The most important drivers in the academic doctors’ lives used to be success in research, making honest and good contributions to the progress of medicine, teaching medical students and residents and being proud of the clinical care they gave. That has all been replaced by the ‘operating margin’. And that has created significant amounts of disaffection.
(Interview, the American Chief of Staff, December 2000)
It is argued that professionalism is not only under attack but that there is a process of deprofessionalization, even prolatarianization taking place. These assertions have been discussed with reference to the medical profession for some decades (Haug 1973; McKinley and Arches 1985: Ritzer 1996), as have been challenges to these critiques (Freidson 1994; Rosenthal 1987, 1995). It can be argued that such analyses reach too high a level of generalization, missing the subtleties and nuances, the ebb and flow of aspects of professionalism. Professional autonomy is a multidimensional phenomenon. The dimensions must be sorted out and examined individually. Furthermore, change does not take place on a single trajectory.
Among the more thoughtful analyses of professional autonomy is the work of Starr (1982). He identifies a number of dimensions of autonomy: political, economic, social, cultural and technical. Freidson (1994) suggests that although doctors will more and more be salaried and responsible to managers, these will often be other doctors who will retain their allegiance to the culture of medicine. Others have argued that the medical profession in a particular country may lose control over some dimensions of autonomy while retaining control over others. Moreover, these elements of control wax and wane (Rosenthal 1987).
This chapter explores the state of medical professional autonomy in an unusual way. It is based on three extensive interviews with chief medical officers in three academic medical centres, one each in the United Kingdom, Sweden and the United States. All the chiefs were asked the same questions from the same semi-structured interview schedule with some small adjustments in country-specific vocabulary. The interviews are rendered as a series of paraphrasing, summaries and direct quotes.