American Medicine and the Public Interest (review)

Even leading journals have an occasional lapse. The republication of this classic book about the organization of American medicine in the first seven decades of this century allows us to make up for one of ours: for some now-unexplained reason, the Bulletin failed to review American Medicine and the Public Interest when it first appeared in 1971. No matter what the reason, I can safely plead innocence: I was no longer in Baltimore, and I did review the book for the Journal of the History of Medicine (in fact, for many years the paperback edition carried a paragraph from that review on its back cover).

Rereading this superb and informative book a quarter-century later only reaffirms my original impression:

At last we have available to us a book that is full of documented evidence, written and organized on the basis of historical trends. Rosemary Stevens of Yale University has given us a book that will allow all present crisis-watchers to catch their breath as they look back and attempt to analyze what happened as well as what is happening. . . . American Medicine and the Public Interest is divided into five parts: the first gives a historical view of the professional setting of American medicine and medical education to the twentieth century; the second describes the early specialty organization and boards; the third and fourth cover the impact of specialization; and the fifth deals with the roles of the medical profession and the public in determining patterns of financing and organizing medical care. . . . All in all, this is a magnificent book, one that is full of references, data, and ideas. . . . It is an important and timely monograph that will guide all who have an interest in the broad field that is medicine, its past, present, and future.¹

The new edition has a twenty-page introduction that allows Professor Stevens, now at the University of Pennsylvania, to reflect on the many changes already set in motion in 1971 and now so frequently discussed. She said then, for instance, that the issue of cost-containment was already crucial. How true that was to become!

American Medicine and the Public Interest was originally supposed to be the middle work in a trilogy. In 1966, Stevens published Medical Practice in Modern England: The Impact of Specialization and State Medicine. A third volume, never written, was to be a comparison of the British and American systems. But in rereading the American part in its entirety, I was struck by how often she did manage to compare the two.

As Stevens notes in her new introduction, in the first seven decades of this century, the distinctive American style of medicine was specialized, disorganized, expansionary, and flamboyant. Is it any wonder, then, that those who grew up in such a medical culture should find that the restraints of managed care, and the new primacy of the third party, provide a particularly stifling and harsh climate in which to carry on the practice of medicine? Our students of the 1990s did not live through the earlier era when we supposed that progress would be continuous and that opportunities were unlimited. It is time for those of us who are older, and supposedly wiser, to stop pining for the “good old days.” Reading this book makes it very clear that we too faced many challenges to maintaining medicine for the public interest.

“There is a tendency in American social planning,” Stevens wrote in 1971, “to assume the past does not exist, or is irrelevant” (p. 528). In this book she has brought the history of medical organization and all of its complexity to life, to show us how relevant our past has been. That past clearly has lessons for us; perhaps more important, it can show us that our future may not be as bleak as some have feared. As I noted in...