Chapter 3: The Consolidation of Professional Authority

This chapter begins with a summary of the social status of medical professions prior to the 20th Century.

Physicians: Classes of Their Own
It seems that physicians had their own "class system" before the 20th century. There was a small, elite class of physicians that had usually been born into the upper class, and already had money they had inherited from their families. On the other hand, most medical professions were of the "lower class," and did not enjoy the amenities of their counterparts. As may be expected, physicians from the "upper class" usually tended to affluent patients and doctors in the "lower class" treated the rest. These class differences oftentimes led to hostility between different physicians.

Maintaining Social Status
However, just because physicians were not born into the "upper class," did not mean they could not enjoy high social status. Simply being a physician at this time allowed individuals to obtain respect and social status from their community. Many physicians became preoccupied with keeping up appearances of high social status in front of their patients that hindered them from providing the best health care possible.

As stated earlier, more affluent physicians would usually tend to upper class patients. Yong physicians were forced to find other ways of establishing themselves in as credible medical professionals. Young physicians began seeking membership to medical professional societies to obtain better social status. The first medical professional society, the American Medical Association (AMA), was created for this exact reason. However, such professional societies were unable to follow through with their original purpose. These societies to "legitimize" their members. Starr states Starr states that, perhaps, if these societies were able to license their members they could have had more success in differentiating their members from other physicians. Unfortunately, these societies had no such power and so proved nearly irrelevant at this time.

Other Sources of Tension
The animosity within the medical field did not simply exist between members of different "classes." Sectarianism also led to different conflicts.

Three main groups arose -- the Eclectics, homeopaths, and medical professions. Each had its own basis for medical practice -- the Eclectics adopted most of the Thomsonian philosophy, homeopaths followed homeopathic philosophy, and medical professions followed the same scientific practice. Differences between the sects led to several conflicts.

By the 1880's, increase in urbanization and scientific knowledge forced individuals from different sects to depend on one another for patients and venues to practice medicine. As members of different sects began to come together, it seemed convergance and reconciliation was near. The final push came from the creation of licensing laws. Licensing laws now mandated medical professionals to obtain licenses to practice medicine. Members from all sects had to depend on one another to obtain a license.

Slowly, some competition between the different sects was alleviated. However, a new problem now arose -- there was now a need to control the sheer number of medical professionals working in America.

Standardizing Education
The heads of several leading universities, beginning with Harvard, saw that medical students were graduating from school and entering their professions with an inadequate education. Thus, reformations began at each school to ensure students graduated with a solid education. Reformation began atHarvard when the school administrators decided all students had to pass all of their exams to graduate. The culmination of change occurred at Johns Hopkins years later when school administrators required all entering medical students to have a college degree and lengthening the medical program to a full 4 year curriculum.

In 1900, the AMA reformed and made school reformation a top priority. Since there was no government intervention, the AMA became the main authority on school reformation. The AMA also began an investigation into how to better the medical school system headed by a man named Abraham Flexner. Flexner led another streak of reformation, which ended with a fixed number of medical schools and associated curriculum in place.

These changes resulted in homogeneity of the the medical profession -- women and minorities were discouraged to enter and the high costs of medical school disabled individuals from working families to enter. Furthermore, the strict curriculum dissuaded individuals from different medical sects from entering.

Drugs-- Eliminating the Competition
The next obstacle that medical professions faced were drug makers. Drug makers advertised their products as "sure-fire cures," which discouraged some patients from pursuing medical care. Physicians now desired to eliminate drug makers from having such a big influence over them.

Three things helped the AMA fight drug makers: a media campaign against them, securing enough financial resources to compete against them, and the fact that drug makers depended on medical professions to tell their patients about different drugs. In the end, the AMA was able to use its cultural authority to win their battle against drug makers. Specifically, they created several different processes and policies that severely cut the autonomy of drug makers.

Cultural Authority
The triumph over drug makers was only the first sign that the medical professional's solidified their cultural authority. Medical professionals also made great leaps in different areas --

• their knowledge of public hygiene, surgical procedures, and diagnostic techniques increased greatly.
  
• They were able to use this well-based knowledge to solidify their stance as knowledgeable and trustworthy members of the professional world.
  

Unfortunately, not all of these advances were backed by empirical advances. Some techniques physicians used were actually harmful for patients. However, it seems not many questioned services doctor's cared. And, eventually, physicians were able to use these advances to obtain and keep cultural authority.

Comparison to Present Times
I wanted to draw a comparison to what happened in this chapter to what is currently happening with Obama's healthcare reform. This chapter shows that throughout the late 19th and early 20th century, medical professionals were constantly at odds with different parties. The base of this conflict seems to always be one thing: physician's need to maintain autonomy.

Recently, the House passed a bill on health care reform and the Senate has just released its own rendition of the plan that will be voted on. Concurrently, many physicians are speaking out against this plan because they believe it will allow the government to gain unprecedented power over how they can practice medicine. The AMA's argument is summarized in the following article: http://www.nytimes.com/2009/06/11/us/politics/11health.html

It seems the AMA will always strive to protect physicians' autonomy.

It seems that the AMA is fighting a constant, perpetual battle against change.