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For the benefit of anyone who has spent the last few weeks living under a rock, Sue Lowden, Harry Reed's GOP opponent in the upcoming senatorial election in Nevada, suggested people barter with their doctors for their healthcare.  A member of the news media, assuming she meant to say "bargain" rather than "barter", gave her the opportunity to clarify her statement, and got more than he bartered bargained for:

You know, before we all started having health care, in the olden days, our grandparents, they would bring a chicken to the doctor. They would say, 'I'll paint your house.' I mean, that's the old days of what people would do to get health care with your doctors.  Doctors are very sympathetic people. I'm not backing down from that system.

Step on across the fold with us and we'll take a look at the olden days when you really could pay a doctor with livestock, and observe a little lesson of the "you get what you pay for" variety.

SNL -- Theodoric of York, Medieval Barber (Hulu embed -- short commercial included)


Even before Henry Pritchett set out to find ways to spend Andrew Carnegie's guilt money, most competent doctors in America had already quit accepting poultry and farm produce in all but the most rural backwaters of the country.  As for the less-than-competent ones, it's hard to say what they might have done to put food on the table.

State and local governments in the 18th and 19th centuries had taken steps to improve the quality of medical practice and practitioners.  Medicine was one of the first fields in which the public rejected a libertarian approach allowing just anyone to hang out a shingle and call themselves a doctor.  By the end of the 19th century, varying requirements for doctors had been implemented pretty much everywhere in the United States.

Central to those requirements was education, usually in a recognized medical school.  There was a question, however, as to just how competent the medical schools themselves were.   Additionally, an array of "alternative" medical theories and practices abounded, with wide variations in the soundness (or complete lack) of scientific principles behind them.  No less than 32 schools of medicine in the U.S. taught medical disciplines based on  these practices, including homeopathic,  eclectic,  physiomedical, and osteopathic medicine.

Medical schools at the turn to the twentieth century were almost exclusively private, for-profit affairs, and as such, often succumbed to the pitfall frequent to such operational models -- greed, and profit-seeking at the expense of quality.  Rare was the institution like the Johns Hopkins medical school, established and supported by the university in 1893.  In 1908, at the urging of the Council on Medical Education of the American Medical Association, Henry Pritchett, the first president of the Carnegie Foundation for the Advancement of Teaching, decided a good use of the old man's money would be to survey the medical education situation to see just how bad the problem was and, if warranted, make recommendations for improvements.


Abraham Flexner

To spearhead this project, Pritchett selected what must have seemed at the outset an odd choice -- a man with absolutely no medical background.

Born in Louisville, Kentucky, just after the end of the Civil War, Abraham Flexner, one of nine children of poor German-Jewish immigrants,  had graduated from Johns Hopkins at the age of 19 and returned to Louisville as a teacher.  After teaching for four years at his old high school, Flexner left in 1890 to open a college preparatory school in which to put his theories of education to the test.  

This endeavor allowed Flexner to practice a rigorous and progressive student-centered pedagogy without the customary rules, tests, and reports. "Mr. Flexner's School" earned the reputation for preparing wealthy and sometimes troublesome boys for college. Furthermore, Flexner's work caught the attention of college presidents in the Northeast, who noticed that Flexner's students outperformed graduates of eastern prep schools.
Abraham Flexner: Biography from the Education Encyclopedia (via Answers.com article)


After a few years, he closed his school and enrolled at Harvard to pursue an advanced degree.  Less than enamored with his professors at Harvard, however, he left the school after only a year and instead spent his time traveling in the US and Europe to observe teaching methods being employed.  As a result, he wrote his first book, The American College: A Criticism.  Published in 1908, the book received little attention -- but one of the few to take notice of it was Henry Pritchett.

Flexner accepted Pritchett's invitation and tackled the new assignment to study and report on medical schools in the United States and Canada with the same industriousness with which he had undertaken his previous project.

"For 16 months, from January 1909 through April 1910," according to an article by Howard Markel, MD in the Journal of the American Medical Association,  "Abraham Flexner crisscrossed North America via train, horse and buggy, and the occasional Ford flivver. Along the way he visited 98 cities and made 174 separate inspections of 155 medical schools. In April 1909 alone, he surveyed some 30 schools in 12 cities. "

Flexner's report, when it was published in 1910, was scathing.

First and last, the United States and Canada have in little more than a century produced four hundred and fifty-seven medical schools, many, of course, short-lived, and perhaps fifty still-born.  One hundred and fifty-five survive to-day. 5 Of these, Illinois, prolific mother of thirty-nine medical colleges, still harbors in the city of Chicago fourteen ; forty-two sprang from the fertile soil of Missouri, twelve of them still "going" concerns; the Empire State produced forty-three, with eleven survivors; 4 Indiana, twenty-seven, with two survivors; Pennsylvania, twenty, with eight survivors; Tennessee, eighteen, with nine survivors. The city of Cincinnati brought forth about twenty, the city of Louisville eleven. These enterprises -- for the most part they can be called schools or institutions only by courtesy -- were frequently set up regardless of opportunity or need: in small towns as readily as in large, and at times almost in the heart of the wilderness. No field, however limited, was ever effectually preempted. Wherever and whenever the roster of untitled practitioners rose above half a dozen, a medical school was likely at any moment to be precipitated.
Abraham Flexner, MEDICAL EDUCATION IN THE UNITED STATES AND CANADA: A REPORT TO THE CARNEGIE FOUNDATION FOR THE ADVANCEMENT OF TEACHING
(Emphasis mine)

Admission requirements were lax, some not even requiring a high school diploma, let alone a bachelors' degree from a four-year college.  The qualifications of many instructors and lecturers were found to be suspect.  The teaching methods in these colleges were often archaic.  

Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated
Still Magazine, "ATSU Builds New Medical School of the Future in Arizona" (pdf)


The amount of time a student might spend in the laboratory dissecting cadavers and engaging in other hands-on studies varied widely.  At many of the schools, laboratory facilities and furnishings were sparse, at best.  And rare was the medical school that could offer its students opportunities for hands-on practice of medicine under trained, practicing physicians in real-world environments.

Many schools of medicine made a cottage industry of sweeping up other schools' rejects, drop-outs, and wash-outs.  While there were schools like this across the country, nowhere, seemingly, were they more concentrated as in the city of Chicago.  Of the city's schools -- where, according to the report, written examinations were given up because "almost everyone failed" -- Flexner charged, "The city of Chicago is in respect to medical education the plague spot of the country," noting that although the laws on the books were adequate to the task of policing medical education,

With the indubitable connivance of the state board, these provisions [of school  and curriculum certification, admission and graduation requirements] are, and have long been, flagrantly violated. Of the fourteen undergraduate medical schools above described, the majority exist and prepare candidates for the Illinois state board examinations in unmistakable contravention of the law and the state board rules.
Abraham Flexner, MEDICAL EDUCATION IN THE UNITED STATES AND CANADA: A REPORT TO THE CARNEGIE FOUNDATION FOR THE ADVANCEMENT OF TEACHING

In Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, Flexner made several recommendations for the reform of medical educaiton.  He concluded that:

  • Medical schools could not reasonably be expected to both operate at a profit and provide an acceptable level of education.  Flexner urged that for-profit schools be closed and their function consolidated into the larger university-supported medical schools.  In speaking of a common practice of charging current students fees to accumulate for purposes of building a new laboratory in the future, Flexner says,

    Before the day of medical school support by endowment or taxation, such procedure compared very
    favorably indeed with the more common practice of doing nothing for the student of to-day and as little as possible for the student of tomorrow. The point now to aim at is the development of the requisite number of properly supported institutions and the speedy demise of all others.
    [...]
    Society ought to provide means for its support according to the best light obtainable

  • Schools of alternative ("sectarian") medicine were recommended to be closed down, although Flexner, after a lengthy discourse on "scientific" medicine versus medicine based on "pre-conceived notions", manages to avoid a direct confrontation on medical merits and reduces the question to one of simple economics and academic requirements:

    Sectarian institutions do not exist in Canada ; in the United States there are 32 of them, of which 15 are homeopathic, 8 eclectic, 1 physiomedical, and 8 osteopathic. Without attempting to indicate the peculiar tenets of each, we shall briefly review them as schools, seeking to ascertain how far they are in position effectively to teach, quite regardless of the individual doctrine each sect may desire to promote.  [They were largely judged to be financially incapable of sustaining themselves and delivering a quality education conforming to the instructional practices recommended in the report.]

    None of the fifteen homeopathic schools 1 requires more than a high school education for entrance ; only five 1 require so much. The remaining eleven get less...

  • Applicants to medical schools should have earned a high school diploma and completed at least two years of undergraduate work with an emphasis in the sciences.  At the time of Flexner's report, only 16 of the 155 medical schools in the United States and Canada required so much.
  • Medical school programs should consist of at least four years of full-time study, following a fairly specific curriculum which followed closely guidelines developed by the AMA's Council on Medical Education. Flexner examined the courses of study at the institutions judged to be most effective at training physicians, and using their curricula as a guide, elaborated a detailed recommended program.

The report held up four institutions as examples of what medical schools should strive to emulate.  Among them were Harvard, Wake Forest, Michigan, McGill in Toronto, and singled out for particular praise, the medical school attached to Flexner's own alma mater, Johns Hopkins (though it would be hard to challenge the point, given Johns Hopkin's stature in a field that wasn't offering terribly stiff competition at the time).


Flexner's report spurred the various responsible state bodies nation-wide -- there is no national entity that oversees medical education, certification, or licensing -- to implement far more strict oversight of the medical school establishment than had existed at the time the report was released.  The reform of medical education occurred with surprising swiftness.  For example, where only 16 of 155 schools had required two years or more of college for admission at the time the report was released, by 1920, a short ten years later, 92% did.  By that time, the number of students enrolled in medical colleges had fallen from 28,000 in 1904 to only 13,000.  By 1935, over half of all medical schools that existed at the time the report was released had closed.  Of the 66 that remained, 57 were connected to universities. [Wikipedia}

The transformation of American medicine that occurred in the wake of the Flexner Report is not without its detractors.  Questions regarding the impact on medical costs of restricting admission to the practice of medicine; the decrease in available positions in classes resulting in the exclusion of women, minorities, and the poor; whether the resulting climate unduly marginalized the more legitimate alternative medical disciplines in favor of surgical and pharmacological solutions; are certainly questions worthy of discussion.  

But on the whole, the revolutionary change in medical education that resulted has created a force of  reliably-trained and competent physicians whose treatment has served the public interest well.

Abraham Flexner lived to not only see American medical education reformed largely according to his recommendations, but also to witness the transformation of the practice of medicine in the United States that came about as a result.  He may even have reaped the benefits of that transformation.  He died in 1959, just two months before his ninety-third birthday.

And that, dear Kossacks, is where regulation comes from -- not from bored bureaucrats sitting in an office in Washington trying to think up ways to make life miserable and expensive for some innocent and unsuspecting businessman, but from real human suffering and tragedy brought about, all too often, by people who shirk what should be obvious responsibilities, who neglect basic diligence, who sacrifice safety for profit.  They bring suffering on those who trust them and their products, and society adopts measures to make sure it never happens again.  We have to force them, through regulation, to behave as they should have been behaving all along.  That's how regulation came to be.

Previous installments of How Regulation came to be:


1938 Food, Drug, and Cosmetic Act
The Iroquois Theater Fire
Radium Girls - Part I
Radium Girls - Part II
Radium Girls - Part III
Construction Summer
Red Moon Rising
The Cherry Mine Disaster, Part I
The Cherry Mine Disaster, Part II
Ground Fault, Interrupted
The Cocoanut Grove
DK GreenRoots: Donora
Confined Spaces
The Hotel Fires of 1946 - Part I
The Hotel Fires of 1946 - Part II
Our Lady of the Angels
The Great Molasses Flood
Toy Safety
The Power of One: Frances Oldham Kelsey
Santa Barbara
The Scofield Mine Explosion
The Triangle Shirtwaist Fire
The Cincinnati Who concert tragedy

Originally posted to dsteffen on Sun Apr 25, 2010 at 02:08 PM PDT.

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