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In the Public Interest

In the Public Interest: Medical Licensing and the Disciplinary Process

Ruth Horowitz
Copyright Date: 2013
Published by: Rutgers University Press
Pages: 268
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  • Book Info
    In the Public Interest
    Book Description:

    How do we know when physicians practice medicine safely? Can we trust doctors to discipline their own? What is a proper role of experts in a democracy?In the Public Interestraises these provocative questions, using medical licensing and discipline to advocate for a needed overhaul of how we decide public good in a society dominated by private interest groups. Throughout the twentieth century, American physicians built a powerful profession, but their drive toward professional autonomy has made outside observers increasingly concerned about physicians' ability to separate their own interests from those of the general public.Ruth Horowitz traces the history of medical licensure and the mechanisms that democratic societies have developed to certify doctors to deliver critical services. Combining her skills as a public member of medical licensing boards and as an ethnographer, Horowitz illuminates the workings of the crucial public institutions charged with maintaining public safety. She demonstrates the complex agendas different actors bring to board deliberations, the variations in the board authority across the country, the unevenly distributed institutional resources available to board members, and the difficulties non-physician members face as they struggle to balance interests of the parties involved.In the Public Interestsuggests new procedures, resource allocation, and educational initiatives to increase physician oversight. Horowitz makes the case for regulations modeled after deliberative democracy that promise to open debates to the general public and allow public members to take a more active part in the decision-making process that affects vital community interests.

    eISBN: 978-0-8135-5428-0
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Acknowledgments
    (pp. vii-viii)
  4. List of Abbreviations
    (pp. ix-xii)
  5. Introduction: Medical Boards and the Public Interest
    (pp. 1-9)

    We know from numerous surveys that most of us are satisfied with our personal doctors. And yet doubts occasionally surface as to whether a doctor did the right thing or put our interests first. How do we know our physicians are competent, ethically fit, and have our best interests at heart? Could a doctor have spotted a tumor before it spread? What do you do if your doctor acts strangely, operates on the wrong body part, reeks of alcohol, or touches you inappropriately?

    All such questions involve issues of public interest and trust. Democratic societies develop mechanisms to ensure medical...

  6. Chapter 1 Public Member, Researcher, and Public Sociologist: The Genesis of a Project
    (pp. 10-31)

    My position as a board member evolved over time. I started as a citizen doing my civic duty, a member of society who happened to be a sociologist, invited to serve first on Board A, then Board B. With the passage of time, my role as a committed intellectual made itself felt, and I slowly became an organic public sociologist in dialogue with public advocacy groups and medical professionals.¹ As my roles merged, the multiple vantage points fed back and forth, providing me a richer understanding. I was also in a position to cultivate a heightened reflexivity in understanding the...

  7. Chapter 2 How Licensure Became a Medical Institution
    (pp. 32-56)

    Eliot Freidson argues that the handful of occupations deemed to be “professions” proper have credentialed practitioners given the exclusive right to provide designated services.¹ Other social scientists provide lists of characteristics of professions or stages distinguishing emerging professions. While there is no checklist against which one can gauge an occupation’s professional standing, there are features that clearly enhance a field’s prestige and give its members reason to claim coveted status enjoyed by established professions like law and medicine.²

    A body of theoretical and technical knowledge and the extensive training needed to master it mark established professional fields. Those in these...

  8. Chapter 3 Public Participation: The Federal Bureaucracy Starts a Public Dialogue
    (pp. 57-70)

    George Bernard Shaw saw the medical profession as self interested: “[Medical practice] is quite unregulated except by professional etiquette, which, as we have seen, has for its object, not the health of the patient or of the community at large, but the protection of the doctor’s livelihood and the concealment of his errors.”¹ While Shaw’s early criticism produced tangible results in 1926 in England with the addition of a public member to its medical regulatory board, the General Medical Council, in the United States, the issue of board accountability and public participation would not arise until the 1970s. It was...

  9. Chapter 4 The State, the Media, and the Shaping of Public Opinion
    (pp. 71-97)

    Local medical societies often resisted changes, yielding only when media campaigns grew too hot and when boards found they had less to do since licensure issues were largely resolved by the use of national exams.¹ As George Bernard Shaw argued in the 1930s, “In the main, then, the doctor learns that if he gets ahead of the superstitions of his patients he is a ruined man; and the result is that he instinctively takes care not to get ahead of them. That is why all the changes came from the laity.”² The 1980s saw a gradual decoupling of boards from...

  10. Chapter 5 Rhetorics of Law, Medicine, and Public Interest Shape Board Work
    (pp. 98-119)

    The language of public protection slowly crept into board work, but it is still often overwhelmed by the discourses of medicine and law in shaping deliberations. The language of “protecting the public” began to appear regularly in theFederation Bulletinin the 1970s and was heard increasingly at Federation meetings. While no longer silenced, the voices of public members are often muffled, their votes sometimes fail to make a difference, and their role in board deliberations remains ambiguous—all of these problems reflect the difficulty of connecting with public constituencies.¹ Some critics insist that nothing much can be done to...

  11. Chapter 6 Medical and Legal Discourses in Investigatory Committees
    (pp. 120-149)

    By the end of the twentieth century board members took their disciplinary authority seriously, framing their goal as public protection. About 12 percent of cases largely concerned incompetence and negligence, but the majority focused on what Dr. Edmund Pellegrino considered character issues or what Charles Bosk characterized as failures of moral performance.¹ According to Pellegrino, “Board members must repress the temptation to protect the profession or retaliate for sometimes vindictive attacks on professional integrity by the media, patient groups, or other professions. . . . Failures of character are more numerous, more subtle, and perhaps, in sum total more damaging...

  12. Chapter 7 Hearing and Sanction Deliberations: Transparency and Fact Construction Issues
    (pp. 150-168)

    Only a small minority of cases, involving a wide range of behaviors (as described by Dr. Alan Schumacher, president of FSMB in 2000), are heard by a hearing panel, an administrative law judge (AJL), or a full board:

    A physician who offers fraudulent treatment to patients, sexually abuses them, or attends them under the influence of a mind altering substance has earned the attention of the state medical board . . . submit fraudulent tax returns, commit acts of spousal abuse, or be guilty of causing an accident while intoxicated. . . . To truly be a professional it is...

  13. Chapter 8 Democratic Deliberation and the Public Interest
    (pp. 169-190)

    For decades critics have wondered if letting professions police themselves was like allowing foxes to guard the chicken coop.¹ The licensure movement unfolded under the banner of ensuring quality of service and weeding out bad apples within the profession—a public-minded rationale, to be sure, yet as this book has sought to demonstrate, community interests have not always prevailed in the course of self-regulation. While social closure greatly improved the practice of medicine, professional autonomy also helped solidify physicians’ vested interests, which have not automatically aligned with the public good. The realization that doctors are propelled by self-interest as much...

  14. Conclusion: An Exercise in Democratic Governance
    (pp. 191-196)

    While bringing this project to a close, I did the paperwork required for my board reappointment. The process has grown more complicated in recent years, with extra forms and documents to produce. The change was made in the name of “good government,” but it reminds us how difficult achieving the intended outcome is and how far we still have to go to achieve democratic governance worthy of its name.

    Traditionally, board members invited to renew their appointments would submit letters of intent and update their vita. This time, attachments and forms sent to us were so massive they crashed my...

  15. Notes
    (pp. 197-228)
  16. References
    (pp. 229-246)
  17. Index
    (pp. 247-262)
  18. Back Matter
    (pp. 263-266)