Academic journal article Journal of Sociology

Changing Professions: General Practitioners' Perceptions of Autonomy on the Frontline

Academic journal article Journal of Sociology

Changing Professions: General Practitioners' Perceptions of Autonomy on the Frontline

Article excerpt

The concept of `profession' in relation to medicine carries with it the central idea of autonomy. Eliot Freidson's (1970) critical writings on how the medical profession attained, maintained and extended its autonomy, represented a shift away from the functionalist approach of Talcott Parsons and others (Macdonald, 1995). In more recent times, it has been argued that governmental, organizational, technological and societal changes have reduced medicine's status (Eve and Hodgkin, 1997; Harrison and Ahmad, 2000; Haug, 1988; Wilsford, 1995). However, much of this debate has been conducted at a high level of abstraction. Scant empirical research has been directed at understanding what autonomy means in everyday practice, and how changes have been experienced by frontline practitioners (Lupton, 1997; Schulz and Harrison, 1986).

The research presented in this article aims to understand how frontline General Practitioners (GPs) in Australia perceive their autonomy in relation to the challenges they have faced over the last decade. It then considers these findings in regard to different theories on how the medical profession's status has changed--in particular, whether medicine is being de-professionalized or proletarianized.

Professional autonomy

Professional autonomy is the legitimate control that the members of an occupation exercise over the organization and terms of their work (Elston, 1991). Some authors have claimed that professions are being proletarianized or de-professionalized. The de-professionalization thesis asserts that professions are losing their monopoly over knowledge, their expectations of work autonomy and authority over the client, and public belief in their service ethos, because of changes in the organization and management of health care services (Haug, 1988). The proletarianization thesis claims that professionals are being de-skilled and their work made routine because of technological developments and bureaucratic requirements (Light and Levine, 1988).

These theses have been applied to general practice in Australia (White, 2000), with the conclusion that a combination of proletarianization in regard to GPs' employment, and de-professionalization in regard to the challenges from self-help and other groups, is at work. However, others have taken issue with these theses, arguing that they may not be relevant in countries other than the USA, and some authors disagree with the analysis even in the US context (Freidson, 1988). While there is evidence that these challenges to the medical profession can be found in most Western health care systems, there are doubts about the explanatory power of these arguments (Calnan and Williams, 1995). The available data indicate change that looks more like adjustments than a major loss of professional autonomy (Elston, 1991).

More recent work on professions has used labour process theory to explain changes in professional work, by analysing the relationship between professionals' subjective experiences of work and the broader structural context of that work, through a focus on the workplace. One example in regard to legal aid lawyers in the UK concluded that new public management initiatives have led to high output and low morale for these practitioners (Sommerlad, 2001). Australian teachers, in another study, reported increased and intensified workloads in more complicated workplaces (Easthope and Easthope, 2000). Applications of labour process theory to health also reveal that there is a struggle apparent for control of medical work (Dent, 1998). However, such studies also suggest that the tension between bureaucracy and professionalism is being recast rather than eliminated and the impact on different types of professionals varies enormously (Warhurst and Thompson, 1998).

In discussing the medical profession it is important to pay attention to the difference between changes to frontline medical practice and changes to the social status and political power of the medical profession. …

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