History of Medicine Revisited: Does It Give a Glimpse Into Our Future?
This issue on sports injuries and how to prevent them is right on target for contemporary pediatrie practice. Knowing how to manage minor trauma, and when and not to refer will be more important than ever during the next decade.
The following editorial digresses from the topic of this issue to speculate about our future. The September 1996 editorial in this journal took a look at the history of US medicine and argued that there have been four major shifts in the last 200 years, including the current managed care revolution.1 The editorial described common patterns in these four shifts and suggested they might give us insight into what will happen next. The following briefly reviews the history of medicine2"4 and speculates further about what is coming. Look for repeating themes in the following.
When the first revolution in American medicine occurred just after the end of the 18th century, the United States had been off to a great start. In 1800, there were foui small medical schools here. The first was the College of Philadelphia, now the University of Pennsylvania. It had combined two of the best medical education systems in the world at the time: the Edinburgh model put the medical school as a scientifically based part of a University. It had professor chairs in clinical and baste sciences, anatomy and chemistry labs, a botanical garden, and library. The London model was hospital-based rather than university-based and put students with attending physicians for bedside teaching at Guy's, St Bartholomews, and other major hospitals. Our tradition of awarding the "Doctor of Medicine" degree was started then, as typical of Edinburgh schools. This was, and remains, an honorary degree by universities in England. Columbia, Harvard, and Dartmouth soon opened here, modeled after the College of Philadelphia. The United States might have been a world contender in medicine during the 19th century had this system for medical education prevailed.
Unfortunately, this model gave way in the first major shift. In 1807, the first "for profit" medical school was established in Baltimore. A small group of entrepreneurial physicians became owner/operators of their own medical school with profit as the primary goal. The model was financially successful and 457 similar schools opened over the next 100 years. Low entrance requirements (usually less than a high school degree although some required a preliminary apprenticeship), short duration of education (usually a few weeks or months), and essentially limiting education to (inexpensive) didactic lectures by the owners were the key ingrethents to making a profit from student tuition fees. Connections with universities were rare or nonfunctional. Trie proprietary schools had few qualifications for graduation but continued to award the MD degree. Lawmakers and the public turned a blind eye and existing regulations for medical training or practice were eliminated or ignored, while new regulations were not forthcoming. The quality of medicine in the United States plummeted. The American Medical Association tried to upgrade standards for medical education unsuccessfully for 50 years. When any school raised the rigor of its education, students took their tuitions to other schools, leaving the first in financial distress. This proprietary teaching model remained dominant throughout the 19th century.
Meanwhile, Europe was taking a different course. Many felt the best medical education at the time was in Germany. This country connected medical education and research with universities where they were protected by academic freedom, and the government supported research and academic salaries. German universities competed with each other for renowned scientists and research discoveries, Europe had undergone a renaissance in chemistry, physics, and mathematics during the 18th century, and the 19th century saw the same happen for medicine. The United States remained in the dark ages for medical research during the 19th century, except for a few demonstrations and the experiment of William Beaumont, an army surgeon who treated a severe wound that left a stomach permanently exposed. Beaumont proved the presence of hydrochloric acid in the gastric juice, established the relationship between emotions and gastric secretion, and described details of gastric motor activity.2 But, for the most part, scientific discoveries were introduced to the United States by those who learned of these in other countries.
The era of proprietary medical education ended with the second major shift. This began during the late 18th century when a few medical schools were able to improve education. Yale raised their entry and educational standards in 1873 and had sufficient funding from nontuition sources to make these stick despite declining class size. Then Johns Hopkins opened in 1989 as what would become the model for medical education in the United States. Actually, the structure of Hopkins School of Medicine had many similarities to the 19th century medical schools in Germany and the first four medical universities in the United States. Abraham Flexner's report on medical education, published in 1910, finished off the proprietary era.2"4
Flexner personally visited and evaluated all 148 medical schools in the United States and 7 more in Canada. He considered strengths as: being part of the University and having access to a teaching hospital, full- and part-time teaching staff, laboratories for anatomy and basic science, a library, stringent entrance requirements, and most important, financial sources independent from student fees such as state appropriations or endowments - so the school could put the necessary rigor into training without fear of financial failure from loss of student tuitions. These strengths had been part of Johns Hopkins, and Flexner, a school master from Louisville who had received his liberal arts degree from Johns Hopkins, was familiar with the Hopkins' model. Flexner used several principals to change medicine. The United States had almost four times as many physicians per thousand population as did Germany at this time, and Flexner recognized that this surplus permitted closure of all but the best schools in each state. He also planned to use public opinion and governmental regulations to change medicine. Lastly, he knew the forprofit medical schools were vulnerable to economic realities and used market forces to wipe them out.
Flexner's report changed public opinion, made it possible for the American Medical Association (AMA) to classify medical schools according to quality, and foundations supported only the best schools. The proprietary schools could not compete and went under. The number of medical schools in the United States plummeted by more than half between 1904 and 1930. Improvement was rapid, and in 1912, L.J. Henderson made the statement, "A random patient, encountering a random physician, with random disease has, for the first time, a better than even chance of profiting from the encounter."3 Thus, began the renaissance in the United States that made us dominant in medical research during the 20th century.
The third revolution was brought about by a flow of money into hospitals, medical education, and the creation of Medicaid and Medicare during the 1960s. This came from the growing availability of commercial medical insurance through employment and Medicare and Medicaid to fund care for the aged and poor. The political decision to create these was based on an evolving public opinion that medical care was a right and not a privilege.3 However, expanding care to large numbers of underserved required an increase in physicians. Our numbers had decreased from 1.76 to 1.42 physicians per 1000 between 1910 and 1967, despite great advances in what these physicians could do.3 So money poured into medicine through research grants, federal funds to build new hospitals, capitation payments to medical schools for students, and most important, better reimbursement for care. Action follows the dollar, and we saw a rapid growth of physician numbers (especially for subspecialists) and our financial well-being over the next 30 years.
The current revolution began in the late 1980s and early 1990s when managed care began to rapidly replace fee-for-service medicine. The former forced groups of physicians, hospitals, and insurance companies to compete against each other for covered lives and the revenue that accompanied them. Managed care contracts were often awarded to the health maintenance organization (HMO) with the lowest bid, forcing prices down. The number of physicians (especially subspecialists), hospital beds, and other medical resources had grown rapidly since the last major shift, producing a relative excess compared with what was needed in managed care. These surpluses gave insurance companies an opportunity for profits because it allowed them to force down payments while keeping a larger proportion of the health'Care dollars for themselves, their corporate managers, and stockholders.
Now, let's step back and look for patterns that might be useful in predicting the future. The most important question is: what caused each of these shifts, especially the one we are in? The common denominator is that each revolution responded to the changing needs of the US population. In 1800, the country needed more physicians. The four medical schools then were raining quality graduates but in small numbers. Meanwhile, the United States had just obtained its independence, immigration was growing, and we were spreading westward. This created a demand for more physicians that encouraged students to pay the fees to become physicians and made proprietary medical schools profitable. Besides, so little was known about medical science then that the main role of a (good) physician was to help see families through illnesses.
One hundred years later, the needs of the American people had changed. Much more of medical practice could be based on knowledge, and scientific investigations were adding to this database rapidly. But medicine in the United State had fallen way behind Europe. The country needed fewer and better doctors and to add medical research. Reforms at a few university medical centers and Abraham Flexner's report made this happen. By the 1960s, our physicians and science were high quality but the American people wanted to expand medical care to the poor and aged. There weren't enough physicians to do this, so enter Medicaid, Medicare, and other federal funds to expand numbers of hospitals and physicians.
The most important shift to understand is the current one. By 1990, we had plenty of physicians, even for an open (protected) system where patients were free to seek whatever medical care they needed, and physicians were free to submit bills to Medicare, Medicaid, and commercial insurance. But the American people were most concerned about our country's economic problems, especially the rapidly growing federal deficit. While total federal income essentially had remained between 17% and 19% of the gross domestic product each year since World War II, total government spending rose from 17.6% of the gross domestic product in the 1950s to 19. 1 % in the 1960s, 20.6 % in the 1970s, and 23.1% between 1980 and 1991. The difference between income and spending was made up by borrowing to pay the deficit. The annual federal deficit went from .6% of the gross domestic product between 1950 and 1969, to 2. 1% during the 1970s, 4-2% in the 1980s, and 4-9% in 1992.5 At the same time, our manufacturers were worried about their ability to compete in worldwide markets. Productivity of Japanese manufacturers had exceeded ours during the 1980s, and inexpensive products were being manufactured in developing countries. The American people made it clear that deficit reduction was a priority by giving Ross Perot almost 20% of the popular vote in the 1992 presidential election. A large part of the 1994 Republican sweep into Congress was also about deficit reduction.
Thus, the government was faced with a mandate to reduce federal deficits from a public unenthusiastic about tax increases. This left cutting costs, which was not an easy task. The debt service was not amenable to cuts, nor was Social Security. And cutting discretionary programs was difficult because they (as distinguished from entitlements) had already been lowered from about 15% of the gross domestic product in the late 1960s to less than 11% by 1990.5 On the other hand, federal spending for medicine was growing rapidly. Medicaid and Medicare had gone from nothing in 1965 to between 2% and 3% of the gross domestic product in 1990 and were projected at more than 5% by the year 2000.6 in the early 1990s, the federal deficit was projected to rise substantially during the late 1990s, driven principally by the increased cost of health programs.5 We also knew that when the baby boomers began to reach Medicare eligibility around 2010, deficits would only get worse.5 And manufacturers were worried about the rising cost of medicine because it made their products more expensive and less competitive in world markets. The medical insurance that each company paid for employees had to be added to the price of its products. Medical costs had gone from 5% of the gross national product in the 1940s to 1 1% in the late 1980s, and 14.3 % in 1993. In that same year, Japan's medical care cost 7.3% of their gross domestic product.7 The rest of the developed world also was spending less for medicine: Canada was spending 9% and the United Kingdom 7% of gross domestic product in the late 1980s.6 American manufacturers thus joined the federal and state governments' quest for lower medical costs, and managed care is the tool they are using. Managed care has already produced some relief. Our costs have remained around 14% of the gross domestic product, and in fact, health benefit costs dropped for the first time in recent years in 1994 - by 1.1%.8
What other patterns are evident in these four major shifts? The most obvious is the alternating relationship between physician supply and quality as illustrated in the Table. Why question physician quality in 1990? We were well-trained and practicing quality medicine, were we not? Yes and no. Our practice was well-suited to the fee-for-service model, but we lacked training and skills for cost effectiveness, and the American people needed this in Addition to traditional medical knowledge. The question of whether physician greed reduced "quality" in terms of what the US population needed also could be asked. But quest for wealth has never been a priority among physicians who choose pediatrics.
Other patterns that have modem implications also are suggested by the four major shirts. One is the importance that public opinion has played in bringing about changes. Each of the four revolutions also was driven by economic forces that could not be resisted by physicians. Actually, universities had little to do with initiating any of the shifts but were dragged along with physicians. But once each change was evident, medicine adapted.
So let's look at what is likely to happen in our future. The patterns that were active in the preceding four shifts seem likely to be active again. Thus, the next shift also should be driven by public opinion and the needs of American people. Is public opinion changing about HMOs? As summarized by Thomas Bodenheimer, "All is not well in HMO land. An angry and determined backlash is spreading across the nation."9 In 1996 alone, 1000 pieces of legislation attempting to regulate or weaken HMOs were introduced in state legislatures, and 56 laws were passed in 35 states.9 The public interest in deficit reduction and concern about the economy also is abating. Rapid reengineering of industry helped the United States regain its rank as the most competitive economy in the world for 1994 and 1995 (The WaU Street Journal. September 6, 1995). The rate of rise of the national deficit is also considerably less than it was in the early 1990s, and deficit reduction is no longer the priority it was. The WaR Street Journal and NBC News recently surveyed 2000 citizens about what the top priority should be for Congress right now. The survey found: "...the economy, the budget deficit and jobs aren't the paramount concerns they were a year ago; or two years ago" (The WoU Street Journal. December 13, 1996). The highest priority was improving public education. Next was reducing crime. Then protecting (rather than reforming or reducing) Social Security, and next the same for Medicare. Reducing the federal deficit was seventh, reforming welfare was eighth, and reducing taxes ninth. Americans were more optimistic than at any other time in the past 4 years and were worrying more about the strength of the family and moral values. You can see many of these themes in President Clinton's successful 1996 campaign. In the meantime, the plight of the poor uninsured is getting worse,8 exacerbated by managed care. So public opinion is shifting, and perhaps the well-being of the underprivileged and children will become priorities again, as they were in the 1960s. Putting this together may give a glimpse of how the current era may give way to the next shift in medicine.
Physician Supply and Quality Since 1800
In the alternating sequence of physician quality and supply, the managed care revolution should overshoot the mark as have each of the preceding shifts, and the next shift should begin with a relative shortage of physicians. And quality should be high, perhaps defined as the ability to practice the best possible medicine at the least cost. If America's social conscience returns to provide better access to the uninsured, more physicians will be needed. If public opinion reduces the ability of HMOs to restrict medical care, demand for physicians also could increase. Further, the baby boomer generation has shaped much of our postWorld War II economy, and as this population ages, they will need, demand, and get more medical care.
When will this next shift occur? A glance at the Table suggests the interval between shifts is decreasing - about 100 years separated the first and second, 65 years passed before the third shift, and only 25 years between the third and current revolutions, Public opinion seems to be changing rapidly, and the baby boomers will be entering Medicare age in about 13 years. So, the next shift may not be so far away - perhaps 10 or 15 years. One wild card is the high rate at which our medical schools are continuing to produce doctors in this time of surplus.
The recent opportunity that some corporate insurance companies have had to take 30% to 50% of health-care dollars for overhead and profits should end soon. Public opinion against this is rising, but more important, market forces of competition should drive excessive profits down as the HMOs bid against each other for covered lives. Of course, any price fixing would slow the effects of competition.
You will note there is no speculation about whether the next shift will retain a softer and gentier form of managed care or whether the United States may shift to the single-payer system used by most other developed countries. Or will it be something else? It is hard to guess which would be better for us and for our patients at this point. Of course, all of the above is pure speculation. I'm not even sure it could be called pure because it is contaminated by hope.
1. Altermeir WA III. Those who cannot remember the pact are condemned ro repeat it. Pediatr Ann. 199625:4 14-4 19.
2. Lyons AS, Petrucelli RJ. Medicine: An Illustrated History. New York, NY: Henry N. Abrams Inc; 1978.
3. Freymann JG. TV American Health Care System: in Genesis and Trajectory. New York, NY: Medcom Pren; 1974.
4. Flexner A. Metical Education in the United States and Canada. New York, NY: Arno Press and the New York Times; 1972.
5. Ooms VD. Budget priorities of the nation. Saemz. 1992;258: 1742- 1747.
6. Fuche VR. The health sector's share of the grow national product. Science. 1990;247:534-538.
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8 T. IglehartJK. Heath policy report: republicans and the new politics of health care. N EnglJ Mei 1995:132:972-974.
9. Bodenheimr T. The HMO backlash - righteous or reactionary! N Enji J Med. 1996:335:1601-1604.
Physician Supply and Quality Since 1800