This issue is the third in a series about emergencies. Instead of another editorial about this, the following diverges to review the history of medicine and how events of the past may help us understand what is happening now. Medical care in the United States has undergone four major changes or "revolutions" during the past two centuries. These four events are described below as equations: the conditions that led to the change are presented, followed by the solution to the equation or how the change played out. See if you agree that these four have the similarities summarized at the end of this editorial.
The first revolution began almost 200 years ago. The equation that set this up was the existence of only four medical schools in the United States.2 The College of Philadelphia (now the University of Pennsylvania) was the first and was modeled after the University of Edinburgh in Scotland and the teaching hospitals of London.3 The Philadelphia founders had studied under the Scottish model that included professor chairs in basic and clinical sciences, an anatomy theater, botanical garden, chemistry labs, and a library. This was combined with the clinical training on hospital wards that was typical of the London system. Graduates received the MD degree, as was the Edinburgh custom. This excellent system for the period was adopted by King's College in New York (now Columbia). Harvard and Dartmouth followed before 1800. These schools provided very good training for the time but could not turn out enough physicians to serve this rapidly growing country. Thus, most physicians were trained by apprenticeships.
This led to the following unfortunate situation. In 1807, the first proprietary medical school was established in Baltimore by a few physicians acting as investor/owners.2 This and the hundreds of similar schools that followed were profitable to physician owners because they were largely didactic and offered little or no clinical experience. A connection with a teaching hospital or a university was the exception. Profits came from student tuition fees that were split among the lecturers.2 Departmental chairs were sold for as much as $3000, and in at least one case, faculty bought and sold stock in the medical school and the sale included the right to be chair.3 The 19th century saw 457 of these proprietary medical schools. Many lasted only a few months, and the number in operation peaked at 166 in 1904.3 Their standards for admission were low (most often less than a high school education), and the duration of lectures was short (often 8 to 14 weeks).2 The quality of physicians in this country plummeted, especially when compared with graduates of scientifically based university schools in Germany and Europe. The state licensing laws that began here in the 18th century were ignored or repealed, and the right to practice was based solely on having the MD degree awarded by all these schools.3 The American Medical Association was established in 1847 to improve medical education, ethics, public health, and the terrible public image of physicians. But attempts to increase the quality of education failed because schools that raised entry requirements or the rigor of training quickly lost students and their fees.2
The poor public image of medicine promoted the next revolution at the end of the 19th century. The formula for change also included the improvements that nonmedicai universities had made during this century, the rapid growth of scientific knowledge in surgery, anesthesia, and infectious disease, and the excess supply of poorly trained physicians practicing at that time.2
This new equation was solved in a positive way by economic forces and public opinion. There were two important breakthroughs. First was the establishment of a new model for medical schools at Johns Hopkins University in 1893.2'3 Mr Hopkins, a nonphysician merchant, endowed a new 400-bed hospital there. He specified this should be free to the indigent but open to patients who could pay. Further, the endowment required the hospital would be connected to a medical school that was part of Johns Hopkins University, which he had also endowed.3 Thus, this medical school had funds independent of student fees and the pressures that went with them to set up a new model. Its governance and faculty were chosen wisely. Billings emphasized science and research, Osier brought bedside training, Halstead brought surgical innovations, and Welch introduced microscopy and bacteriology as a pathologist.
The second instrument of change came from Abraham Flexner and his report of 1910.2'4 The American Medical Association, after its 1906 Council on Medical Education ran into political trouble trying to improve physician education, persuaded the Carnegie institution to undertake an evaluation of medical schools. This nonmedicai foundation interested in general education employed Abraham Flexner to do this. Mr Flexner was a school master from Louisville who had obtained a degree in liberal arts from Johns Hopkins in 1886 and was familiar with their new model. Flexner personally visited all 148 medical schools in the United States and seven in Canada during 1908 and 1909. This ama2ing feat for the time was made possible by new transportation technology. His report of 1910 described the strengths and weaknesses of each school by state, recommended which should survive, which should close, and why. His criteria for a strong medical school included having an "organic" attachment to a larger university, access to a teaching hospital, full-time teaching staff, laboratories including anatomy and basic sciences, a library, strict entrance requirements, a sufficiently long curriculum to cover science and clinical practice, and financial resources independent of student fees (such as state appropriations, endowments, or public contributions).
For example, of the nine medical schools in Tennessee, he felt only Vanderbilt University was worthy and could provide all the physicians needed in this state at that time. Of 12 in Missouri, he felt Washington Uiniversity was the strongest, next came the State University in Columbia, and then the Medical School at St Louis University. But Flexner recommended the latter two should be 2-year schools, sending students to Washington University for their clinical training. Flexner also noted the excess supply of physicians, state by state, and the opportunity this presented to drastically reduce the number of poor schools and their trainees. He felt the ratio of 1 physician per 2000 population that existed in Germany at the time was ideal. The ratio in the United States then was 1 physician per 568 population.
Flexner's report brought the weaknesses of individual schools into the public eye. State licensing laws were strengthened, the American Medical Association was able to rank medical schools by quality, and foundations provided financial support to the best, especially those that adapted the new Hopkins' model. The proprietary schools could not compete, became nonprofitable, and 70 closed within a few years. The total number of schools here dropped to a nadir of 76 in 1930.3
The next revolution occurred in the 1960s. The imbalances that set up this equation included a shift in public opinion to consider medicine a biological necessity instead of a relative luxury.3 Individuals and the private sector were no longer able to support the level and distribution of medical care needed in this country. The growth of medical insurance increased, and the introduction of Medicaio and Medicare in 1965 dramatically expanded the flow of money to medicine and the demand for physicians. The computer made Medicare, Medtcaid, and indemnity insurance systems for massive reimbursement possible. This formula for change included a relative shortage of physicians for the expansion in care. The ratio of nonfederal physicians to population decreased from 1 per 568 population in 1910 to 1 per 706 in 1967. In Boston and Brookline, Massachusetts, the ratio fell from 1 physician per 755 population to 1 for every 1490 between 1940 and 1961. At the same time, residency positions beyond a first year of internship had started to grow rapidly after World War II, and many of these were devoted to subspecialty training so the percentage of physicians who entered primary care had begun to decrease.3
The solution to this equation is well known to us. Federal support of medical education was expanded, and there was an inflow of clinical money from government and third-party payment plus research grants. The number of medical schools, physician graduates, and faculty numbers increased dramatically. Subspecialty training and research flourished.
The formula setting up the current revolution of the 1990s includes a national viewpoint that embraces free markets with decreased government regulation to enhance competition and productivity through the reengineering of all types of business and enterprise. The general public also tends to feel that medical costs have risen to unacceptable levels at about 14% of the gross national product. Also noted is an increasing disparity between mortality and socioeconomic groups, due in part to inadequate access of the poor to medical care.5 Most important is that we now have an excess of physicians, especially subspecialists. A 1992 Council on Graduate Medical Education Report indicates that by the year 2000, we will have 140 subspecialists per 100,000 population while managed care will support about 85 to 105 per 1001000.6 The supply of generalist physicians seems to be about what is needed or slightly shy of this.6,7
The solution to this equation is already underway. Medicine has been thrust into market forces. Managed care organizations must bid competitively for patients and clinical income. Managed care applies economic pressure on physicians and hospitals by gatekeeper limitations on consultations and hospitalizations, reimbursement by capitation, and forcing a surplus of physicians and hospitals to compete for patients and contracts. How it will unfold finally is not clear but some interesting questions are:
* By what means will the current surplus in physicians and subspecialists come into balance with demand?
* Will there be a new model in medical education paralleling the role of Johns Hopkins in 1892?
* Will there be another Flexner-type report if falling clinical income of some medical schools compromises education?
* What will the next shift in public opinion be, when will it occur, and what revolution will follow?
* There have been four major shifts in the history of medicine in the past 200 years, including the current one associated with managed care.
* The specific situation of each shift has been different but the forces causing these changes are similar: each has followed an imbalance in physician supply or quality, each has been driven at least in part by public opinion, and each was implemented by market forces of supply and demand.
* Most of the leadership for initiating each change came from business, lawmakers, foundations, or lay leaders.
* Once initiated, medical education and physicians reacted to public opinion and economic forces to become implementers of change.
* Each of the four episodes of change have eventually led to another imbalance in physician supply and thus contributed to the next major change.
Now that you have read this, do you feel better? I don't think so.
1. Santayana G. In: fitihenry Rl, ed. Chambm Book of Quotations, Edinburgh, Scotland: WStR Chamberí Ltd; 1990.
2. Lyons AS, Petrucelli RY. Mediani: An MuirraW History. New York, NY: Henry N. Abrams Ine; 1978:534-537.
3. Freyinann JG. TheAmerican Hcaith-Cait Syaem Iu GÍTWJIS and Troficrorj. New York, NY: Modcom Prev; 1974.
4. Rexner A, Medical Education in the United Sitati and Canada. New York, NY: Ama Press and thè New York Times; 1972.
5. Pappai G, Queen S, Haddcn W, Filhet G. Th* increasing disparity tn mortality between socioeconomic groups in the United States, I960 and 1986. N Engll Mea. 1993;329:103-108.
6. Rivo ML, Mays HL, Kaaoff J. Kindig DA for the Council on Graduate Medical Education. Managed health care - implicai inns for the physician workforce and medical education. JAMA. 1995;274:712-715.
7. Whitcomb M. A cross-national comparison of generali« physician workforce data. JAMA. 1995;274:692-695.