Scholars, Investigators, and Entrepreneurs: The Metamorphosis of American Medicine

WHEN I ENTERED MEDICAL SCHOOL in 1948, specialization and group practice were developing rapidly, but most physicians were still solo practitioners, often maintaining their office in their home. As proprietors of this cottage industry, physicians were usually financially comfortable, but not rich. They were respected, often revered members of their community, making useful contributions to the health and lives of their patients. For most patients, the relationship with their doctor was mutually trusting and gratifying.

Five decades later, the medical profession has undergone changes much more drastic than the social transformation that raised physicians' incomes from relative poverty in the 19th century to modest affluence in the first half of the 20th (Starr 1982). The changes of the past 50 years can be quickly summarized with the following three vignettes of conversation that might occur when someone met a doctor on a social occasion. In 1957, the statement might be, "So you're a doctor. Hey doc, what do you think about this rash on my arm?" In 1977, the speaker might say, "So you're a doctor. Where's your Porsche?" In 1997, the comment might be, "So you're a doctor. Let me tell you what some damned doctor and health care plan did to my sister."

Why has this change occurred? How did medicine evolve from a caring profession to a business? And how and why did doctors trade their professionalism for commerce? I shall try to answer those questions as an internist whose career allowed direct observation of the cited events.

First Half of the 20th Century

Before World War II, American medical schools were devoted mainly to educating future doctors. After the Flexner revolution early in the 20th century, the schools raised their standards of admission and became academically respectable, usually via affiliation with parent universities (Ludmerer 1985). The schools incorporated contemporary science into the curriculum and established a cadre of full-time clinical faculty, who were encouraged to do research, which consisted mainly of laboratory studies of mechanisms of disease.

Like medical practice, the work of medical research and education was also a relatively small enterprise. Among the faculty at medical schools, the pre-clinical departments (such as anatomy, bacteriology, physiology, and biochemistry) had one or two full-time members, sometimes with M.D. degrees, but usually with Ph.D.s in the pertinent subjects. Because the clinical departments also had few full-time faculty to engage in research, teaching, and patient care, most clinical education was done by the voluntary or part-time faculty. They were practitioners in the corresponding community, and their income came from the practice. Their unpaid educational contributions were motivated by a sense of payback obligation, by the stimulation of the teaching activities, and by the prestige of their faculty titles. Since salaries for full-time university faculty were at the same relatively low levels for professors of either literature or medicine, most full-time academic clinicians who desired moderately prosperous lives would need additional sources of income, obtained from either family or spousal wealth.

Patient care at the medical schools was taught mainly in large municipal hospitals, where the non-paying clientele, treated at in-patient wards and out-patient settings, were clinical material for the students, house staff, and teaching faculty. These non-paying patients also created the challenge, tradition, and ethos of caritas, a word that means both "charity" and "care." In exchange for the experience of learning from the charity patients, the physicians-in-training and their supervising teachers were obliged to provide excellent care. The patients incurred no costs and paid no fees. The municipal hospitals were free, being supported by public taxes and private contributions. The interns and residents who were called "house staff" received minuscule stipends, and the attending physicians charged nothing, being either salaried by the school or sustained, in the old "Robin Hood" practice pattern, by fees from private patients.

The obligation...