Chapter 3: The Consolidation of Authority 1850-1930

As Starr recounts the history of medicine in America, I am continually stuck with the relative role of timing. Rather than a focused movement, the consolidation of authority for physicians seems almost accidental. A few legislative priorities, a scathing report of medical schools and the influence of societal factors such as transportation and urbanization better explain the consolidation of authority than any efforts from within the profession. The comment that sticks in my mind is that which stated that the biggest enemy of physicians were the physicians themselves.

Hindsight is always 20/20 and I imagine the physicians who worked in both the late 19th century and early 20th century would agree that had they known the benefits of consolidation and cooperation, they would have advocated for them earlier. Instead it took the donation of a huge endowment from Johns Hopkins, the leadership of Harvard's president and eventual acceptance of sectarian physicians into the mainstream to march forward towards true professionalism.

It is interesting to me to observe the backswing of the pendulum towards homeopathy. Although generally considered alternative, it seems that alternative medicines enjoy regular spurts of popularity in response to concerns in the medical community. For example, when a report was released that stated that hormone replacement therapy (HRT) was dangerous to menopausal women seeking relief, we saw a rise in alternative solutions such as black cohosh. While I personally dispute the findings on HRT, it is interesting that as consumers, we often view homeopathy as a safer alternative to "drugs." Another example is "Airborne," the miracle tablet marketed by a teacher that alleged great effectiveness against colds with natural ingredients. In clinical studies, Airborne has not outperformed placebos, but for many consumers, the idea of fighting colds naturally is still highly attractive. In recent months, I have observed another backswing as the economy has fallen. Unwilling or unable to bear the cost of doctor's visits, people seem to again be turning to natural remedies for an economical solution. Although I do not discount the benefits of natural remedies, I am always concerned when people assume that because it is directly from the earth (as opposed to derived from, like many "drugs"), there are no side effects, no risks.

Finally, it is interesting to hear about the AMA in its nascency. In a recent economics class, a professor remarked that the AMA is a cartel. I disagreed, stating that although it may be a cartel by definition (controlling the market via medical schools), it is not a cartel in intent or even effect. The plethora of reimbursement structures themselves mean that increasingly, physicians individually and the AMA collectively, lose control over the market. While I don't anticipate a return to the AMA in its diffuse, powerless state, I wonder if the AMA percieves shifts in the health care market to be chipping away at its authority.

The Expansion of the Market

As Starr chronicles, the rise of American medicine was slower than the rise of medicine in other industrialized nations. During the 19th century, however, wheels began to turn that would help medicine begin to morph into a profession. The two that stood out most to me was the development of economies of scale and emergence of a critical mass of patients.

At the turn of the nineteenth century, physicians had to travel to their patients. This was costly both for the physician, who sacrificed time, and for patients, who called a doctor only when absolutely necessary. This distance, however, would shorten both physically and figuratively by the middle of the century because of improvements in transportation and the invention of the telephone. This meant that physicians could see more patients a day, increasing their profit and decreasing the cost passed on to patients. As Starr astutely notes, more availability bred more dependency on physicians, creating a mutually reinforcing cycle. We can observe a similar, but reversed corollary today. As people's schedules become more crowded and the costs of insurance and in-office visits rise, we are beginning to see the rise of "phone in" nurses and other medical services. Like the patients of the nineteenth century, the cost of traveling to the doctor's office, both from time lost and co-pays, has forced possible patients out of the market. Of course, this type of service is evidence of the high level of professionalism we now associate with doctors and nurses; we trust their expertise to the extent that we will accept consultation over the phone.

The other interesting by-product of urbanization that Starr points out is the development of a critical mass of patients. When people were diffuse, doctors had to search for patients and build and maintain relationships. As people migrated to urban areas, a more "automatic" mass of patients emerged. This was accompanied by a shift in family structure that tended more towards care OUTSIDE the home as opposed to within the home. This concentration of people served to increase the professionalism of doctors by exposing more people to the benefits of using a physician. It can also be assumed that at least in some part, word-of-mouth also benefited the profession. Whereas when population was diffuse, interaction between families was limited. As population became more concentrated, social interaction increased between families and people were more likely to know someone who had visited a doctor for more than just a dire situation.

The other issue of note that this chapter raised for me was the beginning of the mental health system. While so many other aspects of the health system have evolved, the mental health system seems to have clung to its original auspices. We still institutionalize those who are insane in many cases and choose to isolate, rather that include. Treatment at these institutions has improved, although in some cases, not markedly. Just this past month, allegations of severe mistreatment resulting in death emerged from a North Carolina mental health institution. Even without this incident, mental health in North Carolina and elsewhere continues to be an Achilles heel politically and emotionally.