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Saturday, August 1, 2009


I read a review of Paul Starr's 1982 book The Social Transformation of American Medicine and a retrospective of this work published in the Journal of Health Policy, Politics, and Law in 2004. The journal published a condensed version of the original work which has prompted me to order the book. Perhaps the work may be a bit dated given it was published almost 30 years ago, but I was struck by two things. First, present events can be viewed with greater insight given the historical background provided by Starr and in addition, Starr was remarkably prescient in predicting future events.

Starr's analysis of professionalism and power in medicine is enlightening and provided me with a better understanding of the role of claims of professionalism in various political positions of organized medicine. The series of events which occurred and allowed medicine to attain power, status, and money during the 20th century were unique and perhaps not sustainable.

A number of changes have occurred in the health care environment have eroded physician autonomy and status. At the same time concerns have been raised regarding the loss of professionalism among physicians and medical practice in general. My own experience in dealing trainees in general suggests that the elevation of medicine into a high income field has fundamentally changed the types of candidates who we attract to the field. Because medicine is so lucrative, we now attract smart people who place a higher priority on income generation. When medicine was not so lucrative, individuals with primary financial motivations steered clear.

An obvious solution to this problem is to decrease physician compensation to attract people with the right motivations to the profession. However, that might solve one problem and replace it with a less desirable state. What is the goal of providing any reward whatsoever? Ultimately what is the purpose of having physicians and what is the advantage of a professional class vs. someone who we employ or contract with to provide services?

Whether we like it or not in the modern world we must rely on other people to provide us with both things we want and things we need. The spectrum of virtues and faults displayed by those who provide our needs is extensive. You can be assured than none are perfect and it is a reasonable assumption that most operate with their self interest in mind. Even if the health care profession is not driven strictly by self-interest, it will be a rare exception who does not suffer from pressures from constituencies other than patients they serve (family, colleagues, employees).

What we want from our physicians is that they fix our problems. If they get rich honestly by doing so, so be it. Cultivating a virtuous but inept workforce creates more losers than winners.

More money less professionalism

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