Professional Monopolies in Medicine

Abstract

PHYSICIANS, LIKE OTHER PROFESSIONALS IN SOCIETY, stake out a scope of practice that gives them ownership rights to performing tasks within a specific clinical territory. Just as lawyers reserve exclusive rights to practice law and pharmacists to dispense pharmaceuticals, so also have physicians demarcated subspecialty lines. Oncologists are the cancer experts, obstetricians bring children into the world, pediatricians take care of children, and neurosurgeons perform brain surgery. These ownership rights constitute professional monopolies. In general, most societies encourage free competition and discourage monopolistic behavior, which restricts supply and raises prices above true costs. Societies do so through the legal system via antitrust legislation to prevent price fixing. Legal exceptions are granted in a few cases to promote other societal goals. In public utilities, for example, monopolies were formerly granted for reasons of standardization and economies of scale (ie, larger size reduces costs). In pharmaceuticals, monopolies are granted to promote innovation and discovery. The rationale for professional monopolies is competency: no one would want a computer engineer to fix plumbing problems. In the case of medicine, the stakes are higher because of the added concern for patient safety; the consequences of inadequate qualifications in medicine lead to disability or death, rather than leaking pipes in plumbing. Medical school dedifferentiates incoming students and lays a basis for general medical knowledge; residency and fellowship training are intended to redifferentiate graduates by teaching specific skills and knowledge necessary for their respective specialties. This partitioning of health care into numerous professions and the medical acts that each may perform is, in a broad sense, determined and monitored by licensing bodies that are occasionally directed by government edict. Specific medical tasks are sometimes determined by specialty certification bodies, sometimes by reimbursement authorities, and sometimes by local facility management. Therefore, precise boundaries are dynamic and disputable. As a result, “turf battles” often occur, with more than 1 professional group competing to perform the same task. These turf battles may occur between 2 members of the same specialty (eg, 2 cardiologists vying to perform procedures on the same patient population), between members of different specialties (eg, a general surgeon and a gastroenterologist both offering endoscopy), or even between 2 members of different health professions (eg, midwives and physicians competing to deliver neonates). In this Commentary, we briefly discuss 4 examples of turf battles to illustrate some of the issues that arise when professional monopolies are disputed in health care.