What the Doctors Read

The rise of corporate enterprise in health services . . . is already having a profound impact on the ethos and politics of medical care.

—Paul Starr, The Social Transformation of American Medicine

By any measure, Paul Starr's The Social Transformation of American Medicine (1982) (henceforth TSTAM) has been an enormous success. Recipient of prizes almost too numerous to count, the book catapulted its author, a previously little-known junior faculty member at Harvard University, into the front ranks of health policy analysts and TSTAM into the public consciousness. Starting with an enthusiastic front-page review (Geiger 1983), the New York Times went on to hail TSTAM as one of the "Best Books of 1983" and to list it as a "new and noteworthy" and then a "notable" paperback issue (New York Times 1983, 1984a, 1984b). The New York Review of Books opined that TSTAM is "indispensable to any discussion of the medical profession's responsibilities and its future" (Relman 1984). This initial public praise was no flash in the pan. TSTAM has continued to be an extraordinarily successful book. It is sold at an astounding rate for a book now some twenty-five years old. When compared with other books on similar topics, some considerably more recent, TSTAM stands head and shoulders above the rest in terms of its persistent sales viability.¹

But why? The answer to this question must rest on how the book was read. In this essay, I am not so much interested in whether the readings were accurate, but in how groups of people could (and did) arrive at a specific set of meanings for TSTAM. I shall focus on physicians. But physicians were hardly the only group of people who took a liking to TSTAM.

Part of the reason for the continued interest in TSTAM is its appeal to a diverse group of audiences. This reach can be demonstrated by the wide range of prizes that came to its author: the C. Wright Mills Award of the Society for the Study of Social Problems (1982), the Bancroft Prize in History (1984), the James A. Hamilton Award from the American College of Healthcare Executives (1984), and the Pulitzer Prize (1984, interestingly for general nonfiction and not for history, for which no award was given that year).

A significant portion of that broad reach was to an audience that was—at least in the minds of many readers—not only a target audience, but also the primary subject of TSTAM: physicians.² When it was first published, TSTAM resonated with physicians unlike any other book of the past half-century, and it continues to be widely recognized and widely owned. Based on an informal survey walking around academic physicians' offices at Midwestern and eastern medical schools, it is by far the most commonly found historically (or sociologically) oriented book seen on physicians' bookshelves. Similarly, asking a cohort of such physicians reveals that TSTAM is the historical or sociological book they are the most likely to know, know of, or have read. Academic physicians, although a small percentage of the total number of U.S. physicians, are worthy of note for several reasons. Academic physicians train new physicians. They make up a disproportionate number of physician-leaders and spokespeople and, almost by definition, tend to publish more than other physicians. But it was not just among academic physicians that TSTAM made an impact—the book was widely noted by nonacademic physicians as well. Absent some sort of systematic survey, it would be hard to quantify precisely how well known, owned, or read TSTAM has been among physicians of any type. However, there is more than sufficient information to make its widespread reception quite clear.

TSTAM is often found in the reference section of medical literature, usually to make some sort of general historical point. Often used in a setting in which any one of at least a dozen books would make the same point, TSTAM seems to be by far the favorite reference source, used almost as an encyclopedia.³ (It should be noted that medicine is not the only profession in whose literature...