Article — From the October 1960 issue

The Politics of Medicine

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the mighty guilds

In ancient Greece, medical knowledge was a holy secret shared only by a few families claiming descent from Aesculapius, who became the god of medicine after his death. Hippocrates devised his oath to regulate the admission of new physicians into guilds, which the ruling families tightly controlled. These guilds of antiquity looked after the professional and economic interests of medicine. This remains the prime purpose of their successors, the medical societies. One of their chief concerns, as with business trade associations, is to help the membership make money, substantial money.

The modern guilds are run by the top practitioners—in income and prestige—in each community. Like their Greek forebears they have seen to it that there are not too many doctors and that those who are admitted to the fraternity abide by the rules. In theory this is not a sinister function—it is fitting and necessary that those of highest competence set and maintain professional standards. But in practice the system controls a good deal more than medical excellence. How it operates has been perceptively analyzed by Oswald Hall, Ph.D., now professor of sociology at the University of Toronto. For his most important essay, “The Stages of a Medical Career,” he conducted confidential interviews with physicians in the United States about intern appointments, hospital department assignments, and the problem of establishing a successful practice. (This study was reprinted in 1958 in Patients, Physicians, and Illness, edited by E. G. Jaco and published by the Free Press.)

As Hall describes it, the “inner fraternity” of medicine uses informal but potent mechanisms to “incorporate the new doctor into the profession, to repel the intruder (i.e., the ethnically undesirable or the idiosyncratic), to minimize mobility, and to control competition.” The medical bureaucracy run by this “inner fraternity” stabilizes the profession by controlling the flow of recruits and by allocating the coveted positions, especially in hospitals.

The process starts the moment a young man tells his family he is going to be a doctor and files his application with a medical school. A physician’s career is constructed brick by brick, and at each level an appropriate echelon of the medical hierarchy stands guard. A hint by one of its members can be an invaluable lever in gaining admission to one of the major medical schools. The “right” medical school provides its students not only with fine training but with a label which will materially help his professional ascent. (This is not to say that every young man’s career will be blighted if he is trained at an undistinguished—or even a foreign—medical school. But he may need extraordinary ability to surmount the handicap.)

Upon leaving medical school the young M.D. takes a step which usually is decisive for his career. He must spend several years as a hospital intern and resident. The prestige of the institutions where he serves will have a crucial effect throughout his life on his associations and opportunities as a practicing doctor.

The most admired hospitals tend to pick a large proportion of their interns and residents from the “top” medical schools. Many other factors also influence their choice. Professor Hall’s interviews with physicians reveal, among hospital staffs in charge of assignments, dismaying prejudice and judgment by trivia of the kind which I associate with college eating clubs and fraternities. Anti-Semitism, for example, survives in hospital administrations in many parts of the country. (Discrimination against other minority groups has been, on the whole, an academic question. Only a very few Negroes, for instance, have any hope of getting the kind of pre-medical or medical education that would qualify them professionally for first-rate internships.)

So the allocation of internships—and of medicine’s other patronage plums—is determined only in part by technical distinction. A vital factor also is what Hall calls “institutional acceptability.” “The cut of a man’s jib” said Dr. Berger in the course of his testimony on the Staten Island case, can make or break him, quite apart from his professional attainments. This means that those familiar yardsticks of organization life—”personableness” and evidence that a man “fits in”—weigh heavily in hospital appointments.

Hall’s observations were made more than a decade ago, before the present critical scarcity of doctors. But there has been little or no change, according to the many administrators I have questioned. And indeed the increasing dominance of the hospital as the center of medical practice has if anything fortified Hall’s thesis. It is only in the average hospital that the would-be intern enjoys a seller’s market for his services. For the most coveted appointments there are still about ten times as many applicants as openings.

To be sure, the applicant’s competence is always pertinent. The written and the unwritten rules of the profession demand that the doctor pass muster throughout his career. Nor can a neophyte skip over the successive stages of his apprenticeship. He must climb up the ladder step by step. And on each rung he can be given an upward or a downward push by the controlling elite—department heads, hospital administrators, medical boards, outstanding specialists—and their lay allies, the hospital trustees.

His own progress within the hospital system will heavily influence not only his status but his earnings. Specialists who are on the visiting staff of the same hospital quite naturally refer private patients to each other for consultations and surgery.

“If a man gets to the top in a hospital in one of the more lucrative specialties,” my own doctor said recently, “he’s also got it made in his private practice.”

The trappings of prestige impress not merely the doctor’s peers but also the wealthiest, best-informed people in the community. It is convenient and flattering to be treated by a physician or surgeon who can always command a fine private room for his patients while others stand in line on waiting lists—or by a surgeon whose mere name inspires a magical deference from other doctors’ receptionists, nurses’ registries, convalescent homes, and even pharmacies. The physician’s prestige, in other words, contributes materially to his success in delivering medical services.

As a result medicine, to a far greater degree than any other profession, imposes upon the doctor the need for endless adjustments to an intricate bureaucratic structure in which powerful political controls are strikingly prevalent. With rare exceptions, only by succeeding within “the system” can he hope to become a leader in his field, let alone a mover in its power apparatus. Success in the system is essential for either “informal” political power, wielded within the hospital, or for formal political power in the county, state, or national medical urganizations. An interlocking directorate prevails, since the brass in the hospital and the brass in the societies gen- erally (but not always) tend to overlap.

As he works his way upward the doctor with political interests will have his reliability tested by appointment to various committees of his county society. In due course, if he proves himself, he may sit on its governing body. From the ranks of this august and dependable group the county society chooses its presidents, in a succession tidily arranged for several years in advance. The progression upward to the state society is automatic for those with time and taste for the medical organization life. The doctor who scales these heights is well schooled in the political and economic orientation of his colleagues. Doubtless he has served on his county’s two most im- portant committees—legislation and public relations. He has been well insulated from any dissenting viewpoints, for his associates—in the hospital, in “the professional building, and at the country club—are almost entirely fellow members of the same “inner fraternity.” He is ready now to contribute his own wisdom—too often a pecul- iar brand of bumbling provincialism—to the supreme guild of his profession: The American Medical Association.

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