Medical Establishment and Professions

Over the last 150 years, professionalism and delivery of health care have changed dramatically. Prior to the beginning of the 20th century, the sick could seek treatment from any number of sources besides physicians, including barbers, midwives, druggists, herb specialists, or even ministers. No standardized medical education system or licensing process existed, and no one oversaw the practices of anyone claiming to be a doctor. In many cases, becoming a doctor followed the same process as any other profession: apprenticeship to someone already a “doctor.”

In 1847, the American Medical Association (AMA) was formed as a self‐regulating body to set standards of professionalism and fight for a more scientific definition of medicine. At first, the organization exerted limited influence; however, as researchers identified bacteria and viruses as causes of disease and developed effective vaccines, its influence grew. The AMA also openly fought against alternative approaches to health care and certified only physicians who completed AMA‐approved programs. The AMA expelled those who failed to complete such programs, or those who used alternative methods such as chiropractic or herbalism.

A definite turning point in medical care came in 1908 with the release of the Flexner report. Funded by the Carnegie Foundation for the Advancement of Teaching, Abraham Flexner investigated medical schools and declared only 82 of 160 acceptable. He cited problems such as inadequate materials, nonexistent libraries, and training programs of only two years. Flexner recommended that the “most promising” medical schools that had high standards of admission and training be supported with foundation and other philanthropic money. The best schools remained open, while the AMA forced the remainder to close. Thus, the Flexner report led to the professionalization of medicine. Physicians now had to undergo rigorous training, base their approach on theory, self‐regulate, exercise authority over patients, and serve society.

The importance of the Flexner report was that for the first time it defined acceptable standards and pointed out inconsistencies and extreme deficiencies in medical education at the time. In some cases, folks could “buy” a medical degree by attending a diploma mill, and doctors improved their incomes by taking on more apprentices than they could actually teach.

While AMA supporters point to its role in protecting public interest and improving medical care, critics point to what they call the AMA's monopoly over medicine. The organization locked out those who did not adhere to the strict, narrow interpretations of the AMA. Interestingly, the medical schools closed by the Flexner report included all but two schools training blacks and one training women. Critics charge that the AMA became an all‐powerful, white male organization that promoted a perception of doctors as all‐knowing authority figures with power over nurses, midwives, and patients. Doctors' use of technical language, confusing and intimidating to patients, reinforced their superiority, as they possessed the power to dispense or withhold information or treatment. Patient advocates argue, and substantial recent research supports the view that passive patients are likely to remain quiet, depriving the doctor of information that can alter a diagnosis. According to these critics, the hierarchy of medicine with doctors on top and everyone else at the bottom can negatively influence patient care.

Millions of Americans, disenchanted with or discouraged by traditional medicine, have returned to alternative forms of medicine. In recent years, naturopaths, herbalists, acupuncturists, and chiropractors have gained new clout and business. Each of these groups has also become more professional, regulating itself and setting standards. However, most alternative therapists work to avoid exerting too much authority over patients, aiming instead for partnership in treatment.

Chiropractors, who generally receive more training than most other practitioners of alternative medicine, have started to gain respect and recognition from the AMA. Many physicians practicing traditional medicine work cooperatively with alternative practitioners to treat patients. Others still openly oppose alternative medicine. Nevertheless, the current trend is for patients to seek greater control and understanding of their health care, demanding more information and choices in the process.