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Book Forum: Changing Paradigms in Education and Psychiatry   |    
Time to Heal: American Medical Education From the Turn of the Century to the Managed Care Era
Am J Psychiatry 2001;158:1171-1172. doi:10.1176/appi.ajp.158.7.1171
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Boston, Mass.

By Kenneth M. Ludmerer. New York, Oxford University Press, 1999, 494 pp., $29.95.

This volume presents a comprehensive study of medical education over the last century. One cannot help but be impressed by the extensive endnotes (20% of the pages), which add many insights.

Kenneth Ludmerer provides an excellent narrative of key events and developments in the history of American medical education. The vast task he has undertaken and his description of the growing complexity of medical education and medical care are very important contributions that health professionals should read to better their understanding of their plight. Context is important for history, and the author attempts to relate medical education to social currents in American society. This is done best in the opening and closing sections of each chapter. The reader limited for time could get a good brief overview of changes in society and their impact on medical education by reading these sections. Ludmerer properly casts medical education as having a "social contract" with society, and he laments the erosion of that contract in recent years. Because of the book’s broad narrative and its concluding focus on the dire impact of managed care on medical education, it has appropriately received much attention and praise. Nonetheless, Ludmerer overlooks several critically important aspects of the history of medical education in the last century.

In my view, the emergence of the organized medical profession in the early part of the century as a major force in shaping medical education—quantitatively and qualitatively—receives too little attention. The role of Dr. Morris Fishbein, for many years the spokesperson for the American Medical Association (AMA) and editor of its journal, is not even mentioned. His views, however, did not go uncontested. To its credit, a group of physicians (The Committee of 430), mainly from academic medicine, drafted a visionary proposal in the late 1930s for medical education, research, and services that called for some public funding. The vitriolic attack on this proposal by the AMA and efforts to intimidate committee members is not mentioned. Our health care system would be in better shape today if the nation had heeded its recommendations. The long-standing role of the AMA in viewing the government as the "enemy" of the profession and the fact that this influenced how medical education and medical educators perceived government as well as how government perceived them receive scant attention.

Although the latter part of the book deals quite extensively with Medicare and its effects on medical care and particularly on medical education, there is no mention of the fact that the AMA’s opposition to the passage of Medicare was perhaps the most bitterly fought political battle of the 20th century and that medical educators were nowhere to be seen (except for a few weak and sporadic efforts). The organized medical profession has never lived down the reputation it gained during this time as a proprietary interest group.

The history of the teaching component of the three-legged stool of medical education (teaching, research, and service) is the central issue of the book and makes for fascinating reading. Ludmerer makes it clear that the "golden years" were not entirely golden. There is a good description of the intrusive pressures of rapidly increasing research funding on education, especially after World War II, but there is too little account of counter-pressures. He properly laments the loss of medical heroes like Eugene Stead but overlooks some medical educators who worked heroically and systematically to keep teaching and curriculum issues alive. There is no recognition of the efforts of the gifted president of the American Association of Medical Colleges, Ward Darley, who came from the presidency of the University of Colorado in 1956 and invigorated the organization. He was prescient in anticipating the need for more precise data on the costs of medical education and initiated the first studies on that subject. In 1953 Darley teamed up with George Packer Berry, the visionary dean of Harvard Medical School, to organize a series of teaching institutes that brought faculty members from around the country together annually over a 13-year period. It is doubtful that the rearrangement of curriculum hours, curriculum innovations, and interest in pedagogical methods would have been accomplished without this network of faculty members interested in education. They fought an uphill battle. Each of these teaching institutes published a volume for all faculty members. Since these volumes are in medical libraries, it is striking that they were overlooked in the light of the extensive documentation from various medical school archives that Ludmerer has mined.

Also overlooked, among the many changes following World War II, is the growing interest in improving and extending the teaching of psychiatry and the behavioral sciences. Analogous to the teaching institutes were two landmark national conferences on the teaching of psychiatry in 1952 and 1967. This openness to the need for better teaching of psychiatry on the part of medical educators antedated the great advances in research on the brain and behavior of recent years.

There is all too little on the role of the state universities in stabilizing and improving medical education between the two world wars. Most of the archival citations are from private universities. Since medical education west of the Mississippi River is largely in state universities, this is a striking underemphasis. Some states (New York, California, Texas) developed networks of medical schools.

It is understandable that the author is at his best in describing the current scene, with which he has firsthand knowledge. A recurring theme is the lack of leadership within medical education during the period when health expenditures were rising from 4% of the gross domestic product in 1950 to almost 15% today. He makes it clear that there is plenty of blame to go around.

Many people recognized that rising expenditures for the health sector could not go on indefinitely. Yet the affluence of the post-World War II period for medical education cultivated an air of complacency rather than challenge. There is too little recognition that without a counterforce from the health care professions, the investment bankers would see health care as a new, lucrative area for profit making and move in. As a consequence, the power shifted to the financiers, who began to determine how medicine would be practiced and taught—a situation unthinkable a decade ago.

The point is well made that the social contract between medical education and society has been broken. That so little leadership emerged from health professionals and educators in striking a balance is important. Part of the diagnosis relates to the profession’s inherent distrust of government and a misplaced trust in the business community’s solutions (which the author presents well in describing the role of "business consultants").

The creativity needed to reestablish the social contract will require bringing together the best minds in the public and private sectors to act in the public interest. The public part cannot leave out government, but our private institutions, especially those in the nonprofit sector, also have a responsibility to act in the public interest, and the corporate sector must ultimately come to realize that the public’s health is also its concern. The notion that the better ideas will come from outside our institutions of higher education is a fallacy. We have the talent to lead if we accept the challenge. That this isn’t an entirely new problem is evident in Elinor Langer’s prophetic observation in 1967:

I think the policy-makers are burdened by what they perceive as the enormous intellectual complexity of the task. Medical ideologists, as well as medical idealists, seem to have passed out of currency in this country, and the men now making decisions are, if anything, too modest and too humble.…But they say they don’t know what the answers are, or how the problems can be solved, or what they ought to do next. They are afraid of imposing overall or systematic solutions, partly because they are afraid their solutions might be wrong ones, partly because they begin with a bias against systematic solutions in general. Instead they try to do a little bit of everything at once. (1)

Langer E: Who makes health policy? Physician’s Forum, June 1967


Langer E: Who makes health policy? Physician’s Forum, June 1967

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