Thursday. .January 29. 1981
'Vernonia Freedom — Page 5
Modern medicine reflects deep cultural traditions and needs
EDITOR’S NOTE: This is the fourth
in a series of fifteen articles exploring
“The Nation’s Health.” In this
article, Rosemary Stevens, professor
of the history and sociology of science
at the University of Pennsylvania,
shows how our medical care system
was shaped by American social forces
and values. This series, written for
COURSES BY NEWSPAPER, a
program of University Extension,
University of California, San Diego,
was funded by a grant from the
National Endowment for the
Humanities.
THE NATION’S HEALTH IV:
THE SHAPING OF OUR
MEDICAL SYSTEM
by Rosemary Stevens
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Medicine is more than a collection
of scientific techniques, experts, and
equipment. It is a cultural enterprise
with roots bedded deep in tradition.
The peculiar forms and nature of
American medicine, its values and
assumptions, rest in large part on two
major movements: the successful
transformation of American medical
education from the hodgepodge
profession
of
1900
into
a
homogenous,
science-based
profession; and the continuing
commitment of the profession to
competitive, fee-for-service, private
practice. Science and free enterprise
have jostled together.
practice. Specialists compete with
each other for patients, and patients
shop
around
for
specialists.
Physicians today are still typically in
private practice; only about 20
percent work in formal groups of
three or more.
This private enterprise tradition
extends to other medical institutions
as well. The majority of America’s
7,000 hospitals, most built in this
century, are private institutions,
reflecting
their
history
as
independent enterprises. In the last
10 years some hospitals have started
to share services, ranging from
laundry through pediatric and
Specialization was grafted onto a
medical organization characterized
by independent, solo, fee-for-service
obstetric services. But hospitals in
the main continue to compete with
each other for patients and for the
services of physicians, who act as
attending staff, admitting their
COLLEGE COURSES BY NEWSPAPER
physicians, are mainly in private
office practice. Other private medical
institutions include home health
agencies, clinical laboratories, kidney
dialysis centers, physical therapy
Part Four
Natioïrs AHealt h
patients to one hospital rather than
another.
Again, science and free enterprise
interconnect. Hospitals compete by
stressing technological excellence.
Hence, 60 percent have intensive care
units; 30 percent, specialized units for
cardiac care; 30 percent, X-ray
therapy.
Nursing homes, established in large
numbers following the Social
Security Act of 1935 and again with
the
Medicare
and
Medicaid
legislation of 1965, are predominantly
profit-making.
Dentists,
like
practices, and blood banks. And there
are a host of voluntary health
agencies.
THE HEALTH CARE INDUSTRY
The evolution of American medical
care as a combination of high
technology, private practitioners, and
independent
organizations
has
created a mosaic of health services. In
terms of costs and personnel,
medicine has become a major,
continued on page 12
In 1900, the average physician
could often do little to cure a patient
with
tuberculosis,
influenza,
pneumonia, diarrhea, or other
ailments that we now regard as minor
risks.
Medical
science
has
transformed our perceptions of birth
(hazardous for mother and child in
1900), of disease, of death.
The streamlining of the American
medical profession around one high,
scientific standard of medical
education began between 1900 and
1920 under the leadership of the
American Medical Association. A
detailed report by Abraham Flexner,
published in 1910, described the
appalling conditions of American
medical schools and dramatized the
profession’s efforts to improve.
Following the report, many schools
closed or merged. American medical
education became university-based,
drawing
on
college-educated
applicants for admission.
Standardization
of
specialist
education followed swiftly. The
American College of Surgeons was
founded in 1913 to provide a training
program and a mark of identification
for competent surgeons. A specialty
certifying board for ophthalmologists
followed in 1915, and most of the 22
present specialty boards, from
pediatrics
and
radiology
to
psychiatry and pathology, were
established in the 1920s and 1930s.
The specialty board both reflected
and shaped an increasing tendency of
physicians to specialize. In 1931, 17
percent of physicians were fulltime
specialists; in 1949, 36 percent.
Today, almost 90 percent are
specialists. The general practitioner
has virtually vanished. A specialty of
“family practice” was established in
1969, recognizing a paradoxical and
final “specialty.”
Copyright© 1980 by the Regents of the University of
California.
Geoffrey Moss—political illustrator syndicated with the Washington Post Writers Group