Before I go on with the Starr book, I wanted to comment on an article I just found. "In a Hospital Hierarchy, Speaking is Hard to Do." This is a NY Times article published in April 2007 that summarizes how hard it is for medical students and new physicians to speak up in front of their older colleagues. The author, Barron Lerner, traces this hierarchy back to the medical education changes that occurred at Johns Hopkins (the same reformation Starr summarizes in Chapter 3). The rotation programs that were put into place at that time are the precursors of modern-day residency programs. Medical students often feel inferior to residents and senior physicians. They may even be admonished for speaking out against their seniors.
Lerner does say that many have recognized the bad effects such hierarchies have on good medical practice. Lerner provides one example, "A student recently told me he had examined a patient and concluded that she might have a severe abdominal disorder. But when he told the resident, who had seen the patient earlier and more quickly, the resident refused to re-examine the patient. He then reminded the student that while he had examined hundreds of such cases, the student had seen only a few."
Some changes have been put into place. For instance, residents and students are now to provide feedback on their rotation experience, in which they could report problems with the "hospital hierarchy." Although, I wonder if such problems can really be fixed? There seems there will always be a hierarchy, not just in hospitals, but wherever you look. I wonder if there are any true solutions to this "hierarchy problem."
As I have commented already, it seems that there is always animosity or tension between medical professionals. I'm beginning to think that such tension can never be assuaged, and it may just be a reality of the medical profession.
Friday, November 20, 2009
Chapter 4: The Reconstitution of the Hospital
Hospitals underwent great change at the turn of the nineteenth century. As stated by Starr, "[this change] involved its redefinition as an institution of medical science, rather than of social welfare, its reorganization on the lines of a business rather than a charity, and its reorientation to professionals and their patients rather than to patrons and the poor." This change also reflected the general changes that were occurring in the social structure of the U.S. Specifically relationships changed from being "communal," relationships reflecting those of family or fraternity, to "associative," or economic exchanges based on similar interests.
The Introduction of Hospitals
Initially, almshouses or poorhouses were the main form of hospital care. These "hospitals" provided care for individuals who did not "fit into the traditional" sense of family care. In other words, they treated destitute individuals who had no other way to turn and housed mental patients who were ostracized from society. Eventually, Hospitals were created and existed alongside almshouses. Hospitals popularized as specialization increased in the medical field and as the number and type of patients, besides the traditionally poor individuals who came to almshouses, increased.
Although, making hospitals the main venue for care was a long process. In order to sustain hospitals, the number of medical professionals needed to increase. Nurses were the first to do so as women who wished to enter the field began training schools. Surgeons were the next group to increase. Knowledge about different surgical procedures increased and tools for surgery, such as antiseptis, were discovered. This allowed surgeons to broaden their practice to encompass more illnesses and let them work more often. At first, surgeons continued to work at patient's homes, but soon there was a need for more space, availability of more tools, etc. Eventually, hospitals became the main venue for surgeries.
Shifting Focus & It's Effects
These changes eventually allowed hospitals to be used for entirely new reasons. Previously, hospitals treated chronic illnesses and housed patients for long periods of time. Now, hospital personnel targeted more acute illnesses that allowed for quick discharges. In the end, there was a shift from moralistic to medical objectives, as hospital personnel focus changed from treating patients for moral, even religious, means to those that best fit the present medical needs.
The shift in hospital priority greatly changed other aspects of hospitals. Hospitals began to serve richer patients as demand for more expensive services (like surgeries) grew. These patients had high expectations for care and many required private rooms. Soon, private quarters replaced customary community patient wards. The reflects the general change that occurred-- instead of serving poor patients, which had been the main goals of hospitals until this time, hospitals were now serving more and more rich patients.
The relationship between patient and physician changed. In almshouses, patients had oftentimes assisted in cleaning and minor treatment procedures. In general hospitals, all services were "taken over completely be employees of the institutions." Thus, there was now a clear distinction between patient and caregiver.
The last major change that occurred was a significant increase in hospital costs. Construction and operation costs went up dramatically. But, instead of depending on donations or charity money as hospitals had in the past, hospitals could now depend on payments from patients. Consequently, medical professions gained power over the hospital as they brought in more money and trustees lost their power.
Physician "Classes" Pursued
There was a specific "class" system in hospitals. The hospital medical staff was arranged into four groups:
Doctors that worked in hospitals were not paid. However, obtaining a job in a hospital was now very important because it helped physicians establish themselves as professionals. Thus, the following system was conceived: all the house physicians gave services in exchange room and board, dispensary staff gave services in hopes of becoming visiting physician, and visiting physicians gave services for access to surgical facilities.
Fraternity Systems
Physicians became obsessed with finding new ways to establish themselves. Although the number of hospital jobs were increasing at a steady rate (more and more hospitals were being built), many young physicians were unable to obtain hospital jobs. When excluded, these young physicians looked for different ways to gain professional prestige.
A new fraternity or ranking system of sorts came to be. Medical professions would work to make connections, etc. in hopes of finding a position in a hospital. Medical societies offered social advantages for their members. They slowly gained influence over hospital employment. By the early 20th century, many organizations, such as the AMA, required hospitals to only employ physicians who were members of their organization. Medical societies enjoyed incredible power at this time; through this social power, they were even able to exclude minorities, such as African Americans, from obtaining hospital jobs.
Physician-Controlled Hospitals
In 1890, perhaps angered by the politics that controlled hospital employment, many physicians began creating their own for-profit hospitals. These hospitals were mostly surgical centers and had no ties to medical schools. They relied only on fees paid by patients. Physicians at these hospitals treated patients from all backgrounds: poor patients were oftentimes treated for teaching purposes and rich patients were often treated to ensure a steady flow of income. This environment allowed for a great teaching opportunity -- physicians came across all types of patients.
Ending Details
There are several other details about the history of hospitals in this chapter. Yet, I find the last couple pages the most interesting. Here, Starr talks about how the source of authority over hospitals changed throughout American history. As stated earlier in this post, hospitals began as almhouses headed by trustees. Trustees were the sole source of authority because they could bring in the charity funds needed to keep the early hospitals going. These hospitals mostly treated poor patients and housed mental patients; neither groups could pay for these services. At the turn of the century, there was a surge in medical knowledge that allowed for medical specialization. Medical professionals were now able to offer a number of specialty services to wealthy patients. Medical professionals now required standardized venues for their services and patients required private, possibly elaborate, quarters to stay in during the services and recovery. Eventually, medical professionals were able to take control of hospitals because the fees they brought in were needed to run hospitals. But, the major change came next. As hospitals' infrastructure and necessities increased, it became necessary to bring in other individuals who could effectively run these large institutions. Thus, administrators were brought in to run hospitals. To this day, three parties have authority over hospitals: trustees, physicians, and administrators.As Starr states, hospitals are one of the few institutions that were able to elude the bureaucratic concept of having one, single authority figure.
The Introduction of Hospitals
Initially, almshouses or poorhouses were the main form of hospital care. These "hospitals" provided care for individuals who did not "fit into the traditional" sense of family care. In other words, they treated destitute individuals who had no other way to turn and housed mental patients who were ostracized from society. Eventually, Hospitals were created and existed alongside almshouses. Hospitals popularized as specialization increased in the medical field and as the number and type of patients, besides the traditionally poor individuals who came to almshouses, increased.
Although, making hospitals the main venue for care was a long process. In order to sustain hospitals, the number of medical professionals needed to increase. Nurses were the first to do so as women who wished to enter the field began training schools. Surgeons were the next group to increase. Knowledge about different surgical procedures increased and tools for surgery, such as antiseptis, were discovered. This allowed surgeons to broaden their practice to encompass more illnesses and let them work more often. At first, surgeons continued to work at patient's homes, but soon there was a need for more space, availability of more tools, etc. Eventually, hospitals became the main venue for surgeries.
Shifting Focus & It's Effects
These changes eventually allowed hospitals to be used for entirely new reasons. Previously, hospitals treated chronic illnesses and housed patients for long periods of time. Now, hospital personnel targeted more acute illnesses that allowed for quick discharges. In the end, there was a shift from moralistic to medical objectives, as hospital personnel focus changed from treating patients for moral, even religious, means to those that best fit the present medical needs.
The shift in hospital priority greatly changed other aspects of hospitals. Hospitals began to serve richer patients as demand for more expensive services (like surgeries) grew. These patients had high expectations for care and many required private rooms. Soon, private quarters replaced customary community patient wards. The reflects the general change that occurred-- instead of serving poor patients, which had been the main goals of hospitals until this time, hospitals were now serving more and more rich patients.
The relationship between patient and physician changed. In almshouses, patients had oftentimes assisted in cleaning and minor treatment procedures. In general hospitals, all services were "taken over completely be employees of the institutions." Thus, there was now a clear distinction between patient and caregiver.
The last major change that occurred was a significant increase in hospital costs. Construction and operation costs went up dramatically. But, instead of depending on donations or charity money as hospitals had in the past, hospitals could now depend on payments from patients. Consequently, medical professions gained power over the hospital as they brought in more money and trustees lost their power.
Physician "Classes" Pursued
There was a specific "class" system in hospitals. The hospital medical staff was arranged into four groups:
- consulting staff, composed of older and distinguished physicians,
- visiting or attending staff, active physicians who supervised treatment;
- a resident or house staff of young doctors in training;
- and, a dispensary staff that saw outpatients.
Doctors that worked in hospitals were not paid. However, obtaining a job in a hospital was now very important because it helped physicians establish themselves as professionals. Thus, the following system was conceived: all the house physicians gave services in exchange room and board, dispensary staff gave services in hopes of becoming visiting physician, and visiting physicians gave services for access to surgical facilities.
Fraternity Systems
Physicians became obsessed with finding new ways to establish themselves. Although the number of hospital jobs were increasing at a steady rate (more and more hospitals were being built), many young physicians were unable to obtain hospital jobs. When excluded, these young physicians looked for different ways to gain professional prestige.
A new fraternity or ranking system of sorts came to be. Medical professions would work to make connections, etc. in hopes of finding a position in a hospital. Medical societies offered social advantages for their members. They slowly gained influence over hospital employment. By the early 20th century, many organizations, such as the AMA, required hospitals to only employ physicians who were members of their organization. Medical societies enjoyed incredible power at this time; through this social power, they were even able to exclude minorities, such as African Americans, from obtaining hospital jobs.
Physician-Controlled Hospitals
In 1890, perhaps angered by the politics that controlled hospital employment, many physicians began creating their own for-profit hospitals. These hospitals were mostly surgical centers and had no ties to medical schools. They relied only on fees paid by patients. Physicians at these hospitals treated patients from all backgrounds: poor patients were oftentimes treated for teaching purposes and rich patients were often treated to ensure a steady flow of income. This environment allowed for a great teaching opportunity -- physicians came across all types of patients.
Ending Details
There are several other details about the history of hospitals in this chapter. Yet, I find the last couple pages the most interesting. Here, Starr talks about how the source of authority over hospitals changed throughout American history. As stated earlier in this post, hospitals began as almhouses headed by trustees. Trustees were the sole source of authority because they could bring in the charity funds needed to keep the early hospitals going. These hospitals mostly treated poor patients and housed mental patients; neither groups could pay for these services. At the turn of the century, there was a surge in medical knowledge that allowed for medical specialization. Medical professionals were now able to offer a number of specialty services to wealthy patients. Medical professionals now required standardized venues for their services and patients required private, possibly elaborate, quarters to stay in during the services and recovery. Eventually, medical professionals were able to take control of hospitals because the fees they brought in were needed to run hospitals. But, the major change came next. As hospitals' infrastructure and necessities increased, it became necessary to bring in other individuals who could effectively run these large institutions. Thus, administrators were brought in to run hospitals. To this day, three parties have authority over hospitals: trustees, physicians, and administrators.As Starr states, hospitals are one of the few institutions that were able to elude the bureaucratic concept of having one, single authority figure.
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 --
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.
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.
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.
Thursday, November 19, 2009
Chapter 2: The Expansion of the Market
One of the main problems for physicians in the beginning of the 19th century was that they could not make enough money. As stated by Starr, at this time, there were limiting "economic conditions that encouraged most families to care for themselves." Without many people to treat, medical professionals did not have the opportunity to make any financial gains.
Unregulated Medical Expansion
Interestingly, circumstances soon changed as more and more people began to pay for medical services and hospital care. As patients pursued more health care, the medical market expanded to provide more and more services. Yet, "the public, as well as physicians, resisted treating medicine purely as a commodity and giving free rein to commercial impulses." Americans did not know whether the medical profession should be allowed to grow without restriction or not. Two sides formed: Some believed that the market should be freed of constraint so that the medical profession can grow. In contrast, some thought it best to protect the economy and also traditional medical institutions by restricting the growth of the medical profession.
At this time, the government was not as involved in treatment of the sick. Thus, with little government intervention, the medical market was allowed to grow without impediment. One consequence of little regulation was the formation of several different payment systems for medical care. For example, in the 1830's and '40's, a fee for service system popularized. So, many physicians would simply collect money for individual services provided. Other physicians provided medical care by credit and collected payments either quarterly or annually. Another consequence was that the number of physicians increased dramatically. Many recognized the lucrative advantages of entering medicine. There were no standards for medical education, thus many medical school and "easy" degree programs were created allowing a flood of people to quickly become "doctors" and begin working.
Economic Problems
A major economic problem was the difference between direct price of medicine (physician's fee and hospital stay fee) and indirect price (transportation, etc.). The indirect price for medicine was very expensive no matter where physicians worked. The major contributing factor to indirect prices was transportation. There was no way to control where and when doctors would have to see patients. Thus, they were oftentimes forced to pay large prices simply to commute to where their patients were. There was no way in generalizing indirect costs in medicine, which led to discrepancies in what a physician should charge.
Some of the pressures of the indirect costs of medicine were alleviated by the construction of railroads, steamboats, and roads. This construction led to larger cities and urban areas in which patients and doctors were much closer together. This allowed the physician to travel shorter distances to see patients, thus reducing costs of transportation. Furthermore, the creation of the telephone and automobiles allowed physicians to talk to patients, which sometimes eliminated the costs of transportation altogether.
Unregulated Medical Expansion
Interestingly, circumstances soon changed as more and more people began to pay for medical services and hospital care. As patients pursued more health care, the medical market expanded to provide more and more services. Yet, "the public, as well as physicians, resisted treating medicine purely as a commodity and giving free rein to commercial impulses." Americans did not know whether the medical profession should be allowed to grow without restriction or not. Two sides formed: Some believed that the market should be freed of constraint so that the medical profession can grow. In contrast, some thought it best to protect the economy and also traditional medical institutions by restricting the growth of the medical profession.
At this time, the government was not as involved in treatment of the sick. Thus, with little government intervention, the medical market was allowed to grow without impediment. One consequence of little regulation was the formation of several different payment systems for medical care. For example, in the 1830's and '40's, a fee for service system popularized. So, many physicians would simply collect money for individual services provided. Other physicians provided medical care by credit and collected payments either quarterly or annually. Another consequence was that the number of physicians increased dramatically. Many recognized the lucrative advantages of entering medicine. There were no standards for medical education, thus many medical school and "easy" degree programs were created allowing a flood of people to quickly become "doctors" and begin working.
Economic Problems
A major economic problem was the difference between direct price of medicine (physician's fee and hospital stay fee) and indirect price (transportation, etc.). The indirect price for medicine was very expensive no matter where physicians worked. The major contributing factor to indirect prices was transportation. There was no way to control where and when doctors would have to see patients. Thus, they were oftentimes forced to pay large prices simply to commute to where their patients were. There was no way in generalizing indirect costs in medicine, which led to discrepancies in what a physician should charge.
Some of the pressures of the indirect costs of medicine were alleviated by the construction of railroads, steamboats, and roads. This construction led to larger cities and urban areas in which patients and doctors were much closer together. This allowed the physician to travel shorter distances to see patients, thus reducing costs of transportation. Furthermore, the creation of the telephone and automobiles allowed physicians to talk to patients, which sometimes eliminated the costs of transportation altogether.
Chapter 1: Medicine in a Democratic Culture
This chapter looks at American medicine from 1760-1850.
Democracy -- Really "Equality" for All?
One of the first, key points Starr notes is that American democracy did not lead to equality for all when it came to wealth. Individuals began to view their fellow man is equal, they had the same status in society. But, the new capitalist economy led to new found concentrations of wealth and power. Particularly in larger cities where specific individuals began to gain more wealth and power.
Similar changes occurred in the medical professions. While physicians tried to retain their social power that allowed them a "monopoly of practice," most of the public did not allow them such power and insisted on maintaining their own "rights and judgement in managing sickness." Thus, there was a constant battle between medical professional's trying to maintain their autonomy (they wanted to practice medicine in their own way, controlling how patients approached and used medicine) and individual Americans who now tried to control what health care they were given.
Tension Within Medicine
Starr delves into how the struggle between physician autonomy and patients' independence effected three parts of medicine: medicine in individual households, medicine practiced by physicians, and medicine practiced by lay healers.
I found the section of lay healers the most interesting. Starr states that lay healers became the competitive counterparts of medical professionals; specifically, lay healers "saw the medical profession as a bulwark of privilege, and they adopted a position hostile to both its therapeutic targets and its social aspirations." Doctors were usually individuals from the upper class, while other medical practitioners (like lay healers) came from lower classes. Social differences, general mistrust of one another's medical practices, and other problems propagated animosity between physicians and lay healers. But, it was interesting that, as Starr points out, both groups oftentimes usd medical practices derived from one another. Then why the animosity?
To answer this question I looked at to different examples. First, I believe that some animosity may stem from the fact that medical professionals did not like women entering their field. Many women who wanted to practice medicine may then become lay healers instead; however, they would still harbor animosity against doctors they perceived to be prejudiced.
Second, I looked at the major lay health movement concerning the Thomsonians. Samuel Thomson started this movement, he began practicing as a lay healer and eventually got a patent to practice botanic medicine. He gained many followers, many of whom came from rural areas. The medicine he practiced were centered around the following principles: all disease is from one cause and can be removed by a remedy, cold is the cause and heat is the remedy. All bodies are composed of the four elements. To restore health, you must restore heat. Many doctors were against the Thomsonians, just like they were against lay healers.
Inititally, I was intrigued by the Thomsonians because I'd never heard of this movement before reading this book. After reading Starr's section about them, I realized they provide one of the best examples to depict the struggle between medical professionals and medical practitioners. First, Thomsonians show how lower class individuals were able to "rise up" and assert their new found "democratic" power equality. Most Thomsonians were from rural areas; so, I'm guessing they did not have a lot of money or education. Thomson's new way of medical practice provided a quick and easy way to quickly begin practicing medicine. Consequently, this new profession provided these individuals with a way to assert power over people they cared for. Therefore, they found a way to exercise the new "power" the democratic idea of equality gave them.
Thomsonians provided competition for physicians. Doctors were not expected to prove their credibility not only for their patients but in comparison to a newly conceived medical practice. Consequently, tensions arose between physicians and the Thomsonians as both groups tried to establish themselves.
A Redundant Cycle?
This is exactly what Starr states happened at this time. Medical professionals tried to retain their social power while other Americans used the idea of equality to substantiate their own individual power. In the end, this constant ba.ttle led to a redundant cycle betwen professionals and lay persons
Eventually, according to Starr, people began to realize that each individual could not become a physician. At the conclusion of this chapter he states "the nineteenth century was a period of transition, when the traditional forms of mystification had broken down and the modern fortress of objectivity had not yet been built." I'm intrigued to see what happens in the nineteenth century. Hopefully, people were not bogged down by their fascination with individual power and, at least some, brought peace and order to medicine.
Democracy -- Really "Equality" for All?
One of the first, key points Starr notes is that American democracy did not lead to equality for all when it came to wealth. Individuals began to view their fellow man is equal, they had the same status in society. But, the new capitalist economy led to new found concentrations of wealth and power. Particularly in larger cities where specific individuals began to gain more wealth and power.
Similar changes occurred in the medical professions. While physicians tried to retain their social power that allowed them a "monopoly of practice," most of the public did not allow them such power and insisted on maintaining their own "rights and judgement in managing sickness." Thus, there was a constant battle between medical professional's trying to maintain their autonomy (they wanted to practice medicine in their own way, controlling how patients approached and used medicine) and individual Americans who now tried to control what health care they were given.
Tension Within Medicine
Starr delves into how the struggle between physician autonomy and patients' independence effected three parts of medicine: medicine in individual households, medicine practiced by physicians, and medicine practiced by lay healers.
I found the section of lay healers the most interesting. Starr states that lay healers became the competitive counterparts of medical professionals; specifically, lay healers "saw the medical profession as a bulwark of privilege, and they adopted a position hostile to both its therapeutic targets and its social aspirations." Doctors were usually individuals from the upper class, while other medical practitioners (like lay healers) came from lower classes. Social differences, general mistrust of one another's medical practices, and other problems propagated animosity between physicians and lay healers. But, it was interesting that, as Starr points out, both groups oftentimes usd medical practices derived from one another. Then why the animosity?
To answer this question I looked at to different examples. First, I believe that some animosity may stem from the fact that medical professionals did not like women entering their field. Many women who wanted to practice medicine may then become lay healers instead; however, they would still harbor animosity against doctors they perceived to be prejudiced.
Second, I looked at the major lay health movement concerning the Thomsonians. Samuel Thomson started this movement, he began practicing as a lay healer and eventually got a patent to practice botanic medicine. He gained many followers, many of whom came from rural areas. The medicine he practiced were centered around the following principles: all disease is from one cause and can be removed by a remedy, cold is the cause and heat is the remedy. All bodies are composed of the four elements. To restore health, you must restore heat. Many doctors were against the Thomsonians, just like they were against lay healers.
Inititally, I was intrigued by the Thomsonians because I'd never heard of this movement before reading this book. After reading Starr's section about them, I realized they provide one of the best examples to depict the struggle between medical professionals and medical practitioners. First, Thomsonians show how lower class individuals were able to "rise up" and assert their new found "democratic" power equality. Most Thomsonians were from rural areas; so, I'm guessing they did not have a lot of money or education. Thomson's new way of medical practice provided a quick and easy way to quickly begin practicing medicine. Consequently, this new profession provided these individuals with a way to assert power over people they cared for. Therefore, they found a way to exercise the new "power" the democratic idea of equality gave them.
Thomsonians provided competition for physicians. Doctors were not expected to prove their credibility not only for their patients but in comparison to a newly conceived medical practice. Consequently, tensions arose between physicians and the Thomsonians as both groups tried to establish themselves.
A Redundant Cycle?
This is exactly what Starr states happened at this time. Medical professionals tried to retain their social power while other Americans used the idea of equality to substantiate their own individual power. In the end, this constant ba.ttle led to a redundant cycle betwen professionals and lay persons
Eventually, according to Starr, people began to realize that each individual could not become a physician. At the conclusion of this chapter he states "the nineteenth century was a period of transition, when the traditional forms of mystification had broken down and the modern fortress of objectivity had not yet been built." I'm intrigued to see what happens in the nineteenth century. Hopefully, people were not bogged down by their fascination with individual power and, at least some, brought peace and order to medicine.
Introduction
I was caught off guard when I began reading the introduction. It starts with "the dream of reason id not take power into account." Isn't this supposed to about the transformation of medicine? As I continued reading, I began to understand what Starr is trying to put across. Medicine probably began as a combination of different types of "reason"-- whether it is scientific knowledge or simply the intrinsic human empathy to help the sick. Yet, wherever there is reason, there comes power and authority. When knowledge begins to build, there is a need to control and regulate it before it goes out of control. Yet, even this process is complicated. As Starr states, "Its authority spills over its clinical boundaries into arenas of moral and political action for which medical judgment is only partially relevant and often incompletely equipped. Moreover, the profession has been able to turn its authority into social privilege, economic power, and political influence."(p.5)
So, some may assume that all medical professionals can use this power and authority to become powerful. Starr immediately states that this assumption is wrong. Many medical professionals, both of the past and present, have not held powers of position.
In the end, Starr states that there three problems with professional sovereignty in American medicine. First, it is historical -- there's no relation between social structure and caring for the sick. Second, to understand the organization of medicine in the United States, you have to delve further than simply looking at the doctor-patient relationship. Finally, you need to use an approach that "encompasses both culture and institutions" to understand this health care system.
Following these premises, Starr delves into what exactly authority is (it incorporates characteristics of legitimacy and dependence). What I find most interesting about this discussion is how he states medical authority came to be. He states that "the rise of professions was the outcome of a struggle for cultural authority as well as social mobility." To me, this makes perfect sense. In order to establish oneself as a medical professional, you have to have cultural authority to ensure that your patients and those related will listen to your professional opinion. Once a professional gains cultural authority, he will more than likely use this power for social mobility. If he is able to establish himself as a member of the "upper class," he will have the power to practice medicine as he wishes.
Starr states something similar to my assumption, "at a time when traditional certainties were breaking down, professional authority offered a means of sorting out different conceptions of human needs and the nature and meaning of events." Medical professionals could offer opinions if someone's medical request was due to his individual need or simply to help prove a point of a certain event.
The practical use of authority is greater than simply offering a medical opinion. Once medical professionals had established their authority, they were able to "control [...] the market, then [use it against] large organizations and government [that] threatened to intervene."
So, some may assume that all medical professionals can use this power and authority to become powerful. Starr immediately states that this assumption is wrong. Many medical professionals, both of the past and present, have not held powers of position.
In the end, Starr states that there three problems with professional sovereignty in American medicine. First, it is historical -- there's no relation between social structure and caring for the sick. Second, to understand the organization of medicine in the United States, you have to delve further than simply looking at the doctor-patient relationship. Finally, you need to use an approach that "encompasses both culture and institutions" to understand this health care system.
Following these premises, Starr delves into what exactly authority is (it incorporates characteristics of legitimacy and dependence). What I find most interesting about this discussion is how he states medical authority came to be. He states that "the rise of professions was the outcome of a struggle for cultural authority as well as social mobility." To me, this makes perfect sense. In order to establish oneself as a medical professional, you have to have cultural authority to ensure that your patients and those related will listen to your professional opinion. Once a professional gains cultural authority, he will more than likely use this power for social mobility. If he is able to establish himself as a member of the "upper class," he will have the power to practice medicine as he wishes.
Starr states something similar to my assumption, "at a time when traditional certainties were breaking down, professional authority offered a means of sorting out different conceptions of human needs and the nature and meaning of events." Medical professionals could offer opinions if someone's medical request was due to his individual need or simply to help prove a point of a certain event.
The practical use of authority is greater than simply offering a medical opinion. Once medical professionals had established their authority, they were able to "control [...] the market, then [use it against] large organizations and government [that] threatened to intervene."
Subscribe to:
Posts (Atom)