all the administrative tasks to members of the managerial culture. Eventually, the managerial culture took over. But health care professionals have not given up the fight for leadership. Physicians deny that administrators have any authority to tell them what to do. At the same time these health care professionals are too busy to attend the meetings that build partnerships and plan for change. They increasingly get left out—even though everyone else is trying to get them involved. They act out and are seen as prima donnas, with their own concerns as dominant.  More doctor (and nursing) bashing occurs and the competition for control gets out of hand. Administrators run their side of the hospital and physicians manage their side. Patients end up worse, not better served.

Although physicians have often wanted to play the lead role on health teams, they must now share this role with other members of the team and must find new ways to gain credibility and exert influence. Although nurses want to be considered equal members of the health team, they have not been altogether successful in challenging medical dominance. Some health care professionals have grown increasing frustrated. They have pushed with some success for the reform of professional regulations. Radical physicians and nurses have begun to criticize the disabling professionals—typically physicians who seem to be so caught up with their own concerns (money, technological advance, and so forth) that they fail to give adequate consideration to consumer needs.

The future of professional health care throughout North America depends ultimately, and critically, on this continuing focus on patient care. Nurses, physicians and other health care professionals can meet on a common ground in their self-identified status as clinicians and in their shared concern for patient care. Nurses can identify with physicians and physicians can identify with nurses because as clinicians they care for patients. This enhances the chances of them working collaboratively with regard to patient care and increases the likelihood that patients will be well-served by the professional health care community.

This ideal state can only be achieved with a full appreciation by each subculture of the professional culture for the role that is played by each of the other subcultures. It is in the struggles among clinicians, scientists and nurses that much of the wounding has occurred. A commonly shared orientation toward patient care is not nice to hold (and advertise). It is an essential component of any sustained effort to reduce or eliminate the wounding process. It is also essential as a means of uniting the subcultures of the professional culture as the members of this culture seek even more challenging dialogues with the other three cultures of contemporary health care.

[i] John Duffy. From Humors to Medical Science: A History of American Medicine (2^nd Edition). Urbana: University of Illinois Press, 1993, pp. 7-8.

[ii] Bledstein (Culture)

[iii] Paul Starr. The Social Transformation of American Medicine. New York: Basic Books, 1982, pp.6-7.

[iv] George Rosen. A History of Public Health (Expanded Edition). Baltimore: Johns Hopkins Press, 1993, p. 49.

[v] John Duffy. From Humors to Medical Science: A History of American Medicine (2^nd Edition). Urbana: University of Illinois Press, 1993, pp. 3-4.

[vi] Bledstein (Culture of prof)

[vii] Bledstein, The Culture of Professionalism.

[viii] Footnote (Henderson

[ix] Donald Schon, xxxx

[x] John Duffy. From Humors to Medical Science: A History of American Medicine (2^nd Edition). Urbana: University of Illinois Press, 1993, pp. 3-4) (check page numbers)

[xi] Kett (1967)

[xii] Godfrey (1979); Gidney and Millar (1984)

[xiii] Barbara Ehrenreich and Deirdre English. Witches, Midwives and Nurses: A History of Women Healers. Old Westbury, New York: The Feminist Press, 1973.

[xiv] John Duffy. From Humors to Medical Science: A History of American Medicine (2^nd Edition). Urbana: University of Illinois Press, 1993, p. 11.

[xv] John Duffy. From Humors to Medical Science: A History of American Medicine (2^nd Edition). Urbana: University of Illinois Press, 1993,  p. 47.

[xvi] Daniel Drake’s characterization of medical students as quoted by John Duffy. From Humors to Medical Science: A History of American Medicine (2^nd Edition). Urbana: University of Illinois Press, 1993,  p. 144.

[xvii] Bledstein (xxxx)

[xviii] John Duffy. From Humors to Medical Science: A History of American Medicine (2^nd Edition). Urbana: University of Illinois Press, 1993, pp. 133-137.

[xix] John Duffy. From Humors to Medical Science: A History of American Medicine (2^nd Edition). Urbana: University of Illinois Press, 1993, p. 143.

[xx] James Cassedy. Medicine in America: A Short History. Baltimore: Johns Hopkins Press, 1991, p. pp. 89-90.

[xxi] James Cassedy. Medicine in America: A Short History. Baltimore: Johns Hopkins Press, 1991, p. 95.

[xxii] Cassady, p. 95 double check this reference. It might be elsewhere in Cassady’s book or in Starr.

[xxiii] Willis (1983, p. 13)

[xxiv] Paterson (1967, p. 851)

[xxv] Snook (1980, p. 79)

[xxvi] James Cassedy. Medicine in America: A Short History. Baltimore: Johns Hopkins Press, 1991, p.31.

[xxvii] Judi Coburn, (“I See and Am Silent”) (xxxx, p. 448)

[xxviii] Coburn (xxxx, p. 448)

[xxix] Coburn (xxxx, p. 451)

[xxx] Coburn (xxxx, p. 452)

[xxxi] James Cassedy. Medicine in America: A Short History. Baltimore: Johns Hopkins Press, 1991, p. 41.