The Death of the Professional: Are Doctors, Lawyers and Accountants Becoming Obsolete?

Yves here. Many members of the top 10% regard their role in society as relatively secure, particularly if the are in a niche that serves the capital-deploying 1% or better yet, 0.1%. But a new book suggest their position is not secure. And trends in motion confirm this dour reading, such as the marked decline in law school enrollments, and the trend in the US to force doctors to practice out of hospitals or HMOs, where they are salaried and are required to adhere to corporate care guidelines. For instance, my MD is about to have her practice bought out, and is looking hard as to whether she can establish a concierge practice. Mind you, she appears regularly on TV and writes a monthly column for a national magazine [not that is how I found her or why I use her]. Yet she has real doubts as to whether she can support all the overhead. If someone with a profile can’t make a go at it solo in a market like Manhattan, pray tell, who can?

Adapted from the new book The Future of the Professions by Richard Susskind & Daniel Susskind (Oxford University Press, 2015).Originally published at Alternet

The end of the professional era is characterized by four trends: the move from bespoke service; the bypassing of traditional gatekeepers; a shift from a reactive to a proactive approach to professional work; and the more-for-less challenge.

The Move From Bespoke (Custom) Service

For centuries, much professional work has been handled in the manner of a craft. Individual experts and specialists—people who know more than others—have offered an essentially bespoke service (“bespoke” is British for “custom”). In the language of the tailor, their product has been “made-to-measure” rather than “off-the-peg.” For each recipient the service has been disposable (used once only), handcrafted ordinarily by a solitary scribe or sole trusted adviser, often in the spirit of an artist who starts each project afresh with a blank canvas.

Our research strongly suggests that bespoke professional work in this vein looks set to fade from prominence, as other crafts (like tailoring and tallow chandlering) have done over the centuries. Significant elements of professional work are being routinized: in checklists, standard form materials, and in various sorts of systems, many of which are available online. Meanwhile, the work that remains for human beings to handle conventionally  is often not conducted by individual craftspeople, but collaboratively in teams, sometimes collocated, but more often virtually. And, with the advance of increasingly capable machines, some work may not be conducted by human beings at all.

Just as we witnessed the “death of gentlemanly capitalism” in the banks in the 1980s, we seem to be observing a similar decline in bespoke professionalism.

The Bypassed Gatekeepers

In the past, when in need of expert guidance we turned to the professions. Their members knew things that others did not, and we drew on their knowledge and experience to solve our problems. Each profession acted as a “gatekeeper” of its own, distinct body of practical expertise. Today this set-up is under threat.

We are already seeing some work being wrested from the hands of traditional professions. Some of the competition is coming from within. We observe professionals from different professions doing each other’s work. They even speak of “eating one another’s lunch.” Accountants and consultants, for example, are particularly effective at encroaching on the business of lawyers and actuaries. We also see intra-professional friction, when, for example, nurses take on work that used to be exclusive to doctors, or paralegals are engaged to perform tasks that formerly were the province of lawyers.

But the competition is also advancing from outside the traditional boundaries of the professions—from new people and different institutions. We see a recurring need to draw on people with very different skills, talents, and ways of working. Practicing doctors, priests, teachers, and auditors did not, for example, develop the software that supports the systems that we describe. Stepping forward instead are data scientists, process analysts, knowledge engineers, systems engineers, and many more. Today, professionals still provide much of the content, but in time they may find themselves down-staged by these new specialists. We also see a diverse set of institutions entering the fray—business process outsourcers, retail brands, Internet companies, major software and service vendors, to name a few. What these providers have in common is that they look nothing like twentieth-century doctors, accountants, architects, and the rest.

More than this, human experts in the professions are no longer the only source of practical expertise. There are illustrations of practical expertise being made available by recipientsof professional work—in effect, sidestepping the gatekeepers. On various platforms, typically online, people share their past experience and help others to resolve similar problems. These “communities of experience,” as we call them, are springing up across many professions (for example, PatientsLikeMe and the WebMD communities in medicine). We say more about them in a moment. More radical still are systems and machines that themselves generate practical expertise. These are underpinned by a variety of advanced techniques, such as Big Data and artificial intelligence. These platforms and systems tend not to be owned and run by the traditional professions. Whether those who do so will in turn become “new gatekeepers” is a subject of some concern.

The keys to the kingdom are changing. Or, if not changing, they are at least being shared with others.

Shift From Reactive to Proactive

Traditional professional work is reactive in nature. The recipient of the service tends to initiate the engagement and then the professional responds.

There is a paradox here, in that the burden of recognizing that professional help is needed lies in the hands of the inexpert. Sometimes the trigger can be obvious—for instance, an unbearable pain, an eviction notice, receipt of a threatening letter from a tax authority, or a meltdown over homework— but often recipients do not know if, or at least when, they should best seek advice. When they are eventually (and unhelpfully) told that it would have been better if they had sought help many weeks earlier, we see the paradox in action. It seems you need to be an expert to know if and when to consult an expert. The concern here is that problems have often escalated unnecessarily by the time a professional is called upon.

To tackle this problem, professional work is becoming increasingly proactive. We have witnessed this phenomenon for some years in health, for example, in the shift towards preventative medicine and health promotion. People are encouraged to opt for exercise and sensible eating rather than heart surgery, or to limit their exposure to the sun rather than have chemotherapy for melanoma. People generally prefer problem-avoidance and problem-containment to problem-solving. In short, they prefer a fence at the top of the cliff to an ambulance at the bottom. And yet, traditional, reactive providers, in their quest for greater efficiency, are often preoccupied with equipping the ambulance better than rivals or ensuring its arrival at the scene of the problem sooner than competitors.

There is evidence that this is changing in sophisticated ways. In medicine, for example, remote monitoring systems track patients’ vital signs, and can prompt an intervention before the patient realizes something might be wrong. In education, personalized learning systems track students’ progress, and can provide advance warning of particular difficulties in understanding. In some professions, this shift to proactivity is expressed as a growing focus on risk management. Another dimension to this issue is that proactivity can be achieved by “embedding” practical expertise in our machines, working practices, and regular daily activities.

The More-for-less Challenge

A more prosaic driver of change is the intense cost pressure that we find across the professions. All recipients of professional service, from major corporations to individual consumers, seem to be short of money. More than this, though, managers in businesses complain not only of shrinking budgets but also that they have more need of professional help. Industry and commerce are becoming increasingly complex, which means that there are more calls for professional help from lawyers, consultants, accountants, tax advisers, amongst others. Similarly, hospitals and schools, especially those that are publicly funded, are also strained, always balancing smaller purses with growing demand. We call this problem the “more-for-less” challenge. How can we find ways of delivering more professional service at less cost? Most individuals and organizations are struggling to respond.

It might be thought that the more-for-less challenge is a child of the global economic downturn. However, in our research and consulting work in 2004 and 2005, prior to the crisis, we were already hearing from the clients of professional firms that cost pressures were building. The recession, we suggest, was an accelerator of a trend that began to take shape a few years before. The challenge will continue after the recovery.

In broad terms, we observe two responses to the challenge—what we have called the “efficiency strategy” and the “collaboration strategy.” The former involves finding ways of cutting the costs of professional work, while the latter requires that users of the professions should come together and share the costs of the service. Both strategies tend to rely on technology.

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67 comments

  1. susan the other

    Should we ever cut costs from the top down? By the time it gets the bottom we are all cut to the quick. So let’s instead look at what the shakedown will be and then do a better estimate of adjusting our economies from the grassroots back up without hardship. I don’t think we are above China’s contradictions – so let’s think it through. It’s like simmering good chile. Gotta thicken it up but gotta live the lid on. Hmmm. Of course it would help if we had a conscious, functioning legislature but we can forget that. So here we are. But let us not discount professionals. No computer is that agile or intuitive. Yet.

  2. polecat

    to have a truly functional legislature we would have to ban ALL professionals,as they profess only for their own vig!

    1. cincop8

      It is not in the nature of a legislature to be “truly functional” unless it represents a homogeneous collective. I submit that such a public would have no use for a legislature.

  3. Gio Bruno

    Plenty of interesting ideas presented in this Post.

    I see elements being manifested in my regular life (interaction w/ MD’s) and my professional life (landscape architect). The emphasis on “costs” is important, but an understanding of “value” is also needed.

    Computerization is definitely affecting doctors lives (digital medical records) and architects (computer graphics). Digital skills raise in importance, some personal touch (unique expression) is obscured.

    As for public agencies using private consultants: if you can’t ID the problem correctly, how do you know from whom to seek a solution? Professional people need to be on both sides of the table. (So the specialized lingo can be interpreted to the political folk.)

    It’s clear to me that the way the design profession functions has changed radically (over the last 30 years).

    [Have no idea why this comment appears in ITALICS.)

  4. Jim Haygood

    Not mentioned in regard to doctors is the issue of capital intensity. Using federal regulation, the health care cartel (hospitals, insurers, Big Pharma) is increasing regulatory overhead to the point that individual practitioners are no longer viable.

    As one example, federal regulations requiring increasing “meaningful use” of electronic health records have caused some individual practitioners with most of their career behind them to say “screw it, I’m retiring.”

    Big Biz has an agenda, and it’s about regulating small business out of existence with compliance burdens that only capital-intensive mega-corporations can shoulder.

    1. cincop8

      I think you’ve misinterpreted both motive and causality in this assessment. First, medium and large corporations are also struggling to deal with increasing regulation so it’s inaccurate to assert that only small business can’t cope. There is plenty of painful flailing happening inside every company in the world. The only reason people get to the top is the manage that confusion with an unending stream of happy horseshit and a good sales pitch. But they sure as shit are not “managing” anything besides their retirement packages.

      Then there is the matter of lobbying and political corruption to stem the tide of regulation. But regulation always follows some egregious abuse. There is no law on the books that addresses a crime that has not already been committed by someone somewhere somewhen. Similarly, there are no regulations disincenting smart, compassionate behaviors. That’s unattractive because everyone thinks they have a god given right to be rich. Society has confused the measure with the value.

      Too, regulation is often written by an administrative bureaucracy charged with interpreting legislative intent. Given the constant pressure on “costs,” the mind numbing nature of bureaucracy, and the itinerant mediocrity, well you can see where this is going.

      Or you might be witnessing attrition from enforcement actions which naturally fall on the small and weak because ambitious young prosecutors a) want the job at wall street or DC, so can’t make enemies, and b) don’t have the budgets to take on big companies.

      Capitalism is antithetical to Democracy, Democracy is not “business” it is civil society.

      When it comes to “healthcare”, that’s really now “insurance” and the provision of medical services is a commodity, just like hair clips and reality TV shows. Pine for the old fashioned ways all you want, and take cheer in knowing the food shortages that’ll start cropping up in a few years will make all of this seem pretty silly.

      1. Jim Haygood

        ‘medium and large corporations are also struggling to deal with increasing regulation’

        My claim is that large corporations don’t “struggle to deal with” regulation — they write it.

        Case in point, Obamacare was drafted by Liz Fowler, formerly of WellPoint.

        1. alex morfesis

          You nailed it on medical professionals…would like to add, that at least here in flori duh there seems to be massive pricing fraud by malpractice and liability insurance providers which state regulators allow to continue to force small or single practitioners to join groups by financial obliteration…at least in floriduh, there is the usual massive distortion suggesting insurance companies are paying out huge amounts when there in fact seems to be collusion amongst insurance companies neglecting the legal requirement to try to settle on good faith and end up forcing people to settle for pennies on the dollar…yet the insurance companies keep picking the pockets of medical professionals

          The proof is in how there is one premium cost if the medical provider is on their own and magically it is cheaper if theu are part of a group or hospital.. Same doctor…same practices…lower rates…prima facia evidence of insurance company rate fraud…

        2. dk

          Yes, and they let everybody else struggle with whatever they dish out.

          The insurers have created a tangle of incompatible record keeping that is unable to handle government initiatives for computerized record keeping. That is the in-place system that medical professional offices are being forced to use.. it’s a billing system, not build for medical needs. I’ve worked on/with a couple of these myself over the years… crappy legacy stuff.

          And in general, the quality of services and consumer products is being crapified.

  5. jrs

    Yes some of it is only logical though, if masses of the population see their income declining and yet the costs of medical care keeps increasing eventually noone can afford to see the doctor never mind the ACA etc.. And it can get to be this way with a lot of professional services less urgent and distorted than medical care, like soon noone can afford an accountant, you use turbo tax, a lawyer – no middle class people start to make their own wills. Many professions seek ever further protections of government for their guilds (more and more requirements to practice to try to preserve their privilege) and yet with nothing protecting the income of the other 80% (read: unions, that would be their role) unless they plan to only serve the fellow 20% …

    So solidarity? Yea, but making the solidarity argument with many (not all) members of such professions is a waste of time as they instinctively side with the 1s.

    1. Local to Oakland

      Re solidarity, you might be surprised. One reason law school enrollments are down is that it is becoming public knowledge that employment for graduates in upwardly mobile career positions is way down …

      Many are shunted into low level proletarian type legal work, churning out evidence for use in lawsuits owned and managed by large firms. Lawyers who do this earn less then a good paralegal with less job security and no benefits.

      1. ilporcupine

        It has been said Paralegals are being squeezed out, to make way for the huge increase in law graduates from prior class booms. Why not use cheap lawyers, with better credential, and desparate for employment?

        1. flora

          So much of the ‘grunt work’ of professions – once the entry and training province of new graduates – is now being done overseas by shops that specialize in legal research, or reading x-rays, or accounting and tax preparation. There are 3 downsides to this, in my opinion. New college grads have fewer entry slots. The ‘grunt work’ that grounds one in the full knowledge of the profession and how it works is slowly removed from the profession. That omission leaves future practitioners with an incomplete understanding. This loss makes them more reliant on big data as both assistant and excuse/defense, and makes them less master craftsmen (if I may use the term without giving offense) and more the front-end interface of one-size-fits-all processes. Very good for corporate profits. Not so good for the professions or their clients.

          1. guest

            Big Data is not a solution.

            Your first two points (no entry-level jobs for beginners, no acquisition of professional basics) are essential — and their detrimental effects are already painfully felt in some professions.

            Case in point: software development.

            Long ago, firms started off-shoring basic, tedious, repetitive tasks, generally considered as unrewarding, such as software testing or error correction to India. The idea was to focus on “high added-value” jobs such as system architects or project management, and leave low-level operations, supposedly requiring less qualifications, to cheaper Indian contractors.

            Decades later, there is a shortage of qualified people for those high-skilled jobs — precisely because fewer and fewer young people have had the possibility to

            (a) start in the profession at entry-level positions (when job postings all require qualifications as senior software engineer and five years experience, what do you do?)

            (b) learn the ropes and practice the skills from the ground up (the necessary step before rising in the professional hierarchy).

            The result? It is now necessary to import expensive project managers and system architects from foreign countries.

            From what I read, the UK has been especially hit by this phenomenon, because it was particularly enthusiastic about off-shoring IT to India.

          2. Valerie

            I agree on every point. This is an excellent comment that succinctly touches on some very relevant issues not addressed in the article.

    2. Phil

      Attorney’s work is being automated and outsourced. For more on one aspect of outsourcing:
      http://www.nytimes.com/2010/08/05/business/global/05legal.html?_r=2

      I can’t find the cite, but last year I read that some of the Indian companies that American law firms have outsourced to are now moving offices “stateside” to hire American attorneys, here.

      Bottom line: the race to the bottom for wages is “on”. Add to this job automation that will only get more efficient, over time.
      http://www.futuretech.ox.ac.uk/news-release-oxford-martin-school-study-shows-nearly-half-us-jobs-could-be-risk-computerisation

  6. mdh

    I have read this site daily for many years but have refrained from commenting, either from knowing too little [most of the time] or more than I felt comfortable trying to articulate. I spent my family residency in a high quality, reform/radically oriented program in the late 1970’s. The ideal was to revivify the art of diagnosing and caring for other people by teaching out of the biopsychosocial model articulated be George Engel at the University of Rochester. One of my faculty mentors, a student of Engel’s and editor of the Merck Manual, repeatedly emphasized that the most powerful diagnostic and therapeutic tool at the physician’s disposal was their relationship with the patient. It took me years of real world experience in private practice followed by a long stint in rural Honduras and AIDS and poverty clinic work to realize the truth of that claim. At least at the primary care level corporate employment has almost completely effaced this truth and it’s associated ethic. To paraphrase Wittgestein, the misuse of words easily beguiles our intelligence. The authors of this travesty use references to medicine and doctors without regard to their historic usage, to obscure and invert their meaning and they and their masters have largely prevailed in this unhappy country.

    1. Will

      Ditto, great comment. All I could think of while reading this was, “why would I go to doctors that follow checklists like that?”

      My mother used to co-run an independent medical practice as an MD. Then she joined MDVIP and had to get her patients to signup with a chunk of change each year (~$1600) which was revenue in addition to insurance payouts. My mom told me of one quite well-off (financially) patient who balked at the expense and left with her husband for another practice.

      What this woman didn’t realize was that my mom had bent over backwards for years for her patients, regularly putting in 90+ hour weeks and not reducing the quality of care despite not being paid well for it. My dad calculated she made less per hour than her secretary.

      This woman went to another doctor, saw the sort of treatment she received, including minimal time and attention, and then snuck into my mom’s office without seeing her, wrote a check, dropped it at the secretary’s desk, and left, and is now a happy patient again.

      1. Jim in SC

        My mom followed her longtime doctor to MDVIP. Her doctor sees far fewer patients than she did. There is a tradeoff: she no longer has hospital privileges, but fortunately, in part because of this GP’s excellent care, my mom stays out of the hospital. We are usually the only people in the office when she goes in for checkups.

        1. Lyle

          Actually the idea of the outpatient physician also doing hospital treatment as well is going away. The Hospitalist has taken over the hospital part of treatment. Note that this does imply that for a lot of outpatient things physicians are drastically overtrained (due to extending residency compared to 50 years ago for example). By doing this you can bring in the nurse practicioner/physicians assistant at the outpatient clinic, as well as having nurse practioners etc with specific training for hospitals.

      2. Inverness

        And you wonder why doctors have high suicide rates. Your mother sounds like an absolute Mensch, however, we shouldn’t accept a system that shoves people into this saint/worker drone paradigm. What bothers me is how these austerity practices grind people down…the people who really care, deeply, and want to help have to choose between being heroes or to accept the system “is what it is,” which is its own sort of moral death.

    2. Julia

      I agree with mdh. The system does not allow physicians to practice good quality medicine. Only profits matter, not quality of care. Both patients and physicians who take their profession seriously suffer the consequences of this disaster.

  7. ilporcupine

    I just tried to comment on this, and date on post says January 9, 4741 !! Time is also way off, (Hour, not just by Millenia.)

    1. Yves Smith Post author

      I don’ t know how you are getting that. As you can see from the date and time log under your handle, it’s not time stamped that way on the site and certainly not in the backstage either.

            1. ilporcupine

              Nope, not only is it still showing up with random dates, I am not alone. See comment from MyWag on the “Oil Limits” story. His showed some bizzarre 87xx date also. I wish I could post the screenshot here. Mine currently says Jan 10, 9250…I’m gonna party like it’s 9999…

              1. alfred

                If you have a Mac the little box with an upward pointing arrow to the right of the URL offers options that include “copy” and “print” for the page being viewed.

  8. armchair

    The Washington State Bar has initiated a legal technician program, and I find the timing questionable, even if the premise of the program is good-hearted. As the market is awash in underemployed, licensed attorneys, the Bar is going ahead and turning veteran paralegals into the people to undercut the market even further. It seems like bad timing to let someone who has years of experience, and no law school debt get over on a bunch law school grads who are facing a life of being hounded for their debts. I spoke to someone at the Bar who made a good defense, that the legal technician is like an ARNP. Only later did it occur to me that there are very few out-of-work doctors.

    From another perspective, the legal technician answers another problem of the collapsing paralegal market. Much of the collapse has been driven by advances in document management, especially scanning that ‘reads’ the text and makes it searchable. But hey, here is a shiny new program. Go ahead and set up a parenting plan with your abusive ex for $75! What could go wrong?

    The key to really get the legal field de-humanized would be robot judges and robotic juries. I hope someone is already working on it.

    1. polecat

      Don’t worry…what’s old is new again. At some point in the future we’ll all be scratching glyphs on clay tablets….once the 2nd law of thermodynamics really kicks in………..plenty of work then!

      1. armchair

        Work! What about George Jetson? The go west value system we are stuck with these days is almost perfectly incompatible with a future that requires very little human labor.

  9. MyWag

    Professionals would be the next logical choice of squeezing cost out of work; unions, middle management, big industry, airlines, manufacturing and construction have all paid their price at the alter of the 1%.
    Public sector unions are hanging on but as the majority of local & state taxpayers have less to give, these wages, benefits and especially pensions will be cut. Those earning less and less will gleefully pull down those public employees who are ‘living like kings’.
    I also agree with the concept of there being less for the bottom 90% to spend. And as more automation kicks in, there will be even less bad choice jobs for these folks to scramble for. Just waiting for truck drivers to be slowly replaced with auto-drive trucks.
    This leads us to an enhanced confrontation at the Federal level on how to go forward. The earned income tax credit, a good concept also under siege, I believe, will have to be supplemented with a minimum guaranteed income.
    By this time, 20 years, the DEMs will be the party of business and the GOP will be entirely dependent on fed govt subsidies. Oh the irony.

    1. Brooklin Bridge

      By this time 20 years, the GOP will be saying, “I told you so”, regarding Global Warming.

  10. Ptup

    Reading Rise of a The Robots right now, and the law and accounting profession have and will continue to be hurt hard by computers armed with big data, and the education and medical profession are next. Has to be. It’s already a travesty that education and medical costs continue to rise as incomes stagnate and drop, and that just cannot continue. Well, maybe it can, until all of those guns out there are used by the people as they rise up. Look at the buffoon who many are considering for the Republican nominee, more out of blind, misinformed anger, than anything. Scary.

  11. kevinearick

    Prologue: Empire Melodrama & Unusual Circumstances

    Marriage for the purpose of raising children is the motor-generator, which requires real work, which is why the majority wants nothing to do with it, except to commandeer yours as a means of extortion. That’s Family Law and that’s History, consumers as heroes replacing parents. Everything else is an add-on.

    Variability, the demographic and derivative financial boom/bust cycle, economic activity measured as GDP, with artificial fiscal and monetary accounting gain, is counterproductive. The industrial revolution wasn’t about providing for people; it was about leveraging economic slavery. The Brits quickly ran through their stock of natural resources and rebooted with a massive new stock in America, with a new mythology, the US Constitution, and the same outcome, which was stupidly replicated globally; a battery as an economy, with no source, perfect.

    Cultural Marxism is the marriage between capitalism and socialism, to maintain feudalism, profit for a few at a loss to the many, and as natural resources are depleted, fascism upon economic collapse is the only possible outcome. Financial engineering simply hides the result from the manufactured majority operating the system, paid in their own debt to ignore plain facts until it’s far too late, when their consumptive habits take the majority over the cliff. Essentially government shorts natural selection and programs stupid for the purpose.

    If you listen to an establishment guy like Rubio, he begins with free enterprise and immediately goes to single females with children, and the many strikes against them, as the customer of government, few of which may be supported in a real economy, as the most cursory examination of demographics will tell you. Trump is the capitalist, Bernie is the socialist and the rest are mutts in the middle. Kasich would have an argument as a centrist if families weren’t exiting Ohio, for decades, leaving the rest with nothing but paper certificates of compliance.

    As you should suspect by now, everything in the empire mirrors itself. Your family is the input from nature, which is smoothed by political media to enter the public healthcare selection IC, represented as a gain with fiscal accounting, smoothed again for a leveraged gain with monetary accounting, smoothed again for entry into the public education programming IC, smoothed again, and Walla Walla Washington, you have poverty driving feudalism in a positive feedback loop, always chasing leakage until it implodes of its own dead weight. The system continually gets SMART only in that more fools enter the casino until there are no more fools and the system is completely disconnected from nature.

    The fools will assume that you are similarly disabled so long as you adopt the arbitrary habits consistent with any one of the artificial event horizons traveling backwards, when in Rome, which is worth no more than 10% of your time, depending upon the gravity required for your development. Economic mobility, ac circulation, is created to the extent you train others to advance time. How much fuel and oxygen you provide depends upon your relative position in the empire cycle.

    Like the end of every empire cycle, this empire is in a wagon with no steering and no gears, approaching a cliff, requiring a quantum leap to avoid WWIII. I’m old. What you want to do about it is up to you, but if you want to carry any of that gravity forward, you will have to translate time in an elevator, which not so luckily has already been provided, and shouldn’t be difficult considering that the empire is always travelling backwards.

    How do you turn a flattop around on a dime?

    The universe is not quite so stupid as the majority would like to assume. Saying one thing and doing another is a game for stupid, not an economy. Of course the morons want you to think in terms of scarcity as a setup for money, which they control.

    Stack stupid on the counterweight and let it hash for itself.

    Obamacare is sterilizing and editing DNA without notice, with an attached information system wherever you go, so you might want to pick another route, if you are the 1% being hunted. There’s a reason why a good repairman is so well paid and hard to find. If you think about it, before you jump, it’s all the same crap and sooner or later you are going to get paid, for educating yourself.

    Chasing pot and smoking the profits on the margin is not the answer.

    Why would you trust a contract adopted by a slaveholder cartel that is made to be broken?

  12. RBHoughton

    “…. Prefer a fence at the top of the cliff to an ambulance at the bottom…”

    You have a delightful way with words Yves. Many thanks.

  13. Jim in SC

    I think that comprehensive financial planners now do a lot of the work that family attorneys did in generations past. This is partly because the sort of person who goes to law school now is much more intellectual–and thus often a little more introverted and socially inept–than in years past. Watergate caused that, I believe. All of a sudden everybody was interested in the mechanism of the law. Fifty years ago a right-of-way agreement from the local utility was three sentences. Now it’s five pages single spaced, in some English derived technical gibberish.

    Anyway, you really need the professional when somebody dies. That professional is far more likely to be the financial planner than the lawyer these days, in part because the financial planner is paid by assets under management, rather than hundreds of dollars per hour, so the financial planner would be paid anyway. I think it is rare to see attorneys designated as executors of estates these days. They charge six percent by statute, and that’s too much for many people’s blood. God forbid that one should be appointed to manage a trust with multiple beneficiaries. They’ll stretch it out thirty years.

  14. different clue

    The rich and the truly rich will always have skilled, artistic human professionals to serve their personally tailored bespoke needs. It is the rest of us who will be assigned the doctorobots, the lawyer machines, etc.

    1. James Koss

      The French phrase “Everything changes and remains the same” remains true today.
      Whereas today the top of society has its professionals to isolate and protect them from the remainder of the population and the rules nobility and the church had its knights, nobles, obedient serfs and peasants to fight and protect “their” nobility. Names and titles changed but the rules remained. Those who have will get those who don’t will not.

    2. Inverness

      Correct. The same applies in education. The wealthy know what kinds of schools serve their children best: those with better teacher to student ratios, rich arts curricula, and a progressive approach to instruction. Just see what Obama’s kids got at their fancy Quaker school. The rest get standardized lesson plans, big class sizes, deep cuts in music and the arts, and high-stakes testing.

      They can privatize their lives; we cannot.

  15. Disturbed Voter

    Part of the “crapification of everything” … except for managers and owners, it is part of their cost cutting plan.

    Why would you trust a medical system run by politicians and insurance companies … a system promoted by those same managers and owners. Like hiring the Three Stooges as your plumber, electrician and roofer. Gullibility will be the death of us … that and malice.

    First they came for the blue collar workers, and I did nothing?
    Then they came for the white collar workers, and I did nothing?
    Now they are coming for the professionals, and they are laughing at my passivity?

    They have played all the classes, higher than the one they are currently discarding, and the remaining consumers are happy to throw their neighbors under the bus. But your turn will come. Karma.

  16. different clue

    There is some truth in this. The professionals supported Free Trade so far as I know, and openly and loudly laughed at the mass jobicide effects on thingmakers. So it is only fair that the professionals also have their jobs destroyed in turn.

    The problem is . . . is that human professionals often gave professional-grade service in their fields, if paid enough for it. Will computerbots and little droids on little tank treads give the same level and quality of service?

    Perhaps now would be a fine time for “the rest of us” to propose an agreement to the jobicide-facing professionals: ” help us abolish Free Trade and restore Protectionism, and we will help you prevent and stop anti-professional careericide.”

  17. flora

    In Oregon some doctors are unionizing to resist medical assembly line medicine.
    From NYTimes:

    Doctors Unionize to Resist the Medical Machine

    “Dr. Alexander and his colleagues say they are in favor of efficiency gains. It’s the particular way the hospital has interpreted this mandate that has left them feeling demoralized. If you talk to them for long enough, you get the distinct feeling it is not just their jobs that hang in the balance, but the loss of something much less tangible — the ability of doctors everywhere to exercise their professional judgment.”

    http://www.nytimes.com/2016/01/10/business/doctors-unionize-to-resist-the-medical-machine.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=second-column-region&region=top-news&WT.nav=top-news&_r=0

  18. digi_owl

    I find myself thinking about an episode of the original Connections series, that was produced in the 70s.

    There it was mused about how corporate management would idle their days away waiting for the computer in the basement to crunch the numbers and come up with company decisions they were then to implement.

    Instead what happened was that the professional managerial class, the MBAs, dug in while computers instead replaced the laborers via robotics.

  19. Jesper

    Or shorter: The common argument that ‘we (by that I mean you) have to become more employable’ is about to hit home among the people with long education. Will they recognise the similarity to what has already happened to others and/or will they themselves make themselves more ’employable’?

  20. financial matters

    I think one of the major consequences we are seeing as a result of a misguided professional system is the lack of basic legal services for millions of people. This resulted in people being thrown out of their homes as the result of very obvious fraud and yet having no recourse unless they were able to spend hundreds of thousands of dollars on legal fees.

    I think the popular new series ‘Making of a Murderer’ emphasizes this problem. I don’t think a show that emphasizes the problems that the very poor have with justice from the lack of being able to pay for legal services would have been this popular 10 years ago.

    1. financial matters

      I think this would require a ‘single payer’ legal system similar to the need for a single payer medical system.

  21. Wade Riddick

    Once corporations start setting guidelines and dictating the drugs you can and can’t use for treatment, do you think they’ll do it according to what’s cost effective and least risky for the patient based on current science or do you think they’ll do it based on their own profits?

    What happens when they own their own pharmacies – as they’re all scrambling to do right now – and try to jack up reimbursement through that unit too? Do you think patients were served when Philidor started (criminally) altering scripts and making substitutions?

    For profit healthcare is really sickcare, isn’t it? Why cure a disease when treating it brings in more revenue? Why sell cheap human insulin when you can patent a variety on the molecule, jack up the price and carve up the market?

    Keep the sucker paying the vig…

    These guys aren’t adopting better guidelines for treating chronic disease based on the best available science. In fact, as they corporatize they’re getting worse. I’ve talked to these clowns. They’re typically ten years behind the state of the art in their field. Patients do the reading and then they stare at us like we’re morons. Fifteen years later they swear they knew the truth all along.

    If these corporate suits are setting the guidelines for care, how come there’s no common national board standard for care, no portfolio investment model approach where they model the disease with the best available experts, determine how to intervene in the various genetic pathways that are perturbed and then pick the simplest, cheapest methods/chemicals to try first?

    That sounds like a pretty reasonable, scientific approach to treatment – but, if that’s your standard, then these people are in breech of fiduciary duty left and right and it all has to do with that old canard “maximizing shareholder value.” What about maximizing customer service? Corporate medicine will lead to tobacco-level deaths. I know doctors who have been personally injured in this system already. Corporations want to avoid risk to their profit – *not* their patient. Imagine what *those* mandatory arbitration clauses are going to look like. Imagine what the sequel to _Merchants of Doubt_ will look like in the era of corporate medicine and Supreme Court decisions that bust doctors’ unions.

    I’m still burning from Peter Thiel’s comments on monopolies in the New York Times this morning. Does he have any clue how bad the service is in regional hospital cartels already and how fast prices are rising?

    It’s not even a matter of price in the drug markets now. It’s basic availability. Aside from the persistent shortages of cheap, effective generics due to the kickback scheme in PMOs/PBMs, we now have explicit regulatory interference. The FDA has been moving to withdraw entire lines of medication from compounding pharmacies even when there’s no rival big pharma product competing against them or any indication of patient risk. These are decades-old treatments. (It’s the CDC’s job to set treatment guidelines, by the way, not the FDA’s).

    It’s just a knee-jerk reaction at this point to protect imaginary future profits, I suppose. You can’t make up this stuff. The FDA has even imposed a 30% sales volume rule for “safety.” It has nothing to do with purity or contamination of compounded products. If Tesla sold exploding cars, how would restricting 30% of their sales volume to California improve consumer safety? It’s clearly a market-rigging reg – and it’s because the corporate medicine lobby wants it.

    What does this have to do with corporate medicine? Compounding pharmacies in big chain hospitals – which are often pitifully narrow in their professional scope – are all magically exempt (oligopolistic and more expensive too). Isn’t that wonderful?

    The current corporatization of medicine rests on the notion that the chief challenge faced by those of us with serious illnesses is that we simply don’t read enough fine print or fill out enough paperwork.

    If you think that corporations have done a fine job handling your retirement investments in this era of lax accounting standards, wait until you see what they do with your actual body.

  22. Moneta

    Here in Canada, Ontario and Quebec teachers have been fighting like crazy to keep their pensions when a huge percentage of jobs out there do not require much more than 7th grade…

  23. Brooklin Bridge

    This article is based on the faulty perception that this is all normal benign efficiency working it’s way out of an antiquated system, perhaps with a few -to be expected- hiccups. It isn’t.

    What we are experiencing is wholesale greed and corruption on an international scale working it’s way into the core of our civilization like mold or cancer, and perverting technology as well as the process of social change and adjustment to that change – for it’s exclusive benefit – as it goes. It is unconscionable that we could call this progress or adjustment in anything but the most cruelly ironic sense.

    The shift from reactive to proactive my foot! 60 years ago doctors were getting out proactive messages far better than today via education, television, the media and so on. And they gave a damn!!! Today, insurance companies are devising ever new ways to minimize what they spend on your care, maximize what they charge you for it, and call it, “proactive.” Proactive theft, or genocide for fun and profit, would be closer to the mark.

  24. Chris Sturr

    My concern about this post is that it seems to take professionalism at face value–that what is central to being a professional is the stated aims and ideals of the profession in question (promoting health for doctors, justice for lawyers, etc.). But professionalism is already highly politicized. My favorite critical source on professionalism is Jeff Schmidt’s excellent book Disciplined Minds: A Critical Look at Salaried Professionals and the Soul-Battering System that Shapes Their Lives (http://disciplinedminds.tripod.com/). It’s worth checking out–here are the basics from the dust cover:

    In this riveting book about the world of professional work, Jeff Schmidt demonstrates that the workplace is a battleground for the very identity of the individual, as is graduate school, where professionals are trained. He shows that professional work is inherently political, and that professionals are hired to subordinate their own vision and maintain strict “ideological discipline.”

    The hidden root of much career dissatisfaction, argues Schmidt, is the professional’s lack of control over the political component of his or her creative work. Many professionals set out to make a contribution to society and add meaning to their lives. Yet our system of professional education and employment abusively inculcates an acceptance of politically subordinate roles in which professionals typically do not make a significant difference, undermining the creative potential of individuals, organizations and even democracy.

    Schmidt’s greatest insight is that professional work *is* creative and independent, but within the narrow constraints of the interests of the boss and ruling elites, and of the hierarchies where professionals work (firms, HMOs, etc.). It is key to professional training (even more important, in some ways, than substantive training in medicine, the law, etc.) that professionals must be trained to be “disciplined” to work within these constraints. My point about this post is that I wish it dealt with the ways that ruling elites and corporations rely on professionals who are trained in this way. The changes the post’s authors say are happening may well be happening, but the idea that professionalism (understood critically, vs. at face value) is becoming obsolete doesn’t make much sense to me given that professionalism has already been shaped pretty thoroughly by the system, and is needed to maintain class power.

    On the other hand, critical/radical professionals, who stick to the ideals of the profession and buck the ideological training, can be allies in bringing about radical social change (think: whistleblowers (I just heard Daniel Ellsberg speak at the big econ conference in San Francisco, so he’s on my mind); also the comment above by mdh above about real medicine; I think many of the commentariat at Naked Capitalism probably fall into the category of critical or radical professionals who have come to side with the ideals of their professions over their training to do the boss’s bidding).

    1. wc

      I could not agree more with your comment. I lived this, and it has taken a toll on me in many ways. As a young 20 something, I was an apprentice to a home birth midwife. This was quite empowering and I received excellent training (far better than I did in formal education). I decided to attend nursing school so that I could become a nurse midwife.
      I finished nursing school with straight A’s and entered the field with extreme passion to change the world for the better. I stayed current on trends in OB/GYN, read medical journals regularly, and excelled in many ways.
      However, I found the hospital environment to be extremely disempowering, abusive to nurses even.
      I made it less than a year and quit. I was good, I had passion, I was a creative and critical thinker, but I could not swallow the politics and abuse.
      I sit around now wondering how much I could have made a positive impact on the lives of others if I had only been willing/able to be a slave to, ‘the system’.
      I realize that nurses are not really professionals in the same way that is being discussed but I know that they do face similar issues, especially the good ones. Many of my peers were happy to get a decent paycheck and I cannot blame them at all. I would have stayed too, for the money, if I could have handled what went along with it emotionally. I did not have what it took–the ability and willingness to be an indentured servant living in fear and anxiety and cutting corners with peoples health.

      Thank you for your comment and observations.

  25. Richard Ohmann

    Participants in this worthwhile discussion might be interested in issue #99 of Radical Teacher, which Ellen Schrecker and I edited: “The Decline of the Professions.” Radical Teacher is online, open access.

  26. ewmayer

    Fusing 2 brief comments together here to save the bandwidth needed by the inline-comments system:

    o Re. screenshots on Mac: [apple-key + shift] + 4, when you release the keys you will find your cursor is showing a target-sight position indicator. Move to one corner of the rectangular box you wish to capture, then click-and-swipe (or click-and-move-mouse) to the diagonally opposite corner, release to auto-copy the capture to your desktop. (And ‘esc’ takes you out of the above, handy for practicing until you get it right.)

    o Re. the topic at hand, here is another recent piece on these trends, specifically in the legal profession: Software putting lawyers’ jobs at risk | Sydney Morning Herald

    Caveat: SMH’s supposed-to-be-reassuring ‘analysis’ of the US jobs market is deeply misleading – all about quantity, no normalization by population, no real-wage-trends data.

  27. Stephen Gardner

    When will administrative costs come under pressure? I suspect that rising medical costs come more from administrative cost increases that doctors at the point of delivery. Why do hospital administrators and insurance execs have to make so much money. What is their true added value?

    1. polecat

      I think we need a pre- ‘butlerian jehad’ *,…….. just to do an end run on silicon valley, before the melding of better than human AI & robots come on line…… Let the mentats prevail !!! *DUNE reference for those unfamiliar with the story line.

  28. nat scientist

    The fix has been in for 100 years. Within one year , individuals like doctors, or say the Surgeons General, are trumped by the Attorneys General, and thus dis-empowered. Human rights became subject to superhuman rights of corporations and their government guaranteed-pension protectors. Flag-pinned Nixon put the hammer to it by 1969 -73. This poisoned fruit takes time to fully disembowel the body politic, but the fire has become a blaze after 100 years of the same old. Pete Seeger could never stop speaking up from the HUAC trials on, taking the First, not the Fifth Amendment, because he had a big world to defend and stood up for the kind people, the human people, the individually-gifted people.

    to wit: the history of collapsing individual rights, fast-forward to post-industrial robot for unpredictable-human substitution, genetically-modified and artificially-sweetened intelligence. Wonders that one’s GMmobile be self-driving as it were, and fraudulent education be not dis-chargeable in bankruptcy. Some thoughts below on a corporately-funded politician’s heart-rending decision to not run for President in the face of millennials who might vote en masse not-so-much to reward his efforts. Four decades of work they say, and success was his crowning achievement for the banks and their syndications.
    Of course, there was the beer summit to cement his regular guy thing.

    (wikipedia)
    On July 24, 2009 Obama invited both parties (Henry Louis Gates arrested for breaking into his own house)to the White House to discuss the issue over beer, and on July 30, Obama and Vice President Joe Biden joined Crowley and Gates in a private, cordial meeting in a courtyard near the White House Rose Garden; this became known colloquially as the “Beer Summit”.

    but then the four decade thing:

    http://www.ibtimes.com/joe-biden-backed-bills-make-it-harder-americans-reduce-their-student-debt-2094664

    (wikipedia)
    The Federal Reserve Act (ch. 6, 38 Stat. 251, enacted December 23, 1913, 12 U.S.C. ch. 3) is an Act of Congress that created and established the Federal Reserve System, the central banking system of the United States, and granted it the legal authority to issue Federal Reserve Notes (now commonly known as the U.S. Dollar) and Federal Reserve Bank Notes as legal tender. The Act was signed into law by President Woodrow Wilson.

    (wikipedia)
    The Harrison Narcotics Tax Act of 1914 was approved on December 17, 1914. It involved “a special tax on all persons who produce, import, manufacture, compound, deal in, dispense, sell, distribute, or give away opium or coca leaves, their salts, derivatives, or preparations, and for other purposes.”

    (link above)
    Vice-President Joe Biden played a key role in the financial industry’s four-decade campaign to eliminate bankruptcy protections for student debtors. Above, Biden takes a selfie with students during a visit to the Miami Dade College where he spoke about the importance of helping more Americans go to college September 2, 2015 in Miami, Florida.

  29. jcc2455

    This post touches some important questions, but overreaches in trying to define a “framework.” In particular, the proactive/reactive section is more than a bit facile, because the authors don’t acknowledge that the horseshit quotient in the hyping of primary and preventive (do let’s drop the meaningless “ta”) medical care in the United States is incredibly high.

    Yes, we should all exercise and eat right. But public discussion of these questions has nothing to do with the future of the profession. It’s an ideological screen that allows doctors, Public Health PhDs and health care economists to pretend they have discovered a deep secret to improving systemic costs and outcomes, while protecting public policymakers from being forced to confront the absurdity of American health care.

    Competitive private insurance is a catastrophically failed 7 decade social experiment. Nobody else in the world tries this, and naturally, nobody else in the world has the U.S.’s insane health care costs. We spend twice as much on average as OECD countries. That isn’t because we eat too much pizza, play too many video games and book the ICU for our vacations. In fact we get a lot LESS health care for our money than the average OECD resident.

    It’s because we have given risk averse entities (private corporations) responsibility for pooling risk. They don’t wanna, so they don’t, and so we waste tons of money, but still have to deal with claims denials and all the other evil tricks that the people whom we pay to pay for our health care play so that they won’t actually have to pay for our health care and can keep our money.

    Remember, Congress had to pass a law to try to get the people who are supposed to pay for our health care to…..actually pay for at least some health care (medical loss ratio limits).

    The first purpose of health care remains the “reactive” response to illness and injury. The aging of the U.S. population, the “diversity” of our population and our unique ruggedindividualistrideahorseshootthebadguyselfreliant “culture” all have nothing to do with our outsized costs. We piss away a half trillion dollars a year in our health care economy, but public discussion of why is not really allowed (until Bernie), so instead, the people with the money convince other people who went to school for a veeeerrrrrrrrrry long time to scratch their chins and talk to us about pilates, and to run around and tell Congress that our greedy overuse of health care is the problem.

    Doctors have lost their autonomy. But that has little to do with a shift from “reactive” medicine. The core of what they do, and certainly of what they should be doing remains intact. Treating and comforting the ill and injured.

  30. Min

    “All recipients of professional service, from major corporations to individual consumers, seem to be short of money.”

    Really? Brad DeLong says that we are in a depression, so a shortage of money makes sense. But the top tier of the economy seems to be going strong. Major corporations are really strapped for cash?

    Serious question. Are we all suffering from too little money?

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