The Maintenance of Professional Authority: The Case of Physicians and Hospitals in the United States

Abstract

Professions are a mode of organization in which work is highly uncertain and contingent, requiring professional practitioners to rely heavily on their individual skill and judgment within the norms of accepted practice for their particular professions. But professionals must often draw on resources that are concentrated in institutions that they do not control. While these organizations may be intended specifically to assist professionals in the independent use of their judgment and skill, they nevertheless pose problems because they are most often not owned by these professionals and their administration is not entirely under professional control. This creates the potential for conflicts between independent practitioners, who seek to preserve their authority and autonomy, and the administrators of complementary institutions, who have responsibilities of their own. In this article, we examine the growing tension between the monitoring of the use of hospital-based resources and the maintenance of profession authority and autonomy in the medical profession in the United States since 1918. We begin by describing the connection between individual and collective autonomy and authority within professions as network organizations, and then trace the development of monitoring procedures and discuss their impact on the ability of physicians to use their individual judgment in treating patients. We show that, from the end of the First World War, the professional behavior of physicians was monitored on the Joint Commission Model in which boards composed of local medical practitioners sought to maintain professional standards and allocate local resources but did not inquire into cost factors at the system level. More recently, however, privately-sponsored health-care reforms as well as various government programs have led to significant changes. Now, the use of physical resources by physicians is also monitored in ways that may impinge on their authority and autonomy.

JEL Classification: I1, L2, L3