The Social Transformation of American Medicine
Social scientists have been perplexed by the remarkably favored position of doctors in American society. Few other professions conduct their affairs with so much autonomy and receive in return such generous economic benefits. In a country historically suspicious of privilege and authority doctors have enjoyed a large measure of both, and—at least until recently—their views have generally been accorded a respect usually given to astronauts, coaches of championship football teams, successful Wall Street analysts, and other heroes of contemporary culture.
The medical professions have virtually unchallenged economic control of what is now called the “health care industry.” The laws of the market seem to have little effect on this peculiar industry, and doctors, who are the suppliers of medical services, have pervasive influence over the demand for the very services they sell. Doctors seem able not only to monopolize the market but to control their own numbers and set their own standards of education and professional performance—all with public approval and, through licensing laws, government support.
Authority, self-regulation, and socially sanctioned monopoly in a defined field of competence characterize virtually all professions, but medicine in twentieth-century America has enjoyed a sovereignty unmatched by that of any other field. How did this come about?
In his important book, Paul Starr, a young sociologist at Harvard, attempts to answer this question. The first half of The Social Transformation of American Medicine is a history of the social and economic growth of the medical profession from precolonial times to the present. Medicine in America was not always the powerful and respected institution it later became. Throughout the eighteenth century and for most of the nineteenth, doctors had little economic or political power. They were often distrusted by the public and faced competition, at first with lay practitioners, midwives, and herbal folk doctors, and later, beginning in the mid-nineteenth century, with a succession of more ambitious challengers, including “eclectic” practitioners, homeopaths, chiropractors, and osteopaths.
In resisting these movements, orthodox medicine was at first hampered by its own lack of organization and its ignorance of science. Not until the final decades of the nineteenth century did the profession begin to gain public support. By the 1920s it had been transformed into a disciplined, state-licensed but largely self-regulating profession which had consolidated its social and political power and established a virtual monopoly over health care. The eclectic and homeopathic physicians were assimilated; chiropractors were confined by law to limited practices, and osteopaths, although independently licensed, were greatly outnumbered, and losing influence and prestige.
This story has been told before from different perspectives, by historians such as Richard Shryock (Medicine in America), William Rothstein (American Physicians in the Nineteenth Century), Rosemary Stevens (American Medicine and the Public Interest), and many other writers, on whom Starr has drawn. But Starr’s work is unique in the way it shows how cultural, political, and economic factors contributed to the profession’s rising power. As he points out, most other accounts emphasize the primary influence of scientific and technological change, claiming that medicine came to dominate the health care system because, unlike other healing sects, it became part of modern science and could therefore hold out the prospect of steadily increasing competence. But Starr argues that
the advance of science and technology did not necessarily guarantee that physicians would remain in control. Quite the opposite result might have occurred: The growth of science might have reduced professional autonomy by making doctors dependent upon organizations. Modern medical practice requires access to hospitals and medical technology, and hence medicine, unlike many other professions, requires huge capital investments. Because medical technology demands such large investments, it makes the medical profession vulnerable to control by whoever supplies the capital.
In fact, as the doctors’ professional competence and personal authority increased, so did their quest for both autonomy and higher financial rewards. They sought to organize themselves in order to control not only the market for their services, but the health boards and other organizations that govern these services, provide facilities, and determine public policy. To do so, physicians had to gain the public’s trust as qualified and ethical protectors of their patients. They had to assure the public of the reliability of their “product,” by imposing regulations for licensing and training, and by establishing professional organizations such as the AMA that were to set ethical codes and expose quackery, fraud, and incompetence.
At the same time, Starr shows that physicians made sure that nothing came between them and their patients. The AMA’s public strategy was to defend the kind of practice in which the doctor—and only the doctor—charged fees for medical services. This model was held to assure both the quality of care and patients’ “freedom of choice.” Of course, such an arrangement also assured each doctor control of his own practice and his economic fortunes. Whenever government, business corporations, labor unions, community agencies, or any other third party threatened the fee-for-service arrangement by, say, attempting to hire their own physicians, organized medicine reacted strongly. The AMA and local medical societies opposed what they called the “corporate practice of medicine” as unethical arrangements interfering with the traditional relation between doctor and patient. Even when they were run by doctors themselves, any organizations that paid doctors a salary, such as, for example, group practices, were disapproved of by the AMA.
Direct marketing to the public of potent drugs and therapeutic agents was also seen by the profession as a threat to public safety and as an interference with doctors’ control. So were attempts by nurses, pharmacists, and midwives to treat patients independently. Starr wants to show how such challenges to the “doctor-patient relationship” were successfully resisted or converted to the advantage of the medical profession, and he devotes most of the first half of this book to explaining how doctors were able to keep their control.
To this part of his story, Starr brings impressive scholarship and a broad understanding of social forces. Even those familiar with the subject will find in his book fresh insights. Unhappily, they will also find that Starr is not always objective and at times interprets events too narrowly. He does not propose “solutions” or promote particular policies; but he has preconceived ideas about the nature of professions in general and of medicine in particular. In his introductory chapter, “The Social Origins of Professional Sovereignty,” he describes the rise of the medical profession as largely the story of a special-interest group seeking to gain an economic monopoly, and this premise dominates the book. Medical treatment itself, the growth of its technical effectiveness, and the public’s rising demand for medical services, he mentions only in passing. Starr’s history concentrates mainly on economic and political forces, as if moral considerations, such as a doctor’s commitment to his patients’ interests, count for very little.
For example, in describing the AMA’s campaign in the early part of this century against advertising patent medicines in the popular press, Starr says, “The logic of the AMA’s regulatory system was to withhold information from consumers and rechannel drug purchasing through physicians.” That is one way of looking at it, but a more dispassionate view would recognize that the AMA was also trying to protect the public at a time when many people were being victimized by worthless or dangerous nostrums. Most of the constraints the AMA fought for in the early days were later written into federal law and are now generally accepted as necessary for the public safety. Starr knows this, of course, but to emphasize the dark side of the profession’s motives better suits his thesis.
When he discusses the educational and licensing reforms that led to the closing of many substandard medical schools and the elimination of many unqualified practitioners, Starr asserts that physicians thereby succeeded in controlling their own numbers, chiefly for their own benefit. “The main function of medical licensing,” he writes, “was…to cut down on the number of regular physicians.” And what of the function, emphasized by the doctors themselves, of keeping up the quality of medical practice? When he ignores this question and its importance to the public, Starr sounds curiously like the “right-wing advocates of the free market” whose libertarian views on health care he criticizes elsewhere.
Explaining how physicians came to control the hospitals and laboratory facilities they needed to practice medicine, Starr writes:
They [doctors] wanted to be able to use hospitals and laboratories without being their employees, and consequently, they needed technical assistants who would be sufficiently competent to carry on in their absence and yet not threaten their authority. The solution to this problem—how to maintain autonomy, yet not lose control—had three elements: first, the use of doctors in training (interns and residents) in the operation of hospitals; second, the encouragement of a kind of responsible professionalism among the higher ranks of subordinate health workers; and third, the employment in these auxiliary roles of women who, though professionally trained, would not challenge the authority or economic position of the doctor. [Here he refers to nurses, nurse-anesthetists, X-ray and laboratory technicians, and so forth.]
Starr’s interpretation of the first of these “solutions” will be unconvincing to anyone familiar with graduate medical education. Training programs for resident doctors were established primarily for educational purposes and at first in a relatively small number of teaching hospitals where most of the patients did not even have private physicians. As for his comment about the exploitation of women in “auxiliary” hospital work, Starr should have noticed that, in their policies toward women employees, hospitals were reflecting the views prevailing throughout American society at the time. Furthermore, it is not clear whether he thinks that nurses and technicians should have been expected to “challenge the authority” of physicians and how that would have contributed to improving the quality of care in hospitals.
Starr acknowledges that scientific and technological progress had something to do with the success of the medical profession, but he understates how important this was to the victory of organized medicine over the other healing sects and to the ability of doctors to gain public confidence. This suggests the perils of trying to write a social history of medicine without taking account of the scientific work on which medical practice is based.
Starr accuses the medical profession of using “paternalism” to establish its monopoly of health care. He doesn’t consider the doctor’s claim, which can be strongly argued, that the relationship with the patient may depend no trust in the doctor. The sicker and more anxious the patient, the greater may be the need to depend on a doctor’s competence and judgment. Without that trust, therapy may be less effective, the patient more distressed. We can all think of cases where acceptance of such paternalism was not justified, but it is hard to imagine the medical profession functioning without it.
This does not mean that patients should be kept passive and uninformed. There is a growing sense—still resisted by some doctors—that patients should be involved in their own treatment whenever possible and as much as they wish to be. Starr is right to say that paternalism enlarges the profession’s authority, but he does not suggest what he would substitute for trust. This is a complex issue; by concentrating mainly on the profession’s self-serving motives, Starr over-simplifies it.