Journal of Management & Marketing in Healthcare

ISSN: 1753-3031 (Print) 1753-304X (Online) Journal homepage: https://www.tandfonline.com/loi/yjhm19

The demise of the 'iatrocracy'

Ole Berg

To cite this article: Ole Berg (2008) The demise of the 'iatrocracy', Journal of Management &
Marketing in Healthcare, 1:2, 117-119, DOI: 10.1179/mmh.2008.1.2.117
To link to this article: https://doi.org/10.1179/mmh.2008.1.2.117

Published online: 18 Jul 2013.

Submit your article to this journal

Article views: 685

View related articles

Citing articles: 2 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=yjhm20
MMH_022.qxd 12/14/07 2:16 PM Page 117

Editorial
The demise of the ‘iatrocracy’
Until about a generation ago, most healthcare organisations, indeed healthcare systems, in most
western countries were organised and managed as ‘iatrocracies’, that is, physician-dominated
systems.1 The closer one got to the clinical level, the more iatrocratic they were. Clinical
organisations still bear much of the stamp of the iatrocracy, and the iatrocratic regime still lingers in
the minds of those who incarnated it, the physicians, and all the others — the nurses, administrators,
technicians and patients — who mostly took it for granted. Since the 1960s and 1970s, this
managerial system has come under increasing attack, and it has started to crumble. We cannot yet
talk about its demise in any healthcare system, whether Bismarckian, Beveridgean or American, but
we can discern it in the not too distant future.
Some may claim that the iatrocracy is not giving way to another system but is simply transforming
itself. Old-style and managerially amateurish medical management is giving way to a more
professional, indeed increasingly evidence-based, clinical governance. I shall argue that the iatrocracy
is coming apart in ‘all’ western countries, and yielding to a different kind of regime. The new system
will be industrial and increasingly also businesslike. It represents the fusion of the logics represented
by the technologist and the MBA. One may argue that it contains a neo-iatrocratic element,
represented by the new breed of ‘indirect’ clinicians in the growing institutions of knowledge-based
medical governance, but I maintain that this ‘indirect’ medicine fits well into the emerging
industrialising clinic.2 Indeed, it is a precondition for its success: it provides the new managers of
care with the technical means to industrialise.
The iatrocracy has its basis in the original medical organisation — the solo practice. The physician
in practice was an autonomous practitioner; that is, he managed himself, and partly his patients.
There was some sort of outside management, but that came from his colleagues, the only ones
competent to keep him under some kind of surveillance. Where there were public physicians they
were also by and large autonomous practitioners. Even the central administration of healthcare was to
some extent dominated by physicians and medical concerns. Health administration was, by most
physicians, regarded as merely indirect medical practice. Politicians and bureaucrats did not always
see it in that way, but to some extent, the iatrocracy in most countries extended all the way up to the
bureaucratic and even political level.
The iatrocracy also extended downward, to the market. By obliging themselves not to behave
competitively vis-à-vis one another, physicians were able to suppress much of the market as an
invisible managerial ‘agent’. To suppress the ‘invisible hand’ further, physicians fostered a culture of
trust and loyalty among patients. Physicians did of course allow patients the freedom to choose
physicians, but emphasising the importance of continuity, they effectively restricted that choice.
Ideally, it became a once-and-for-all choice.
The collegial control had two components, a cultural, or pedagogical, and a social. Physicians were
to be managed primarily through primary and continuing education. To ensure the effectiveness of
this pedagogical management, a social management was added. Physicians overviewed one another
through the collegial network, though mostly informally, and intervened, though again often
informally, if some were to fail either commercially (eg by advertising their services too blatantly),
professionally or ethically. The social control was an important part of the tacit pact into which
medicine had entered with society. Medicine could retain its autonomy to the extent that it behaved
itself.

© HENRY STEWART PUBLICATIONS 1753-3031. Journal of Management & Marketing in Healthcare. VOL. 1 NO. 2. PP 117–119. JANUARY 2008 117
MMH_022.qxd 12/14/07 2:16 PM Page 118

Editorial

In a fundamental way, the source of the demise can be found within medicine itself, and its
companion disciplines of technology and chemistry. The supply-side development spawned a plethora
of new opportunities for diagnosis and treatment. This development led to a radical specialisation of
the clinic and a steep rise in the need for personnel. All this gave rise to a cost explosion and to
dramatically increased coordination problems. In other words, it created a need for a more
specialised, professional management. Hence managerial functions were shifted from clinical
physicians to a new breed of managers, often trained in business schools.
Many physicians reacted negatively to what, in the USA, was called managed care. But not only
had they contributed significantly to making such care more necessary, they now also started to
fashion medicine in such a way that managed, industrialised care became a real possibility. They,
or some of them, did so by beginning to divide care into a number of increasingly standardised
procedures. Specialisation and standardisation are necessary conditions for industrialising care, for
creating clinical pathways. In hospitals this means creating the equivalent of the manufacturing
assembly line. We are there today. The standardisation of procedures is proceeding apace, and the
once iatrocratically-managed hospital departments are becoming work stations in an increasingly
process-oriented form of (supply chain) management. Just like the similar process, which began in
England in the mid-18th century and led to the demise of many of the old crafts and their guilds, the
current standardisation of medical care may lead to the demise of the physician as an autonomous
professional and medicine as a profession. The more successful the efforts to standardise and to
streamline medical care, the more likely it becomes that extensively trained, and costly, physicians may
be replaced with very specialised, technically trained, and cheaper medics of various sorts.
We could dramatise their role yet further: they are making it easier for the industrialisers to start
not just the destruction of the iatrocracy but also medicine as a relatively integrated discipline and
profession. They are contributing to ushering in the post-physician era that the US psychiatrist
Jerrold Maxmen in 1976 predicted would become reality by the end of the first quarter of this
century.3
Under this industrial regime, physicians will become ‘indirect’ carers. They will retreat to the
arenas backstage, where they can work as basic and applied researchers, as procedure and technology
(co)developers, and as ‘production line’ planners and monitors. They may also still, for some time
to come, function as consultants, but then in the true sense of that word. In other words, they will
work like engineering graduates, as theoreticians more than as practitioners. There will be far fewer
of them.
It remains to be seen whether this development will be driven most energetically by increasingly
financially-strained public agencies or by private investors. In the long run it is my prediction that the
latter will play a growing role. In spite of the industrialisation of care, costs will continue to rise, and
thus a re-privatisation of the financing of an expanding part of healthcare is unavoidable. As this
happens, investors will be attracted.
What I am depicting is the general trend that we are now witnessing — I am just extrapolating a
little. The question is whether the iatrocracy may have a new lease of life. It may be argued that
medical specialisation can never be a true specialisation: the specialist must also to some extent
remain a generalist. The human body is after all an integrated whole and not a construct (I assume).
Further, it may be argued that standardisation is only to some extent possible. This is so both because
the biology is so complex and varied and because the procedures cannot be designed without any
reference to the carer, but above all, to the patient. In addition, medicine contains a pedagogical
element that should be regarded as an integral part of the care. Medical care is to an important extent
interactive. As Albert Schweitzer once remarked, one of the physician’s main challenges is to
mobilise the doctor who resides in each and every patient.4 Given these characteristics of medical
care there are also limits as to how far one can pre-program treatment lines from above. Physicians
may also be allowed some managerial discretion in the clinic.

118 © HENRY STEWART PUBLICATIONS 1753-3031. Journal of Management & Marketing in Healthcare. VOL. 1 NO. 2. PP 117–119. JANUARY 2008
MMH_022.qxd 12/14/07 2:16 PM Page 119

Editorial

Hence, there is potential for a renewal of elements of the iatrocracy, but whether this potential is
going to be realised remains to be seen. What we are witnessing now is a regime on the defensive.
Whether a renewal of the iatrocracy is to come about is, obviously, up to the physicians. The current
trendsetters among them are not showing many signs of trying to revitalise the iatrocracy, nor even to
consider how the industrial logic can be adapted to and reconciled with the iatrocratic logic. True,
many clinicians do express doubts about current developments. However, if they are to achieve
constructive results they have to make an impression on their ‘backstage’ colleagues.

Ole Berg
Professor of Healthcare Management,
University of Oslo
Editorial Board Member
Journal of Management & Marketing in Healthcare

References
1. From Greek iatros (physician) and kratein (to rule).
2. By ‘indirect’ clinicians I mean physicians who provide the clinic with clinical premises (often
as guidelines), but do not do so based on their clinical experience. Most of these physicians
are researchers, knowledge ‘organisers’ (like the Cochrane Collaboration) and knowledge disseminators.
3. Maxmen, J. S. (1976) The Post-Physician Era, Wiley, New York.
4. Cousins, N. (1979) Anatomy of an Illness as Perceived by the Patient: Reflections on Healing and Regeneration, W. W. Norton, New
York, p. 69.

© HENRY STEWART PUBLICATIONS 1753-3031. Journal of Management & Marketing in Healthcare. VOL. 1 NO. 2. PP 117–119. JANUARY 2008 119