Thursday, May 1 2014
A while back a friend asked me that question: when did being a physician get to be a big deal? She reads a lot of 19th-century novels, which describe doctors as being very ordinary professionals — not enjoying anywhere near the prestige or wealth of modern physicians.
Just based on her taste in literature, I guessed the 20th century as the turning point. Meanwhile, her question made me curious as to not just when, but also why physicians attained that position in society. To that end, I checked out John Duffy’s From Humors to Medical Science; a history of American medicine (1993, U. Illinois Press).
The anecdotes Duffy recounts about early American physicians’ practice and demeanor will make your skin crawl. Early practitioners made use of cupping, bleedings, mercury, emetics, and other dangerous techniques as their front-line treatment, even until the 20th century. They quarreled over perceived insults to their skills, to the point of duelling with pistols. Physicians were sloppy, ignorant, stupid, cruel, and more often than not lethal to their patients. There were more of them — far more — than necessary.
And, tellingly, they were not well or often paid for their services. A starting physician could expect to earn $400 in 1860 — about $10,000 in today’s dollars using the WestEgg calculator. In 1898, physicians in New Orleans made $1000 a year — almost $30,000 in today’s dollars.
In the late 1800s, the profession began organizing itself to improve education and eliminate quacks, primarily through state and local medical societies. This process pitted allopaths (what we now call MDs) against homeopaths, naturopaths, and other forms of medicine. By 1900, about 100,000 ‘orthodox’ physicians practiced in the U.S., only 25% were members of any medical society, and only 9 percent were members of the American Medical Society.
The start of the 20th century saw the increasing strength of the AMA and other societies, which drove policy changes to prevent unqualified physicians from practicing medicine. Coupled with increases in scientific medicine — germ theory was widely accepted, along with appropriate and effective treatments — this greatly increased the quality of medical practice in America. At the same time, it decreased the supply of available physicians, while increasing demand as more people saw physicians for routine check-ups and vaccinations.
The result was that physicians incomes began increasing — in the late 1930s, that increase was ‘well in excess of rising prices’. By the 1950s, “medicine was at least one of the highest paid professions, a position it maintains today” — meaning 1993, but still very true 20 years later.
Duffy estimates that, “In terms of prestige, the American medical profession probably reached its zenith around 1960.” When folks (physicians) lament the decline in prestige of the medical profession, they probably are using the 1960s as their point of reference. What did not change is physicians’ relatively high incomes.
Duffy explains that the AMA opposed any health reform that threatened its members’ financial interests, including veterans’ hospitals — blocking those it could, and shaping any that passed. He points out that although the AMA opposed Medicare and Medicaid, the programs as passed proved a boon to the medical profession. Here let me add a little more detail and theory to that claim, via this chart I pulled from an HRSA report on graduate medical education: the solid dark line shows the ratio of specialists per 100,000 population; the dashed dark line shows the ratio of generalists to population. As you can see, starting in 1965, the proportion of specialists shot up, while the generalists stayed almost flat. Because specialists are paid so much more than primary physicians (on average), the effect is that physicians’ salaries (on average) have continued to stay extremely high.
The timing here can’t be coincidental: in fact, Medicare made it feasible to spend large amounts of money on previously expensive, probably hopeless geriatric conditions. This ended up being more or less a subsidy to the specialties, and the pool of generalist providers has never caught up. The HRSA report, written in 1996, recommends pretty drastic changes in graduate education, in order to correct the imbalance: almost 20 years later, that imbalance is pretty severe.
So in a little over a hundred years, the American physician has gone from being scandalously bad and poorly bad to prestigious and wealthy. A physician practicing today might have have been born to a father practicing at the height of the profession in the 1960s, whose father in turn was among the first to take medical board exams, whose father believed cholera was caused by bad air and treated it with bleedings. Four generations separate our medical science from ignorance and superstition.
A lot of the credit is due to the American Medical Association and allied groups: the increased rigor in medical education and the stiffer credential requirements for medical practice have greatly improved the efficacy and safety of medicine in the United States.
The problem is that those same policies have also diminished the supply of trained providers, thereby increasing their salaries and elevating them above the ordinary middle-class professions. This has added to the great increase in the cost of healthcare across the 20th century — not the sole driver, certainly, but a driver nonetheless. We have yet to find a proper balance for this trade off.
I can understand why many people who worked hard to become physicians still want to cling to the prestige (and associated income) of their profession. At the same time, that prestige is due to the scarcity of generalists and proliferation of specialists, which is demonstrably harmful to the sick and injured people in this country.
So it is important to remember that the status of physicians in this country has only recently been so high, and that peak may well be unsustainable for our society in the long run. Maybe a hundred years from now, audiences reading about our physicians will wonder why they were ever such a big deal.