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How doctors became powerful – Arguments from Paul Starr’s ‘The Social Transformation of American Medicine’ – Part 2

Sociologist Paul Starr’s book ‘The Social Transformation of American Medicine’ is among the most important expositions of the evolution of medical practice and the biomedical profession in the USA. It was published in 1982 and won the 1984 Pulitzer Prize in General Nonfiction. It is quite a thick book and contains several crucial arguments about the history and sociology of the medical profession (and of medicine in general) in the US. The arguments are of relevance for other societies too. Here I try to organize those in what I hope to be an easily readable and understandable format.

[Also see below for criticisms of Starr’s approach]

In the previous post (Part 1) I summarized the general sociological arguments using which Starr and other sociologists explain the power of the medical profession. In this post (Part 2), I will summarize the main historical arguments mentioned in Starr’s book regarding how the biomedical profession in America acquired authority, power, and wealth in the late 1800s to early 1900s. While most people might find the status and influence of doctors to be a self-evident fact, historians have shown that the status of healers and physicians widely varied in different societies and at different times – and that for much of history physicians as a group – apart from elite physicians – did not enjoy the high respect they began to gain at the beginning of the 20th century.

I have described, in a different post, the state of medical practice in the USA during the early to mid 1800s: ‘The time when anybody could practise as a doctor in the United States‘. According to historian Nancy Tomes, 19th-c Americans “embraced a freewheeling approach to health care, characterized by enthusiastic self-medication and unapologetic questioning of medical authority.” On the side of practitioners there existed what has been called the ‘regular’ medical profession, and a number of its variants and other sects (like Methodists, homeopaths, etc.) The regular profession consisted of a small number of elite practitioners in the big cities like Boston, Philadelphia, New York, plus thousands of small-town and rural practitioners. In the world of 19th-c USA, most medical practitioners – a lot of them in towns and villages – were on their own and had no incentive to be united as a singular profession. In fact there was every incentive for them to be competitive and rivals of each other.

It is this internal division and competition that is the starting point for Paul Starr’s historical exegesis. He devotes much of the book elaborating how such a fragmented body of individual practitioners became, within four to five decades, one of the most powerful and wealthy professional groups in America. The following three paragraphs from the book describe, very briefly, the several changes which happened roughly over the period of late nineteenth to early twentieth centuries, that radically transformed the medical profession in America:

“Authority, as I’ve indicated, involves a surrender of private judgment, and nineteenth-century Americans were not willing to make that surrender to physicians. Authority signifies the possession of a special status or claim that compels trust, and medicine lacked that compelling claim in nineteenth-century America. The basis of modern professionalism had to be reconstructed around the claim to technical competence, gained through standardized training and evaluation. But this standardization of the profession was blocked by internal as well as external barriers—sectarianism among medical practitioners and a general resistance to privileged monopolies in the society at large.

“The forces that transformed medicine into an authoritative profession involved both its internal development and broader changes in social and economic life. Internally, as a result of changes in social structure as well as scientific advance, the profession gained in cohesiveness toward the end of the nineteenth century and became more effective in asserting its claims. With the growth of hospitals and specialization, doctors became more dependent on one another for referrals and access to facilities. Consequently, they were encouraged to adjust their views to those of their peers, instead of advertising themselves as members of competing medical sects. Greater cohesiveness strengthened professional authority. Professional authority also benefited from the development of diagnostic technology, which strengthened the powers of the physician in physical examination of the patient and reduced reliance on the patient’s report of symptoms and superficial appearance.

“At the same time, there were profound changes in Americans’ way of life and forms of consciousness that made them more dependent upon professional authority and more willing to accept it as legitimate. Different ways of life make different demands upon people and endow them with different types of competence. In preindustrial America, rural and small-town communities endowed their members with a wide range of skills and self-confidence in dealing with their own needs. There was a strong orientation toward self-reliance, grounded in religious and political ideals. Americans were accustomed to dealing with most problems of illness within their own family or local community, with only occasional intervention by physicians. But toward the end of the nineteenth century, as their society became more urban, Americans became more accustomed to relying on the specialized skills of strangers. Professionals became less expensive to consult as telephones and mechanized transportation reduced the cost of time and travel. Bolstered by genuine advances in science and technology, the claims of the professions to competent authority became more plausible. Technological change was revolutionizing daily life; it seemed entirely plausible to believe that science would do the same for healing, and eventually it did. Besides, once people began to regard science as a superior and legitimately complex way of explaining and controlling reality, they wanted physicians’ interpretations of experience regardless of whether the doctors had remedies to offer.”

Starr describes and analyzes these changes in huge detail, at the same time providing us an exciting narrative of how ideas about healthcare and medical care took shape in the USA. What follows are simply a few selective glimpses of specific historical events (for the fuller story, of course, do read Paul Starr’s fabulous book):

~Early to mid 1800s: Adversarial public opinion and economic realities

Apart from the philosophical resistance to the idea that one’s health problems can be resolved best only by ‘regular’ doctors (as outlined above), there were also great economic difficulties for people to visit doctors.

In the early and mid-nineteenth century, the indirect price of medical services probably outweighed the direct price. Dispersed in a heavily rural society, lacking modern transportation, the great majority of the population was effectively cut off from ordinary recourse to physicians because of the prohibitive opportunity cost of travel. For a farmer, a trip of ten miles into town could mean an entire day’s lost work… For major services, the indirect price was less significant; the fee for serious operations could overshadow the charge for mileage. So indirect prices especially limited use of physicians’ services in routine illness. In rural areas, many families would not think of calling in a doctor except under the most grave conditions.When patients were treated at home, before the advent of the telephone, the doctor had to be summoned in person. So the costs of travel were often doubled, as two people, the physician and an emissary, had to make the trip back and forth. Furthermore, since the doctor was often out on calls, there was no guarantee that he would be found when someone went in search of him.

~1870s – turn of the century: Transformation of the market – Roads, rail, telephones, & urbanization

In the late nineteenth century, doctors moved to cities even more rapidly than the population as a whole. The rise of cities was brought about partly by the building of canals and the development of steamboats and railroads. This “transportation revolution” widened the markets of cities and enabled the larger and stronger producers to penetrate what were previously fragmented local markets.. The growth of cities, the advent of modern means of transportation, and the building of hard roads radically altered the structure of prices. By reducing the opportunity and transportation costs for services, urbanization and improved transportation generally promoted the substitution of paid, specialized labor for the unpaid, unspecialized labor of the household or local community. Getting a haircut, visiting a prostitute, and consulting a doctor all became, on the average, less expensive because of reduced costs of time.. Doctors were among the earliest to buy cars.. As more Americans and more physicians began to live in larger towns and cities, they came in closer contact with both their patients and their colleague.. The telephone made it less costly to reach a physician by greatly reducing the time formerly spent tracking down the peripatetic practitioner on foot. (In an apt analogy, one manual for medical practice in 1923 commented that the telephone had become as necessary to the physician as the stethoscope.)

Early 1900s: Transformation of public opinion

In the American case, perhaps the most crucial change was in the public sentiment regarding the authority and autonomy of doctors. As seen earlier, the American public and government were dismissive of professional claims for most of the 1800s for a variety of reasons, but especially because they abhorred granting monopoly power to a small group of people on something as “commonsensical” as caring for one’s health. Since the late 1800s (with the advent of bacteriology, public hygiene and preventive medicine, vaccines, diagnostic technologies, etc.) public ideas began to change and, in the words of Starr, people began to accept and respect the “legitimate complexity” of what by then had become mainstream medicine.

It seems reasonable to look for the origins of increased resort to professional advice in the new conditions of life at the end of the nineteenth century than in the self-serving exhortations of professionals. The pervasive changes in everyday experience brought about by revolutions in technology and social organization altered perceptions of the value of specialized knowledge… As the main emissaries of science, physicians benefited from its rising influence. The continuing growth of diagnostic skills and therapeutic competence was sufficient to sustain confidence in their authority. And with the political organization they achieved after 1900, doctors were able to convert that rising authority into legal privileges, economic power, high incomes, and enhanced social status.. The strength of classes, as Polanyi has written, depends “upon their ability to win support from outside their own membership, which again will depend upon their fulfillment of tasks set by interests wider than their own.” This was exactly so for physicians, who, alone, had little power. With widespread support, which they received because of complex changes overtaking the entire society, physicians were able to see social interests defined so as to conform with their own. This was the essence of their achievement.

Caveats and criticisms:

Starr’s account is no doubt an eloquently written description of a lot that was happening in the field of medical practice in America during the nineteenth and early twentieth centuries. Obviously – and quite naturally – it is not a description of everything that was happening then. One of the most important critiques of Starr’s book is that his narrative overwhelmingly privileges the conventional biomedical profession, especially when historians had for quite some time (at the time of the book’s publication) urging academics to focus on the plethora of equally important other actors in medicine, like patients and other types of healers. Doctors indeed have been privileged by most narratives in the history of medicine. While it can be argued that Starr’s story was anyway more about the rise (and some fall) of the medical profession itself than exactly a grand history of medicine in America, the title of his book doesn’t make that explicit. In the next post, I will look in some detail at the rich historical literature where doctors are but just one small part of the process of healing in modern human societies.

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