Blog | Tuesday, October 30, 2012

Social history of medicine, self-reliance and health care today

Over my vacation I read a bit on the history of health care in the United States. The Social Transformation of American Medicine, by Paul Starr, was first published in 1982. The author, a professor of sociology and public affairs at Princeton, gives a fascinating, relevant account in two chunks. In the first section, he details the rise of professional authority among physicians in the U.S. In the second part, he focuses on the relationship of doctors to corporations and government.

I couldn't put this book down. Seriously, it's a page-turner, at least in the first half, for anyone who cares about medical education, doctors' work, and how people find and receive health care. In an early chapter, on medicine in colonial and early 19th Century America, Starr recounts the proliferation of medical schools and doctors, or so-called doctors, in the years after 1812.

One problem of that era, besides a general lack of scientific knowledge about disease, was that it didn't take much to get a medical degree. State licensing laws didn't exist for the most part, and where they did come in place, such as in New York City, they were later rescinded. Then as now, many practicing folks didn't want regulations.

Doctors were scarce and not always trustworthy. People, especially in rural areas, chose or had to be self-reliant. Many referred to lay sources for information. Starr writes of the "domestic" tradition of medical care:

"... Women were expected to deal with illness in the home and to keep a stock of remedies on hand; in the fall, they put away medicinal herbs as they stored preserves. Care of the sick was part of the domestic economy for which the wife assumed responsibility. She would call on networks of kin and community for advice and illness when illness struck ..."

As he describes it, one book, William Buchan's Domestic Medicine, was reprinted at least 30 times. It included a section on causes of disease and preventive measures, and a section on symptoms and treatments. By the mid-19th Century a book by John C. Gunn, also called Domestic Medicine, or Poor Man's Friend ... offered health advice in plain language.

Starr considers these and other references in the context of Protestantism, democracy and early American culture:

"... while the domestic medical guides were challenging professional authority and asserting that families could care for themselves, they were also helping to lay the cultural foundations of modern medical practice--a predominantly secular view of sickness ... the authority of medicine now reached the far larger number who could consult a physician's book."

Reading this now, I can't help but think of the Internet and other popular and accessible resources that challenge or compete with doctors' authority. Other elements of Starr's history pertain to current debates on medical education, credentialing and distribution of providers.

Just days ago, for example, the New York Times ran an editorial on a trend of getting Health Care Where You Work. The paper reported on Bellin Health, an allegedly non-profit entity, that designs on-site clinics for medium-sized companies. "It has managed to rein in costs while improving the availability and quality of care--in large part by making it easier for patients to see nurses and primary care doctors," according to the Times opinion. The clinics are "staffed part-time by nurses, nurse practitioners or physician assistants, who handle minor injuries and illnesses, promote healthy living and conduct preventive screenings."

The editorial touts Dartmouth Atlas data and other high marks for the care Bellin provides at low costs to possibly happy workers and their satisfied employers. Still, it's not clear to me that an on-site clinic would be a great or even a good place to seek care if you had a subtle blood disorder or something like the newly-reported Heartland virus.

On reading the editorial on delivering health care to the workplace, I was reminded of Starr's tale of the development of clinics at railroad and mining companies in the first half of the 20th Century. This happened mainly is rural areas where few doctors lived, at industry sites where injuries were frequent. The workers, by Starr's account, were generally suspicious of the hired physicians and considered them inferior to private doctors whom they might choose if they became ill. They resented paying mandatory fees to support those on-site doctors' salaries. Doctors' groups, like the AMA, generally opposed and even ostracized those "company doctors" for selling out, or themselves, at a lower price.

The second half of the Social Transformation, on failed attempts at reform before 1982, is somewhat but not entirely outdated in light of Obamacare and 40 years intervening. But many of the issues, such as consideration of the "market" for doctors and the number of physicians we need, relate to the papers of this week including an Economix column by another Princeton professor, Uwe Reinhardt, who puts forth a view that, well, I don't share. As I understand his position, Reinhardt suggests that there may be no real shortage of doctors, because physicians can always scrunch their workloads to fit the time allotted. But that's a separate matter ...

In sum, on the Social Transformation, today: Worthwhile! Curious! Pertinent! Starr's book is chock full of history "lessons" that might inform medical practice in 2012. And I haven't even mentioned my favorite segments on prohibiting doctors' advertisements (think websites, now), the average workload of physicians before 1900 (think 5 or so patients per day), and the impact of urbanization on medical care and doctors' lives and specialization.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.