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Rise of Specialization: the intellectual basis?: The intellectual basis for specialization began at time of the Paris Clinical School when they developed the notion of anatomical pathology and disease located in an organ. Suddenly, knwoing about a particular organ, knowing particular mechanisms, was more important than knowing about the whole person.
Thought during the the late 19th century when treating disease?: When treating pneumonia in 1880s in Philadelphia, they were still trying to raise the system or lower the system depending ipon how they saw the entire illness. Holism was the way people tended to think about their patients.
Pre civil-war and specialization?: AMA and other organizations did not consider it respectable

in early 19th century, physician could not claim to be a specialist that was something for "quacks" and "elite urban consultants"
Two areas of specialities that first appeared and why were they the first?: Opthamology and orthopedics

Appeared because broken bones and and the eye are more economically important

If physicians were to make a mistake there, you cant hide it and it's really devastating to patients

thats why focus on these areas
Did these early opthomolagists and orthopedics call themselves specialist?: No, they claimes they were GP with who has a special interest in these areas

only quacks (those not associated with medicines) and elite urban physicians associated with term of specialist
Describe the development of specialties.: 1. Have increasing knowledge about organs or organ system (ex. specialty of the eye)

2. Patients sort themselves into groups in a natural way -- Pediatrics and adults

3. Development of technology -- skills/technique or apparatus
Compare and contrast the development of peds with geriatrics.: Pediatrics was controversial because it was argues that kids are minituare adults adn their problems were no different. What became important for development of peds (not until 20th century) was a political constituency driven by mothers and people concerned about mother/infant health before WWII.

Geriatrics does not appear. There were fewer old people and the political power in teh elderly becomes an issue only in 1960s and onwards with passage of medicare.

Politics was important in formation of pediatrics as well as geriatrics.
Describe how technology can make a speciality come together.: Apparatus of germ theory (microscope) allowed a discipline to coalesce to become ultimately infectious disease.

Radiology -- this was originally totally removed from medicine. Person who invented it began a pattern for how specialities developed. They practiced it before a formal organization was formed.
Describe the inpatient hospitals for the eye.: Inpatient eye hospitals before the Civil War simply b/c surgical techniques are becoming sufficiently sophisticated that you have to do them in hospitals.
Name one inpatient hospitals and when it formed.: 1822 - New York Infirmary formed
Important dates in Opthamology.: De facto eye â€œspecialistsâ€ pre-1820
Inpatient Eye services 1820s-1830s
Am J Ophthalmology 1862
Am Ophthalmological Society 1864
Inclusion in Medical Curriculum at Penn 1879
1897 American X-Ray Journal
1900 Roentgen Society of America
1902
AMA-affiliated docs take over
name changes to American Roentgen Ray Society

DOCS WIN in early 20th centure.
When is the opthalmoscope and diagnostic technique invented?: mid-1850s
Does speciality development have antyhing to do with medical education?: No. Speciality development has nothing to do with medical education. These are two separate things and it generally only comes to medical education once its already fully formed.
3 constituencies are potential candidates in controlling radiology.: Physicist developed X-Rays in 1895

Pictures have to be developed by photographers

Physicians are needed because it takes medical judgement to be able to read and interpret these pictures
Many things were treated using x-rays, did anyone understand teh toxicity.: No one understood the toxicity and this is a great example of how something can be overused before understanding the toxicity.

Also an example of life in US before FDA - no regulatory bodies that can tell physicians how to practice medicine
When do specialities begin to pull themselves together?: latter part of the 19th century
Money and doctors. how did physicians reconcile the fact that we dont want our profession to be determined by economic considerations vs. the fact that we have to be a business person to make a living?: In early 20th century - American physicians did have professional, ethical identity but were also business pple.

To be successful they had to get patients, see patients efficiently, bill them efficiently, and keep patients while attracting new ones.
How was medicine much like law then than it is now?: There were more physicians
Easier to become a physician
Income depended upon who constituted ur practicep
Describe the professional ethics regarding economics of practice.: Prohibited Practices per AM A
Fee-splitting - im a surgeon and youâ€™re a gp; you refer me a patient and if I take out their gallbladder I pay you a percentage of my feeâ€¦

Physician-owned pharmacies and dispensing
Physician patenting/selling of medical products
Advertising
Charges: the sliding scale - based on the pt. ability to pay
Why was there a assertion by AMA: No Government Involvement in Health Care?: States didnt have a tradition of government involvement in social welfare.

States didnt have class based political parties that would make demands for free medical care.
Claims of priviledge that society grants doctors in early 20th century?: 1. We control entry into the profession b/c we regulate the # of med schools

2. We control certification

3. WE claim that we wont work for anyone else; we charge the pt. and no one should interfere with that.
Describe the avg physician.: middle class
Describe the specialist and economics.: Specialists making more than the GP. Market is such that specialization will win out against generalism from early 20th century onward. Physicians are able to elevate position by reducing their numbers.

by late 1920s, 25% physicians are now self-identifying themselbes as specialist.
Flexner report caused....: Have the Johns Hopkins models and number of medical schools shrinks and they all become more like Johns Hopkins

Medical education is regulated very closely by AMA council and medical schools become very uniform
Series of techonological developments made graduate education explode in particular surgery in 1890s: 1890s, mortality rate for abdominal surgeries is 40%

by 1900, that has gone down to 5% as a result of antisepsis

Also, both surgery and x-rays have to be done in hospitals; this results in explosion in number of hospitals and also a movement of medicine taking place from home to hospital. The hospital is no longer a last resort for poor people who cant take care of themselves, but also a place for the middleclass.
The increasing number of patients in hospitals and increasing number of tests cause.....: 1. Help in hospitals
2. supply of medical students who just graduated and now need experience which previously had not been necessary

3. Meeting of supply and demand occuring in the internship and becomes a universal experience in 1925
Licensing...: Present since 1880s... During WW2, Surgeon General decides that only graduates who have done an internship will be allowed into military

The state licensing board followed suit and gave licenses only to people who had cared for patients

In concert with state medical boards, not how National Board of Medical Examiners is formed and have 3 Steps

1932 - most states require to get a license to practice medicine - graduate med school, internship, and take 3 steps and pass
Specialist licensing: Specialists because major force in 1910s and 1920s

1913 - surgery speciality exam given
1915 - internal medicine speciality exam given
by early 1930 - other speciality exams are given

Many speciality boards decide that this will allow only people to take exam after they have additional training after internship
Compare present residency program to Osler: Osler's preparation for academic medicine became a preparation for speciality practice
In mid-20th century, are people comfortable with rise of specialization?: people uncomfortable with specialization.. 50% of profession in 1950
Physician vs. Empiric: 1. Problem with our current system: In theory, we are not empirics. Basic sciences provide a framework for our practice and gives us an understanding of what we are doing when we enter the clinic. The reality is that basic sciences are so far from medical practice that it doesnâ€™t really work that way now. You almost have to read the science and the medicine texts to make the connection between sciences and clinical medicine
Explain the phrase naturalist to a disease: Knows disease concretely through:
long and varied clinical experience gained in the hospital as well as outside of it
The autopsy lab
Prizes accurate diagnosis and prognosis

. To be able to diagnose someone accurately and to predict when someone would be sick are the skills that make you a good physician as opposed to a good surgeon.

If the physician knows pathology and science really well and has experience doing autopsies, that physician can become like the good botanist who can look at the plant and know what it is from his knowledge and experience.
Innere Medizin: 1880s - physicians in Germany began to take the laboratory developments and bring that to patients in the clinic and in the hospital.

They began to talk about the notion of â€œInnere Medizinâ€ --emphasized the chemical and physiological aspects of a disease, as opposed to the pathological aspects.
i. The notion of Innere Medizin emphasized the distinction between physicians and surgeons or physicians concerned with surfaces such as dermatologists.
1. It also emphasized the contributions of laboratory experiments to medical knowledge.
ii. Internationally, that became the â€œgermâ€ of internal medicine. The early American internists, however, had all been trained in that earlier French-tradition of pathology only and not the laboratory teachings.
iii. The result was a melding together of laboratory contributions, pathology contributions, and clinical contributions.
iv. These all came together to compose the ideal of an Internist
William Osler: 1849-1919
early American Internist
Educated in England (physiology lab) and in Germany
McGill in Montreal (Prof of Physiology) --- published papers on platelets
UPenn - continued autopsies
Hopkins - first prof of medicine
Conducted almost a 1000 autopsies and became the botanist of human disease

Internist would help the GP when the GP didnt know the answer
Internal Medicine from 1920-WW2: Research is of a reductionist manner - productive research by treating the body by smaller and smaller pieces of the whole

Researchers begin to take charge of medicine
Oslerian Internist characteristics: Abstract knowledge
Wide, deep clinical experience/knowledge
Expert differential diagnosis
Humanistic, holistic, compassionate
Specialist (in spite of general focus)
England vs. US GPs: England GPs have to refer a patient to a specialist. In the US, there is no distinction. GPs allowed to admit to hospitals. Inernists deal with complicated patients of GPs
Generalist: Certify or Not? List the Pros and Cons: Pros: Could design a residency and have training similar to specialists

Cons: Will lead to a definition of what GP is and this might limit what they can do
Sequence of events for GPs deciding on whether to certify: 1. Early 1960s, GPs oppose board certification because think it may limit scope of practice

2. 1965 - GPs realize they were not going to be able to perserve as much they wanted to so they formed FP

3. Up until 1970s, started your special residency after intern year.

4. In 1975, you have to decide from get go if you want to do GP or FP
Difference between GP and FP: Both did primary care. FP conciously retreated from notion that a physician can do everything. FP REPLACED SOME PROCEDURES WITH CONCERN FOR PSYCHIOLOGICAL CARE AND CONCERN OF THE PT. AS A PERSON
What does primary care become fragmented into?: Peds, OB/GYN, and Internal Med

Overlap with FP is caused by the lack of involvement of the government and the natural evolvement of these specialties
From 1920-1930, what happens to cost of medical care?: It doubles due to surgical and technological innovations
Name two obstacles for insurance.: 1. Adverse selction - people who need insurance are those who are sick so how can you maintain business when always paying out to sick

2. If doctors and pts. are controlling expenses, there is potential for moral hazards -if have insurance may use Drs more often and Drs. will want patients to visit more often to make more money
Name the two types of insurance benefits.: Indemnity - Payment of a preset monetary amount in settlement of a claim (no matter how large the claim)

Service benefits - Payment for given medical services in response to a claim (whatever they may cost)
First Hospital Insurance Plan: Baylor University 1929
Unpaid bills from schoolteachers
VP Justin Ford Kimball
Former superintendent Dallas Schools
Designed a prepayment plan for schoolteachers
50 cents/month  21 days/yr hospitalization semiprivate room at Baylor
Progenitor of Blue Cross
AHA Principles Governing Acceptable Insurance Plans (1933): Non-profit
promotion and advertising limited
coverage to be hospital charges only
â€œfree choice of physician and hospitalâ€
AMA Principles for Acceptable Private Insurance Plans (1934): No restrictions on treatment
â€œfree choice of physicianâ€
indemnity plans acceptable, service benefits not so
What do physicians want indemnity vs. service plans?: They want indemnity plans so the dr-pt relationship stays the same. With service plan, the premium is paid to the hospital which then pays the physician. Physician doesnt want 3rd party
What is the Post WWII Boosts to Health Insurance?: 1942: employers offer insurance as benefits.. employers receive tax benefits

1947: unions allowed to include health insurance benefits as subject to collective bargaining
Describe the Medical Profession by 1950.: Increase in number of physicians and increased income.

Insurance is good for doctors especially those at the lower end. The median is more representative than the mean since mean can be distorted by the "high-rollers." As the median appraoches the mean, the lower end physicians are making more money.
Describe the trend of insurance from 1940-1960s. Use percentages: 1940 - 40% of pple have health insurance

1950 - half have health insurance

1960s - 70% insured and 30% uninsured

Those not insured are the poor, small business owners, and dont forget the ELDERLY
What were the 3 revolutions in medicine and how did they impact care?: 1. Surgery - 1940s
2. Antibiotics - 1950s

With these, pt had surgery and given antibiotics. They were usually cured or died

3. Technology - this causes people to not be cured but able to live longer with the illness

Hemodialysis - 1960s
Renal transplantation - mid 1960s
Positive pressure ventilation
Cardiac catheritization - late 60s, early 70s
Describe Medicare Part A and Part B: Part A:
hospital care
payroll taxes during working years (2.9% of wages)

Part B: doctor visits
general revenues and subsidized insurance premium
Describe Medicaid.: care for the poor
grants to states, which put up their own funds, design their own program
Doctors arent happy so what happens?: Government sets it up so a commercial insurance company will administer medicare... the nominate BCBS that way dont have to work with government
Describe the effects of medicare.: Protected the wallets of the elderly
Reinforced prevailing patterns of private hospitals and insurance
Health insurance tied to work
Reinforced a bias to high tech and acute care
Describe Medicare reimbursements.: Hospitals: Costs + 2%

Physicians
â€œfree choice of providerâ€
â€œusual, customary and reasonableâ€ charges (UCR)
At what % did Medicare set its value that it would pay?: 90% of the cost. Doctors began charging outrageous prices so as to receive the 90% reimbursement. If dr. charged less then they would only get what they charged.
Did the cost of medical care accelerate faster than normal inflation in the early 1980s?: Yes. Medical Care Price Inflation surpassed normal CPI
Describe the scale at which medical care expenditures increased.: Logarithmic scale
What was the 3rd revolution of medical care?: The high-tech revolution
What was the effect of the 3rd revolution of medical care?: The technology in medicine was able to perserve people in a compromised state of health, rather than curing them
When was the Tuskegee Study?: 1970s
What kinds of sentiment did the Tuskegee Study bring about in the public regarding medicine?: Makes people wonder if their faith in doctors is misplaced.
What develops as a result of the public disenchantment of the medical authorities that occurs throughout the 1960s and 1970s?: The patient bill of rights
What did the patient bill of rights state?: Patients have the right to informed consent, considerate and respectful care, and the refuse treatment.
What were the threen areas where people believed needed to be taken back from doctors?: Women's Healthcare
Hospice Movement
Mental Illness
Describe the women's healthcare "movement".: Women of 1960s and 1970s decided the GYNs controlled too many aspects of their lives and these DRs. were predominately males.

This resulted in a movement to teach GYN self-care, increase, midwifery, and childbirth and other health care concerns were placed back in the women's hands.
Describe the hospice movement.: Began in England and began to gain momentum in 1960s. People argues that the dying should be able to spend their last days at home in peace with family and not with technological interventions
What is Foucault's view of mental illness?: French historian.

Insitutional power not a neutral way of deailing with disturbances that are out there.

Mental illness is just a way of stigmatizing people who just happen to be different from us. Denies that there is a significant biological reality to mental illness.
Who describes mentally ill individuals as "people behaving differently in a way we find inconvenient": Foucault
Who is Szasz?: American writer who wrote "The Myth of Mental Illness"
What did Szasz argue for?: Sets of movement for the deinstitutionalization of the mentally ill. His ideas enter pop culture (ie. movies that display these individuals ase loveable)
Who is Ivan Illich and what did he write?: He is a former priest who bacame a critic of medical profession and wrote "Medical Nemesis: Exploration of Health"

Idea is that the medical profession itself is the obstacle to overcoming illness. Public would be better off it can rid itself of the medical profession.
What is the main idea for managed care?: An insurance entity paying for medical care can contract with subsets of providers who offer services at a lower cost
What is HMO?: Physicians were paid by capitation. If patient does not see doctor often to use up money, the doctor has made profit. Leads to doctors wanting to keep pts. healthy
What is PPO?: Group practices that offer lower fees to an insurance company to get their business
What is IPAs?: individual doctors band together and contract to offer services to an insurance entity at lower prices
T/F: Managed health care is the opposite of the idea of free choice: True
In the late 1970s (the recession) what happpens that makes offering health insurancec less profitable from the employer's perspective?: Reagan enacts many tax cuts

Recession: B/w Carter and Reagan
Goldfarb vs. Virginia State Bar?: 1975
Shopping for a house and wants to hire lawyer to do title search -- realizes all are charging same

Brings a suit against the state bar for price fixing for services. Argues that this should not be allowed for it prevents competitive economy. Goldfarb wins after going to Supreme Court
FTC vs AMA?: 1982
Carter's admin brings a suit for price fixing in medical profession -> Reaches Supreme Court -> AMA is defeated
Who was the head of the FTC at the time of the FTC vs. AMA trial?: Barry Castillo -- stated just trying to make medical service same as any other business
Between what years did the HMOs and managed care assume a huge proportion in the total insurance market?: 1970s and 1990s
In what year does the total number of people with insurance actually fall?: 1980s
When do HMOs become a success?: early 1990s
What are DRGs?: Diagnose Related Groups

This system reimbursed the physician based on diagnosis rather than the amount of time that the actual amount of services rendered the patient
What does it mean to be an intergrated delivery system?: be the insurer, provider, and have the patient base all in one organization

this was the thought to succeed
When is there an equilibrium b/w specialists and generalists?: at the middle of the century
When does research at medical centers greatly increase and what is the result?: 1960s-1970s
Research becomes organized by subspecialty and subspecialty physicians get the grants and they become more powerful in medical school
Describe the reorganization of hospitals in the 1970s and 1980s.: Hospitals go from being all general wards to being organized by subspecialty. The gen. med wards are the place for those patients whom no one else wants
T/F:DRs. now have to go to the insurance company or HMO for approval before they can do diagnostics, referalls, and other things: True
Cost escalations started to go up by what percentage every year in the early 2000s.: 10%
What is the Golden Age of American Medicine: mid-20th century

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