We chose to study two specialties within the medical profession that differ with regard to their working conditions: general practitioners (GPs) and surgeons. We assumed that both groups would have been confronted with the effects of marketization by now; GPs because their payment system has been changed and surgeons because several operations have become the object of market negotiations and may have been included in treatment guarantee packages.
Dutch GPs work in independent practices in the neighborhood of their patients. Most Dutch citizens have their own GP whom they can consult for health-related problems. Dutch surgeons work in hospitals. Patients are referred to surgeons by their GP (who functions as a gatekeeper to hospital care). Surgical work is more specialized than GP work and involves other contact with patients. We assumed that working conditions might influence the way in which doctors are confronted with elements of marketization. For example: GPs might be confronted most directly with demanding patient-consumers whereas surgeons might have to deal with eager hospital managers, looking for quick wins.
We chose to do qualitative research. This would allow us to ask respondents for all sort examples of marketization they encountered in their work which we could not construe beforehand. Moreover we could ask them to discuss these examples and their ideas about them at length, thus allowing for more insights and more nuance than would have been possible in a written questionnaire.
We performed 27 interviews with surgeons and 28 with general practitioners in 2008 and 2009. We strove to interview both male and female doctors, doctors of different generations, doctors working in different regions of the country (more and less urbanized) and surgeons working in different types of hospitals (academic hospitals where surgeons have a fixed salary as well as smaller hospitals ‘in the periphery’ where surgeons get paid on a fee for service basis) We did not include surgeons working in newly founded private clinics (zelfstandige behandelcentra) who specialize in certain types of surgery (e.g. cosmetic surgery, eye surgery or varicose vein surgery). Although these newly founded clinics may be considered a direct result of marketization in health care we assumed that medical staff in these clinics would be a special segment of the profession. We wanted to find out how market changes play out for rank and file medical professionals in ‘ordinary’ settings.
Obviously the number of respondents is too small to establish correlations (such as: surgeons in the periphery are more affected by the marketization of health care than surgeons operating in academic hospitals), but our attempt to achieve variation will at least prevent us from drawing conclusions based on the experiences of one particular type of doctors in one particular hospital or one specific municipality. Table provides an overview of the respondents and their background.
The interviews were semi-structured and part of a broader research project, relating to two other topics besides marketization (the growing percentage of well educated, well informed patients and the growing percentage of female doctors).1
With regard to marketization we asked our respondents whether they had noticed any changes in their work as an effect of marketization. Most respondents had an understanding of what marketization meant in the context of Dutch health care in general and their own work in particular,2
but for those respondents who asked for a clarification we provided some examples, such as: more competition between care providers, more marketing and public relations, fear of losing customers, shifting priorities. After their first answers we asked our respondents to elaborate. If they had noticed change as a result of marketization we asked them to give examples and to describe their thoughts and feelings about the changes they saw. If they had not noticed any change we would ask them if they had witnessed changes outside their direct environment, that is: in other hospitals, other GP practices, other parts of the country or other specialties.
We did not specifically ask our respondents if they had noticed any bending or breaching of medical professional principles, since such questions would be leading in nature. However, we had considered three specific medical-ethical principles that might change as a consequence of marketization. These principles were:
- The principle that physicians should regard other physicians as their ‘brothers’, a moral norm which might change as a consequence of more and harsher competition among doctors;
- The principle that patients ought to be treated according to urgency and medical need, which might change if certain patients come to be more profitable than others and
- The ‘primum non nocere’, first of all do no harm principle, which might change because a more market oriented ethic could make physicians more inclined to ‘sell’ unnecessary and thus potentially harmful treatments or diagnostic interventions.
We will address each of these principles in the presentation of our findings.
The interviews were transcribed verbatim and were then analysed in a two phase model. During the first phase the first author coded the interview material using the computer programme Atlas-ti. Atlas-ti allows the researcher to first establish broad categories and then subdivide these into smaller categories. For our research project we used three broad categories, related to the three topics we wanted to investigate. For this article we selected all interview fragments related to market developments in the health care system (one of the three broader categories). The first researcher coded these fragments in smaller categories.
During the second phase the two other researchers read all interview transcriptions and checked the codes attributed to the interview fragments by the first researcher, so as to enhance the validity of our analysis.