their physical and social environment, humankind has sought to maintain some control over disease. Anthropologists have identified the healer role across cultural boundaries as one-way cultures attempt to understand, influence, and control human disease. The earliest historical records of Egypt and Mesopotamia document an understanding of illness as a divine punishment for sins committed by the patient.10 The healer in cultures as diverse as those in native New World populations, Asia, Africa, Europe, and Oceania can be described as a shaman, whose cultural purpose is to serve as a mediator with the spirit world for purposes of relieving the physical distress of a suffering individual. The shaman holds cultural power by bridging the natural world and the spiritual world for the benefit of the community.11
In modern Western culture, the scientific revolution led to a rationalist approach to physical disease, and, as Paul Starr articulates in his introduction in The Social Transformation of American Medicine:
Though the works of reason have lifted innumerable burdens of hunger and sorrow, they have also cast up a new world of power. In that world, some people stand above others in knowledge and authority and in control of the vast institutions that have arisen to manage and finance the rationalized forms of human labor.12
Starr’s Pulitzer Prize-winning work analyzes the role of the physician in American society from the colonial period until the advent of managed care in the 1980s. Starr describes the rise in status of physicians that resulted from their control and exploitation of emerging innovations in technologies and practices grounded in research, scientific evidence, and medical education. The resulting improvement in medical treatment accelerated the perceived value of the medical profession over the past hundred years in America. Starr discussed the important role of medical education in the United States and the historical significance of the Flexner Report of 1910, which led to national physician curriculum standardization emphasizing the scientific method as critical to ethical high-quality patient care. While we shall discuss the significance of medical education from the perspective of physician leader development, here we wish to note that the standardization of curricula emphasizing scientific inquiry helped improve the abilities of our nation’s physicians to continually improve patient care through the development of evidence-based orders, guidelines, and practices.
Starr analyzed the complexities of how the physician profession rose to the level of power and authority in the United States that we see today.13 He argues that modern medicine has developed “an elaborate system of specialized knowledge, technical procedures, and rules of behavior” granting to the medical profession an especially persuasive claim to authority.
Even among the sciences, medicine occupies a special position. Its practitioners come into direct and intimate contact with people in their daily lives; they are present at the critical transitional moments of existence. They serve as intermediaries between science and private experiences, interpreting personal troubles in the abstract language of scientific knowledge.14
Starr’s analysis is focused upon the sources of power in the medical profession leading to cultural authority and occupational control, economic power, and professional autonomy that was at its peak at the time of his publication in 1982. He accurately predicted the current threats to professional sovereignty through “competition and control” as “hospitals and other organizations merge into larger and more powerful corporate systems…and beyond private bureaucratic organizations looms the regulatory power of the state and federal governments.”15
Of course, Starr did not predict the impact of the Internet on patient access to information sources for helping them make personal health care decisions without yielding to the authority of physicians and other health care service providers. This issue has accelerated the threats to professional authority embedded in regulation and economic management models.
Starr’s analysis can be applied today in the context of understanding the contemporary health care industry landscape with its various economic and societal factors our nation’s physician leaders must address and consider in critical decision making for their own organizations and patient care decisions. While the industry has been transformed organizationally through waves of both vertical and horizontal integrations and mergers, even today a large percentage of the nation’s physicians still operate as small business entrepreneurs. In this transitional state, both the complex structures of large organizations and smaller entrepreneurial ventures are better understood with their historical context. Starr’s analysis demonstrates the application of market dynamics in health care as a force for evolutional change within complex adaptive systems.
This implication that historically physicians have always faced the market dynamics of their time permits a larger insight into the tension present between the professional obligations of patient care and the economics of the community in which care is rendered. Today, the market dynamics regulated through the Federal Trade Commission and the Department of Justice create an environment for medical practice in which physicians must adjust their objectives to improve access to care, affordability and the quality of care with the need to meet co-occurring interests of cooperation and competition as they occur within the financial market.16 The individual professional decisions made to achieve these objectives will involve economic impact issues (e.g., number of health care professionals to employ to meet consumer demand for services; impact of various supplier relations, etc) and social relation issues (e.g., determining associations and advocacy agendas to support), some of which occur simultaneously and are collectively influenced by the actions taken by various stakeholders in our nation’s health care community.
The “subtle loss of autonomy for the (medical) profession” resulting from the rise of corporations controlling the economics of the healthcare industry through “increasing corporate influence over the rules and standards of medical work” predicted by Starr in 1982 is old news now. He accurately foreshadowed that “the new generation of women physicians may find the new corporate organizations willing to allow more part-time and intermittent work than is possible in solo practice” and had the foresight to recognize that:
There will be more regulation of the pace and routines of work. And the corporation is likely to require some standard of performance, whether measured in revenues generated or patients treated per hour.17
Paul Starr did not predict the advent of the hospitalist movement, the rise of physician executives as a hybrid clinician/management role, or the regulation of resident physician work hours. However, these developments led to value-based health care that challenges the economic status quo in the health care delivery system. The rise of managed care in the 1980s and 1990s is now under siege as the result of legislative insurance reform and the demographics of the aging population. The Affordable Care Act, Health Information Technology for Economic and Clinical Health (HITECH) Act), widespread consolidation of the industry through mergers and acquisitions, the development of patient-centered medical homes, and clinical integration among complementary provider organizations will result in innovations in care delivery models. For the physicians and care providers in the medical profession, delivery system reform will accelerate organizational change and provide an opportunity to improve the continuity of care and result in a revitalized health care system going forward.
Alongside this potential renaissance, the information-system technology revolution offers us the opportunity for improvement in evidence-based medicine practices, communications, and stronger opportunities to deliver high-value care to patients. The necessity of keeping pace with continuous clinical advancement, new technologies, and increased reporting requirements will accelerate the rate of change in the health care delivery system. Physicians must both adapt and continue to provide the leadership and social authority to make these changes patient-centric, or our special position in American health care will erode and become increasingly irrelevant.
The Individual Physician
The shamanistic healing role is a powerful one across many cultures, but the special authority physicians occupy in our culture still to a large extent is dependent upon the prolonged years of medical training, where professional competencies develop that permit physicians to assert their shamanistic authority within our own cultural context. Physicians (and other health care workers) push beyond the genetic and social