The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry

I am a physician engaged in the US healthcare system for the past 50 years. I read Starr's book first in 1985. For me, engaging this book was like "Saul on the road to Tarsus" . The film fell away from my eyes and for the first time, I began to "see" the American healthcare system. The complete title of the book is: "The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a VAST INDUSTRY". The title is completely apt and accurate. US medicine has experienced transformation and will continue to undergo change. American physicians as a profession boot-strapped themselves into a dominant force that effectively protected the boundaries of the profession from any outside encroachment up until around the 1990s. US doctors did not possess the status of a "sovereign state within a state" but they came close. For assorted reasons that Starr illuminates, doctors came to a point in the late 20th century where they no longer could keep "big business" at bay or curb inexorable relentless price inflation in medical goods & services. They fought a rearguard action for several decades against the "marauding barbarians at the gate" until such time "Big Business" breached the Rhine River and invaded the US doctors' turf.The second aspect of Starr's book title is described as the "Making of a Vast Industry". US Healthcare system (US HS) understood as a "Vast Industry" is a "vast" understatement. US Healthcare is a mega- gigantic, mind-numbingly immense "Industrial- Complex" unlike anything seen on the planet earth. The US HS was HUGE in the 1980s and 1990s;. Consequently, measures were set in motion to break the upward-directed cost curve. The rate of rise was moderated but THE RISE continued, and like an out-of-control Godzilla, scavenges the countryside - consuming vastly large sums of money lying loose in its pathway. For example, 2020 US health care expenditures approached $3.8 TRILLION.Very few Americans could truly grasp just how much money $3.8 trillion is. To put that in perspective: If US Healthcare were a "sovereign country" it would rate 5th in the world - based on the size of its GDP- exceeded only by China, Japan, and about tied with Germany. Walmart the largest corporation in America based on yearly revenue takes in ~ $546 B; Amazon takes in $347 B and 3rd place goes to Apple @ $ 274 B. Of the top 13 companies in the US Fortune 500 ranking, 5 companies belong to the "Healthcare Industry". Together these 5 companies haul in $1.6 TRILLION. The top 3 companies: Walmart, Amazon, and Apple together collect $1.17 Trillion. It was recently reported that US Big Pharma (J&J, Pfizer, Merck, Lily, etc) based on revenue generated from the sale of the TOP 20 Drugs absorbs >$100 Billion-- MORE than every other country on the planet- COMBINED!AND, it's actually WORSE than it seems. Scholars have consistently observed over the past 30 years that the administrative overhead within "the system", i.e. transactional costs incurred in measuring, tracking, overseeing, controlling "the system" - consumes ~ 20% - 25% of the total costs. OR about $700 billion/ year. This overhead is considered "deadweight" "dross" "waste".$700 billion in deadweight is appreciably more money than Walmart makes in an entire year. $700 billion is about the same amount of money the USA elects to spend yearly on "defense" - DoD procurements; AND this sector of spending ie "Arms & Weapons" is more than every country on the planet earth spends on "defense" - COMBINED!Most countries in the OECD spend ~ 7% -13% on administrative costs.Starr's book provides the seriously inquisitive student of US Healthcare Policy an explanation of how these staggering numbers came to be and why they continue to be relatively so immense.Finally, Starr does not call into question healthcare service quality. It has been and remains very good. The primary problem is: it is so damn expensive!Starr alludes to some of the reasons for this. The "Social Transformation of American Medicine", though, is a sociological analysis of the environment and of varied factors - a deep context - out of which a "Vast Industry" emerged and continues to thrive.

This book is VERY worth purchasing and reading ... from beginning to end. Begin with the book's title and meditate on each word chosen by the author to describe the dilemmas confronting individual Americans whose hope is to be as well and comfortable as possible in their lives and in the lives of those they love.For me the key word in the title which needs contemplation is "Sovereign". American physicians are granted a life tenure to 'practice' their craft; once having been licensed, the technical competence of individual physicians is never again questioned, except in the grossest of public cases. In America, to be a licensed medical doctor is as close to being 'king' and 'sovereign' that a child of immigrant children will ever have.Why is this a problem? From the standpoint of the individual who 'hopes' to live well, be healthy, and integrate effectively with the socio-technical economy of his era ... this person equates 'Medical Care' with 'Health Care'. KEY: Physicians practice Medicine ... they do not practice Health. Only one to three percent of physicians in American have ever had even a single seminar on 'health' and what factors constellate into that dynamic mind, body, spiritual reality which we humans come to recognize as being 'healthy'.Americans of 2011 are in the the grip of what the author has titled a vast industry. Individual come to recognize that they are 'not well' or are 'ill', or 'sick'; they want, hope, desire to be health, restored and at peace with their life and their body and relationships. These individuals make what they believe to be a reasonable, rational decision to seek help from their 'health care provider', their physician. But the elephant in the front room is the unspoken reality that their physician practices 'medicine' and not 'health'; medicine is Anything a licensed doctor says it is. There are few guarantees given to an individual who has 'health care benefits' in America ... but one of them is that the 'patient' will leave the transaction with large quantities of pharmaceutical products ... These are 'BENEFITS' of being a American being 'CARED FOR' by licensed and certified American medical practitioners and their collectivized organizations: HMOs, PPGs, etc.This book is a history of the vast American clinical pharma industry. It is thought provoking ... and rightfully anxiety provoking because all is not right in the 'American Health Care'. I hope that you the reader of what I am writing can take a moment to reflect upon the time: total hours and rapid frequency ... with which your senses of sight and sound are inundated with Disney-esque marketing, advertizing and sales of pharmacological 'cures' to diseases invisible to your current minds. These advertisements are actually not directed to you ... they are directed toward your infants and your smaller children. Their consciousness are being primed and fixed to respond in a predictable manner to view pharma products and 'other stuff' as 'good and beneficial'If you have a few minutes for a world class lesson ... Thomas Kuhn discussion on how clinical scientists are inculcated in their trade.[...]And the Flexner Report of 1910 (101 years ago) which created the groundwork for the sanctification of Medical practitioners. Note it was not until 1938 that a person visiting their physician was more likely to be helped than harmed by the events of that visit. ... Notice the correlation of arrival of Sulfa antibacterials and eventually the miracle of penicillin.Buy the book ... read the book ... and Stop presuming that physicians are health care providers. PleaseJeff Anderson, RN, MS Comprehensive Health Planning.