Is U.S. medical education based on an elitist, costly, and backwards tradition?

[mTOR]

Death by Degrees
19 JUNE 2012

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Our elaborate, expensive system of higher education is first and foremost a system of stratification, and only secondly — and very dimly — a system for imparting knowledge.

The original universities in the Western world organized themselves as guilds, either of students, as in Bologna, or of masters, as in Paris. From the first, their chief mission was to produce not learning but graduates, with teaching subordinated to the process of certification — much as artisans would impose long and wasteful periods of apprenticeship, under the guise of "training," to keep their numbers scarce and their services expensive. For the contemporary bachelor or master or doctor of this or that, as for the Ming-era scholar–bureaucrat or the medieval European guildsman, income and social position are acquired through affiliation with a cartel. Those who want to join have to pay to play, and many never recover from the entry fee.

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When we ask ourselves whether populist hostility should be directed against the rich or against the professional elite, the answer must be, "Yes, please!" From 1980 to 2007, the financial sector grew from 4 percent of GDP to 8 percent, but it's shrunk since and may shrink further. The medical sector, on the other hand, grew in the same period from 9 percent to 16 percent — and is expected to account for a full 29 percent of the economy by 2030. Goldman Sachs makes for an attractive monster, but the bigger vampire squid may be the American Medical Association, which has colluded in blocking universal coverage and driving up health costs since World War II.

If not earlier: the AMA owes its authority to America's most notorious robber barons, who invented philanthropy as we know it by establishing foundations capable of long-term, organized interventions in the country's political and cultural life. The first foundations poured money into medical schools — but only if those schools followed the example set by Johns Hopkins, which in 1893 had introduced what's now the standard formula: students attend four years of college, then four years of medical school. Institutions that didn't follow this model did not get donations, and they also got denounced in a 1910 report sponsored by the Carnegie Foundation. After the Carnegie survey published its "findings," scores of medical schools — schools whose students could not afford the additional years of study now required, and nearly all of the schools that admitted blacks and women — closed.

Today, we take it for granted that practicing medicine or law requires years of costly credentialing in unrelated fields. In the law, the impact of all this "training" is clear: it supports a legal system that is overly complicated and outrageously expensive, both for high-flying corporate clients who routinely overpay and for small-time criminal defendants who, in the overwhelming majority of cases, can't afford to secure representation at all (and must surrender their fate to local prosecutors, who often send them to prison). But just as a million-dollar medical training isn't necessary to perform an abortion, routine legal matters could easily, and cheaply, be handled by noninitiates.

The standardization of these professional guilds benefited undergraduate institutions immensely, a fact that was not lost on university administrators. College presidents endorsed the Hopkins model and the AMA's consolidation of medical authority for good reason: in the mid-19th century, bachelor's degrees in the United States were viewed with skepticism by the private sector, and colleges had a hard time finding enough students. The corporate-sponsored consolidation of the medical establishment changed undergraduate education from a choice to a necessity. Where once there was indifference, now there was demand: "I want to be a doctor when I grow up," the child in the PSA says. "I want to go to college."

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Intredasting points raised... Thoughts?

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[Bancrofti]

Not surprising. If anyone could recommend a good read on medical school in the US history I'd appreciate it because think it would be nice to know everything. I had known already that for the first few decades in the 20th century doors were closed to many blacks, women, and Jewish people as well. The opinion isn't founded on much so hopefully nobody gets their jimmies in a bunch... but I'd say the elitist attitude has trickled down and is still present, despite attempts by many foster equality and set standards for what is in the best interest of students.

Can't fault people though, that's pretty much how everything works. Get on board with where the money is or get left behind.

 

[ensuii]

Costs related to Step 2 CS/PE certainly don't help any counterarguments...

 

[projectlogic]

Isn't medical education in the U.S. based on the Flexner report (which is more than 100 years old!)?

 

[Shnurek]

Its OK more early specialization schools will produce medically trained graduates at a lower cost but same competence in their focal field of study. The general medical educational pathway is unsustainable for the future. Why? Because of the explosion of the complexity of modern day medicine. No one human mind can retain all of the now known information in medicine. We see the beginning signs of this decline with PAs and NPs taking over the primary general medical care market and specialists like dentists making more than GPs per hour even though they had to go through 2-3 less years of training.

Sorry guys. Had to do my shpiel again.

 

[nysw]

Isn't medical education in the U.S. based on the Flexner report (which is more than 100 years old!)?

Yeah, the Flexner report was supported by the Carnegie Foundation.
This article makes it sound like standardization was a horrible thing for medical education, and absolutely nothing good came of it. I think only 2 out of the 9 African American colleges survived, but it closed scores of medical colleges that weren't making the cut.

 

[nysw]

Not surprising. If anyone could recommend a good read on medical school in the US history I'd appreciate it because think it would be nice to know everything. I had known already that for the first few decades in the 20th century doors were closed to many blacks, women, and Jewish people as well. The opinion isn't founded on much so hopefully nobody gets their jimmies in a bunch... but I'd say the elitist attitude has trickled down and is still present, despite attempts by many foster equality and set standards for what is in the best interest of students.

Can't fault people though, that's pretty much how everything works. Get on board with where the money is or get left behind.

I've read excerpts of this for a class: "American Medical Schools and the Practice of Medicine: A History"by Rothstein.

It's not an opinion, it's a fact - the doors were closed for many at several points in their careers - entrance into medical school, applying to residencies, landing their first job..

If you're interested in primary sources, I'd check out "Major Problems in the History of American Medicine and Public Health" by Tighe and Warner. It covers more than education though, but still a very interesting read nonetheless.

 

[Danbo1957]

Humans are healthier now than ever. Why? Medicine is different than other trades. We use our educated judgement on when and how to use knives and chemicals to prevent death and offer health. It's a steep learning curve... shamanism is the other option.

 

[gactv]

http://mises.org/daily/4276

100 Years of US Medical Fascism
Mises Daily: Friday, April 16, 2010 by Dale Steinreich

One hundred years ago today, on April 16, 1910, Henry Pritchett, president of the Carnegie Foundation, put the finishing touches on the Flexner Report.[1] No other document would have such a profound effect on American medicine, starting it on its path to destruction up to and beyond the recently passed (and laughably titled) Patient Protection and Affordable Care Act of 2010 (PPACA), a.k.a., "Obamacare." Flexner can only be accurately understood in the context of what led up to it.
Free-market medicine did not begin in the United States in 1776 with the Revolution. From 1830 to about 1850, licensing laws and regulations imposed during the colonial period and early America were generally repealed or ignored. This was brought about by the increasing acceptance of eclecticism (1813) and homeopathy (1825), against the mainstream medicine (allopathy) of the day that included bloodletting and high-dose injections of metal and metalloid compounds containing mercury or antimony.[2]
.........

The AMA formed its Council on Medical Education in 1904 as a tool to artificially restrict education.[11] However, the AMA's conflict of interest was too obvious. This is where Abraham Flexner and the Carnegie Foundation entered the picture. Flexner's older brother Simon was the director of the Rockefeller Institute for Medical Research and he recommended his brother Abraham for the Carnegie job. Abraham's acceptance of the role was the perfect special-interest symbiosis. Carnegie's desire was to advance secularism through higher education, thus it saw the AMA's agenda as favorable toward that end. Rockefeller's benefactors were allied with allopathic drug companies and hated for-profit schools that couldn't be controlled by the big-business, state-influenced foundations. Last of all, the AMA got an objective-appearing front in Carnegie.[12]
Not only was Abraham Flexner not even an allopathic physician; he was not a widely known authority on education,[13] never mind medical education, as he had never even seen the inside of a medical school before joining Carnegie. His report was already effectively written, since it was essentially the AMA's unpublished 1906 report on US medical schools. Furthermore, Flexner was accompanied on his inspection by the AMA's N.P. Colwell to insure the inspection would arrive at the preordained conclusions. Flexner then spent time at the AMA's Chicago headquarters preparing what portion of the final product was his actual work.[14] .........

 

[JackShephard MD]

I think medicine definitely has lots of self-serving individuals (not exclusive to medicine). In general, doctors want to maximize their profits, insurance companies want to make money, hospitals want to turn a profit, drug companies, our schools want nice buildings + cush jobs, etc.

Nepotism is rampant and the organizations out there like the AMA are self-serving.

It's a pretty broken system and that's why it's beginning to crash down. It's too bad because we provide such an important service to the community and everyone's trying to get rich off it. The system can't support all these people wanting to take the largest piece of the pie possible.

This is our system:
[YOUTUBE]Muz1OcEzJOs[/YOUTUBE]

Medicine definitely tries to keep people out and keep the demand high. $$$. Heck, we don't have competitive specialties anymore, we have specialties that have protected turf, high reimbursements, and easy lifestyle. What medical students are interested are are the same things that the people who created all these restrictions. $, exclusivity, and the good life.

 

[ucladoc2b]

Medicine is essentially a system of guilds (and not a unified guild). Your "true" guid is your board specialty (which you need to bill Medicare, and consequently, private insurance) for your work (and any particular procedures done). Hence, it is not uncommon for any high pay, new procedure, once the a particular group lobbies to Medicare to cover it, to require a fellowship (which are essentially barriers to entry). This is why you'll see IR and interventional cards fight with eachother over coronary stenting, for example.

This is also why the AMA is not an effective lobbying organization anymore. At one point, before the rise of Medicare and several subspecialties, it was way more powerful. Now, there is too much infighting and too many turf wars for it to be as strong as it was.

If bundled payments for physician services ever becomes a reality, this might change. We'll have to wait and see.

There are good and bad things to the system.

 

[oldbearprofessor]

Your "true" guild is your board specialty (which you need to bill Medicare, and consequently, private insurance) for your work (and any particular procedures done).

Really? Neonatologists can't bill until they pass their boards? Since boards are only administered every two years, that would be a lot of unpaid neonatologists out there. Perhaps it is not that simple?

Edit: and as far as bundled payments, are you referring to the long-standing critical care "codes" that bundle all of our care in the NICU?

 

[link2swim06]

I think medicine definitely has lots of self-serving individuals (not exclusive to medicine). In general, doctors want to maximize their profits, insurance companies want to make money, hospitals want to turn a profit, drug companies, our schools want nice buildings + cush jobs, etc.

Nepotism is rampant and the organizations out there like the AMA are self-serving.

It's a pretty broken system and that's why it's beginning to crash down. It's too bad because we provide such an important service to the community and everyone's trying to get rich off it. The system can't support all these people wanting to take the largest piece of the pie possible.

This is our system:
[YOUTUBE]Muz1OcEzJOs[/YOUTUBE]

Medicine definitely tries to keep people out and keep the demand high. $$$. Heck, we don't have competitive specialties anymore, we have specialties that have protected turf, high reimbursements, and easy lifestyle. What medical students are interested are are the same things that the people who created all these restrictions. $, exclusivity, and the good life.

But at the end of the day money is pretty much the strongest motivator out there. Its not a coincidence high paying professional jobs attract the smartest out there.

By guaranteeing a large financial rewards our society attracts an unlimited supply of very smart and talented people.

Take away this guarantee and the generation of future doctors is going to be of much lower quality.

 

[oldbearprofessor]

we have specialties that have protected turf, high reimbursements, and easy lifestyle.

When on the clinical service, neonatologists routinely spend 60-80 hours/week in the hospital caring for very sick patients. Protected turf? Not really. High reimbursements? I'd say "appropriate", Easy lifestyle? Hmmm, not so sure it's that easy.

 

[oldbearprofessor]

It's not an opinion, it's a fact - the doors were closed for many at several points in their careers - entrance into medical school, applying to residencies, landing their first job..

True story - My grandmother was very concerned that I apply to med school (1970's) "early" to make the 4% quota. I laughed and didn't believe her that any such quota had EVER existed. I was wrong. I went and did some historical reading. It is well-documented. Mostly ended after WW2 when it became hard to figure out so readily who was Jewish but continued into the early 50's in a few places.

 

[JackShephard MD]

When on the clinical service, neonatologists routinely spend 60-80 hours/week in the hospital caring for very sick patients. Protected turf? Not really. High reimbursements? I'd say "appropriate", Easy lifestyle? Hmmm, not so sure it's that easy.

Oh, I agree with you.

My quote:

we don't have competitive specialties anymore, we have specialties that have protected turf, high reimbursements, and easy lifestyle.

Was to point out what is considered a competitive specialty today usually fits these requirements, pediatric neonatology isn't super competitive (someone posted a question a week or two ago about it and I happened to look it up).

But at the end of the day money is pretty much the strongest motivator out there. Its not a coincidence high paying professional jobs attract the smartest out there.

By guaranteeing a large financial rewards our society attracts an unlimited supply of very smart and talented people.

Take away this guarantee and the generation of future doctors is going to be of much lower quality.

Possibly.

I don't know if we can conclude that the smartest people in our classes become the best doctors. We would have to define what makes a doctor good, then determine if that correlation follows through: Class rank #1 - best doctor in class, Class rank #20 - pretty good doctor - Class rank #110 - below average doctor... not sure if we'd see that.

 

[KinasePro]

what is considered a competitive specialty today usually fits these requirements

This is definitely true, and is one of the reasons I feel conflicted about the competitive specialties. On one hand, i feel like these specialties are really just more business savvy and organize better than the rest, but OTOH it is easy chastise them for the reasons you described.

 

[link2swim06]

Oh, I agree with you.

My quote:



Was to point out what is considered a competitive specialty today usually fits these requirements, pediatric neonatology isn't super competitive (someone posted a question a week or two ago about it and I happened to look it up).



Possibly.

I don't know if we can conclude that the smartest people in our classes become the best doctors. We would have to define what makes a doctor good, then determine if that correlation follows through: Class rank #1 - best doctor in class, Class rank #20 - pretty good doctor - Class rank #110 - below average doctor... not sure if we'd see that.

But isnt that the entire premise of choosing applicants for med school and residency based on GPA, MCAT, and board score?

 

[JackShephard MD]

But isnt that the entire premise of choosing applicants for med school and residency based on GPA, MCAT, and board score?

Yes.

 

[alamo4]

True story - My grandmother was very concerned that I apply to med school (1970's) "early" to make the 4% quota. I laughed and didn't believe her that any such quota had EVER existed. I was wrong. I went and did some historical reading. It is well-documented. Mostly ended after WW2 when it became hard to figure out so readily who was Jewish but continued into the early 50's in a few places.

Great Malcolm Gadwell piece on the history on exclusivity in US education:

http://www.newyorker.com/archive/2005/10/10/051010crat_atlarge

I'm not really a Gladwell fan, but as people caught up in the world of standardized tests, the ideals of being "well rounded", college rankings, etc, it's a great read. Anti-semitism played a big role in shaping our educational selection process.

 

[Narmerguy]

Great Malcolm Gadwell piece on the history on exclusivity in US education:

http://www.newyorker.com/archive/2005/10/10/051010crat_atlarge

I'm not really a Gladwell fan, but as people caught up in the world of standardized tests, the ideals of being "well rounded", college rankings, etc, it's a great read. Anti-semitism played a big role in shaping our educational selection process.

Lots of books on this as well. Our educational system is not the "meritocracy" we crack it up to be...but most of the beneficiaries of the system are also the ones with the power to change it so I don't see that changing significantly any time soon.

 

[Lokhtar]

I think it's decent to be honest. Too expensive, but the education itself is fine.