Doctors and How They Got That Way
BELLIN, LOWELL E.
Doctors and How They Got That Way The Social Transformation of American Medicine By Paul Starr Basic. 514pp. $29.95. Reviewed by Lowell E. Bellin Professor of Public Health, Columbia University...
...Neither functionalists, who stress the impact of technical knowledge, nor power theorists, who point to doctors' monopolistic customs, can by themselves wholly explain the development of American medicine...
...As Starr puts it, they may be "more interested in freedom from the job than in freedom in the job...
...I can attest to the fact that private doctors resent the real or potential competition of public health agencies from my experiences while serving as Commissioner o f Health in Springfield, Massachusetts...
...Reviewed by Lowell E. Bellin Professor of Public Health, Columbia University School of Public Health According to Paul Starr's perceptive analysis, the prestige and affluence of American doctors-taken for granted today by physicians and laity alike-was not preordained...
...In this competition allopathic medicine triumphed, buttressed bythesuccessful application of the experimental method to problems of diagnosis and therapy...
...Corporations will not be the final word in American health care, for the consumer of health services is not enamored of size and structural complexity...
...Health administrators with MBAs are taking the managerial posts in corporate practice, and "health care marketing" is the buzz phrase epitomizing the corporate ethos that pervades the field today...
...To prosper, medical schools had to graduate the greatest number of physicians possible, and the ensuing glut compelled many to work arduous hours to scratch out a meager living...
...The egalitarian impulse dominated in the 19th century, when American physicians were held in low regard...
...Proponents of each school championed the virtues of their own techniques while deriding the alleged deficiencies and quackery of the others...
...Between 1850 and 1960, our culture hosted two opposing attitudes toward the medical profession, one respecting physicians as possessors of special knowledge, the other favoring the com-monsense approach of the average man...
...It was able to restrict the supply of doctors, constrain the expansion of public health, slow the progress of prepaid multispecialty group practice, hinder the seekers of national health insurance-the list goes on...
...The private sector's view of public health was summed up by a prominent physician who declared that a major goal of the Health Department should be "health education"-that is, "persuading the public to see their private physicians for regular checkups...
...sought favor...
...The AMA once resolutely fought this kind of arrangement, prizing physicians' autonomy and condemning the competition that corporate practice encourages...
...The city's ophthalmologists opposed a glaucoma detection clinic jointly sponsored by the Health Department and the local chapter of the Lions Club, for example...
...How medical resources are to be distributed has been decided through the competitive interplay of various actors: individual physicians practicing solo or with partners...
...Like the British House of Lords, it can only delay, not stop completely, the enactment of the various benchmarks of sociomedical progress...
...Today's growing physician/population ratio suggests the possibility that the doctors' domination of health care is again falling prey to a buyers' market...
...Shades of the 19th century...
...Starr also covers the American hospital's astonishing change from a locus of suffering, filth and death to a bureaucratic institution of care and a secular temple of knowledge...
...Two demographic trends have brought this about: the slow population growth owing to a falling birth rate plus a high abortion rate...
...Initially, they were rightly viewed as places where one went to die...
...medical schools experiencing long overdue reforms...
...Part of the current widespread support for the profession stems from the converging interests of patients and physicians, which converted a potentially hostile or indifferent public into an approving constituency...
...Although not yet rendered clawless and toothless, its influence has steadily waned...
...hospitals undergoing their own metamorphoses...
...and, more recently, research institutes and the government-All subject to the effects of periodic technical advances...
...These victories were especially notable given the fact that progressive reforms in the delivery of medical care already were under way in Europe...
...For all the talk about the "private doctor," though, the most recent evolution of the profession has produced the medical corporation-where an entrepreneur, hospital, or other agency hires physicians, usually on a salary, and profits from their labors...
...Doctors underbid each other, offering their services at disastrously low rates and suffering a high proportion of defaulting patients...
...Market forces already are partly responsible for doctors' moving to hitherto underserved areas, for instance, and among younger physicians there is a sharpening contest for jobs...
...Starr tracks the history: the early high mortality rates, the particulars of charity wards, the impact of private philanthropy, the origin and spread of nursing services, the advent of the ethnic hospital, and the staffing of voluntary hospitals with "attending" physicians who, unlike their European colleagues, followed and continued their private patients' care from office to medical facility...
...and the expansion and proliferation of medical schools, giving us more physicians every year...
...But the AMA finally had to withdraw its objections as physicians joined hospital-based groups in increasing numbers...
...In a similar spirit, the leadership of the local medical society resisted mass inoculation of Sabin vaccine...
...Instead of science, dogma reigned as numerous ideologies of care-including osteopathic, chiropractic, Thomsonian, homeopathic, and allopathic...
...Only in the 20th century did encounters with hospitals become likely to cure or at least alleviate suffering...
...His excellent study examines the medical profession's rise to "cultural authority, economic power and political influence," its role in shaping the institutional structure of medical care, and the evolution that has now put its "autonomy and dominance in jeopardy...
...At present fewer than half of American physicians choose to belong...
...But ultimately, as scientific medicine developed with its concomitant growth in complexity, professionalization prevailed over committed amateurism...
...physician may be on the way to becoming a thing of the past...
...Evidently, young MDs are disposed to trade some independence for security...
...This was best done in the doctors' offices, the society maintained...
...the American Medical Association (AMA...
...They became the doctors' workshop...
...This convergence combined with other workings of the political process to help bring about the field's professional sovereignty...
...Witness Medicare, Medicaid, health systems agencies, and professional standards review organizations...
...Indeed, health administrators are in a better bargaining position with potential employees than ever...
...This book also discusses the suspicions private practitioners have always had of the intentions of public health physicians, especially where patient care of any kind is provided...
...Yet the AMA has not been invincible...
...If it turns out that separating bigness from depersonalization is impossible, the consumer may press for a return of the solo MD with afternoon and evening hours in the neighborhood...
...Hospitals gave the profession an opportunity to exert authority within an institution that was increasingly indispensable to society...
...Whatever happens, the present prestige and affluence of the typical U.S...
...In retrospect, this way seems to offer access, personal warmth, and some compassion...
...The AM A, one is forced to concede, demonstrated superlative political skills in protecting this turf...
...The Social Transformation of American Medicine shows that the rise of the hospital was a prerequisite for the larger change it documents...
...They argued that a negative screening might lead persons without glaucoma to conclude all was necessarily well with their eyes, and that the false sense of security could result in a failure to visit their private ophthalmologist for a comprehensive eye examination...
Vol. 65 • December 1982 • No. 24
