Book Reviews |
The Company Doctor: Risk, Responsibility and Professionalism
E Draper. New York: Russell Sage Foundation, 2003; 397 , index.
This book could have been a valuable contribution to the literature on health services in the United States, in the tradition of Paul Starr's The Social Transformation of American Medicine [1]. It could have documented the rise of occupational medicine as a story of maturation and adaptation gained the hard way through bitter experience, ups and downs, hard knocks, and changing attitudes and have been the successor to an earlier outstanding work, Diane Chapman Walsh's Corporate Physicians [2]. All the elements of a masterpiece are there—and tragically wasted.
Elaine Draper is assistant professor of sociology at California State University, Los Angeles, a lawyer and the author of Risky Business, a highly respected title on genetic testing (Cambridge University Press, 1991). She can be held to a high standard. This book was based on 100 interviews she conducted with American occupational physicians.
The basic premise of the work is that a corporate structure has been imposed on the practice of medicine by employers and various organizations concerned with the business of medicine and that this has created conflicts between the physicians' loyalty to their employers and medical professionalism. Draper uses occupational medicine as a case study, with an emphasis on its perceived failings and image problems. She does not convey the message that the history of occupational medicine can be read both as a cautionary tale and as a success story.
Her book starts with an inadequate and inaccurate history of occupational medicine in the United States. Much of the background material is superficial or off point, reflects uncritical conventional wisdom or contains technical errors. Important developments in medical–legal work are ignored and treated as unsavoury, reflexively assuming that occupational physicians are always defence experts.
The essential part is the second chapter, which explores loyalty and professionalism, her primary interest. It falls far short of potential because it treats conflicts between employer and loyalty and medical professionalism in occupational medicine as a static, structural problem. There is no discussion of how conscientious occupational physicians navigate these issues, which they do, for the most part successfully, every day. By contrast, her treatment of the many similar situations elsewhere in medicine is strictly cursory. Priorities in managed care, health care rationing and population health management often conflict with individual care and patient interests. In that sense, the rest of medicine is ‘catching up’ to issues and the sense of ethical ambiguity that occupational medicine has dealt with from its inception.
Occupational medicine pioneered the practice of medical care undertaken within large organizations. It experienced a great setback in the United States in the 1950s, when it was bitterly opposed and denounced as unethical, together with group medical practices and prepaid healthcare, as the insidious face of ‘socialized medicine’. In the fullness of time, occupational medicine showed that preserving a form of practice that existed mainly for the convenience of the individual practitioner was not at bottom an ethical issue after all and that the future would inevitably force different forms of organization of health care. In this light, arguments from the 1950s look prescient in hindsight, predicting the coming era of institutionally organized and managed health care delivery and calling on American physicians to embrace, steer and manage the process. In the end, they did not, because they were too busy denying or opposing the inevitable, and as a consequence ended up working for someone else.
Occupational medicine, and what happened to it within the memory of the older physicians she interviewed, was a bellwether of major changes in health care in the United States. Draper missed the biggest story remaining to be told in the history of health services, which is how occupational medicine pioneered using the power of organizations and employment to advance health and well being, for the benefit of the worker as well as the employer and for society as a whole. Pity.
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References |
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 Top References |
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- Starr P. The Social Transformation of American Medicine (1982) New York: Basic Books.
- Walsh DC. Corporate Physicians: Between Medicine and Management (1987) New Haven, CT: Yale University Press.
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