american medicine, mid20th century

1、American Medicine, mid-20th CenturyEvolution of Internal MedicineGeneralism 1940s-60sDevelopment of health insurance 1930sffMedicine and Medical Economics in the 60sMedicine vs SurgeryTraditional: Physician vs empiric Physician vs surgeon“Physician” after Paris: the “naturalist of disease”Knows dise

2、ase concretely through:long and varied clinical experience gained in the hospital as well as outside of itThe autopsy labPrizes accurate diagnosis and prognosisInternal Medicine1880s Germany: “Innere Medizin”Physiological/chemical aspects of diseaseContribution of laboratory experiment to medical kn

3、owledgevs surgery and dermatology“Consultant-generalist” IdealKnows disease through long and varied clinical experience gained in the hospital as well as outside of itThe autopsy labPrizes accurate diagnosis and prognosisLaboratory knowledge supplements clinical and pathological knowledgeWilliam Osl

4、er, M.D. 1849-1919 M.D. 1872England and Germany 1872-74FacultyMcGill 1874-1884Penn 1884-1889Hopkins 1889-1905Osler as a young professor of physiology at McGill 1875Osler at the autopsy table, Philadelphia Almshouse Hospital, mid-1880sDoing autopsies with students and residents, Philadelphia Almshous

5、e Hospital, 1885Horse and carriage in front of Penn Medical building, 1875Urban streetcar, 1887Osler teaching at Hopkins n.d.Oslerian InternistAbstract knowledgeWide, deep clinical experience/knowledgeExpert differential diagnosisHumanistic, holistic, compassionateSpecialist (in spite of general foc

6、us)Internal Medicine 1920s-WWIIMedical SchoolsResearch emphasis on “innere medizin”Research increasingly subspecialty-orientedBench researchers take over departments of internal medicineInternal Medicine 1920s-WWIIAcademic Practice/Residency TrainingRemains generalist“consultant-generalist” ideal po

7、werfulWorld of PracticeSome primary care(preventive medicine, common outpt problems in their simpler manifestations; e.g. dm, htn, utis)Complicated patients referred by gpsGeneralists (GPs) Dilemma: to certify or not?ProOfficial recognition of educationComparison to specialist credentialsConWill def

8、inition of general practice?surgery ?obstetrics1960s: Generalisms Transformation1960: American Academy of General Practice (AAGP) opposes board certification1965: AAGP favors board certification1969: American Board of Family Practice formed1975: rotating internships eliminatedFamily Practice vs Gene

9、ral PracticeGPPrimary careAdult and child (non-surgical) medicineVarying amounts surgery, obstetrics, orthopedics, otherFPPrimary careExpertise in psycho-social aspects of careLess emphasis on all-round competence (esp regarding surgery)Primary CareTraditional: GP1970s and afterFPIMPedsOb/gynEconomi

10、cs of Medicine 1920sAn unfettered marketplaceLots of docs relative to populationDocs exhibit a wide spectrum of incomes, statusCharges: Sliding scaleMedical Costs $ av total bill/yr/ $1999 hosp % family1918 48.41 530 7.61929 108 1044 13Obstacles to Insurance for Hospitalizationunpredictability of cl

11、aimsadverse selectionservice benefits threatened unlimited liabilitymoral hazardInsurance BenefitsIndemnity: Payment of a preset monetary amount in settlement of a claim (no matter how large the claim)Service:Payment for given medical services in response to a claim (whatever they may cost)1st Hospi

12、tal Insurance PlanBaylor University 1929Unpaid bills from schoolteachersVP Justin Ford KimballFormer superintendent Dallas SchoolsDesigned a prepayment plan for schoolteachers50 cents/month 21 days/yr hospitalization semiprivate room at BaylorProgenitor of Blue CrossJustin Ford Kimball1872-1956AHA P

13、rinciples Governing Acceptable Insurance Plans (1933)Non-profitpromotion and advertising limitedcoverage to be hospital charges only“free choice of physician and hospital”AMA Principles for Acceptable Private Insurance Plans (1934)No restrictions on treatment“free choice of physician”indemnity plans

14、 acceptable, service benefits not soPost WWII Boosts to Health Insurance1942: employer tax incentive to offer health insurance as fringe benefit1947: unions allowed to include health insurance benefits as subject to collective bargainingMedical Profession, 1929-1949 19291949#doctors 140,000 160,000i

15、ndependentsalariedDistribution gps74% 54% part-specialists (21%)(16%) specialists26% 46%Median Net Incomes, 1949Private Practice $1949 $1999General Practice 7428 51,748Internal Medicine 10,944 76,240Surgery 15,389 107,205 Pediatrics 10,695 74,505Orthopedics 15,063 104,934OB/GYN 14,288 99,535Radiolog

16、y 16,550 115,293All specialties 12,599 87,769Physician Income Spread 1929-49Median% mean overIncome median1929 3827 38%1949 9561 23%Insurance Coverage for Hospital ExpenseMedical Care Price Inflation (1982-84 =100)60s Medicine70% Hospital Patients are 65% Docs who are Specialists: 70% 1966Style of M

17、edical Practice11% Group89% Solo or Small PartnershipHospitals increasingly complex, high techMedical Technology1960: longterm hemodialysis1000 pts by 1969mid-60s: renal transplantationearly 50s to early 60s: development of positive pressure ventilationicus common by mid 60slate 60s-early 70s: cardi

18、ac catheterizationMedicare/MedicaidPart Ahospital carepayroll taxes during working years (2.9% of wages)Part Bdoctor visitsgeneral revenues and subsidized insurance premiumMedicaidcare for the poorgrants to states, which put up their own funds, design their own programMedicare Administration“fiscal inte