History and Health Policy in the United States: Putting the Past Back In

3. Medical Specialization as American Health Policy: Interweaving Public and Private Roles

Life usually doesn’t just dump truth on your plate, neat and simple. It usually comes with a side of nuance, garnished with paradox. Chris Satullo, Avoid the Dreaded Either/Or— Seek the Sweet Bird of Paradox What is health policy? On the face of it, there seems a simple answer. Health policy is what governments do, or try to do, to further health care, typically at the national level. As other essays in this volume resoundingly attest, however, seeing health policy only as what government does or fails to do gives a blinkered , partial—and much too tidy—view of the rich, complex, and constantly shifting landscape of health policy in the United States. I want to suggest some of this complexity, nuance, and paradox by examining specialization in American medicine as a vital, yet often neglected, policy issue. Public and private policy making have long been entwined in American politics. Specialization weaves together several histories: the history of government , to be sure, but also the histories of science and technology, the medical profession, health care, business, consumerism, and other more generic historical fields. I concentrate here on the history of the U.S. medical profession, which is now formally structured—through education, examination, and certi- fication—into thirty-seven primary specialties and ninety-two subspecialties Medical Specialization as American Health Policy Interweaving Public and Private Roles Chapter 3 Rosemary A. Stevens 49 (with more under way). New historical interpretations of the profession are overdue. This is also a particularly important time to reconceptualize the policy role of the medical profession in setting standards in the informationoriented health-care system of the twenty-first century. In the last quarter of the twentieth century, ruling narratives within the scholarly and medical communities included the rise and current decline of the medical profession, and thus gave negative interpretations of the social role of medicine as a profession. In turn, such perceptions obscured the very real challenges faced by professional organizations, particularly their roles as public agents (Stevens 2001a). Yet, as this chapter shows, during this same period professional organizations in and across the medical specialties struggled successfully to create and legitimate new fields of medicine through a process of private negotiation and organizational consensus—influenced by related government policy but outside the realm of government. Today, twenty-four medical specialty boards, each sponsored by national specialty associations in the field of interest, certify almost ninety percent of all practicing physicians in the United States. For a list of the boards, see Table 3-1 at the end of this chapter. Through their umbrella organization, the American Board of Medical Specialties (ABMS), these boards embarked in 2000 on a new policy to require board diplomates to not only demonstrate current knowledge in their chosen field but also fulfill specified curricula for life-long learning, periodic selfassessment , and peer and patient assessment as a condition of maintaining board-certified status. (I have served as a public member on the ABMS since 1999.) The formative history behind this movement is part of the larger evolution of medical specialization as a central—if hidden or implicit—theme in American health policy from past to present, coloring options for the future. These specialty certifying boards, and medical professional organizations in general, have been surprisingly silent in public debates. It is useful to consider why this is. How might professional groups participate more fully in health policy in the future? Should they? Twentieth-Century American Medicine: Two Overlapping Reform Movements Specialization as a movement was evident well before the famous Flexner report (1910) became the symbol of reform in American medicine in the early twentieth century.1 Historians have paid considerable attention over the years to the success of the “Flexner reform movement” as the exercise of professional power: in defining the American Medical Association (AMA) as the central professional institution for organized medicine, a position it held up to the 50 Rosemary A. Stevens 1960s (Burrow 1963; Fishbein 1947); for demonstrating, in a nation unwilling or unable to enact governmental health policies, the political role of private institutions in effecting social change—not only the AMA, voice of an autonomous profession, but also the charitable foundations that supported professional reform with money drawn from profits in commerce and industry (Brown 1979; Starr 1982; Berliner 1985); and for forming long-lasting, cherished characteristics of America’s medical schools as...