The Supernatural. Non-Human Organisms. Arts - Literature. Pillar 1: Foundations. Pillar 2: Supernatural. Pillar 5: Organisms. Pillar 7: Society. Pillar 9: Technology. Pillar History. Neue Felder entstehen, wie wir konzipieren innovative Ideen, die Verbesserung unserer wissenschaftlichen Methoden und neue Technologien.
Doch, wir nicht, um das ganze Bild und die logischen Beziehungen zwischen den verschiedenen Teilen von Wissen. Supernatural die Mystik und Religion. Materie und Energie untersucht die Grundlagen der physikalischen Welt. Weltraum und Erde erforscht unseres Planeten und im Weltraum. For this reason, it is hardly surprising that the medical professional organizations are fiercely fighting the threat of their privilege of autonomy being restricted and dominated by outside influences. The medical profession is fighting against the demands to be more economic and limit their budget, which they see as a means for the state to gain control.
It is also fighting against the suspicion that it is mainly interested in upholding its own economic advantages at the cost of society [ 32 ], [ 82 ]. It fights on both fronts by putting more emphasis on its orientation toward the public good [ 55 ], [ 54 ] and by trying to convince the public that if patient care in the sense of representing patients' interests is committed to humanitarian objectives, it has no room for cost-benefit analyses. Physicians also argue that the financing of health care services must be oriented toward the particular services needed, and not vice versa.
Furthermore, physicians argue that the quality of medical services cannot be appropriately judged from a position outside the medical profession by health care economists, for example. That the medical profession's resistance to outside control can be successful is visible in the shape the health care reform has taken. Although the implemented structural measures of the Health Care Reform Act that took effect in have influenced and limited the medical profession's autonomy, this has been to a much lesser degree than the government coalition originally intended.
Important areas of physicians' responsibilities have remained intact due to the medical profession's power potential, which is still strong. As a result, the new Institute for Quality and Economic Efficiency in Health Care IQWiG , which designs guidelines for treatment and provides expert reports, remains outside of the state's direct influence.
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Further education also remains physicians' own responsibility. Even the monopoly of the Regional Association of Statutory Health Insurance Physicians KV , which conducts the payment negotiations with SHI institutions and is responsible for the allotment of funding among groups of physicians, remains largely untouched.
The medical profession fears and laments that the health care reforms implemented so far have meant an increasingly stronger regulation by the state on their free professional conduct.
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However, they have overlooked the fact that extensive autonomy as it existed in the time before the reforms can only be claimed as long as it lives up to its responsibility to the public health system and its share in the economic use of resources [ 84 ], [ 13 ]. In other words, as the health care expert Schmacke stated, "the measure of responsibility and power granted by politics and society to regulate economic resources in the public health system will remain intact as long as society's expectation connected with this responsibility can be validated" [ 72 ], p.
The medical profession stresses its medical orientation and adherence to the public good as justification for its claim to autonomy when arguing with representatives of the political system and the public. According to Meuser and Hitzler [ 54 ], [ 55 ], this can be understood as an attempt of professional policies to gain acceptance, though it is hardly enough to keep health care economists and health care policy-makers from criticizing physicians' lack of cost responsibility. Whether or not medically-responsible conduct and the management of limited resources and its accompanying logic are mutually exclusive, or if they can be combined, remains a point that is constantly disputed.
Though the medical profession has mainly kept itself away from economically rational criteria so far, the demand to be simultaneous oriented toward both the patient's well-being and economic conditions forces it to at least take economic aspects more into account or add economic orientation by weighing benefits and costs of several kinds of medical intervention to their otherwise exclusively medical orientation doing everything that could help the patient.
This therefore results in the necessity to reflect more on a fundamental redefinition of the relationship between medical and economic orientation and its integration for example in the development of integrated care that contains new forms of organizing health care. This means the point of view representing this particular profession and physicians' responsibilities must be expanded to form a perspective that is oriented toward the entire system and to include an economic dimension and the idea of community solidarity public health care perspective.
This must then be conveyed at all levels of college, training and further education as for the economy and for management, the opposite is needed: recognizing medical ethics within medical orientation and integrating this in education. Medical autonomy is not a right acquired forever, but rather a concession made to physicians in exchange for medical, and now economic, responsibility.
If the medical profession chooses not to take part in a constructive and necessarily interdisciplinary debate on how medical and economic orientation can be conveyed and kept in balance sensibly and on how the quality of health care can be optimized the medical profession could push ahead with the first step in this direction by establishing forums for the active, interdisciplinary exchange of ideas with the objective of establishing legitimating bodies and processes for solving the dilemma , then it will lose more control over the public health system, which will be increasingly under the conditions of shrinking resources expected in the mid-term , to the state, economy, and management.
This would mean that the erosion of physicians' autonomy, which scientific experts have observed in Germany and other industrial states [ 51 ], [ 4 ], [ 22 ], p. Therefore, as the medical historian Unschuld states, physicians will indeed be demoted from being designers to co-designers, from those responsible to those sharing responsibility [ 85 ].
The erosion of medical autonomy has increased in intensity in the last few years due to the fact that health care occupations are being made into academic subjects and being professionalized nursing, for example and the fact that the increasing number of new expert occupations and the qualifying academic education programs they require are developing and establishing themselves as players in the public health system, occupations such as health care managers, health care economists, nursing scientists, nursing managers, and so forth [ 36 ].
Although physicians' dominance and autonomy is undermined by the public's loss in confidence, the increase in state and economic regulations inspired by cost issues, patients becoming more and more assertive, and the volume of new expertise occupations, the medical profession is still the most important discipline and the most powerful player in the public health system with its extensive dominance over the other health care occupations from the point of view of the sociology of professions, there is a controversial debate as to whether or not evidence-based medicine strengthens physicians' autonomy, or if it rather weakens it [ 86 ], [ 48 ].
This paradoxical image characterizes the current situation of the medical profession in Germany and in other industrial nations [ 26 ], [ 46 ], [ 45 ]. In regards to the dimension of autonomy in the medical profession discussed here, it remains to be seen whether or not external political and economic regulations are indeed able to guarantee an occupation's quality in the same way professional autonomy has, at least in principle, been able to do. The reorganization of the health care system to establish an effective and efficient system that meets patient's needs but also equally takes basic economic conditions into account has become a constant task of health care policies.
The medical profession has yet to provide its own stringent reform plan for this reorganization. Furthermore, the medical profession appears to have underestimated the speed, the degree, and effects economic change has had on the public health system for some time this is apparent in the fact that management functions in health care institutions are increasingly performed by economists and lawyers, for example, who only have limited medical expertise.
Not only will new and changed forms of organizing care and patient-related services emerge within the process of changing the public health system to incorporate more integrated care individual practices could be a thing of the past , but physicians will also have to face radical changes in the structure of their profession.
The Health Care Reform Act that took effect in has created the opportunity for physicians together with other health care providers to develop and try out new forms of organization that make more quality and economic efficiency possible for example by supporting competition between the different forms of care, by approving ambulant medical care centers and by opening up parts of hospitals for ambulant care.
It is likely that medical quality will thereby become a decisive factor of competition. The successful physicians of the future will be those who are able to combine cost efficiency and quality and integrate economic aspects into their occupational conduct without compromising their medical orientation. It is not easy to resolve this conflict of objectives between medical and economic orientation; it will require a solution in the near future though there is no satisfactory solution in sight today. However, this conflict could lead to an acceptable solution through the utilization of potential economic efficiency and processes of optimization at least in the mid-term.
If it is not possible to relieve this tension, then it is the patients who could especially suffer negative effects through the rationing of health care services, for example. However, this is not the only reason why the medical profession should be taking part in, or even leading, the attempt to change the public health system so that it meets patients' needs, is affordable, and anticipates future developments. In order to meet their future demands, physicians need more than just their medical expertise, they need to have a solid knowledge of the economy and of management, be able to work in a team, and cooperate and communicate with other professionals.
This cooperative ability must also be integrated in medical education and training on all levels [ 35 ]. A new form of professional competence may also be necessary. Hitzler and Pfadenhauer propose to call this new form of professional competence "reflexive competence" [ 30 ] keeping in mind the increasing dissolution of the binary concept of "healthy" and "ill". What they mean by this with the acknowledged and considered ambivalences arising from the progress of medical and technical knowledge and with the unintended consequences of medical conduct in mind is that "reflexive competence" qualifies physicians to be able to constructively deal with ambivalences professionally and to provide innovative answers to the questions discussed here and to the problems of modern health care.
This article is a newer version of a talk given for the workshop "Mercatus ante portas! Professionals and the demand for economic efficiency in their performance of services" at the conference held by the Swiss Sociological Society October , University of Zurich. I would like to thank the anonymous experts at the journal PSM for valuable encouragement and criticism. National Center for Biotechnology Information , U. Journal List Psychosoc Med v. Psychosoc Med. Author information Copyright and License information Disclaimer.
You are free to copy, distribute and transmit the work, provided the original author and source are credited. This article has been cited by other articles in PMC. Abstract The current discussions surrounding the German health care system are being determined and defined by the concepts of "profitability", "efficiency" and "saving".
Keywords: medical profession, professional autonomy, theory of professions, economy, efficiency, health care system, health care reform. Introduction Increasing costs and limited financial resources have led to many considerations in the German health care system regarding economic efficiency [ 2 ]. Changes in the basic conditions and reforms of the health care system The demographic development, the shift in the health problem situation, the continuing medical and technical progress, the rising care demands of those receiving services "the spiral of demands" , and the increase in health care expenditure that has been caused by the complex ensemble of these factors while financing possibilities become more limited and premium income erodes have all put the German system of health care provision under constant pressure to reform and transform itself [ 58 ], p.
The profession and professional autonomy Professions are a special type of occupation [ 11 ], p. Medical autonomy before and in the age of economization and cost-containing policies The medical sociologist Siegrist stated that there are only a few groups of occupations today that are capable of exercising occupational autonomy to such a great extent as the medical profession does. The necessity of redetermining the relationship between medical and economic orientation Whether or not medically-responsible conduct and the management of limited resources and its accompanying logic are mutually exclusive, or if they can be combined, remains a point that is constantly disputed.
Conclusion and outlook The reorganization of the health care system to establish an effective and efficient system that meets patient's needs but also equally takes basic economic conditions into account has become a constant task of health care policies.
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