Medical Organization

1. Medical Organization • Professional dominance • McDonaldization • Newfound power of the patient • Light– “Patients, governments, and corporate purchasers are taking back the cultural, economic, and even the technical authority long granted to the medical profession”

2. Countervailing powers • Interaction of powerful actors in a milieu of interdependence • Dominance is contextual • The context has changed • Unbalanced power creates the need in a system to create and reward polar opposite power

3. Countervailing Power • Opens the door to new relationships and alliances in medicine • Example—emergency medicine • Economic structure wanted more control • Prior authorization • EMTALA • Melding of patient and medical interests—reasonable patient standard

4. Nursing • Helper • Now separate profession with theory and practice parameters • Co-professionals • Gender considerations

5. Allied Professionals • Also have separate nature and rules/power • Team conceptualization now

6. Emergency Medicine • Alliance between patients and doctors made visit to ER guaranteed by law and not subject to prior restraint • Consequences to hospitals, specialists, patients, payers and ED physicians

7. American Medicine • Overspecialized—why? • Costly • Unnecessary treatment • No controls on medicine and medical industries • Payers complained and they gave money to legislators

8. What we expect from medicine • Quality • Safety • Involvement • Privacy • Financial • Rapid, always available, and on demand

9. American medicine • Trust eroding • Fixed payments and controlled costs • Legal and administrative controls on medical practice • Controls on research • Corporate industry—profit matters

10. Consequences to present trends • Stratification of who receives care and what care is received • cuts in services • cuts in professional staffs • reduced quality • paperwork, bureaucratization and regimentation

11. Practice patterns • Paperwork—up to 60% of physician time • Patient time—5-7 minutes per patient • Incomplete diagnosis despite better technology • Physician salaries drop by 30-60% • Changes in practice patterns—less work, less obligation, defensive practice

12. Economic Concerns • Capitalist doctors • Managed care and the failure of the management model • Decline in reimbursement

13. Trust • Behavior that is consistent and beneficial to self, others engenders trust • Credibility • Compassion • Interpersonal and social • Emotional bonds

14. Trust • Bonds—transference, social contract • Interpersonal trust because of personal integrity and altruistic behavior • Social trust because of Obligations we have taken willing to protect and serve • Institutional and professional trust distinguished

15. Factors in trust • responsive, compassion • Feedback, information • optimism • Affiliations with credible institutions

16. Erosion of trust • Doctors are answering to others • Compassion to standard practice • Credibility questioned • Who is the master of the doctor • The relationship of managed care to trust in the doctor-patient relationship

17. Example • Medicaid pays 4% of each total bill • Physicians can opt out of the program • New Medicaid patients cannot find doctors • Solutions?