Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (review)

Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. By Kenneth M. Ludmerer. Oxford University Press, 1999. Pp. 516. $29.95.

"Producing good doctors is a responsibility shared between society and medical [school] faculties." From this starting point, author Kenneth Ludmerer carefully, critically, and fairly leads the reader through a century of American medical education. He stresses how medical education was influenced by society's volatile relationship with its doctors, medical school faculties, teaching hospitals, and--more recently--the academic health centers. In a beautifully written narrative, Ludmerer depicts how the changing intensity of acceptance of this covenant, both by medical school leaders and by society, was influenced by multiple forces: the intellectual revolution championed by Flexner as the century began, the advancement of quality research and its generous public funding, and the augmented role medical professors accepted for the direct and indirect provision of clinical care. For me, a senior faculty member, this history is an insightful "déjà vu all over again." ¹ For junior colleagues, it is perspective developing. For our students, it is a must-read: it nourishes professional identification and develops an understanding of the past leading to acquisition of the tools of leadership.

As Ludmerer guides us through an interpretative history of this century's American medical education, he prepares the reader well for the last two and most challenging chapters. They could have been entitled "You Are Here" and "Now Be a Leader." Nevertheless, the more formal appellations disguise neither his meaning, nor his spirit. He presents his argument in a scholarly, thoughtful, and sensitive manner.

The author's approach is illustrated by the open, well-documented, and free-flowing discussion of how, in the last two decades, academic health centers under stress have dealt with the process of student admissions. In an almost tongue-in-cheek fashion, Ludmerer documents, with annotated references, how some insightful faculty members recognized that "medicine's popularity during the Viet Nam war . . . related primarily to the changing attractiveness of other careers rather than to the perceptions college students held about medicine." He traces how the annual number of medical school applicants changed over time in a manner parallel to the perception of future financial remuneration. He speaks of admission committees' dilemma of which qualified applicants to accept, how much weight to place on GPAs and MCAT scores, and whether it was proper to attempt to select from "two contradictory images" of the new medical student: the socially committed versus those plagued by the "pre-medical syndrome." He laments the absence of quantitative data associated with the prevalence of these two prototypes, as he indicates that the "quality of medical education and practice . . . depended heavily on the characteristics of the individuals who chose medicine as a career" and those who were chosen for that career. Admission committees faced with this dilemma rarely were swayed by outside "influence." This statement is supported by a reference to a letter from a medical school dean responding to the urgent request for admission by an applicant's mother, in which the dean states: "I have not interfered in the cases of children of my own closest friends and relatives." To be fair, Ludmerer also cites newspaper articles and medical school archives to document less virtuous behavior. It is this intermingling of sources--scholarly literature, data bases, and personal letters--that lends intellectual and emotional credibility to the work.

The last chapters are concerned with medical education in the contemporary era of cost containment and managed care. Sensitized by the vivid history Ludmerer depicts, one sees the influences prevalent in today's health care scene as they sometimes strengthen, but more often weaken, each leg of the medical schools' traditional three-legged stool. Quite deliberately Ludmerer brings closure...