The Social Transformation of American Medicine: The Rise of a Sovereign Profession & the Making of a Vast Industry  by Paul Starr. Basic Books, Inc. Publishers, New York, 1983.

Review by Del Meyer, MD

This monumental work was researched and written over many ears beginning in 1974-75, when Harvard Sociology Professor Starr was a Fellow in Law, Science, and Medicine at Yale Law School. He did the final editorial work when he returned as a visitor to Yale’s Institution for Social and Policy studies in 1981-82. My copy carries an inscription from my wife on my birthday in 1983. Now 10 years later, with two copies in our Society library, a few copies left in the bookstores, and still listed in Books in Print, a brief reminder of this treatise may be in order.

Dr. Starr divides this very readable work into two books to emphasize two long movements in the development of American Medicine. Book One traces the rise of professional sovereignty from England through the colonies, the development of professionalism, the medical counterculture; the eclipse of legitimacy, the changes of the civil war; sectarianism, how we gained authority over medications, the making of the modern hospital, corporate medicine, resistance to control, and the evolvement of the economic structure as we know it.

Professor Starr states many of the chapters can be read as self-contained studies. If the lengthy introduction, “The Social Origin of Professional Sovereignty,” is too sketchy or abstract, he suggests skipping over to chapter one and returning if desired after chapter three.

Could anything be more relevant than chapter one of book two, titled “The Mirage of Reform?” He opens with, “Whoever provides medical care or pays the costs of illness stands to gain the good will of the sick and their families. The prospect of these good-will returns to investment in health care creates a powerful motive for governments to intervene in the economics of medicine. Political leaders since Bismarck . . . have used insurance against the costs of sickness as a means of turning benevolence to power. Similarly, employers often furnish medical care to recruit new workers and instill loyalty to the firm. Unions have used the same means to strengthen solidarity. To be the intermediary in the costs of sickness is a strategic role that confers social and political as well as strictly economic gains.”

Starr continues, “From the viewpoint of physicians, all such intermediaries represent an intrusion and potential danger. Traditionally doctors gave care according to the needs of the sick and regulated fees according to the patients’ ability to pay. This system did not always provide economic security for the physician, much less for the patient, but it meant that doctors did not face any larger and more powerful organization that could dictate their income and conditions of practice. And many physicians valued this freedom from hierarchical control more than the stable income that an organized system of payment or health insurance might lave arguably provided.”

Dr Arnold Relman, Editor of he NEJM, wrote in his February 24, 1983 review, “Starr, a young Harvard sociologist, has produced a tour de force – a provocative, insightful study that is both scholarly and readable. . . . Physicians will disagree with at least some of what it says, but they can ignore its message only at their own peril.”

For this work, Dr. Starr received the 1984 Pulitzer Prize, the 1984 Bancroft Prize in American story, the 1983 C. Wright Mills 1 ward in sociology and the 1984 James A. Hamilton hospital administrators’ book award. He was in our midst on Thursday, May3, 1984, giving the annual Nelson Medical Lectureship at UCD on “The Future of American Medicine,” which was well received. He predicted much of what we’re experiencing. He stated that “Health care will continue to spend millions of dollars on a few persons with limited chances of survival, and economize on less dramatic areas . . . where the money could do more good.” It would be appropriate to have Dr. Starr return to Sacramento to give us a 10-year follow-up of what I’m sure will be continuing research in this relevant area that will shape our future. How about an address to the Comstock Club at their Monday noon meeting, another group on Monday night, the University on Tuesday and meet with our Society on our Tuesday meeting night?  

Dr. Starr’s compendium is a valuable reference that will provide a historical and worldview as we discuss organized medicine, national health care, physician, hospital, insurance, nursing and allied health issues in our journal over the next six months. Let’s get our personal copy to remind the bookstores that this book is still in print and that they should order more. We will then see the current issues in perspective and be more articulate and better able to effect more appropriate changes.