American medicine has gone through technological, structural, and professional changes

since the late 19th century that have transformed the power of physicians within hospitals and

dramatically improved public perception and legitimacy of the medical profession. As public

demand for medical care and the authority of physicians increased, they co-produced the

institution of the modern hospital, which has led to increasing health inequalities. The interplay

of institutions and the physicians who comprise them has led to individual physicians having

control over their patient’s lives. Through the work of Paul Starr, Armando Lara-Millán, David

Sudnow, and Janet Shim, the sociological implications of physician power are brought to light.

The power of physicians within medical institutions to make decisions based on their personal

judgments about patients’ perceived morality, criminality, and cultural health capital has

negatively impacted the quality and equity of patient care in America.

In The Transformation of American Medicine, Paul Starr details the reconstruction of the

medical profession that has led to the influence physicians hold today. In the late 19th century,

the formerly disorganized profession of medicine became standardized, which led to the practice

gaining more authority in the public view. As transportation improved, more spaces were built

around medicine, and there was a separation of public and private life; hospitals and the

physicians who worked in them became more important to society as a whole and gained

prestige. As the public perception of the medical field’s significance increased, so did public

trust and dependency, which led to more power in society for physicians. The habitus of the

medical practice had been legitimized in the public view and then institutionalized in the form of

hospitals, and this authority and external legitimization contributed to building the “cultural

health capital” of physicians that exists today (Starr). Cultural health capital is defined as an

intangible currency used in social interactions to gain power; a concept from Janet Shim’s

“Cultural Health Capital: A Theoretical Approach to Understanding Health Care Interactions and

the Dynamics of Unequal Treatment.” With the legitimization and social capital present in the

medical profession, physicians gained more power along with the institutions in which they were

co-produced by.

The transformation of the medical profession’s legitimacy and its subsequent power in

society then contributed to physicians having the power to make medical decisions based on their

own judgements of the patient. In “Dead on Arrival” by David Sudnow and “Public Emergency

Room Overcrowding in the Era of Mass Imprisonment” by Armando Lara-Millán, physicians

and medical staff determine the quality of patient care by the latent rules of the hospital rather

than the manifest functions of the emergency room. In County Hospital, Sudnow details how

patients presenting the same symptoms and given the same diagnosis were treated differently

because of their age differences. Additionally, physicians spent less time checking for vital signs

with patients who they deemed less worthy of the effort because of alcohol on their breath

signaling their perceived immorality. Physicians have the power to discount patients based on

their own judgment rather than the manifest functions of their profession, which leads to

physicians defining morality. The negative health implications of this latent definition of

morality in emergency rooms contributes to wider health inequalities. The professionalization of

medicine described by Starr has impacted the equity of patient care by giving modern physicians

the power to determine whether patients live or die based on their perceived morality (Sudnow).

The trend of perceived negative moral associations influencing medical care is also

present in Lara-Millán’s piece, where the admission process to receive emergency room care is

shaped by perceived levels of criminality in a low-income neighborhood with a high proportion

of people of color. If medical staff believe patients are associated with criminality or have

questionable morality they receive longer wait times to receive care and many patients in such

neighborhoods don’t seek care at all because of the policing and surveillance inside of hospitals.

The presence of this policing only reinforces the perception that the community is associated

with criminality, along with the institution of the media, which disproportionately depicts people

of color as criminals. These various institutions along with society as a whole co-construct the

association of criminality which impacts the quality of patient care in hospitals. This co-construction serves as an example of how institutions shape individuals, whose actions then

shape the habitus of the institutions they are a part of (Lara-Millán). Throughout both Lara-

Millán’s and Sudnow’s pieces, the evidence reveals that medical professionals have been given

power over the quality of medical care different patients receive based on their perceived

morality and criminality. Along with this, the conflict of manifest and latent functions in the

habitus of hospitals leads to disparities in quality of health care.

Medical staff’s judgments about patient morality also depend on the individual’s cultural

health capital. Cultural health capital, a symbolic social currency used by patients, is acquired by

gaining biomedical knowledge and the ability to make sense of that knowledge, which translates

into physicians offering better care. This currency gives those with the privilege and power to

obtain it even more of an advantage over those who do not have the opportunity or the social

connections to navigate complicated medical institutions. Shim’s article also states that cultural

health capital’s impact on the quality of patient care depends on the patient wielding it, the

physician receiving it, and the characteristics and actions that are valued by the physician in the

clinical interaction. These valued characteristics are then habitualized and institutionalized by

those already in power, which widens the gap of health inequality. Physicians inherently have

power over the characteristics they value and in this way, they are able to shape the latent

functions of medical institutions to favor those already in power (Shim).

Throughout the modern history of American medicine, physicians have gained more

influence and autonomy as medical institutions acquired more authority through improved

professionalization and standardization. The cultural health capital gained through increased

legitimacy has led to physicians having the power to make medical care decisions based on their

judgments of a patient’s perceived morality, criminality, or social value. Along with this ability

comes the responsibility of determining the cultural health capital that is valued in institutions.

The transformation of the role of physicians in social structures and institutions has dramatically

contributed to the health inequalities in treatment that are present today.

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