MEDICAL PROFESSION. Before the Civil War, physicians directly competed for access to patients within a weak marketplace. The income from practice was limited, and physicians struggled to maintain control over the provision of medical services. Many states had licensing laws, but these were rarely enforced and did little to limit the activities of lay and sectarian practitioners. The care the physician provided therefore represented only one of a variety of options available to the sick in early America, including regular recourse to self-treatment with home medical guides or folk remedies. The profession lacked the cultural authority and political clout to stop patients from seeking out these alternatives, and the little authority they did have came to be further eroded as the populist spirit of the Jackson Era ushered in distrust for all forms of orthodox medical expertise.
The conflict between the interests of the patient and those of the profession culminated in the 1830s with the repeal of medical licensing in a number of states. This shift was coupled with the growth of a variety of populist medical movements—notably Thomsonianism—which provided botanical alternatives to the mercurial compounds and bleeding many doctors relied upon. The development of professional control was also impeded by an overproduction of doctors and a lack of effective occupational oversight. The proliferation of proprietary medical schools and the corresponding increase in the number of graduates intensified competition during the middle years of the nineteenth century. No national standards existed governing the educational quality these schools provided, and there was significant variation in the length of training and expectations of cognitive competence. As a result, the profession lacked a shared intellectual base or a sense of proper conduct, impeding the growth of professional associations, which might have provided medical practice with oversight and common identity.
This situation began to change with the founding of the American Medical Association (AMA) in 1847. The AMA initially had little power to influence the behavior of its small number of members. By 1910, however, overall membership had swelled to 50 percent of all practicing doctors, making it by far the largest medical society in the nation and providing it with an adequate working budget. The period from 1870 to 1900 also saw a renewed concern with medical licensing, and by 1901, twenty-five states required doctors to present a diploma and pass an independent exam in order to practice. Medical schools began to standardize their curricula and introduce more stringent requirements, limiting the number of new graduates. This led to the closure of many proprietary medical schools, which were unable to cover the costs of the new standards. Although these events strengthened the social and political position of the profession, the authority of orthodox medicine remained constrained by the persistence of alternative sources of treatment until the turn of the twentieth century. This threat decreased gradually between 1880 and 1900, as homeopathic and eclectic medicine
gained some acceptance among regular members or the profession. The incorporation of these practitioners into the AMA allowed the association to regulate their education and practice, transforming them from excluded opponents into active consultants. The growing strength of regular medicine was also fostered by changes to the association's organizational structure in 1901, making local membership a prerequisite for national membership. The new organization promoted local involvement with the association, and improved collegiality of doctors working in close proximity. As association membership increased, the AMA progressively came to represent and reflect the interests of the profession as a whole, setting standards for practice and laying down professional guidelines governing the relations between physicians. It also increasingly came to control access to the medical technologies necessary for treatment, since membership was often a prerequisite for using hospital facilities.
The fee-for-service model of care, which arose in the wake of AMA reorganization, placed significant emphasis on the autonomy of the individual practitioner. Patients were free to choose any doctor they wished and were directly billed for the services they received. Doctors were generally self-employed, allowing them to maintain personal control over the treatment and services they provided. This approach to medical care prevailed throughout the first half of the twentieth century, and represents the height of professional control. Supported by successes in surgical practice and public health, which enhanced the cultural authority of the profession, fee-for-service allowed doctors to monopolize access to patients and limit their ability to seek out alternatives. The control doctors wielded was reflected in improvements in the average annual income, which jumped from between $750 and $1,500 in 1900 to $6,000 in 1928.
While fee-for-service benefited doctors financially, it led to significant increases in the overall cost of medical care. Public concern over these costs grew throughout the 1950s and 1960s, culminating in the passage of Medicare in 1965. This legislation resulted in increased profits for health care providers, thereby making medical management attractive to investors and giving rise to large-scale corporate involvement in medicine. In order to limit medical expenditures and thereby increase profits, many corporations have implemented systems of managed care, in which doctors receive a fee directly from the corporation with which they are contracted. Oversight is high, and most doctors are limited in the number and type of procedures they may perform, and in the drugs they may prescribe. The introduction of cost management controls has meant decreased economic independence for many doctors, and while the cultural authority of the profession remains strong, its autonomy in diagnosis and treatment has been eroded as a result of corporate involvement.
The professionalization that took place following the Civil War resulted in greater internal control over education
and occupational values, the development of a set of shared financial and political interests, and more extensive power to limit patient access to alternative sources of treatment. While professionalization has often been seen as an artificial control upon the free functioning of the medical marketplace, the changes it brought about resulted in the effective regulation of treatment and pharmaceuticals, and greatly enhanced the social influence of medical practice in America.
Freidson, Eliot. Profession of Medicine: A Study in the Sociology of Applied Knowledge. New York: Dodd, Mead, 1972.
Starr, Paul. The Social Transformation of American Medicine. New York: Basic Books, 1982.