American Medicine 1900-1940 Early development of specialism

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American Medicine 1900-1940

• Early development of specialism
• Economics of medicine 1900s-1940
• Emergence of postgraduate medical education

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Early Specialism

• Early development difficult Parisian localism vs
  therapeutic holism
• Practice preceded naming
• Pre-civil war specialists
• Quacks
• Elite urban consultants

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Development of Specialties

• Growth of Knowledge
• organs or organ systems e.g. eye
• groups of patients e.g. kids
• Development of Technology
• Skills/technique or apparatus

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Wills Eye Hospital Founded 1832
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NY Eye and Ear Infirmary founded 1822
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American Ophthalmology

• De facto eye specialists pre-1820
• Inpatient Eye services 1820s-1830s
• Am J Ophthalmology 1862
• Am Ophthalmological Society 1864
• Inclusion in Medical Curriculum at Penn 1879

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Rontgen Xrays 1895
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xray equipment, Roosevelt Hospital, NY 1900
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Radiology in America

• 1897 American X-Ray Journal
• 1900 Roentgen Society of America
• 1902
• AMA-affiliated docs take over
• name changes to American Roentgen Ray Society

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Specialty Societies

• American Ophthalmological Society 1864
• American Otological Society 1867
• American Neurological Society 1875
• American Gynecological Society 1876
• American Surgical Society 1880
• American Pediatric Society 1888

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Economics of Medicine 1900-1940

• 1920s Medical Profession, Doctors Income and
  Fees
• How do the economics of medicine relate to our
  professional identity?

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Economics of American medicine early 20th Century

• An unfettered marketplace
• Lots of docs relative to population
• Docs exhibit a wide spectrum of incomes, status

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Professional Ethics re economics of practice

• Prohibited Practices per AM A
• Fee-splitting
• Physician-owned pharmacies and dispensing
• Physician patenting/selling of medical products
• Advertising
• Charges the sliding scale

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Fee Schedule Wash DC 1924

• Fee 2005
• first visit 3-25 34.46-287
• home visits 3-10 34.46-115
• night visit 5-25 57-287
• smallpox vac 3-25
• cxr 15-100 172-1150
• urinalysis 5-50 57-574
• major surgery 100-5000 1150-57,426

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AMA No Government Involvement in Health Care

• absence of a tradition of government involvement
  in fostering social welfare
• lack of social unrest, of class-based socialist
  political parties

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Median Incomes late 1920s

• Incomes
  2003
• Doctors 3827 41,000
• College
• Teachers 2704
  29,000
• Mechanical
• Engineers 4100 44,000

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Median Net Incomes, 1928 Private Practice ()

• 1928 2005
• General Practice 4138 47,526
• Internal Medicine 7365 84,589
• Surgery 8975 103,081
• Pediatrics 6671 76,618
• Orthopedics 10,109 116,104
• OB/GYN 6371 73,173
• Radiology 7420 85,221
• All Specialists 7072 81,224

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Increases in Professions 1900-40

• 1900 1920 1940 inc
• lawyers 108 123 182 68.5
• Doctors 131 146 168 28.2
• Engineers 38 134 297 681
• college fac 7 33 77 1000
• US pop 76 106 132 73.7

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Medical Profession, late 1920s

• 142,000 physicians
• 121,000 private practice
• 21,000 salaried employees
• Distribution
• 74 general practitioners
• 21 claim some specialist practice
• 26 specialists

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Early 20th Century Physicians and Economics of
Doctoring

• Small businessman outlook combined with ethical
  constraints
• Sliding scale charges equity to patients and to
  doctors
• Market increasingly favors physicians (as numbers
  decrease) but especially specialists

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Medical Training 1900-1940

• Medical Schools consolidation of Flexnerian
  model
• Hospitals and postgraduate training
• Rise of internship
• Formalization of specialty identification
• Residency

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• 1846 anesthesia
• 1867 antisepsis
• 1880s antisepsis generally adopted
• 1890s surgery takes off
• 1895 xrays

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Rise of Hospitals in America

• Hospitals
• 1872 172
• 1909 4359
• 1931 4309
• 1950 4713

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Internship

• Grads Participating
• 1904 50
• 1914 75
• 1925 95

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• Internship for Liscensing
• 1915 Pennsylvania
• 1932 17 states
• National Liscensing Exams
• 1915 National Board for Medical Examiners formed
• Exams accepted
• 1915 8 states
• 1932 41 states

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Possible Means of Specialist Recognition

• Liscensure
• Degree Courses
• Examination

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Specialty Boards

• American College of Surgeons 1913
• American College of Physicians 1915
• American Board of Ophthalmic
• Examinations 1916
• Natl Board of Examiners in
• Otolaryngology 1925

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Specialty Boards

• OB/GYN 1930
• Dermatology 1932
• Pediatrics 1933
• Radiology 1934
• Orthopedics 1934

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Residencies

• 1923 AMA principles (including prereq of
  internship)
• 1930
• 338 hospitals 2208 positions
• 1939
• 518 hospitals 4556 positions
• 1950
• 19,464 positions

Residency positions exceed internship slots in
1945
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Housestaff in living quarters, PGH, n.d.
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Medical Training 1920-40

• Medical Schools ?Flexner Ideal
• Postgraduate Training
• internship ? general practitioners
• residency ? specialists
• Regulation
• AMA Council on Medical Education
• Specialty Boards

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Medical Profession, 1929-1949

• 1929 1949
• doctors 140,000 160,000
• independent
• salaried
• Distribution
• gps 74 54 part-specialists
  (21) (16)
• specialists 26 46

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• Life Magazine, 1948
• Annually the nation's medical schools send a
  majority of their graduates into specialization.
  The current of need runs in the opposite
  direction. (What is needed is) a reformation on
  the part of the schools, which as a rule present
  specialization as a glamorous occupation and
  general practice as the thankless chore of a
  drudge..