Map of life expectancy at birth from Global Education Project.

Thursday, May 09, 2013

Okay, back at it . . .

Pardon the interruption. The radical discontinuity in 1910 was the famous Flexner report. Abraham Flexner, who worked for the Carnegie Foundation for the Advancement of Teaching, was commissioned to study medical education in the U.S. and Canada. Back then there were 155 medical schools in the former British possessions, all of which he visited. (He is often said to have studied medical education in North America, but, err, Mexico. I digress.)

It turned out that most of them were not affiliated with universities, but were owned by one or a few physicians. They had what Flexner considered insufficient curricula and clinical training. States generally did not regulate the practice of medicine or have licensing requirements for physicians. Most important, in Flexner's view, medical training and practice was not uniformly based on science. His ideals were the few university-affiliated medical schools of the time, and particularly Johns Hopkins. Flexner's recommendations led to the current model of medical education based at universities, followed by clinical apprenticeship and university-affiliated hospitals,  taught by clinicians who were also research scientists, based on claims for effectiveness based on scientific knowledge and reasoning. Less directly, his work led to the imposition of standards for medical licensing and practice. These were imposed by the states piecemeal, and I have not come across a comprehensive history, but by now we take it for granted that every state does this.

Following this revolution, the number of medical schools in the U.S. at first shrank dramatically, and as it rebounded, all of the new ones adhered to the new standards and philosophy. For better or for worse, medical school faculty came to be evaluated based on their research activities, rather than their teaching. Various heterodox "schools" of medicine, such as homeopathy and chiropractic, lost their claim to legitimacy within the new structure of scientific medicine, because their claims are biologically implausible and not supported by rigorous experiments. (Although, inexplicably, at this late date, they seem to be worming their way back in. But that's for another day.)

Medicine's claims of scientific authority were certainly vindicated by many important developments throughout the 20th Century, notably effective antibiotics, insulin for Type 1 diabetes, incremental advances in surgery and trauma care that ultimately added up to huge benefits, effective immunization against more and more pathogens. As recently as 20 years ago, when I first got into this racket, there was a legitimate argument about whether the contribution of scientific medicine to health and longevity at the population level was very important, or even provably positive; but that is no longer true.

But, history has not ended. Medical practice, and the physician and patient roles and their relationships, remain deeply problematic.

To be continued.


Anonymous said...

I think your interruption could have lasted longer.

Daniel said...

I hope you don't include naturopaths in your category with homeopaths. They do interesting health care.

The other day a friend told me her son was allergic to wheat flour. Interesting, how did you determine that I said. My naturopath tested him she said. How I said. He held a bag of wheat flour in each hand with arms outstretched while she held a crystal to the back of his neck she said. Interesting I said.

Well maybe I would have said more if I thought it would have made a difference.

Glad to read this post.

Don Quixote said...

Thanks for the story, Daniel . . . I have been to a "chiropractor" who used the same "method." I never went back. What a crock. He could have stuck to cracking necks.