Doctors drifting: autonomy and career uncertainty in young physicians’ stories

Social Science and Medicine 52 (2001) 227–237

Doctors drifting: autonomy and career uncertainty in young physicians’ stories Varpu Lo¨yttyniemia,b,* b

a School of Public Health, University of Tampere, 33014 Finland Department of General Hospital Psychiatry, Tampere University Hospital, P.O.Box 2000, 33251 Tampere, Finland

Abstract In the early 1990s unemployment among physicians was experienced, though transiently, in Finland for the first time. The situation was new both for the entire profession and for professionals, especially for young doctors and medical students who were given pessimistic prospects for the future. In this paper I analyze the life stories told by these young doctors and ask how this period of unemployment and insecurity can be explained and experienced in a way that is compatible with the professional identity of a good, valuable young physician. First, however, I look back to the context of unemployment and the public debate among the medical profession. I point to the collision between what seemed to be the best way for the profession to react and what it could mean for a young doctor actually threatened by unemployment. The results show that it was a question of retaining autonomy and drifting but these words gain different meanings depending on who is defining them. # 2000 Elsevier Science Ltd. All rights reserved. Keywords: Physician; Life story; Qualitative study; Unemployment; Career; Profession

Whether the concept profession is used for certain occupations (e.g. Freidson, 1986) or occupational strategies (e.g. Selander, 1990), the efforts to achieve high status, autonomy and control are usually considered to be part and parcel of it. Parallel with the autonomous profession is the idea of a professional as autonomous, consistent and in his/her career advancing steadily up on the ladder of qualification, rewards and recognition (Davies, 1995; Johnson, 1983). Neither professions nor professionals in practice are as homogenous as these idealized images of them, and they meet many other challenges as well (Freidson, 1986; Witz, 1992). It can still be argued that unemployment challenges much of their previous definitions of themselves, their very status and control over their work situations (Riska, 1995,1996). In this paper, I first look back to the early 1990s when unemployment suddenly, though in the end transiently, became a reality for doctors in Finland. Then I discuss

*Correspondence address: School of Public Health, 33014 University of Tampere, Finland. Tel.: +358-3-215 6003. E-mail address: [email protected] (V. Lo¨yttyniemi).

insecurity as it is present in young physicians’ life stories told in the ongoing uncertainty which was left by unemployment.

Unemployment among physicians: the context of the 1990s in Finland Up to the early 1990s, unemployment was practically unknown for Finnish physicians, even if future oversupply had been foreshadowed in the estimates made in the early 1980s. However, the late 1980s still showed a lack of physicians in some parts of the country, and student intakes were increased as late as 1988. Quite suddenly, the new decade and economic depression introduced to the so far expanding health care sector financial difficulties, insecurity, and economizing tendencies. Physicians in the Finnish health care system are predominantly public employees (Riska, 1993). They are salaried by health centers and hospitals owned by local authorities or municipalities; only 7% of doctors earn their living solely through private practice (Halila, 1998;

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Health care in Finland, 1997). Along with depression, new work opportunities were no longer created in the public sector, vacancies were left unoccupied, and substitutes for doctors and other personnel were not hired during holidays or periods of leave (Ministry of Social Affairs and Health, 1997). The future orientation of new graduates and medical students, who could not take work for granted anymore, was most radically changed. In Finland students are allowed to work as doctors after four years of studies in medical school, and traditionally, experience gained before graduation has been considered essential for the professional competence of a new graduate.1 Now this opportunity no longer existed, and the security taken for granted by previous doctor generations seemed to vanish into thin air. Unemployment among physicians became a reality during 1991. The working team appointed by the Ministry of Social Affairs and Health estimated in 1993 that working opportunities would continue to decrease until the year 2000 and beyond, and there would be a surplus of at least two thousand working-age doctors by the end of the century (Ministry of Social Affairs and Health, 1993). Furthermore, EU membership and the associated two-year Eurotraining for doctors appeared to become just another hindrance on the way to full authorization, as young doctors, with little experience, had a hard time finding even short periods of work. As the Ministry of Social Affairs and Health then started giving state support to the employers of physicians in Eurotraining, the previously felt hindrance turned into relief, even if unemployment was now thought to be waiting at the end of the two-year period and thus became the problem of those who had already completed their training. Nevertheless, the peak of unemployment among physicians was reached in the beginning of 1994 with 4.6% or about 700 doctors out of work. The present unemployment rate at the end of 1998 is under 2% (source: Finnish Medical Association), so 1

Medical education in Finland is organized in medical faculties at five universities. The total curriculum takes at least six years, the average length of studies being somewhat longer. Until 1995, one pre-registration year of work after medical school was needed for authorization. Since Finland joined the European Union at the beginning of 1995, doctors have been licensed immediately after medical school but are only allowed to work under the guidance of another physician. To be fully authorized as a general practitioner takes a two-year training (additional training for primary health care or a so called Eurotraining) which is basically normal clinical work as an assistant physician in both hospital and primary health care. At the moment almost all doctors undergo this training in order to receive full rights to work as independent practitioners. (Halila, 1998) Today most young doctors want to specialize, which can happen after the Eurotraining. Only 3% in a wide national survey had decided not to specialize (Virjo, 1995).

the estimates have not materialized. Besides state support for Eurotraining, other explanations have been suggested for the decline in doctors’ unemployment rate: state support for university hospitals and new graduate schools opened up new research opportunities and, most importantly, after the initial fright the economy of the local authorities has partly recovered its balance and more doctors are being hired again (Ministry of Social Affairs and Health, 1997). The latest estimates do not try to foresee the demand too far into the future as the consequences of the inestimable economic development and the changeover of the whole health care system (Ministry of Social Affairs and Health, 1992) are too many faceted (Ministry of Social Affairs and Health, 1997). The introduction of an EU directive has seen the law regulating working hours applied to doctors for the first time since 1997, which has increased the demand for specialists and, it seems, for non-specialists as well. The student intake, reduced in 1993, is being increased again.

Making sense of unemployment: the public debate within the profession During the years of actual unemployment the debate in the national medical journal was one way for physicians to create a mutual understanding of what had happened, what it meant for the profession and a professional, and what should be done. Hafferty (1986) has discussed physician shortage and surplus in the USA, against the background of changes in the national economy, as shifts in rhetoric, not so much in reality. He points out that physicians nonetheless believed in the existence of a surplus, which meant it was real for them and guided their action. In Finland, the future excess supply of doctors was anticipated to be unavoidable. Unemployment became a rhetoric to argue for measures that needed to be taken, but it was reality for those constructed as being threatened by it, that is, for young physicians. A quotation from an editorial sheds light on what the debate was about: Unemployment among physicians will keep the Medical Association office busy in the near future, because it is obvious that the Association cannot leave its unemployed members drifting with the wind. It has been maintained that the complicated employment situation would result in doctors’ loss of professional ambition and encourage some doctors to seek practise with vague and scientifically deficient forms of care. It is true that increasing unemployment will probably change doctors’ traditional professional image, an increasing number of physicians will earn their living as entrepreneurs or private practitioners, or work outside the health care system.

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This does not mean though that the present employment situation as such would gnaw to pieces the very basis of doctors’ professional identity. (Suomen La¨a¨ka¨rilehti, 1993c, p. 2755) The situation was new. As a professional association, the Finnish Medical Association2 admitted the responsibility for the necessary procedures, which included emphasizing a fast reduction in student intake on the one hand while supporting the unemployed on the other. Additional training was needed to enable physicians to find new career paths other than a traditional career in medicine, for example in research, and also to maintain the professional skill of the young and unexperienced. But first of all senior colleagues were challenged to create work opportunities and share existing ones by working fewer hours and taking leave (e.g. Suomen La¨a¨ka¨rilehti, 1993b,h; 1994c,e). The 1993 Ministry of Social Affairs and Health working team report mentioned above also suggested that it would be necessary to encourage non-traditional careers. Yet the debate in the Finnish Medical Journal reported other voices as well.3 For example, encouraging doctors to non-traditional careers was conditioned by pointing to the thin line between non-medical and paramedical, or what was referred to as ‘‘humbug’’ (Suomen La¨a¨ka¨rilehti, 1993f, p. 3188). Young physicians messing around with humbug or ‘‘odd jobs not compatible with a medical education’’ (Suomen La¨a¨ka¨rilehti, 1993g, p. 3219) was seen to be a threatening sign of lost ambition that would result in the demoralization of the entire profession. An obscure professional identity (Suomen La¨a¨ka¨rilehti, 1994d, p. 1883) and the lost autonomy of (young) professionals would thus not only be a personal problem for those marginalized to the unemployed ‘‘low-status professional subgroup’’ (Suomen La¨a¨ka¨rilehti, 1994b, p. 1549) and a ‘‘permanently distorted career development’’ (Suomen La¨a¨ka¨rilehti, 1992b, p. 306), but would also harm the very basis of collegial and highly ethical doctoring (e.g. Suomen La¨a¨ka¨rilehti, 1993e). To put it briefly, an unemployed physician was considered to be exposed to the temptations of the immoral world. Further, in the face of unemployment, a physician was seen as ‘‘drifting with the wind’’ (Suomen La¨a¨ka¨rilehti, 1993c, p. 2755). He/she was considered to be in need of 2

95% of Finnish physicians are members of the Finnish Medical Association. 3 I have read texts in the Finnish Medical Journal between 1991 and 1995 that deal with unemployment among physicians. The overview presented here is based on this reading. Instead of a thorough analysis, I refer to those voices of the debate that were the most frequent and that create the dialogue with the stories and the points of view of the young doctors who were threatened by unemployment at the time of the debate.

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the ‘‘support’’ of colleagues (Suomen La¨a¨ka¨rilehti, 1994b, p. 1549) or ‘‘sacrifices’’ made by colleagues (Suomen La¨a¨ka¨rilehti, 1993a, p. 1588), which means he/ she was not considered much of an actor him/herself. In the debate within the profession, the unemployed doctor was advised to seek training rather than ‘‘lie around at home’’ (Suomen La¨a¨ka¨rilehti, 1994a, p. 1545), but he/ she was also referred to with words like ‘‘pawn’’ (Suomen La¨a¨ka¨rilehti, 1992a, p. 6) and ‘‘lost generation’’ (Suomen La¨a¨ka¨rilehti, 1993d, p. 2937), and his/ her own efforts were mentioned when he/she ‘‘tried to employ him/herself by holding on to some research project’’ (Suomen La¨a¨ka¨rilehti, 1994f, p. 3375; emphasis added). The debate left little room for an autonomous unemployed professional. What could appear to be proletarianization or declining professional status (Riska, 1995, 1996) or moral obscurity of the medical profession was still to be a part of the lives and careers of the then medical students and young doctors. How can insecurity be built into a young physician’s career prospects? How can the risk of unemployment be incorporated into a valuable professional self? Or rather, are the upheavals represented above a substantial part of the story a young doctor tells about his or her personal past, and if so, what kind of meanings will they be given?

Life stories: theoretical and methodological points The material reported herein consists of oral life stories told by physicians who graduated in 1995 from two Finnish universities. I conducted 19 interviews between October 1996 and May 1997, and another eleven between October 1997 and February 1998. Fifteen interviewees were male and 15 female. In the interview I asked the doctor to tell me his or her life story. When the story was finished, we discussed the events and themes brought up. The interviews were taperecorded, transcribed, and analyzed both by reading and listening to the original tapes. In this article, I will concentrate on the first 19 stories that were told in a context of decreasing unemployment but still prevailing uncertainty. Johnson (1983) has suggested a biographical approach to understanding the logic physicians adopt when directing their subjective careers and lives. In story form, events and ideas are related to one’s own life and experience, not so much to the theories presumed to guide the researcher and her asking questions (Chase, 1995). I am not so much interested in what really happened while these doctors, medical students of the early 1990s, lived, studied and graduated through their years of financial insecurity. Instead I want to know how they now tell about their previous experiences and insecurity } ‘‘truth such as it appears to them’’

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(Lejeune, 1989, p. 22). Life story is connected to the material realities of life, concrete events, persons, conversations (Stanley, 1992). Still it is not meant to be, and it cannot be, an exact reproduction of the past. Instead, life story is a construction made by selecting events, or memories of them, making sense of them, connecting them so that they build a plot that makes the past and present belong together. The story is told to understand the present self or to have an identity, to answer the question ‘who am I?’ (Freeman, 1993). Life story is about understanding the self, and a part of this self is knowing its goals and principles in life, the way it wants life to be lived further. To work as a guiding light for the future, the story has to be one that can be lived and realized. It has to take into account the concrete circumstances and the limits the material, as well as the ideological world, sets to an individual living in it, in a particular place and particular time (Rosenwald & Ochberg, 1992). From this point of view, the doctors interviewed have to take into account the actual conditions at the time of the interview, the rate of unemployment, and the difficulties in finding work, as long as these exist. Stories are in essence social. Social and cultural conventions hint to us what is worth telling, what cannot be told, and how things can be explained (Somers, 1994; McAdams, 1993). Telling is also guided by a particular listener, which in my research is another physician. A life story is not only a way of knowing the self but also a way of letting others know this self. As I ask a doctor to tell me his or her life story I am really asking, ‘who are you?’. The narrator, consciously or not, answers my request of a story not only special and unique but, essentially, also a story of a good, valued, respectable young professional as we both should comprehend it on the basis that we are members of our professional culture and share its discourses and its norms (Linde, 1993). To fulfil its function as the essence of social interaction the story has to be understandable and acceptable to me, so it has to be put together by explanations and social conventions we share. The listener is not just a pair of ears but an active conarrator whose task is to make known his or her understanding and approval, or disagreement, as well. Traditionally, the influence of the researcher on the interviewee has been minimized, but the meaning of this scientific norm changes if we take seriously the social and cultural basis of the life story. Negotiating meanings is done in any kind of interview, or any social interaction (Mishler, 1986). As soon as a life story is given words, it becomes a part of social interaction and is apt to be retold and re-negotiated over and over again in the process of striving for an understanding of the self, by the narrator her/himself or by others, or in the construction of personal and social identity. Constructing identity is always made in relation to others.

Furthermore, the interviewees are not only talking to me but also to the readers, maybe foremost other colleagues, of my future publications. So the conventions guiding them are not only the ones thought to exist between us in the context of the interview, but those existing in the professional culture more comprehensively (Burgos, 1988).

Results The past experience and present identity are intertwined in the story. I will present Laura, one of the interviewees, as an example of this theoretical and practical point. As for the past, Laura tells about the public sentiment when the future appeared hopeless: We used to sit and whine and wonder if anything would come from this and why we had ever decided to be doctors. (Laura) She started doing research and concentrated more on her doctoral thesis than studying medicine during her last years in the medical school. She committed herself to her research team, and the project still needs her. The irony of the quotation above and the evaluation of what happened are given in her present situation, after Laura has refused clinical jobs she badly wanted to accept but had promised not to leave the research team yet: It was not good for anyone that (..) nobody encouraged us and said that we may be able to find work, it was all negative that was given to us from above, so our motivation to study declined a great deal. (Laura) Finally she is able to explain what happened in a way that supports her idea of her present self: It has made me grow personally, you know you can survive even the hard times and know that nothing is as certain as uncertainty itself. (Laura) Unemployment as opportunity Petra is the only interviewee who had been officially unemployed for a longer period, about a year. It was before graduation, which is not usual as students are in principle not paid unemployment benefits. Before unemployment, she had been working in primary health-care far away from her university town. She was from the beginning offered a post for longer duration but she only wanted to stay for a few months so as to not get stuck there. She was looking for a subject for her advanced studies project, and knew she would not find one there. In the meantime, the financial

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situation changed in the country, and she could not find another job. She still feels she made the right choice by refusing the job and doing what she felt was right. She concentrated on finding out what she really wanted to focus on. Petra does not, like most others, start telling a chronological story. She starts with her motives instead: I think the most determining motive in my life must be to increase my autonomy, or to find my own way and to walk my own way, like how to fit it together with realities. I suppose it is the central motive in both my studies and in my childhood (..) for example my father has told that when I was learning to walk he observed that when somebody tried to help me I got very upset and told them to go away. I would rather fall and try myself. (Petra) For Petra, autonomy is not to be able to control the reality but to know what is the right choice for her to make, the right way to go, in an actual situation } and not to be forced to choose too early. The same theme of autonomy repeats itself numerous times and in many different episodes in her story. She says she decided to be a doctor, instead of a nurse or a vet, because she did not know exactly what she wanted to do and needed thus to leave many doors open. This is not to say that she was not interested in medicine but she was weighing in her mind other choices and shorter educational paths. What she now says was the most weighty reason for choosing medicine was her fear of getting stuck in routines, with no way out, no way ahead. Medicine was both an interesting and extensive discipline. Once she had decided, there was no doubt. She was not admitted when she applied the first time, which increased her determination: I decided not to try anymore, but just do it. (Petra) For Petra, not getting stuck in routines means the possibility of finding new challenges, of moving on instead of reconciling herself to an unchangeable situation } however safe it is. This has not been a problem so far as every job she has had has been temporary. During her first years in medical school she worked hard for a year in a cafe´. Finding herself no longer motivated, she knew it was time to quit, to go for something else. And it was not only a question of satisfaction but of lacking commitment and thus, importantly, morals. To stay where she felt she had no way to self-fulfilment was to threaten her work ethic. Again, the same holds true for Petra’s advanced studies. She says she did not want to accept any subject in order to get them done but wanted to wait until she found one she really wanted to be absorbed into and could

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incorporate into a deeper understanding of herself and her patients-to-be. It was clear to me from the very beginning that it would not be enough for me to be doctor but I would like to be a good doctor. (Petra) Now that she was unemployed she could take her time and read, and she found a subject and a tutor for her advanced studies project. It became a heavy project and she went deep both into her research and her own motives and past choices. She says she went through her personal revaluation process when orienting herself to her future, something she felt she had to do after being unfair to herself during her years in medical school when she had been acting on motives and impulses given to her from outside of herself, from the routines and necessities of medical school and both the theory and practice of medicine. She felt she had lost her autonomy. She says now when looking back to this process that she was surprised by how little her previous motives finally changed. But now she knew they were her motives, not forced upon her by somebody, or something else. I have been satisfied somehow, I reached a peace of mind and freedom after that, I would say my stress level changed considerably. I have done something I wanted to do and obviously it was a vital question for me personally. (Petra) To have been unemployed is not too simple, though. Petra remembers how she realized she could no longer count on getting the job she wanted and had applied for. It was hard for her to accept, but she could take comfort in thinking that she was not to blame: It was terribly difficult for me to accept failure, like to apply and not get a job. Then a friend of mine told me he had sent hundreds of applications and I thought I had to see things in their proper light. (Petra) Telling a story like Petra’s carries a risk of depicting a physician who does not take work seriously enough. She has to make sure I know that she did not want to be out of work or that while unemployed she could not feel guilty only because she was ready to work as soon as she would find a job. On the other hand she points out that she actually felt brave, daring to venture into unemployment, with no role to make her thoughts stay on track. After about a year the employment authorities found a job for her, and she has been working ever since with only a few weeks’ breaks between jobs. At the time of the interview she had a job for the next four months, beyond that she was uncertain. And she likes it that way. She says she is willing to work in different places,

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different specialties in hospital and primary health care, until she finds out where she wants to stay. Thus, for Petra the uncertainty of future work opportunities is actually an opportunity to realize what is the main thread in her story: autonomy. Autonomy to which the unpredictability of life is no threat but which is risked by unconditionally following a path opened by somebody else. In her story, she tells about unemployment as a phase of her life and career when she could re-establish her experience of autonomy. It was more important for her to find out what it was she wanted to do and then to realize it, than it was to graduate as soon as possible and work uninterruptedly. In Petra’s story, chance and intuition may show her the way, just like they show the way in the not-always-rationally lived lives of her patients. Logic of chance A male doctor, Jaakko, too remembers. how the employment situation suddenly changed and he recollects his uncertainty just before graduation, as it seemed it would be very hard to find work, not to mention choosing between specialties. At the moment of the interview he had, however, been working in a permanent post for 16 months, specializing in a medical branch that he finds interesting. At the same time, he was working on his doctoral thesis. Throughout his story he resists giving explanations for why things happened the way they have, that is simply not how he sees life. According to his logic, it was by chance he ended up in this very speciality. Or rather I mean it was by chance. But of course if you want to analyze it afterwards, from outside, on the basis of visible facts alone, you can arrive at either drift or purpose. (Jaakko) Life stories are never single-voiced in the sense of being unambiguous. Instead, they are scenes for negotiating meanings, not only between narrator and listener but for the narrator with her/himself, and they are dialogues where old and new meanings exist side by side (Bakhtin, 1981). Drift and purpose co-exist and cooperate in Jaakko’s story. In his early years in medical school, he says, he wanted to try a little bit of everything, without thinking too much about where these trials would take him. He found himself in a research team that could even offer him summer jobs during the years of unemployment. Thus he did not gain much clinical experience before he graduated but he gained experience that made it possible for him to apply for his present post. As Jaakko himself points out, from pure facts he could tell a story much more ambitious and goaloriented. But he tells of his past with the same logic that he says he thinks about life at present. He throws about

different ideas, either to himself or aloud, to others, and some of them just turn out to be right. It makes no difference if it is explained to have happened through drift or purpose, but: Then you do what you are interested in, and is it good, it is good then. (Jaakko) Jaakko’s story is about a young physician who to me appears both deep and, in his ideas, very tightly bound to the practice of life. It is only in practice, by trying out, that he can tell which ideas are right for him. His philosophy is not very far from the one presented above by Petra’s story: It is good to have some plans, so that when you meet different situations you have an idea of where you stand. I would say it is like having a street-map, like if you are thrown somewhere in the city and your eyes are unbound then you know in which quarter you are and which way you’ll have to go in order to get where you want to go. But it is not to decide in advance where you want to go because if you just fixedly head for something you will miss something else, perhaps something much better but something you didn’t know existed. (Jaakko) In addition to building a basis for self-understanding and an identity introduced to me, this story provides its teller with the means to make the years of unemployment and lack of pre-graduation work experience a part of the story, in a way that sounds to be how it was supposed to be. Something of this logic is found in most of the stories. Some doctors have a career plan for the future but they still want to leave the door open for the unexpected. Karita has been working in psychiatry for months and she has been told that she can have this job for as long as she wants and needs to in order to specialize. At the moment psychiatry is the only specialty she can think of, but she is now going to work six months in primary health care to finish her Eurotraining. I asked her if she had any alternatives in mind: I don’t know, it may well be because I usually like best whatever I happen to do at the moment. Now I will leave for primary health care for six months (..), it is safe to go as I know for sure that I can come back here (psychiatry) after that. And who knows, I may become interested in general practice and want to stay there instead. (Karita) Further, many interviewees had not decided where they wanted to direct their careers and their lives. Martti speculates in detail on which parts of the medical field interest him and why, and he emphasizes his

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preserved optimism and faith in the future even when all ways seemed to be blocked for a medical student. He is aiming high in his career, both in clinical practice and in science; his aims are not fixed, but more like visions or possibilities. For Martti, future can never be fixed anyway. He summarizes his story in the beginning of the interview by sketching the future: I always enjoy talking about future, what will probably happen and what I would like to happen, and how should things go and what are the problems with it. And then I would ponder over what the consequences would be, and what else could happen. I suppose you can speculate about the future all the way to the cemetery, but what will happen in reality is hard to say. (Martti) Curious and optimistic, at the time of the interview, he was waiting to see what will happen. His post of 18 months was about to end and he was applying for others. What will happen depends, according to Martti, on the general employment situation, on his own decision to move or not to move the house in order to find work, on where he then wants to stay and work, and on all the unpredictable. There is no need to fight this. More explicit still as to openness is Annika’s story. She says she never had alternatives to her professional choice and remembers saying she will be a doctor when she was five. While still in medical school she felt she had more of herself to devote to something, and she started to do research and is still working on her doctoral thesis. She did not even try to find clinical work before graduation but has worked later on for shorter periods. She says although that she has always regarded herself as a clinician and, when asked to, she can tell what kind of clinical work she is most interested in. But the logic more faithful to her whole story is that of openness. More or less, what finally happens is always decided by chance. Life is drifting, and steering is needed where you meet with something worth aspiring for. Now, Annika says, it is time to concentrate on research, and what she will, and wants to, do next remains to be seen: I suppose after I finish this phase of life, the dissertation, I will be a different person again and think about things differently, so I have to reconsider it then. (Annika) In Annika’s story, like the others quoted here, there is space for both determination and chance, for both steering and drifting. You can only decide when you know what you choose from, and only here and now, not in advance.

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To compete or not to compete Aleksi is one of the most determined as to his future specialty. He tells about his first years in medical school, how they saw older students being paid flight tickets if only they would be on duty for a weekend in some smaller town. And they could hardly wait, Aleksi says, to do the same. And then suddenly it all changed and hardly any of them could get a job. Aleksi tells about the others being in low spirits, but unemployment, panicking, or being worried about the future are not a part of his story or career: There was this half-panicky atmosphere and continuous discussion about the fact that there was simply no work, and people were under stress, no doubt about that. But it never concerned me really, I thought well, there will be more and more rivalry and everybody can’t win. But I just felt I wouldn’t be one of the losers. (Aleksi) If it takes being the best to get a job, then he will be the best. He, too, is working on his doctoral thesis, and he believes it will be of benefit for him in this competition between colleagues. Lassi, another male physician, tells a different story: Our family economy is not in such a bad shape, so even if I was unemployed or out of work and had no income I would do just fine for a while. My wife is working and even if she doesn’t have a permanent post she makes more money than I do. (Lassi) Like in Petra’s story, advanced studies is something of a turning point in Lassi’s story too. He tells about his enthusiasm for his research project when he started it, but there is an ironic touch in his telling. He had expected a lot, but had been disappointed, for many reasons. He felt he was left very much alone with his project and he found out in the end that he had done a lot of wasted work. He felt he was not treated as a colleague at all in the clinic where he was working. To him the atmosphere of the clinic and perhaps the whole university hospital appears very strongly marked by competition, but he is not willing to accept it the same way Aleksi does. He has not totally given up the idea of doing research, but he says that he should start some day, it has to be because he is interested. For him a dissertation will not be a tool against others in the competition for posts. Talking about this episode for some 15 min, Lassi is here trying to understand his present situation. He is in a parting of ways in his career, he is working in primary health care where he is treated as an equal, he is one of the colleagues, but he does not find the work itself very challenging. He is trying to choose between the hospital,

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that is, challenging work but in the atmosphere of competition, and general practice, but he says he will not make the final decision in haste but will work in many places in order to know what he wants. On the other hand, he means that if he had to choose between having a job and living with his wife, he would choose the latter. If he cannot find a job in the city where he lives it will be no catastrophe for him to be unemployed for a while. Being out of work is one alternative for him, his career, or his story. Weighing in his mind collegiality on the one hand and competing on the other, Lassi brings up a worry presented in the Finnish unemployment debate and a result arrived at in a Norwegian study (Akre, Falkum, Hoftvedt & Aasland, 1997): competition and mutual support seem to be the opposite ends of one continuum, the former of which often means less coping, less learning, and less transferred information. Decreasing work opportunities and increasing competition for posts tend to make doctors’ careers much less flexible, with any break or sideways move being a slip from the ladder (Allen, 1988). Young doctors, both men and women, interviewed in Allen’s study criticize the rigid career structure and worry about having to stick to the specialty and career path once, and early, selected, with no choice and no opportunity for ‘deviations’. But they do not question the climbing itself and thus chance or drifting can only mean ending up somewhere undesirable. Allen notes that a general openness to other ways of organizing medical jobs and careers would take fairly fundamental changes in the medical profession. The question often asked is whether the increasing proportion of female doctors will further this change (Allen, 1988; Riska & Wegar, 1993). In my interviews it is men as well as women who consider a general practitioner’s career in order to avoid rivalry and hierarchies, the possibility of making sideway moves (Davies, 1995) instead of going merely up in their careers, and the unnecessariness of having life under strict control. If it is possible for a male doctor to say so, it can be possible to even make it come true.

Discussion Proponents of the proletarianization hypothesis have argued that when professionals become salaried employees they lose their autonomy and professional status (Murphy, 1990). Yet in Finland, as well as in Sweden, physicians have been public employees for the past 100 years and enjoyed a secure economic and social position (Riska, 1993). Even during the years of unemployment, they defended their privileged status as employees instead of seeking a solution in a free-market system. Still, the threat of unemployment laid bare the vulnerability of a profession whose work opportunities

fluctuate with the movements of the public sector economy (Riska, 1995). When, after years of expansion, the health care sector suddenly started to close down hospital units and to freeze physicians’ posts in Finland in the early 1990s, the security of doctors’ economic position was called into question. The profession entered a lively debate on the consequences of thousands of young colleagues not being able to find their way into a conventional professional career and status. Voices were raised for both variety and homogeneity, the latter of which were related to concerns about a lost professional identity and the ethics of physicians working in untraditional careers, outside the health care sector, or in ‘‘humbug’’. In unemployment, in other words, the medical profession saw a threat of deprofessionalization. The then young doctors and medical graduates faced this threat in their personal lives and careers. They met with an insecurity that was essentially different from the clinical uncertainty that is an inseparable part of medical practice and a challenge for medical training (Fargason, Jr, Evans, Ashworth, & Capper, 1997). They needed to construct professional identities that would be both valuable and compatible with the insecure reality, and they needed to redefine autonomy. In the young doctors’ life stories analyzed in this study, there is determination and ambition. Still, against the background of an autonomous and ambitious professional, their logic of chance is what stands out as something new and different. It challenges the idea of autonomy as an ability to independently and consciously guide one’s own course of life or career in a linear way. Instead, autonomy may come to mean, as in Petra’s story, a sensitivity to one’s own, and others’, ever-changing will and susceptibility to the unexpected. It is far from unproblematic to parallel the two levels of autonomy: autonomy of the profession as a corporate entity, and autonomy of an individual physician (Levine, 1993). However, I have attempted to show that these two levels intersect. The anxiety of the medical profession over its ethics and status in the face of unemployment implied what an individual doctor’s work and career should be like, an ideal that then seemed hard for young doctors to meet. Conversely, individual physicians did (and do) possess the possibility to redefine, at least partly, what it takes to be professional. Interestingly enough, in the 19 interviews analyzed some of the doctors who cherished the logic of chance, and who were not willing to know where their lives and careers would finally take them, were actually working on a secure and permanent basis. In other words, they could have told a story of stability but chose not to. What they told was a story of commitment to their present work, whether that was with patients or a research project. Johnson (1983) argues that biographies will both question the stereotypical conceptions of doctors’

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careers and be sensitive to the increasing unpredictability of them in times of change in society and health care. It seems that in Western societies, the modern traditions of social class, occupation, sex roles, and nuclear family, are losing their imperative power on individuals. Instead, individuals are left with ambivalence, or freedom, responsible for producing their own biographies. And ‘‘not just one’s own biography but also its commitments and networks as preferences and life phases change’’ (Beck; 1994; p. 14). Who can learn this and live with uncertainty, Beck writes, becomes a ‘‘key biographical and political question of the current era’’ (p. 12). Unemployment would thus be just one of the personal risks individuals, in this case young Finnish doctors, face in their lives. The stories they tell show that they are able to include unpredictability in their biographies, without losing their identity as moral actors. Of course, the stories were told in a reality where there was work to be found and where a doctor drifting could expect to meet with opportunities. The opportunities would be different in a situation where there are thousands of unemployed doctors, and they would often be outside the medical sector. Instead of deprofessionalization, this would mean differentiation of the medical profession by a segment of physicians producing their own biographies in an untraditional way (see also Riska, 1995). Besides employee status and unemployment, theories on professions have suggested other challenges to professional autonomy. For example, information society calls into question the knowledge monopoly that has been used to legitimize professional authority (Haug, 1988). From another point of view, the amount of medical knowledge is expanding in the postmodern world where the individuals depend on knowledge as a resource when making choices concerning their own life and the authority of experts is rather enhanced (Bauman, 1992). However, this happens in a world where rationality and universality are, according to Bauman, being replaced by pluralism, variety, contingency, and ambivalence. People who still listen to their doctors now view them as fallible human beings and challenge, from their consumerist position, the dominance of biomedical knowledge over other modes of explanation and understanding (Lupton, 1995). Uncertainty enters medical practice in a form that is not controllable with the scientific discourse of universality. Instead of deprofessionalization, the young doctors interviewed suggested a possibility of redefining professional; they confirmed that it is possible to blend susceptibility to change, ambivalence and strong commitment in one single story, one image of a young professional, one identity. For this kind of physician, power and control would no longer be core characteristics of being professional and yet much of the moral values of the medical profession could be captured. Perhaps this professional would be able, in the

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world of contingencies and ambivalence, to meet other viewpoints, other values and other expertise at the same ‘‘round table’’ (Beck, 1994, p. 28), letting medical knowledge enter a true dialogue and negotiations about truth.

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