If I Could Have My Way: Challenging the Medical Monopoly on Personal CareE. A. Stead, Jr., M.D.
Medical education in the United States is controlled by 4 year medical schools which are usually a part of a public or private university. The schools have, until recently, been well financed and their faculties enjoyed a larger degree of freedom and high salaries. All medical schools have three responsibilities:
Many medical schools organize their faculties to perform a fourth function: the creation of new knowledge by research. In 1930 when I saw my first sick patients, the sciences applicable to patient care were just evolving in the medical school. The practitioner of that day had little knowledge of what was taught to the first and second year medical students.
Until recently, four year universities of professional schools in the United States were well financed. The faculties of these prestigious institutuions transmit to their students the information accumulated over the ages. The problem is that these institutions live in the past and absorb too much of the money that the society is willing to allot to education.
In the past, the knowledge from the past generations was passed to the new by books, lectures and demonstrations. There has always been a shortage of gifted scholars and for efficiencies sake, scholars, books, and laboratories were concentrated in geographical areas which we called universities. Students coming to these universities were given the best information on a large variety of subjects. Professors prepared lectures, selected textbooks, assigned material to be read in the library and conducted simple laboratory experiments to acquaint the students with how preperly designed laboratory exercises could create new knowledge.
Hundreds of universities developed in widely dispersed areas throughout the world. In the best universities, the dispersement of knowledge and the acquisition of new knowledge proceeded apace. People with the knack for creating new knowledge were scarce and universities with the best access to capital captured the cream of the crop and in time, were designated research universities. Smaller colleges concentrated on encouraging their students to grow in skills and knowledge. Attention to the individual student and encouragement to gain joy in learning was their forte.
The libraries were the essential part of the colleges and universities. Some portions of science (physics) required accelerators and nuclear reactors in order to create short lived isotopes and other very expensive research tools, which required the interactions of many scientists and a large support and maintenance staff which fostered the development of large central campuses. In time, some of the ventures became so expensive that government laboratories were developed where faculty members from a group of universities could become scholars in residence away from the parent university. State universities usually started colleges of agriculture and engineering. In time, many state universities evolved into a community of institutuions distributed state wide.
Experience showed that many capable students did not enjoy the four years of college largely devoted to books and learning and wished to combine the theoretical work with hands on experiences more directly related to the job market. At the same time, industry wished to have graduates who could enter the labor market after two years of post high school education. Each state developed a network of community colleges to meet the needs of students and industry.
The biological and physical sciences underlying the practice of medicine developed slowly during the latter half of the ninetheenth century. By 1890, enough specialized knowledge had evolved to justify the emergence of four year medical schools. Because the best science was in the universities, most medical schools became affiliated with one or more nearby universities.
Medical schools have never fit easily into the academic environment. They are graduate schools because they usually require a college degree for admission. The first two years of medical school consists of course work, somewhat similar to that required for a masters degree in the biological sciences. There is usually no requirement for original research. In an academic procession, the MD graduates are placed with other members of the university faculty holding master degrees. In the last two years of medical school, the students are apprenticed to excellent practitioners of medicine.
The graduate of a medical school cannot practice his profession until the state awards him a license. Only graduates of approved medical schools can be admitted to the licensure examination. The medical schools have an absolute monopoly. In the best of times, the monopoly admits to the practice of medicine only the best. In the worst of times, it excludes any graduate, no matter how skilled, whom the members of the examining team do not like.
The medical schools have a great stake in requiring students to attend four full years. Many studnets seeking adminssion to medical schools have had extensive experience in the medical and scientific world. The schools rarely give the seasoned medical worker any credit for courses taken outside of the medical school or for apprentice experience more extnesive than those of the third and fourth year medical students. Without the four years of college and four years of medical school tuition, admission to the qualifying examination is denied and the school's monopoly is maintained.
Because the practice of medicine gives great personal satisfaction, an honored place in one's community and a much better than average income, medical schools always have many more applicants than places. They can and have raised tuition and fees at will. Students frequently graduate with the burden of an $100,000 debt or more. The tuition fees cannot be justified. Laboratory instruction which does require hands on contact with instructors is at a minimum. All the lecture material can be obtained from the medical library at a very reasonable cost. With proper planning the student can be apprenticed to a private practitioner at nominal cost.
Different medical schools perform different functions. Some schools prepare doctors for practics, some place emphasis on producing teachers and some have extensive research programs. The most prestitious schools combine the research activities and the production of teachers. When a new school is started or when a school in the lower ranks finds enough money to upgrade the faculty, persons are recruited from the top twenty schools. This eventually results in all schools being remarkably alike. Few medical schools show any originality in their adminstrative structure or in their curriculum.
From the above, readers of this paper will sense that I am critical of the present situation and will offer an entirely new paradigm. What are my creditionals for this venture to take my new school seriously.
I grew up in a family that valued education and that encouraged the children to read widely. In my small southern town , education had no honor and I was looked on as a peculiar child who read too much and who used too many long words. I had a somewhat lonely but otherwise pleasant childhood. Emory University had recently moved to Atlanta and offered a one year tuition free scholarship to graduates of Georgia high schools. Having no competition from any students in my high school, I was awarded the scholarship. None of my family had ever entered a university and I was left to explore the area with little direction. Not knowing what courses to take, I turned my attention to raising money for tuition for my sophomore year. There were a number of student assistants who helped with laboratory courses and all but one paid the same small stipend. The year was 1925 and the boll weevil had descimated the cotton crop. Funds were so scarce that all requisitions, even one for twelve pencils, had to be signed by Harvey Cox, the president of Emory.
How to obtain the biology student assistanship? Luck was on my side. The incumbant would graduate in July. He was courting my older sister and planned my course. Biology was considered an upper class subject and would be taken by few freshmen. If I had a year of biology under my belt and might be available for three years and was recommended by the incumbent, then I had an excellent chance to be appointed student assistant. Things worked out as planned and I had an interesting and rewarding two years of as student instructor. In my third year, I tried my hand at coaching. I offered my serivces at $5 an hour for students in the B+ area who wished to move up to A. I made some life long friends, one of whom cast the deciding vote that led Emory to offer me the Emory professorship in Medicine which I eventually accepted.
I received my BS degree from Emory, completing the required courses in three regular years and three summer school sessions. On applying to medical school, I was asked only one question, "Son, can you borrow the money?" The Atlanta Rotary Club agreed to pay the tuition for the first two years and required that I take out a $1000 life insurance policy to cover the loan. I still have that $1000 policy.
The curriculum in the first two years of medical school was taught by six departments. Gross anatomy (? instructors), neuroanatomy (two + student instructors), Chemistry (one professor, two instructors), Pathology (one professor), Physiology (two professors) and Pharmacology (one professor). In the latter part of the second year, introductory lectures were given in physical diagnosis, obstetrics, and clinical pathology. The lectures were given by volunteers from the practicing community.
A few of the students in my class discovered from our friends attending more prestigious medical schools that Emory frequenly used watered down textbooks for instruction in the sciences. A few of us obtained more sophisticated textbooks and set up our own program of reading. On arriving in Boston to begin my internship, I discovered to my surprise, that I was ahead of the other interns because, not being given any assignments, I would read the whole book. This resulted in my life time habit. I never gave a student a specific assignment. I always started with a patient and found out what the patient wanted from us. We presented what our small group had about the problem at hand. Today, I'd suggest topics that seemed of interest in light of the problem presented by the patient. Tomorrow, we would meet and review the patient problem in the light of our new information and proceed from this. A month later, some of us would still be pursuing some aspects of the problem and sharing information as we met in the hall.
In the fall of 1941, Emory asked me to visit the school and find out if I would consider coming back to Emory as Professor of Medicine. At that time, I was a member of the Army Researve Corp and held the rank of Captain in the recently organized Harvard Brigham Hospital Unit headed by Elliot Cutler. Cutler had served in World War I and he wished his unit to be the first one overseas. We all believed that the United States would be drawn into the war and made our plans accordingly. Emory persuaded Cutler to allow me to resign my reserve commission and Emory appointed me Professor of and Chairman of the Department. I was to report for duty at Emory on the 7th of May, 1942.
Soma Weiss, Hersey Professor of The Theory and Practice of Physic at Harvard and Physician-in-Chief at the Brigham, died in January of 1942. Soma was the chairman of a committee componsed of senior Harvard professors who were physicians-in-chief at the Brigham, Massachusetts General Hospital, Beth Israel Hospital and the Boston City Hospital. This committee was responsible for the instruction in medicine of the third and fourth year Harvard students. After Soma's death, I became the acting Chief of Medicine at the Brigham and acting chairman of the committee responsible for the instruction of the third and fourth year students in their medical rotations.
The fist and second year students received their instruction on the Boston campus of the Harvard, Longwood campus. The Harvard faculty were a distinguished group of scientists and they were employed full time by Harvard. THe third and fourth year students served apprenticeships in seven hospitals, the MGH, Brigham, Beth Israel and second and fourth services of the Boston Psychiatric Hospital. Harvard supported in part the chiefs of service in these hospitals. The chiefs were allowed to create additioanl income by caring for private patients. THe medical committee was composed of Howard Means (MGH), William Castle (City), Herman Blumgart (BI), and myself, as acting chief for the Brigham. The meetings were pleasant; various subjects were discussed but the question of curriculum or teaching was rarely mentioned. There was no effort to direct the chiefs of service because the students had an effective way of assuring excellent performance. The Harvard hospitals not only competed among themselves for the best students; they wanted the best students from the rest of the world. A decline in applications for internships produced immediate evaluation of the hospital program and changes rapidly restored the balance of applications.
It finally dawned on me that Harvard, for all its distinction, was really a two year medical shcool and a two year hospital school. Harvard was fortunate that it had this cover of excellent hospitals within bicycling distance. The hospitals would supply the cash flow to support a large number of part-time faculty and Harvard could spend the majority of its funds on its library and on scientists who could offer world leaderhsip in their disciplines. This two year medical school became a marvelous institution and its supporting hospitals were the envy of the world.
At the end of May, 1942, I left the Brigham and became the first paid Professor of Medicine in the Emory Medical Shcool. I assumed that I would be Physician-in-Chief at Grady Hospital, the main teaching hospital of Emory.
Grady was divided into two division, Colored Grady and White Grady. Each division had a chief and neither one offered to step aside for me. The instruction in medicine was conducted by the staff. There were no paid faculty. Could you be an effective teacher of medicine with no patients? Gene Stead could not. I debated on rejoining the Harvard unit which had gone to England or returning to the Brigham which was probably impossible because the new chief would have no funds to support an unexpected extra faculty member. Then my brain began to recover from the school with no patients. I found that each chief of the two divisions spent only a few hours a day at Grady. I was spending a minimum of ten hours per day and slept at the hospital Friday, Saturday, and Sunday nights. Why should I care who called himself chief?
The students and the few residents who had not been inducted in the armed services welcomed my input and I became Physician-in-Chief, de facto. After a year, the hospital administrator accepted the reality. They wanted to have a formal banquet and announce my appointment. I declined with thanks but suggested that caring for the sick was more important than banquets and that I no longer felt the need for a formal appointment. In retrospect, I learned a valuable lesson. Authority and power cannot really be given. In the end, they have to be seized, hopefully, constructively.