American College of Physicians: Internal Medicine — Doctors for Adults ®

Advertisement
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laws didn't exist for the most part, and where they did come in place, such as in New York City, they were later rescinded.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.

Labels: , , , , ,

0 Comments:

Post a Comment

Subscribe to Post Comments [Atom]

<< Home

Share

 

Contact ACP Internist

Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, 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.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

Powered by Blogger

RSS feed