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PubMed1991

New Oslerians and real Flexnerians: the response to threatened professional autonomy.

As federal governmental involvement in U.S. health care had become a fact in the mid-1960s, a significant number of contributors to The Journal of the American Medical Association (JAMA) had recommended educational reforms to save an autonomous profession. In the late 1970s, demands for additional professional reforms began to appear in JAMA and The Journal of Medical Education (JME), particularly from contributors who perceived threats to professional autonomy from corporate medicine. The New Oslerian reform agenda is an application of the "humanizing" movement to the clinical phase of medical education. In its most restricted formulation (the inherent ethic argument), proponents simply urged clinicians to permit every student's inborn sense of moral duty to blossom on the wards. Others argued that Sir William Osler's legacy was more complex and involved systematic instruction, especially in ethics, at the bedside (the service ethic argument). Real Flexnerian reforms were based on an assumption that unintended distortions in Abraham Flexner's reform measures had eventuated in stultifying and counterproductive teaching of the biomedical model. Consequently, medical education should be altered to train future physicians in what Flexner had really intended--the capacity to think and problem-solve in a scientific manner. In time, many reformers emphasized the complementarity of Real Flexnerian and New Oslerian curricular proposals. The most comprehensive proposal to date, GPEP (General Professional Education of the Physician), makes a strong case that implementation of these old, turn-of-the-century reform proposals would make physicians in the 21st century well-rounded and competent. But GPEP's proposed changes in medical education are inadequate because the recommendations do little to prepare future physicians to contend with the corporate context in which most of them will be practicing.

Decision Making↗
PubMed1981

Towards professional autonomy: a commentary on "Expectations and disappointments' in development of the Royal College of Nursing.

The Royal College of Nursing of the United Kingdom has been engaged over recent years in a unique process of organizational change. Since 1973 sustained efforts have been made to mobilise widespread membership participation in shaping a new college structure which enables the Rcn to function effectively in representing the profession and in developing expertise on all aspects of nursing. A critical element has been creation of a network of "Rcn Centres' to provide a professional forum in each locality. A recent study by Bridget Ramsay has followed up this process. Its title, Expectations and Disappointments, reflects the mixed views of those involved on the progress which has been made. This article provides a commentary on Ramsay's analysis against the background of the complex situation of the Rcn in the early 1970s and the considerations which led the College to adopt an innovative approach to change. Particular attention is given to the influences which have made the growth of an active and integrated "Rcn at local level' quite problematic. It is suggested that the course Rcn development has taken in part reflects important elements in the nursing culture which members learn from their work in hospitals. Accordingly the Rcn experience has wider implications for the profession, not least for contemporary efforts, to achieve the greater professional autonomy necessary for nurses to implement more individualized patient care.

Humans↗
PubMed1990

Practice guidelines and professional autonomy in a universal health insurance system: the case of tissue plasminogen activator in Ontario.

Ontario's universal health insurance system has placed few constraints on the clinical and economic autonomy of medical doctors. Although fees are standardized, most physicians remain in private fee-for-service practice and thereby retain control of the mix and volume of services. Utilization review is minimal. While organized medicine has argued that health care is 'under-funded', the government is pressing for better use of extant resources through firmer management of the medical services sector. The Ontario Medical Association (OMA), the major bargaining agent for doctors in the province, has accordingly sought to protect professional autonomy by developing voluntary self-regulatory approaches that obviate the need for external controls over physician practice patterns. Part of this strategy is promulgation of practice guidelines. Tissue plasminogen activator (t-PA), a clot-lysing drug for myocardial infarction, was released in late 1987, and, at C$2950 per treatment, constituted an unforeseen add-on cost for hospitals. The OMA subsequently convened an expert panel to develop guidelines for thrombolysis in myocardial infarction. Among the unanticipated results was the conclusion that insufficient evidence had accumulated to recommend routine use of t-PA instead of streptokinase, an older drug costing C$290. The OMA panel's guidelines were approved by the OMA executive, and led the government to reject special add-on funding for hospitals purchasing t-PA. The OMA's position and government decision provoked negative reactions from the OMA's own cardiology section. Indicative of clinicians' feelings, a follow-up survey of cardiologists and internists showed that only 28% of respondents were indifferent between t-PA and streptokinase, while 64% preferred t-PA. On the other hand, 74% supported clinical policy development by the OMA, while 94% opposed direct government involvement in guideline-setting. The case of the OMA thrombolysis guidelines illustrates a strategic conundrum facing Canadian organized medicine. Professional activism in guideline-setting may in theory protect the individual practitioner's autonomy by offering a voluntary alternative to utilization management by government, and is likely to strengthen the collective influence of organized medicine. However, among the risks are alienation of practitioners who see professional guidelines and government control as two sides of the same regulatory coin, and the transmogrification of voluntary guidelines into parameters for cost control and utilization management by government or hospitals. Future initiatives will depend on how these benefits and risks are weighed.

Cost Control↗
PubMed1998

[Is professional autonomy of value? From the viewpoint of the medical director].

Professional independence is one of many steps to a self-sufficient personality. Especially for surgeons who are used to working directly and independently during operations, professional independence is important. It is best achieved in a private surgical office. The chief position in a hospital also guarantees a certain independence. Professional independence is limited by many political and financial restrictions. Nevertheless, every surgeon should try in his own area to reach as much independence as possible. Even in a subordinate position, one can achieve a personally satisfying degree of independence by special surgical skills and knowledge.

Attitude of Health Personnel↗
PubMedDate not supplied

Professional autonomy and the work satisfaction of nursing educators.

The importance and satisfaction associated with 21 characteristics of a nurse faculty position were examined, using 1974 questionnaire data from schools of nursing at four major state universities. Teaching, supportive colleagues, keeping clinical knowledge current, and faculty autonomy were seen as the most important aspects of the job by the 154 nursing educators surveyed, while salary, fringe benefits, and other extrinsic rewards ranked substantially lower in importance. Satisfaction with the more important conditions was generally low, with lack of faculty participation in decision making a particularly noteworthy source of dissatisfaction. Importance and satisfaction ranking of the 21 characteristics remained fairly stable across the four schools and across groups broken down by martial status, experience, and other personal attributes. Increased professional autonomy, it was suggested, would benefit faculty morale, recruitment, retention, and overall effectiveness in nursing education.

Clinical Competence↗
PubMed1998

Guidelines as a strategy for preserving professional autonomy.

Practice guidelines are often perceived as a threat to physician autonomy. However, the true challenge to physician autonomy is the rising costs of health care, which in turn is the result of continued progress in medical research. Since, inevitably, choices must be made about how our limited resources are expended, an increasing number of physicians are concluding that health care providers should assume financial risk for providing care--so that providers can make the decisions about which interventions are used for which patients. In this context, groups of physicians are adopting practice guidelines as an important strategy for providing high quality and efficient care under capitation. At least in some areas, practice guidelines are emerging as a critical tool for physicians to assume financial risk, and thereby protect professional autonomy.

Capitation Fee↗
PubMed1999

Evidence-based nursing: a stereotyped view of quantitative and experimental research could work against professional autonomy and authority.

In recent years, there have been calls within the United Kingdom's National Health Service (NHS) for evidence-based health care. These resonate with long-standing calls for nursing to become a research-based profession. Evidence-based practice could enable nurses to demonstrate their unique contribution to health care outcomes, and support their seeking greater professionalization, in terms of enhanced authority and autonomy. Nursing's professionalization project, and, within this, various practices comprising the 'new nursing', whilst sometimes not delivering all that was hoped of them, have been important in developing certain conditions conducive to developing evidence-based practice, notably a critical perspective on practice and a reluctance merely to follow physicians' orders. However, nursing has often been hesitant in its adoption of quantitative and experimental research. This hesitancy, it is argued, has been influenced by the propounding by some authors within the new nursing of a stereotyped view of quantitative/experimental methods which equates them with a number of methodological and philosophical points which are deemed, by at least some of these authors, as inimical to, or problematic within, nursing research. It is argued that, not only is the logic on which the various stereotyped views are based flawed, but further, that the wider influence of these viewpoints on nurses could lead to a greater marginalization of nurses in research and evidence-based practice initiatives, thus perhaps leading to evidence-based nursing being led by other groups. In the longer term, this might result in a form of evidence-based nursing emphasizing routinization, thus--ironically--working against strategies of professional authority and autonomy embedded in the new nursing. Nursing research should instead follow the example of nurse researchers who already embrace multiple methods. While the paper describes United Kingdom experiences and debates, points raised about the importance of questioning stereotyped views of research should have international relevance.

Evidence-Based Medicine↗