Review Essay: Avoiding conventional understandings: the enduring legacy of Eliot Freidson

Abstract

. . . insofar as my publications have been coherent and systematic, showing design, they do not reflect their origin in accident . . . I wish to discuss the interaction between the accidents of career and the designs of intellectual production. My aspiration was to avoid the conventional . . . I wanted to become a poet. Only later did I discover that sociology, too, could sustain a position of critical detachment from conventional institutions. Eliot Freidson The Development of Design by Accident [A Premature Autobiographical Note] 1978. The first sentence of the announcement of Eliot Freidson's death from the Office of Public Affairs at New York University, his academic home from 1961 to his retirement, describes him as a ‘founding figure in the sociology of the professions’. In the second paragraph, The Profession of Medicine is hailed as a ‘landmark study in the sociology of medicine’, which won the American Sociological Associations's Sorokin Award and has been translated into four languages. A description both so incorrect and so on target in the space of a few sentences is dizzying to comprehend. To those familiar with Durkheim, Marshall, Carr-Saunders and Wilson, T.H. Marshall, Hughes, Parsons and Weber, Freidson, for all his other noteworthy achievements, is not a founding figure in the sociology of professions. Rather, his work in that domain was revolutionary, changing the way sociologists ever after understood, researched and wrote about the professions. He is a founding figure in medical sociology – one whose contribution was so profoundly original that he played a major role in the explosive growth and institutional legitimation of this once marginalised area. One of Freidson's broadest and most enduring legacies was simply this: all of us who follow are obliged to treat what were once unquestioned theoretical assumptions about the nature of professional work as open issues for empirical inquiry. Freidson subordinated the study of medical labour to the sociology of work and occupations by using physicians as a test case. Freidson's work was inspired by workplace studies of humble workers in wiring rooms, machine shops or assembly lines rather than armchair pronouncements about the nobility of professional work. As a result, he never allowed us to forget that being a professional involved working at a job in order to make a living. For Freidson, a close analysis of the social organisation of the settings of medical work was critical if one wished to understand the natives’ point of view, and the claims to power and authority based upon it. When the medical profession is viewed from this perspective, settled pieties are overturned and exciting new lines of research are initiated. A consequence that flowed from recognising the critical importance of the work setting was the recognition that, however lofty physicians’ claims to serve the collective good, and however strong the collective wish of a needy laity to believe in them, behaviour that rested on appeals to a service ethic, a fiduciary duty, or public trust was always subject to empirical scrutiny. As a result, inquiries into the choices that physicians faced, and the decisions that they made, began to pay closer attention to the exigencies of the workplace, particularly the demands made by employers, lay or professional, and to view more sceptically claims that specialised knowledge was always deployed in the best interests of both individual patients and the collectivity. Freidson took seriously Parson's description of the physician's role as one in which professional authority is limited by ‘functional specificity’. Physicians are not experts in everything; rather, their expertise is limited to a body of theoretical knowledge related to health. Freidson was adamant about patrolling the borders of that specialised expertise, the sensible limits to the application of medical knowledge. Moreover, he used rigorous analytic standards to assess whether medical practice made sense, given the theoretical grounds used to justify it. Freidson's work is foundational for those who, early in the 1970s, began graduate studies in the sociology of medicine, the professions, or work and occupations. Extending a theme of one of his mentors, Everett Hughes, Freidson focused on the various ways that physicians attempted, successfully more often than not, to exert their influence and authority, to extend both their ‘license’ and ‘mandate’, and to reap all the advantages of monopolistic control of a marketplace. Part Three of The Profession of Medicine is titled ‘The Social Construction of Illness’ and describes one tactic to maintain and extend control – the power to define, diagnose and expand the domain of illness in need of expert intervention. To the best of my knowledge, this is the first extended application of labelling theory beyond mental illness to physical illness and disability. No longer described as neutral gatekeepers, physicians become active moral entrepreneurs, lobbying for an expanded jurisdiction in defining ‘the pathological’. In this discussion, Freidson both anticipated and animated the concern of medical sociologists who, following his lead, developed the concept of medicalization. Before moving on to discuss what made Eliot Freidson's voice as a sociologist so distinctive, morally grounded and politically impassioned, a brief comment on the arc of Freidson's career is necessary. This sketch of Freidson's rise to prominence within sociology highlights changes, not necessarily for the better, in the organisation of the academy. The features of his life that Freidson chooses to emphasise in his 1978 ‘premature’ autobiographical statement are precisely those that would preclude his admission to selective graduate programmes today. One failure of imagination among the young is the inability to picture their elders as once young themselves – unformed, full of uncertainties about the future, anxious to know if their efforts will both amount to anything of worth and, if they do, whether that worth will be recognised by others. Like Freidson, I was a graduate student at the University of Chicago. The Department of Sociology is found on the third floor of a building whose address is its name, 1126 East 59th Street. During my student years, a lounge was located along the main corridor. The lounge was furnished with two scratched round tables and a few rickety chairs. But for one feature, its inhospitable decor would have signalled that graduate students ought not to be lolling around – they needed to be elsewhere doing their work. The feature of the room that provided grandeur was found along the perimeter. One wall was framed by mullioned, leaded glass windows of the type that make clear why universities are often referred to as ‘ivory towers’. Bookshelves lined the other three walls. These were filled with dissertations bound in maroon with author and title engraved in gold-leaf lettering along the spine. On the kind of cold, windy winter day for which Chicago is rightly famous, I spent a lot of time gathering wool in this room. I would sit in the room and pull down the dissertations and read pages from them at random. Embarrassing as it is for me to admit this now, I thought of the Chicago School not in terms of the sociologists who, between the First and Second World Wars, worked with Park and Burgess describing ‘the mosaic of urban life’. Rather, whenever anyone referred to ‘the Chicago School’, I immediately thought of the cohort of sociologists who came to the department after the Second World War and who focused, typically although not exclusively, on the study of work and occupations: a cohort that included among others Howard Becker, Melville Dalton, Fred Davis, Erving Goffman, Joseph Gusfield, Oswald Hall, Donald Roy, and, of course, Eliot Freidson. The thought never occurred to me, despite the fact that I was leafing through their unpublished student work, that any of these astonishingly creative sociologists suffered uncertainties similar to mine when they were graduate students. I simply assumed that, as they all rose to prominence, they encountered no obstacles, that their career paths resembled superhighways much more than meandering country lanes. I assumed an aura of greatness was always attached to this group. I felt this especially keenly in the case of Eliot Freidson. In part, this was a reflection of the power and centrality for any neophyte of my era studying medical sociology of The Profession of Medicine, Professional Dominance and the anthology edited with Judith Lorber, unfortunately titled from today's perspective, even if then empirically accurate, Medical Men and their Work. In part, this was a response to the clarity, power and uniqueness of his voice, which combined tight propositional logic and empirical rigour with moral outrage. This tone was itself like that of many others in the field who found much in social arrangements about which to be outraged. The social critique in Freidson's discussion of physicians was apparent. However, the placement of the interpretations on which the critique rested mattered – they followed carefully assembled theoretical propositions buttressed by empirical data. If there were judgments being made – and it is impossible to deny that this was the case – these followed from sociological analysis that met the highest craft standards that the discipline was capable of setting. One did not need to agree with each and every one of Freidson's explanations of, conclusions about, or recommendations for reforming the profession of medicine. However, each was so firmly rooted in a theoretical context and buttressed with data that one had to engage with them; and, in so doing, sharpen one's own sociological vision. One had to take what he wrote very seriously. This serious engagement is the greatest homage one can pay to another's scholar's work. My own fantasies of the fast track that Freidson travelled on his way to a place of pre-eminence in the sociology of medicine were reinforced by the place of prominence he had attained as my own career was beginning. How many sociologists have an ASA section award named for them while they are still alive? The facts of the matter were, of course, much different from those I had imagined. ‘Design by Accident’, Freidson's autobiographical note, which somewhat playfully and, given the later development of his thinking, quite accurately, has the adjective ‘premature’ affixed to the subtitle, tells a very different story. The narrative bears repeating as a cautionary tale – one that reminds us that our own world has become a little too rigid and a little too orderly, and that there is much lost when we foreclose opportunities for those committed to doing something unconventional. Originality, creativity and the ability to turn a field on its head – all may be lost if we too firmly insist on having students jump over the requisite hurdles at a faster and yet faster rate. Freidson's recounting of his journey into sociology, and then to a lofty pinnacle within it, is a sober reminder that the race is not always to the swift – no matter how much administrative pressure is placed upon us to reduce ‘time to degree’ so that our programmes are well-regarded in the next US News and World Report survey. Eliot Freidson was the third child (and first) son of immigrant parents who ‘drifted away from Orthodox Judaism during the course of their lives’. As the family business prospered, the family moved from the Dorchester section of Boston to Brookline, then an upper-middle-class suburb. This was a place in which ‘“Yankee” norms, including its politely condescending form of anti-Semitism were dominant’. By high school, Freidson reports he was alienated from, and questioned the authority and virtue of, both Yankee and Jewish institutions. By his own account, he read voraciously but did little school work. He kept company with those who ‘drove automobiles too fast and drank too much’. Failing to graduate high school in the usual four years, he was sent to boarding school in Maine. High school diploma belatedly in hand, he entered the University of Maine. As rebellious in Maine as in Brookline, he continued to follow his own intellectual interests and, not surprisingly, compiled an unimpressive academic record. Upon discovering that the University of Chicago admitted students on the basis of an entrance exam, past poor performance notwithstanding, he applied and was accepted. There he spent six months as previously, following his own interests while ignoring formal coursework. In 1943, he entered the Army – he spent the next three years as a soldier, with ‘half the time’ spent in Italy. The curiously unrevealing ‘half the time in Italy’ signals for me how much Freidson valued his personal privacy – how much he wanted us to pay attention to his work rather than to him. It is hard not to wonder how his experience in the Armed Forces shaped his already problematic relationship to hierarchy, institutional authority, official rules and formal procedures, and then his later thinking and writing about systems of expert knowledge. Mustered out of the Army in 1946, Freidson returned to the University of Chicago. He claims that he was ‘still without any definite purpose or aim except to write’. He reports receiving no encouragement from professors in the Humanities and much support from David Riesman. Even so, exactly how he entered graduate study in sociology remained ‘entirely obscure’ in his memory. As a graduate student, he describes a familiar personal pattern – within the sociology department, he felt himself an outsider. The two faculty members who he mentions as critical influences are Robert Redfield in anthropology and W. Lloyd Warner, also an anthropologist but one with secondary appointments in sociology and human development, whose influence on the cohort of post-war graduate students at Chicago remains an untold chapter in the history of sociology. As a graduate student, he became involved in ‘exploring the problem of understanding the effect of mass communication on audiences, and the social character of language and symbolism’. While these were themes that engaged sociologists as they began to pay attention to the increasing importance of popular culture, they hardly foreshadow greatness as a medical sociologist. More disturbing still, having completed his dissertation, Freidson discovered that these topics had no market value at all. Even if they had, he reports that he entered a very depressed academic marketplace in which neither he nor any of his classmates had any prospects of a tenure track appointment. The postwar expansion of both the American economy, and with it, the system of higher education, was still some years distant. At this point, Freidson became something of an itinerant scholar. A two-year postdoctoral fellowship in the psychology department at the University of Illinois allowed him to publish some articles from his dissertation while beginning to pursue with Howard Becker ‘a continuing interest’ in occupations. He notes – with sadness – that this collaboration never resulted in any shared publications. The two years at Illinois were followed by a one-year research job in Philadelphia. Research support from the Russell Sage Foundation for a participant-observation study of a small college fell through at the last moment. The scramble for support that followed this unexpected turn of events led Freidson into medical sociology. A staff member from Russell Sage steered him to an experimental one-year ‘Social Science Residency’ at Montefiore Hospital in the Bronx. In this position, he immersed himself in an interview study of patients’ views of medical practice. In 1956, Freidson finally obtained a full-time academic job at City University of New York. Over the next few years, Freidson grew increasingly committed to studying the dynamics of a newly emerging form of medical practice, one he somewhat presciently realised, represented the future of medical practice: Health Maintenance Organisations (HMOs). Academic leaves to conduct research supported by external funding alternated with time teaching – a body of work in the not yet clearly identifiable field of medical sociology began to accumulate. In 1961, Freidson moved to New York University. Aside from the occasional sabbatical year spent elsewhere, he remained a member of the sociology department at NYU, which he chaired from 1976 to 1979. Nine years after moving to NYU, Profession of Medicine as well as Professional Dominance appeared. These two books cemented Freidson's position as a leading sociologist who, as it happened, studied the medical profession. Eighteen years passed between the receipt of the PhD and the publication of his Sorokin award-winning masterpiece – a pace more indicative of tenacity than a meteoric rise. While a lesser scholar might have rested on these laurels, Freidson did something much rarer and more admirable – he continued to evolve his understanding of the medical profession, recognising the dynamic between the profession and the larger cultural, social, economic and political context in which it was embedded. The dynamism of his sociological imagination becomes apparent when Profession of Medicine is compared to the last book published during his lifetime Professionalism: the Third Logic. Before turning to that comparison, however, we need to examine what made Profession of Medicine such a ground-breaking work. As Hippocrates is reported to have said, ‘Life is short, art is long’. What is true of life is also true of tributes in journals. Much of importance has to be compressed; much goes unsaid. As a consequence in characterising both Profession of Medicine and the evolution of Freidson's perspective on professional work, I will be forced to make some rather sweeping, but I hope not inaccurate, generalisations. Even if Freidson never succeeded in becoming the poet he aspired to be, with the publication of Profession of Medicine he, nonetheless, produced a classic that is Whitmanesque in scope: ‘[it] is huge, [it] contains multitudes’. He also succeeded in producing something of lasting worth that was, for its time, decidedly unconventional. Its propositions overturned so much of the prevailing wisdom of its time and have so completely become the conventional wisdom of our own that a student encountering the work for the first time today might wonder what all the fuss was about, why this work was considered so path-breaking when it first appeared. The book is, like many classics, simultaneously a product of its time and timeless. The sustained use of a conflict perspective to characterise the relationship between a profession and its lay clients identifies the work as a product of its time. Each of the first three sections inverts the then conventions for considering professional work. Instead of a consensual and co-operative working relationship between physicians and patients, Freidson sees conflict and diverging interests. Freidson takes the medical profession to task for manipulating patients by their selective use of expert knowledge. By failing to communicate the range of treatment options and choices to patients, physicians rob patients of their autonomy and, as a result, their fundamental liberty to make important life choices. Freidson was not the only sociologist to note the conflict and divergence of physician and patient interests. In his essays, Everett Hughes had long emphasised ‘the rough edges’ of practice – those places where the expectations, understandings and evaluations of professional and client diverge. Both Fred Davis and Julius Roth had written earlier about how physicians feign uncertainty as a strategy to enhance patient compliance with unpleasant treatment regimes. Anselm Strauss and Barney Glaser had written about the ‘closed awareness context’ or more simply the lack of candour that characterised physicians’ interactions with dying patients. Each of these analyses, however, was presented as a discrete case study. Freidson's accomplishment was to bring all these strands together and through them, as the subtitle of Profession of Medicine suggests –a study in applied knowledge– create an entirely original and comprehensive theory for understanding the role of the expert in modern society. Whatever its brilliance, however, had Profession of Medicine only marked a turn to conflict theory as a lens for viewing the relationship of doctor and patient, we would read it today for its historical interest alone. The ability of the medical profession to assert its dominance has waned considerably. No longer a dominant profession, physicians are hemmed in on all sides by what Donald Light has called ‘countervailing powers’, the former editor-in-chief of The New England Journal of Medicine, Arnold Relman, has called ‘the medical-industrial complex’ or Paul Starr has characterised as ‘the coming of the corporation of medicine’. Despite this dramatic shift in the social organisation of medical practice, a movement of tectonic plates large enough to reshape the landscape in which physicians work and the ecological niche in which they live, Profession of Medicine possesses a timeless quality. The book still rewards a close reading and rereading – I take something new away on my annual revisits for class preparation. The timelessness of the text is found in its two concluding chapters, a stirring restatement of the grand question that Weber stated in Science as a Vocation: In a democratic society which decisions are settled by expert knowledge and which are reserved for the people? As technical rationality possessed by experts grows, does it inevitably shrink the domain of substantive decision-making in the hands of the people? The concluding section of Part Four is full of angry rhetorical passages, all of which express outrage at the disjuncture between actions by the medical profession which are justified as using specialised knowledge for the collective good, and the baleful consequences for the public welfare of an unquestioning acceptance of this deployment of expertise. Freidson's own words make this point more sharply than any explication: ‘Indeed I now believe that expertise is more and more in danger of being used as a mask for power and privilege rather than, as it claims, as a mode of advancing the public interest’ (1970: 337). A somewhat polemical tone marks the conclusion of Profession of Medicine: ‘What professionals do represents their effective knowledge or expertise; how they regulate what they do in the pubic interest represents their effective service orientation or ethicality’ (1970: 361, emphasis in original). Using this criterion, Freidson asserts that the medical profession acts with precious little ethicality and displays a service ethic in the breach rather than the observance. The profession has left the social control of its members to the courts, does nothing to prevent its members from exploiting their privileged market position, and has exerted its influence in such areas as the social organisation of practice where it has no special expertise. The concluding paragraphs of Profession of Medicine invoke an image of a group of professionals isolated from the community that they exist to serve, blinded by self-delusion and deceit, and whose actions create a new, oppressive ‘tyranny’ while always claiming to serve the public good. In Doctoring Together: a Study in Professional Social Control (1975), the angry Old Testament Prophetic voice that Freidson used to close Profession of Medicine has been replaced by one more tempered and sad. This book is a study of a group of physicians organised along the lines that liberal reformers have suggested provides both optimal patient care and social control of colleagues. But optimal care and effective social control prove to be elusive goals. Little is done to create standards of care or to monitor the care that is given. Social control is exercised haltingly, and then only when spectacular incompetence provides administrators no alternative. Face-saving resignations and private boycotts substitute for more direct sanctions; errant colleagues are let go to do damage elsewhere. The medical profession is still dominant and Freidson is not sure what, save a ‘rededication to a service ethic’, is likely to improve this dismal state of affairs. By the time of his last work, Professionalism: the Third Logic (2001), the world of healthcare has changed; and Freidson's analysis has changed with it. Physicians are no longer quite so autonomous; their ability to act on their own, or on behalf of the patient's best interest, is constrained by both the need of public agencies to cut the costs of medical care and by private third-party insurers more interested in corporate profit than individual wellbeing. In short, there are three different logics – or heuristics – available for understanding how healthcare as a commodity is distributed: (1) determination by pure market forces, a world where individuals compete with one another to sell goods and services at the highest possible price and buy them at the lowest; (2) determination by large social organisations, either public or private, in which elaborate rules determine who gives, and who is entitled, to goods and services and (3) determination by workers with specialised knowledge who do not exploit their exclusive rights to control the distribution of goods and services because they are guided by both a pride in their own craft and a desire to serve the public. This third logic – the beneficent labour of professionals – has now become transformed from oppressive tyranny and a grand threat to civil liberties to the only source of effective leverage for organising the delivery of healthcare so that it serves the public interest. What made Freidson such a great sociologist, such a dynamic thinker, was his ability to reframe his analysis to fit the social context. At the time that Freidson wrote Profession of Medicine, there was an uncritical acceptance of the claims that the profession made; and if one graphs the rise in physician income before and after the adoption of Medicare, monopolistic control appears to have been used in exploitative ways that did abuse the public trust. When Freidson wrote Doctoring Together, he had become convinced, long before the advocates of ‘managed competition’, that health maintenance organisations were not capable of meeting the goals set for them. HMOs were unlikely to emphasise prevention, improve access, reduce demand for services or effectively regulate the quality of service. In 2001, when Professionalism: the Third Logic was published, government had been reinvented so that its operation was leaner, more efficient, more like a business. Private for-profit HMOs had replaced the more communitarian models of liberal reformers; the suspicion was commonplace that service denials were the exploitation of the patient's pain for profit. Trust in the healthcare system had eroded. In this context, the medical profession is no longer a danger – it represents the one group with the moral authority, however tarnished, to achieve genuine reform in the service of the public good. Freidson was a rare sociologist, one whose sociological imagination was so dynamic that he was able to recognise that different times called for a different analysis. He recognised that sociologists were free to create their own analyses but not necessarily under conditions of their own choosing. The last sentence of the announcement of Eliot Freidson's death expressed his wish that donations in his name be made to the Electronic Frontier Foundation, Doctors Without Borders or Human Rights Watch. The choice of these two organisations expresses perfectly the professional commitments forged in a lifetime of scholarship. First, individual patients rather than specialised experts need to have the freedom to determine how they wanted their illness treated. In a democratic society, civil liberty trumps expert knowledge. Second, the highest calling of a profession is to use its specialised knowledge to serve humanity. Both organisations display those characteristics that Freidson believed to be the highest expression of a professional calling: transparency, public accountability and a concern for the welfare of our global village. In death, as in life, Eliot Freidson used for himself the standard he set for others: actions not ideals were the only test of ethicality.