Health care in America seems to be in nearly permanent crisis --
a staple feature of the front page and political campaigns since
Medicare and Medicaid made their debut in 1965. Thirty-five years of
perpetual struggle is a long time, as living memory goes. What if
the Vietnam War was still going on?
Then again, why shouldn't there be turmoil in this industry? Life
expectancy has risen from 47 in 1900 to 60 years in 1944 to 80 for a
child born today. The only comparable success in an activity
directed at a universal fundamental human need is farming, and there
the costs have gone down instead of up.
At the center of the storm are the medical schools or, in their
more elaborate delineation, the academic health centers, meaning
teaching hospitals and schools of public health and dentistry as
That cumbersome catchall term is as useful as it is unlovely, for
it reminds us of the compound nature of the thing. It was from the
schools of public health (and, to a lesser extent, the hospitals)
that the 20th century's greatest improvements came, and those mainly
in its early years: sanitation, improved living conditions and
nutrition. (Remember, Louis Pasteur died only in 1895!)
Now, a revolution of similar significance looms, this one
emanating from medical schools themselves, the hospitals and their
new adjuncts, the biotech and pharmaceutical industries.
In the form of new drugs, tests and procedures, molecular
medicine is just now moving into the delivery system. Its deep
understanding of the basic mechanisms of the human body and disease
promises over the next 50 years to transform medicine yet again.
But precisely at the moment of their triumph, medical schools and
teaching hospitals find themselves in danger and disarray, thanks
mainly to the advent of managed care. That's the emphatic warning
from a distinguished physician-historian, Kenneth Ludmerer, author
of the much-heralded Time to Heal: American Medical Education from
the Turn of the Century to the Era of Managed Care.
Underwritten by a number of blue-chip foundations, Ludmerer's
book is being billed a "the new Flexer report,'' recalling the
penetrating jeremiad whose appearance 90 years ago sparked the
eventual transformation of American medicine from a lagging trade in
personal services to one of the crown jewels of the American
I don't know if Time to Heal will achieve similar results. I hope
it does. Ludmerer, a professor of both medicine and history at
Washington University in St. Louis, may be (as Harvard intellectual
historian Donald Fleming says he is) `'the most eminent historian of
American medicine of his time and a notable figure in the medical
profession as well.'' Certainly he has had unprecedented access to
people and to archives. He writes with uncommon clarity about an
industry of unrivalled complexity and opacity.
But Ludmerer is also a reformer bent on a mission -- rescuing
medical faculties, physicians and their patients from a return to a
souped-up version of the profit-driven system of commodity medicine
in whose grip the health care industry found itself when the century
began. And it is to that end that Ludmerer has written a magisterial
narrative of the profession's largely successful struggle to escape
that earlier system. Its eighteen chapters each read about as
smoothly as a magazine article.
It was in 1910 that Abraham Flexner wrote Medical Education in
the United States and Canada. His client was the Carnegie Foundation
for the Advancement of Teaching. Muckraking in its most
sophisticated form, the report lambasted medical schools for their
commercialism and low standards, doctors for their parochial aims.
Nothing more was required for matriculation than the ability to pay
the fees; two four-month terms of lectures, the second
recapitulating the first, and presto! …