Organizations, and the Quality
of Health Care
ROSEMARY A. STEVENS
Specialization is a defining word for American medicine in our time. If it were still possible for a generalist to understand medicine as a body of knowledge and skills, we would not now have mighty health care corporations, millions of workers in hundreds of health care occupations, sprawling academic medical centers with their associated networks, or even managed care. However, while technological innovation and improvements in the quality of health care available to earlier generations testify to the manifold benefits of medical specialization, its downside has also long been evident.
For more than a century specialization has been portrayed as a force for disorganization in medical care, challenges in medical education, opportunities for profit seeking, and power plays among rival claimants (Rosen 1944; Somers and Somers 1961; Stevens 1971; Starr 1982; Ludmerer 1985, 1999). Today competition for market share in lucrative fields such as cardiology characterizes our health services, jurisdictional disputes mark professional organizations, and massive government programs, including Medicare, Medicaid, and the National Institutes of Health, subsidize and underpin the whole.
For the past two decades medical specialists have moved efficiently into market niches. Health policy has been largely silent about regulating and organizing such services, but signs of change are promising. Here I focus on four essentials: the need for a workable information infrastructure, strategic planning at the community level, encouragement of primary care, and public support of lifelong learning for physicians through “maintenance-of-certification” programs. Achieving these would enhance quality of care by better aligning the advantages of medical specialization with the needs of consumers searching for physicians with top-notch skills and expertise, the latest technology has to offer, and the most effective treatments.
Why do we have such a complex and confusing array of specialists? Partly because patients have long been complicit in the rush toward specialized medical