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

Kenneth M. Ludmerer. Time To Heal: American Medical Education from the Turn of the Century to the Managed Care Era. New York: Oxford University Press, 1999. xxvi + 494 pp. Ill. $29.95. Uncorrected proofs.

This book completes Kenneth Ludmerer's history of American medical education since the late nineteenth century, which began with Learning to Heal (1985). Time to Heal covers the period after World War I, but emphasizes developments since the 1960s. Because of the great amount of detail in the book, this review will describe several of its themes concerning the primary functions of academic health centers--research, patient care, and teaching.

When research became a major medical school activity in the 1920s and 1930s, basic science and clinical research were of direct clinical significance. The faculty taught medical students their own and others' research findings, and residents often participated in research. After mid-century, biomedical science research became molecular and much clinical research laboratory-based, so that research findings no longer had direct relevance to undergraduate medical education. Biomedical science courses were increasingly taught by clinical faculty, while the science faculty taught their own graduate students. As federal funding for research grew, the loyalty of research faculty shifted from their institutions to funding agencies. About 1980, competition for funding among the growing number of researchers forced them to turn to private corporations. Commercial research led to patents and other efforts by individual faculty members and academic health centers to increase their incomes.

During the first half of the century, the primarily charity patients at teaching hospitals were treated by clinical faculty members. The patients, although atypical of community practice, enabled students to study very sick patients under the guidance of faculty members. Private health insurance and Medicare and Medicaid replaced the charity patients with paying patients, and clinical practice became the academic health center's "core business" (p. 226), providing almost one-half of total income in the 1990s. Private patients were less accessible to students and residents and took faculty time away from teaching and research. Third-party reimbursements led to a sometimes "staggering" (p. 338) increase in salaries for many clinical faculty members and subsidized teaching, research, and the biomedical science departments. Personal wealth became a goal for many clinical faculty members.

In the 1980s the increasingly commercialized medical schools thrived by employing large numbers of clinical faculty solely to provide patient care, establishing referral networks with community hospitals, and obtaining extra government payments for their educational activities. However, managed care and health maintenance organizations sought to avoid hospitalization, especially in the more expensive teaching hospitals. Their growth led to faculty salary freezes and layoffs and to teaching hospital mergers and divestiture. Academic health centers thereupon developed an even more explicitly corporate culture in which they went "where the money was, doing whatever was asked of them along the way" and moved to the "periphery" of their universities (p. 336).

Developments in research and patient care affected the education of medical students. In the 1920s and 1930s, teaching was the primary mission of clinical faculty members, who accepted lower salaries and spent much of their time educating students in class and on the wards. The growth of research and patient care after mid-century deemphasized undergraduate medical education and led to a rigid, overcrowded curriculum with an excessive use of lectures. Clinical education suffered from "a dearth of faculty teachers and role models, which left students to fend for themselves in an unstructured, sometimes poorly supervized environment" (p. 308). Despite the changing nature of the health-care system, little emphasis was placed on teaching cost-effectiveness and ambulatory care.

Internships and residencies became popular in the 1910s and 1920s to provide practical experience and train specialists, although the service responsibilities often overwhelmed the education. In the 1960s residencies...