CH. 3

One of the most striking aspects of this chapter is the extent to which social inequity and class systems factored into the history of medical practitioners. On one level, you have the struggle of practitioners for legitimacy in their profession. With any physician being able to practice regardless of a standardized education or document, physicians as a whole were relegated to a lower class with the exception of those elite who managed to rope in high-paying clients. It is interesting that despite the fact that their lack of a unified standard kept them at a low scale of security and respect, physicians from the three distinct classes were divided on their support of formalizing one and with very different motivations.

As Starr described, the sectarian physicians and physicians without licenses or diplomas were against standardization for fear that it would exclude them. Elite physicians opposed it in order to maintain their social status by maintaining "lower" untrained physicians in the pool. But only physicians in the middle--those with legitimate degrees, but less clientele--fought for standardization. The objective is clear: only those in the middle would benefit by reducing competition for the average citizen by cutting out physicians without legitimate degrees while elevating their qualifications to the same level as their more successful colleagues.

But the irony of the social status debacle is not lost on me. On the whole, physicians were struggling to stabilize their standing socially and professionally. However, the fragmented social hierarchy within their profession was at odds, with most objecting to the one move that would secure the profession stability and legitimacy in the long run.

And yet, these divisions were masked form the public to maintain the facade of unified perspective in the field. In many ways, this is the perception that the public still has today about medical research and health provision. The interesting change in our current society seems to be that any division that might exist within the field is enjoyed less because of the actual debate on research or perspective, but because of its conflict. We live in an era where the existence of differing viewpoints is viewed as far more interesting than the actual viewpoints themselves. "Scientific" journalism (or what passes for it these days) seems to have trouble differentiating between legitimate differences in health perspectives and those that are on the fringe.

However, I wonder how one might categorize the division between the medical society and the homeopathic movement that Starr wrote about. In this instance, the fractured profession seemed unified in its derision of the homeopathic philosophy. Even these seem to be tied in subtle ways to class and social standing. As Starr points out, homeopathy emphasized above all else, the testimony of the patient and an empathetic attention and treatment. This support of the patient as an elevated individual rather than another patient to be quickly diagnosed highlights other ways in which social status of the physician (which had its own intra-level dynamics) interacted with the social status of the patient.

Very cool.

CH. 2

The evolution of the role of the physician is the main focus of this chapter. In readings from the first chapter of Williams & Torrens, their chart was broken into several components that affected change, one of which was the social organization of the culture and society to handle health care. It is interesting to see the mapping out of cause and effect laid out by Starr regarding social organization and how it shaped the role physicians played and how it freed and constrained their abilities.

For example, Starr describes the advent of hospices and mental institutions and how they were originally institutions of isolation and how their transformation facilitated the evolution of the medical physician's position. Previous to this you can consider health provision as being an omnipresent concept--health was everywhere and never in one place. Health was practiced by every family, doctors traveled wherever they were summoned, or a location had its own doctor on staff. Physicians were at the beck and call of circumstance. But the creation of mental institutions and hospices centralized health, creating a domain of ownership in which physicians were rulers of their own services and where power became focused--it is almost metaphysical to consider the way in which creating a locus of their abilities facilitated the transformation of physicians into figures of power. Of course, this may have been more circumstantial than purposive, but I find the transformation to be quite amazing.

While calling it metaphysical may seem odd, another way to describe it may be to portray it in the light of modern business and marketing theories. Medical practitioners existed in the role of being available and subject to patient's control. The establishment of a base with which to be sought is a basic principle of pro-action and marketability. Though it was not purposive, medical practitioners were elevated to a higher status by shifting the paradigm of their services and availability. In essence, they created demand for their services and in a new way that forced patients to seek them out in a power exchange.

It is also interesting how the creation of a physical location shaped the medical profession in other ways. Starr describes most medical professionals of the time also having other equivalent or more important professions besides medical care. He also explains how many medical practitioners held positions that made them powerful or respected members of society. By tethering medical professionals to hospices and mental institutions, the requirements of the profession, the time commitment, and the responsibility probably made it less and less feasible to hold a second or primary profession outside of medical care. Medical professionals probably had to devote more time to being medical professionals and the added time and attention probably contributed to the expansion of knowledge and consideration for the practice itself. Thinking about the various effects of the environment and institutional changes on the direction of a profession (one in which medical practitioners are full time work or more) is fascinating and a definite highlight of this chapter.

CH. 1

Starr begins his Pulitzer Prize-winning work with an interesting and surprising look at the very humble beginnings of the physicians and the evolving practice of medicine from the 1760 to 1850. My initial interpretations of the practice of medicine were that since the age of Asclepius, physicians and other healing practitioners were venerated and that their expertise was one passed down as a solemn oral history.

Starr's description of the diffusion and transformation of medical information astutely shoves my perception of the field of medicine off its pedestal. Not only was my perception incorrect from a historical perspective, but as the Introduction described, this is not even a universal guarantee of a prestigious career. It is incredible to consider the myriad of ways in which medical information (and medicine itself) has been passed on, warped, redefined, transformed, and rediscovered.

There were many transformations and interpretations of medical knowledge and what it meant to practice medicine throughout the eras, such as William Buchan's Domestic Medicine, displacing it from mystified Latin and technical terminology and supporting medical practice with the layman. That the concept of medical practice could shift from formalized academia to casual salt of the earth (and back again) is astounding.

What I find most interesting in these examples of the fluid and every changing "practice of medicine" is the story about James Still. Still's very elementary means of tapping into medical knowledge--buying a book and following its instructions--is a delightful counter to the common view of medical practice. I think typically, we are lead to believe that medical practice is a highly regulated body of knowledge where you have to learn from square one and must have accreditation and license to even begin providing basic care. The basic medical school education requires study in organic chemistry, physics, microbiology, and biochemistry to even begin schooling. Yet it is easy to forget that behind the lectures and the lecture halls and within the pages of text books is the raw history of medical instruction. Still's case is a reminder that the spirit of medical practice need not be mired in academia and rigid pathways to knowledge. Medical practice is not just in the office or in a sterile room. It occurs with everyday people applying scientifically supported knowledge to promote their health and the health of those around them.