The Social Transformation of American Medicine by Paul Starr

Book Review 
by Natalie Martinez

Paul Starr, author of The Social Transformation of American Medicine, writes about how the medical profession developed a role of authority, power and political influence, and how these forces and others shaped medical care. Further, he analyzes how American medicine has evolved to what health care is today.

Starr begins survey’s the history of the role of a physician. How they were not rich and successful as they are now. Why then are physicians so successful in the United States? Star points the answer to be the result of social influences. The first influence was a perceived authority role to society. They have achieved authority by proving their competence through graduation from medical school and through vigorous training after medical school. Physicians had a sense of authority since part of their job was to advise behavioral changes to their patients. Physicians also had authority over nurses and other health care workers. The belief in the health paradigm and their skill for medical care sustained the physician’s authority. With the increase of science and technology so did the competence and authority of physicians. Another factor that influenced success in America was the relationship amongst physicians in America. With the growth of hospitals and specialization, doctors became more dependent on one another for referrals. This decreased competition and created more of cohesiveness between physicians. People had more respect for physicians as a whole because of this.

Starr then goes to argue that a physician’s role of authority led to economic power. The healthcare physicians supplied became a commodity for society. Physician’s therefore gained control over the market and services. There was a limited supply of physicians because of licensing laws. This limitation made the demand increase and led the healthcare system to become a monopoly. Physicians sold to individual patients ( not organizations). This contributed to their economic power by avoiding power competition from other organizations. Success also came from the avoidance of political involvement that could hinder their economic success by restricting it.

The physician’s role of authority began to change. In the 1880’s and 1890’s health care was an interdependent system. It was not until the end of the 19th century had health care became a interconnected system with the rise of expanding hospitals. Organizations came into the picture and began to employ physicians. This left physicians who worked in private and voluntary hospitals at competition. The physician’s authority diminished as organizations expected physicians to follow their new rules. Physicians kept some authority because of their gate keeping position that gave them the purchasing power given to them by their patients. This and their power to decide who and where a patient was going to be hospitalized also kept their autonomy. Professionalism also was a big factor in securing autonomy. Training interns and residents kept the name of professionalism.

As technology and science increased so did specialization of physicians. Specialized physicians left general practitioners behind. Organizations preferred to employ specialized physicians rather than general practitioners. For this reason and the no need for a referral reason did competition arise amongst physicians and an eventual breakdown of physician team players.

America went through a time of reform for a structured economic system. Competition between physicians changed to a more corporate orientation by enacting the use of referrals. Professional authority was divided amongst different departments. An example of this is the public health department and the hospital for medical services. The medical system acted complimentary toward physicians by allows physicians to access hospital facilities without being part of an organization. This was made possible by the costs partly paid by public institutions. By the 1900’s, the health care system enforced strong licensing laws, created boundaries, controlled technology and organizations, and established a division of labor. Physicians not only had this new system but also the support of hospitals, drug manufactures, and public health.

The second half of the book surveys what Medical care is now and how it has evolved to that. As the availability of medical care rose so did the cost of medical care. Medical care was not available to those who could not afford it. During that time rights movements was occurring. The women’s movement made a big impact on the political involvement for the Bill of rights. While women were gaining more equality, the demand for a right for medical care increased. The Government had to look at supplying the nation’s needs and health care was one of them. This brought on the formation of Medicare and Medicaid.

Patient’s rights were next in line to be questioned in America’s government. The patient wanted to have the right to chose to not be treated if they wished so. Patient’s rights also included an array of other rights such as confidentiality. Patient’s rights brought the physician and the patient on a more equal level and decreased the physician’s authority. The involvement of rights and the increasing development of ambivalence toward medical authority cause the government to intervene. With the government’s now involvement, the structure of medical care changed. However, the rise in medical costs did not change. The government did not take this problem into account and choose to reduce federal aid as a last resort. The reduction in funds resulted in a fall of voluntary (non- profit) hospitals and a rise in organization hospitals ( for profit). Therefore the institutions that serve poor patients will longer have the funds to help the poor.

Because of the cutbacks of federal aid and rising costs of medical care, the government allowed public financing and public investors to manage the costs. This is where the insurance companies such as HMOs came in. What began as trying to regulate uprising cost of healthcare, resulted in corporate control. HMO is a type of vertical integration that is not single level of care organization (as it used to be) but various levels of care organization. The once traditional freestanding general hospital, governed by its own board, administrators, and medical staff is changing to corporate management. Instead of voluntary hospitals, organization hospitals will dominate and provide incentives to physicians such as working more regular hours. Solo Practice will be rare and practice groups will be more common. Instead of public regulation, there will be private regulation. Instead of public planning, there will be corporate planning. Instead of public financing for prepaid plans there will be corporate financing for private plans. Profit will be made by interests that will be determined by the rate of return. It is sad how what began as an inexpensive cost to treat the sick has turned into a money hungry business.

Paul Starr does a great job explaining how authority, power and political influence has shaped medical care and how medical care has evolved today.

I recommend the book to anyone who will be working in the medical field.