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The state of American medicine has always been of a very large concern, and I guess that is why its quality is really high nowadays. Medicine is certainly a powerful world that is usually perceived as a complex system of diverse hospitals, clinics, and other organizations employing labor force. American medicine has experienced a set of transformations and significant changes that can be compared to an epic of progress. However, as Paul Starr states in his book, all the transformations in American medicine are also closely related with the creation of new hierarchies of power and the authority. Medicine cannot exist without the impact of new conditions of belief and experience. The medical profession can be considered to be the most dominant position in America throughout many years. Paul Starr’s book The Social Transformation of American Medicine covers a very important topic in the development of American society as the entire American health care system changed. This was not an immediate change and it took much time for American hospitals, health plans, and government programs to submit these alterations. The fact that this book won two significant prizes in American History such as the 1983 Pulitzer Prize and the Bancroft Prize proves its uniqueness and high importance.

The book The Social Transformation of American Medicine by Paul Starr certainly helps to shed more light onto this issue and it certainly must be read in order to understand the complex structure and the state of American medicine. This book was published in 1982, and it became a real success. Paul Starr is certainly a very experienced and highly-qualified professor and he managed to make his book extremely fascinating and very informative. Paul Starr’s background of a professor of sociology and public affairs surely helped him to make this book easy to read and quite educational. The author decided to divide the book into two parts in order to make it easier for understanding. The first part is devoted to the history and rather long-terming process of the rise and development of American medicine and professional authority among physicians. As for the second section, it deals with the interrelation of doctors to different institutions, and particularly government.

Important Aspects in Paul's Book

Paul's book made an emphasis on several important aspects. First of all, he indicated on the emergence of the national labor market, which is in constant movement and development. This force is much more mobile, and a key resource for it is a national unified education. Therefore, the leading national universities are booming demand for its graduates. All want someone from a good college first, and then a good research university to learn.

The second process, occurring simultaneously with the first one is a change in the patronage research funding. Now there are big grants for graduate schools and research facilities, universities such as Johns Hopkins, who handed out the oligarchs. These oligarchs make their position in prestigious universities, richer, easier in terms of teaching loads, and all want to get it to that position. This is a career peak. And now everyone knows what leading universities are like. Thus the process of changing the balance of power in the university occurs.

Paul Starr’s book The Social Transformation of American Medicine is surely a much researched study that comprises a great amount of material and still is absolutely readable. Paul Starr is actually the first author, who analyzed such a vast amount of historical and cultural material. This book helps to see the new aspects and horizons that exist between both the health care providers and recipients. Patients keep having a great percent of frustration and disappointment concerning the current medical system, and Starr highlights the importance of conversations and gradual changes within the system.

Two Major Tendencies in American Medical System

According to Paul Starr, American medical system experienced two major tendencies throughout its development including the "professional sovereignty" of physicians, and the close relation of healthcare to business and corporate regime (Starr, 1982). The sociologist uses rather original approach in his study as medical care discussed in the book is analyzed in the context of the need to break limits of relationship between the patients and physicians. Starr states that as compared to the previous times, the cultural authority of physicians has significantly increased (Starr, 1982).  Medical sphere has been lately less focused on the impact of collective consciousness, and Paul Starr tries to renew this process by his research study. The sociologist believes that physicians have always been successful and deserved honor and comfort, however, such a status was admitted only by the 20th century. Physicians used to be always deprived of honorable and respectful attitude, and only past a huge time lapse they managed to capture one of the main aspects of the healthcare system. “Caring for the sick” is not an easy task according to Paul Starr’s book “The Social Transformation of American Medicine”, and thus physicians should be highly appreciated and respected.

Starr divided his research study into 2 parts and published 2 separate books that are interrelated. The first part is devoted to the gradual and complex development of the healthcare system since 1760 and till 1920. This period can be characterized as rather an aggressive one as physicians tried to preserve their typical lifestyle and resist to corporate control. The second part marked out by Starr is a more detailed discussion and analysis of the struggle among old and new medical traditions and viewpoints. According to Starr, the main problem that requires attention is the status of private corporations as they tend to obtain too much power and acquire the leading roles in American medicine (Starr, 1982). It is possible to understand this issue and take urgent measures only with the help of past lessons and conclusions regarding the medicine.

The Homeopathic Approach to Treating

In his book, Paul Starr also makes an emphasis on the status of homeopathy, which it reached in the U.S. in the middle and second half of the 19th century. He states that "because homeopathy was simultaneously philosophical and experimental, it seemed to many people to be more, rather than less scientific than orthodox medicine".

As it is known, homeopathic medicine is at present one of the leading forms of alternative therapy in the whole world. Although homeopathy developed as a medical specialty only in the early 1800s, still it managed to become one of the main alternatives to orthodox medicine internationally and is certainly a significant danger for the scientific, philosophical, and economic foundations of traditional medical treatment.

Now the homeopathic approach to treating serious attention is paid to the symptoms of the disease as an important manifestation of the immune and other parts of the defense system of man. According to Paul Starr, “before 1840 homeopathy had only a few proponents in a few states, but it became better known in the next decade, and in 1850 a homeopathic college was founded in Cleveland”. While conventional medicine often sees symptoms as something "wrong" for a man, and they are required to treat, inhibit, suppress or influence them in any biochemical way, homeopaths tend to believe that the symptoms are an important manifestation of the defense, which is the most effective when the treatment of the symptoms is provided carefully, they do not suppress and adjust for them to begin the process of healing. These are two different approaches to healing people led in the end to a variety of conflicts.

For example, homeopaths usually have skeptical conclusions of "scientific" studies on the therapeutic efficacy of conventional medicines, as they fear that many of these drugs suppress the symptoms or break a complex internal environment of the body, which leads to much more serious diseases. However, many modern drugs, according to homeopaths, provide only temporary relief blessed, but reserve the many chronic disease processes. In addition, studies state that many people today prescribe several medications, though it is quite dangerous, and this fact evokes doubts concerning the ethics and truly purpose of modern medicine.

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History is full of examples where orthodox medicine and science stubbornly resisted the various systems of medicine and healing paradigms. But, while the regular doctor and a scientist, as a rule, is frightened of new ideas, the general characteristic of the leading physicians and scientists - the reconciliation of the opening and the fact that the evolution of knowledge is common and even expected.

As Paul Starr stated, “homeopathy had one foot in modern science, the other in pre-scientific mysticism; this became an increasingly untenable position and while regular medicine was producing important and demonstrable scientific advances, homeopathy generated to new discoveries” (Starr, 1982). It should be recognized that the homeopaths, patients and those who simply use these absolutely natural medicines do not expect that the results obtained in the treatment of themselves, children, including babies, animals, and even plants can be so successful. Many people are quite skeptical of homeopathy, as long as they do not turn to it and see its effect on themselves, and there is a good reason why millions of people around the world use these natural medicines and rely on them for treating a wide range of acute and chronic diseases. However, the problem is not only to try to use homeopathy, but that you first need to know something about it, to use it properly and effectively.

Nowadays, the U.S. health care system is represented by independent agencies on three levels, the family medicine, hospital care and public health (Starr, 1982). Medical services in the U.S. are held by private individuals and legal entities. Various commercial, charitable and government organizations offer patients both outpatient and inpatient services.   Family medicine is quite a sophisticated structure in the United States. Family doctors examine and observe patients, and if necessary, refer them to specialists or hospital. Payment of such doctors is obtained directly from the patients. Typically, the family doctor has his own office or cooperates with other professionals.

Hospital or hospitals are the largest components of health care system. Inpatient treatment is the most expensive and important component of the health care industry in the country. Recently, however, there have been significant shifts in the direction of other agencies, mainly clinics, the emergency room, and nursing homes (Starr, 1982). Outpatient services are slowly but surely replacing hospital care, and home care - stay in nursing homes.

Nowadays there are two types of hospitals in the U.S: those having the right of ownership, often controlled by large private corporations and non-profit hospitals that are managed by county and the state authorities, religious communities or independent NGOs. They have a certain amount of out-patient care in the emergency department care and specialty clinics, but mostly they are intended to provide in-hospital care. Most attention is paid to the emergency room. In the offices of ambulance and emergency, treatment centers have sporadic, focused on the issue of aid. SurgicalCenter is an example of a specialized clinic. In addition, the U.S. has the highly developed network of hospices for terminally ill with a life expectancy of six months or less, which are usually subsidized by charities and the government.

The Model of "Fee for Service" Payment for Medical Services

In the U.S., however, as in other countries, the concept of ambulatory care includes medical services without hospitalization, accounting for a large share of health care. Home treatment is mainly produced by nursing organizations and is usually ordered by doctors. Private sector outpatient care are personal doctors (specialists in internal and family medicine, pediatrics), specialists, such as gastroenterologists, cardiologists, pediatric endocrinologists and nurses and other medical staff. Back in the 1986 Act on medical emergency and labor was passed, which at the state level secured an access to emergency medical care for all people regardless of insurance.

Besides, an investigation Budget Committee of the U.S. Congress concluded that the increase in health care costs are directly related to changes in health care that have occurred due to the improved technology, and because of the growth of income, changes in insurance coverage, and price increases.

People mature and older spending on health care is much more money than working, or the child population. There is a considerable geographical variability in the level of care for chronically ill patients. It is mainly dependent on the availability of expensive techniques available in any geographic area, and only a small part of the cost (about 4%) is explained by the number of critically ill patients in the region (Starr, 1982). Most Americans (59.7%) have the health insurance that is provided by employers. In addition to health insurance, there are benefits to employees in case of loss of ability to work, life insurance, etc (Starr, 1982). Although the employer is not required to provide insurance to their employees, even a full-time one, large companies have such an insurance practice.

The model of "fee for service" payment for medical services is performed by each person individually at their own expense, as for any other service provided. Insurance model provides the financial risks, in which each individual or his employer makes a set monthly fee. This mechanism allows the separation of funds is often necessary to pay for a full range of medical services, but sometimes you have to pay a certain amount for their services - so-called franchise, or pay extra for some part of each procedure.

Despite numerous studies showing a high quality of service and cost-effectiveness of HMOs, these organizations are losing their market share. They are replaced by organizations with more flexible management models that can offer customers significant discounts through a developed network of contracted hospitals. Today, the picture is typical, when a doctor or clinic has a dozen or more contracts with various companies, diagnostic laboratories and in our work uses several practical guides.

The evolution of American medicine and healthcare system could not have taken place without a set of fundamental complexities. Paul Starr explains the background and causality of every complexity and its impact on the medical system. What I liked a lot is that although this is rather a serious book on the topic of American healthcare, still it is absolutely accessible for a general reader and does not require some particular knowledge and understanding of the topic. The distinguished sociologist explains every viewpoint and all the material is structured and perfectly organized. The book The Social Transformation of American Medicine can be used as a critical background for other similar studies or researches.

The Evolution of Quality of Clinical Care and Medical Education

In my opinion, this book is an example of the early exposure to improve the quality of clinical care and medical education. The evolution of quality improvement was a sustained response to the need for the error correction.

The state of American medicine has always been of a very large concern, and I guess that is why its quality is really high nowadays. Medicine used to be rather erratic and only in 1847, in response to the need for more rigorous, standardized medical education AMA (American Medical Association) appeared. Medical education and the practice of medicine in colonial America were mainly unreliable. As Paul Starr wrote in The Social Transformation of American Medicine, people used all the kinds of medicine in the colonies and nearly everyone could perform the duties of a doctor. Later, during the American Revolution, approximately 400 of 3,500 to 4,000 doctors of the country received formal training, and only half of them had a medical degree, which, however, was not much valued and, as required, a maximum of only 6-8 months of training on medical school and three years of probation.

One more interesting fact that is mentioned by Paul Starr is that times have changed a lot, and some time ago it was much easier to get a medical degree as there were far less requirements. By that time period, there was little knowledge of diverse illnesses and diseases and the role of a doctor was not so obligatory. Such a situation created a couple of negative stereotypes concerning doctors, as they were often regarded as scarce and absolutely not trustworthy. The situation was even much worse in rural areas, where it was far more efficient to solve your problem yourself and fins some cure, then wait for a doctor’s help and assistance. Such a tendency resulted in the development of domestic medical care. Paul Starr describes the way people dealt with various illnesses without doctors’ assistance. For instance, it was quite typical for many families and women particularly to collect different types of herbs and store them in case some illnesses struck.  By that time it was woman’s responsibility to deal with the domestic medical care. There were also special books devoted to domestic medicine. Paul Starr mentions the best known book at that time - William Buchan’s Domestic Medicine (Starr, 1982).  As Paul Starr states, that book was reprinted approximately 30 times and used in many families. It was extremely popular as it contained a great list of diverse symptoms and disease causes. Besides, it was extremely helpful as there were also preventive measures that could provide individuals with cure from particular illnesses.

Paul Starr believed that such domestic guidelines were challenging professional authority and although many families had an access to the list of symptoms and prevention methods, still there was no guarantee that they could deal with a particular illness themselves. Thus gradually the role of doctor was developed and improved. Besides, the status of a physician became associated with honorable and respected activities.

As Paul Starr stated in his book, Caring for the sick is not an easy task, and thus physicians should be highly appreciated and respected (Starr, 1982). I totally agree that it is not easy to be a good physician and real professional in the United States and in any country in general. First of all, such an aim requires approximately ten years of study. Plus future doctor is obliged to pay the debt institution - students who complete the municipal medical school have an average debt of about $ 100,000 graduates of private universities - about $ 135,000. In addition, doctors in the U.S. are defendants in lawsuits patients. Most of the claims submitted by the most frivolous reasons, doctors have won 91% of all claims for improper medical practice (medical errors, etc.) considered by juries in 2004. Protecting your reputation costs a lot for every physician. Although many states are trying to pass a law to protect doctors from frivolous litigation, still there are many relevant problems.

These and other reasons encourage practitioners to discourage their children follow in their footsteps; so many doctors do not advise their children to choose this profession. However, there are also advantages in the medical profession. One of the main benefits is certainly salary. In addition, the medical profession has been one of the most respected not only in the U.S. but around the whole world. However, it is expected that in the next 15 years the United States will experience a shortage of 90 to 200 thousand working places for physicians. The American Medical Association (AMA) points to the lack of doctors in specific geographic areas and in certain specialties. This is partly due to an aging population and the same number of graduates of medical schools. From a lack of doctors strongly affected consumers, in 15 years it will be difficult enough just to get an appointment with a specialist. In this regard, the Association of American medical colleges said the United States should increase the number of students by 30% each year to meet the needs of the community in health care. It is expected that in 2012, admission to medical schools increased by 21% compared with 2002.

In an effort to reform medical education, AMA in 1904 established a Council on Medical Education, which appealed to the Carnegie Foundation for the development of education with a request to conduct a study of medical faculties. At that time there were no books in libraries, and members of the teaching staff were fully engaged in private practice.

Although this book was written quite long time ago, still its content and all the aspects it covers are relevant and important till nowadays. I agree that today, most employers use the services of so-called managerial insurance companies that organize medical services at a price much lower than what the employee would have paid for the individual seeking help. The main feature of such organizations is the conclusion of selective contracts, that is, with multiple health care providers, to achieve lower prices. In addition, these organizations often offer attractive schemes for the employer to reduce excess medical costs. In order to minimize costs to the patient, specialist care must first be examined by a generalist. Managerial insurance companies and conventional insurers often use such non-financial controls, an administrative approval or receipt of second specialist before prescribing expensive procedures.

The Introduction of Universal Compulsory in the U.S. Public Health System

The most urgent topic of the American political parties is the question of whether to make the introduction of universal compulsory in the U.S. public health system. Proponents of a universal system argue that the provision of medical care to uninsured citizens leads to huge costs that can be avoided, covering the entire population of a system of compulsory medical treatment. Their opponents have appealed to the freedom of choice of each person, including health care, arguing that the introduction of such a system would increase taxes and reduce the quality of care. But opponents agree that today the government had to spend huge amounts of money on health care and that the most effective solution to this problem could be to encourage market solutions, increasing the efficiency and the introduction of innovative approaches. In addition, all political forces unanimously assert an inviolable right of every person on health care, which should be protected by the state.

Paul Starr stated that there are always certain changes in the healthcare system, and I totally agree with this statement from my own experience. Nowadays, nurses that are involved in a great number of community health settings have to adapt to all the changes and innovations and thus perform new roles that are completely unknown for them. Community-focused nursing has acquired many new features and now much attention is paid to such aspects as activism and advocacy. It is believed that nurses can serve as highly efficient agents and help to implement changes both in healthcare system and the whole society; however, their activism is surely the result of thorough planning and professional management. I also find it really fascinating that nurses have become able to cause serious changes and perform actions that can affect both the individual and organizational levels. Besides, nowadays nurses are required to use creativity in order to think of the new methods, solutions, and way outs concerning various problems and issues. I totally believe that all the efforts I’ve taken and my practice can cause certain changes; the only thing that should be considered is whether to be reactive or proactive. I fully understand that the scope of my practice is very large and it is necessary to demonstrate such skills as flexibility and ability to adapt to fast changes and help other people to cope with this task.

There is no doubt that now nurses have a very strong esteem both in the public and professional sphere and their participation in the political arena is no surprise or a strange thing. The scale of nursing knowledge, scope and various roles have significantly increased with a growing number of degrees in different that provide nurses with all the required components in order to become active participants and activists in modern society. It is rather difficult to say for sure whether nurses should stay out of "politics" or not as there are both pros and cons in this issue. As for the cons, it is believed that politics is intended for other people and nursing has no relation to it, with all the complications and difficulties typical for it. However, the experience, knowledge, and the level of insight into the vital health care issues that the majority of nurses possess can definitely turn out to be very efficient for politics and simply priceless. I totally agree that nurses have recently acquired a great set of new roles that are dictated by the changes in the modern world and society, thus putting an emphasis on the advocacy and activism in nursing practice.

Paul Starr’s book The Social Transformation of American Medicine is certainly a very interesting source for everyone, who is interested in medicine and its peculiar features. It is very well-written and full of detailed and easy for understanding explanations. Professor Starr makes a rather complex work as he describes the process of evolution of the practice and the culture of medicine that was typical for the United States from the end of the colonial period till the beginning of the twentieth century. Paul Starr states that within this time frame American medicine has acquired many important features such as more power, technical expertise, and effective modes of diagnosis and treatment. However, such changes have also resulted in a more detached status of the relation between medicine and patient. This factor can certainly be viewed as a drawback. Starr also makes an emphasis on the effect of modern stress on professionalism and thus the population it deals with. America certainly has the most expensive health care system in the world. U.S. spends on health care for more than any other country - both in absolute terms and in relation to gross domestic product. However, over the last 30 years, an increase of the healthcare sector is mainly due to the government programs, which can seriously undermine the financial stability of the country.

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