Transforming practice organizations to foster lifelong learning and commitment to medical professionalism.

Practice organizations will increasingly engage in activities that are the functional equivalents of continuing medical education. The authors maintain that if these activities are properly structured within practice organizations, they can become powerful engines of socialization to enhance physicians' lifelong learning and commitment to medical professionalism. They propose that this promise can be realized if new or reformed practice organizations combine education and service delivery and institutionalize processes of individual and collective reflection. The resulting "institutions of reflective practice" would be ones of collegial, experiential, reflective lifelong learning concerning the technical and normative aspects of medical work. They would extend recent methods of medical education such as problem-based learning into the practice setting and draw on extant methods used in complex organizations to maximize the advantages and minimize the disadvantages that practice organizations typically present for adult learning. As such, these institutions would balance the potentially conflicting organizational needs for, on the one hand, (1) self-direction, risk taking, and creativity; (2) specialization; and (3) collegiality; and, on the other hand, (4) organizational structure, (5) coordination of division of labor, and (6) hierarchy. Overall, this institutionalization of reflective practice would enrich practice with education and education with practice, and accomplish the ideals of what the authors call "responsive medical professionalism." The medical profession would both contribute and be responsive to social values, and medical work would be valued intrinsically and as central to practitioners' self-identity and as a contribution to the public good.

Responsive medical professionalism: integrating education, practice, and community in a market-driven era.

Revolutionary changes in the nature and form of medical practice institutions are likely to reverberate backward into medical education as leaders of the new practice organizations demand that the educational mission be responsive to their needs, and as these demands are increasingly backed by market power. In the face of this pressure, medical education's traditional response--that it should have autonomy in defining its mission--is no longer viable. Instead, more explicit, formal, and systemic linkages between practice and educational institutions are inevitable. The crucial question is whether these linkages will reflect the values of the market, oriented by economic self-interest, or the values of medical professionalism, oriented by the obligation to sacrifice economic self-interest in the service of patients. The authors maintain that the realization of the normative ideal of professionalism in medical education within the emerging market environment requires that a vision be articulated that is distinct from that of either autonomy or the market, and that combined lay-professional institutions be established to integrate--and perhaps merge--education and practice, and to foster responsiveness to lay values and community needs. The authors conclude by briefly describing examples of current efforts in this direction.

The normative constitution of professional power.

This article concerns the manner in which we think and talk about power in health care policy and regulation, and the political and social practices allied with that discourse. I assert that in health care policy and practice we speak of and live within the era of countervailing power. In this language and practice power is a force exercised by one actor to enforce its will against another actor against whom power is exerted. I contend that this language inculcates an individual and social passivity in which citizens rely upon various types of representatives to constitute health care for them in a manner in which they do not and cannot participate. However, this language of power and the political and social practice with which it is associated is merely a contingent, historical product. I claim that an alternative discourse of power is possible, in which power consists of the social interactions in which all of us mutually participate but no one of us can control. Power in this sense is participatory by nature, and because no one is in control, it makes no sense to relegate tasks to specialized, nonparticipatory domains. This alternative discourse of power, therefore, might call forth participatory practices in health care and a concomitant diminution of specialization and expansion of the public sphere. The result would be to blur the lines separating politics from everyday interaction, politics from economy, professionals from patients, and insurers from insureds. Participation would mean much more than casting a vote or writing a check but would also include the mutual sharing of time and energy in the tasks that need to be done: long-term and short-term care, practices of prevention, caring for the chronically ill, and monitoring bureaucratic and professional activities.

Scientism and economism in the regulation of health care.

As health care costs continue their apparently relentless rise, it seems to be universally perceived that the United States and western Europe are gripped by a cost crisis. To resolve the apparent crisis, U.S. and western European governments and third-party payers are turning increasingly to a new positivist discipline, called health services research, for which neoclassical health economics is the dominant discourse. However this discipline may actually reinforce the strength of biomedical positivism and the concomitant technological imperative. Like biomedicine, health services research is technologically driven, dependent on "advances" that generate more comprehensive and therefore more "accurate" data. Accordingly, just as biomedicine causes health care workers and patients to depend on technologies for diagnosis and treatment, health services research instills in the body politic dependence on technocratically conceived solutions for political problems. Moreover, because biomedicine and health services research share positivist epistemic and methodological premises, both objectify the subjects they study, abstract those subjects from context, and thereby ignore the cultural dimensions of the problems at hand. Rather than inculcate an ethic and practice in which medicine focuses on the meaning of illness for a life, a cultural phenomenon, this form of positivism strengthens the tendency to reject meaning in favor of the causes and course of disease and the abstracted probability of its occurrence. Accordingly health services research and the forms of regulation with which it is allied threaten to overwhelm the medical humanities movement. Furthermore this scientism precludes the institutionalization of political forums in which we can deliberate on the meaning of medicine, health, and death in our lives.