In 1904 the AMA created the Council on Medical Education (CME) whose objective was to restructure American medical education. At its first annual meeting, the CME adopted two standards: one laid down the minimum prior education required for admission to a medical school, the other defined a medical education as consisting of two years training in human anatomy and physiology followed by two years of clinical work in a teaching hospital. In 1908, the CME asked the Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote the CME's reformist agenda and hasten the elimination of medical schools that failed to meet the CME's standards.
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When Flexner researched his report, many American medical schools were "proprietary", namely small trade schools owned by one or more doctors, unaffiliated with a college or university, and run to make a profit. A degree was typically awarded after only two years of study. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training left something to be desired. The regulation of the medical profession by state government was minimal or nonexistent. American doctors varied enormously in their scientific understanding of human physiology, and the word "quack" flourished. There is no evidence that the mass of Americans were dissatisfied with this situation.
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To a remarkable extent, the following present-day aspects of the medical profession in North America are consequences of the Flexner Report:
A physician receives at least six, and preferably eight, years of post-secondary formal instruction, nearly always in a university setting;
Medical training adheres closely to the scientific method and is thoroughly grounded in human physiology and biochemistry. Medical research adheres fully to the protocols of scientific research;[5]
Average physician quality has increased significantly;[6]
No medical school can be created without the permission of the state government. Likewise, the size of existing medical schools is subject to state regulation;
Each state branch of the American Medical Association has oversight over the conventional medical schools located within the state;
Medicine in the USA and Canada becomes a highly paid and well-respected profession;
The annual number of medical school graduates sharply declined, and the resulting reduction in the supply of doctors makes the availability and affordability of medical care problematic. The Report led to the closure of the sort of medical schools that trained doctors willing to charge their patients less. Moreover, before the Report, high quality doctors varied their fees according to what they believed their patients could afford, a practice known as price discrimination. The extent of price discrimination in American medicine declined in the aftermath of the Report;
Kessel (1958) argued that the Flexner Report in effect began the cartelization of the American medical profession, a cartelization enforced by the American Medical Association and backed by the police power of each American state. This de facto cartel restricted the supply of physicians, and raised the incomes of the remaining practitioners.
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According to Hiatt and Stockton (p. 8), Flexner sought to shrink the number of medical schools in the USA to 31, and to cut the annual number of medical graduates from 4,400 to 2,000. A majority of American institutions granting M.D. or D.O. degrees as of the date of the Report (1910) closed within two to three decades. (No Canadian medical school was deemed inadequate, and none closed or merged subsequent to the Report.) In 1904, there were 160 M.D. granting institutions with more than 28,000 students. By 1920, there were only 85 M.D. granting institution, educating only 13,800 students. By 1935, there were only 66 medical schools operating in the USA.
Between 1910 and 1935, more than half of all American medical schools merged or closed. This dramatic decline was in some part due to the implementation of the Report's recommendation that all "proprietary" schools be closed, and that medical schools should henceforth all be connected to universities. Of the 66 surviving M.D. granting institutions in 1935, 57 were part of a university. An important factor driving the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced the Report's recommendations.
Why would it be any different than how we do it today with say contractors or mechanics? They set their prices and we hear from word of mouth or from online sites that judge these places. Restrictions on how is allowed to become are doctor are way too tight. As a prospective medical student, I have first hand experience with all the crap you have to go through even in the undergraduate level.
I agree that basic standards have to be set, I just disagree with how it is done. I'm not a fan of the AMA in any sense of it's being and have some second hand experience with them as my mother and godfather are medical professionals. My mom is an LPN, my godfather is a former Oncologist current General practicioner and both have told me horror stories about some of the legally licensed quacks that have some horrid habits in their practices, even with the AMA in place many doctors are still mis-diagnosing or improperly providing care not through accident but negligence and gross incompetance. So to summarize my position I do believe in a minimum quality standard, but agree with the op that competition will bring that about if the regulations allow for both competitive market influences and legal responsibility to truly compliment each other.I think restricting the supply of medical professionals does contribute to excessive prices for health care.
I would be willing to endorse that relax the AMA hold on the industry as long as doctors were required to make information about the success rates and prices of their treatments available. I would prefer that information be posted in their waiting rooms or outside their facilities. The reason I say this is because the AMA does serve an important function in standardizing training and if there were multiple agencies serving that role or if there were none, we would need some way of telling the good doctors from the bad ones. But generally, competition is good.
I agree that basic standards have to be set, I just disagree with how it is done. I'm not a fan of the AMA in any sense of it's being and have some second hand experience with them as my mother and godfather are medical professionals. My mom is an LPN, my godfather is a former Oncologist current General practicioner and both have told me horror stories about some of the legally licensed quacks that have some horrid habits in their practices, even with the AMA in place many doctors are still mis-diagnosing or improperly providing care not through accident but negligence and gross incompetance. So to summarize my position I do believe in a minimum quality standard, but agree with the op that competition will bring that about if the regulations allow for both competitive market influences and legal responsibility to truly compliment each other.
I see medical issues as being more fundamental to humanity than structures (even though they can fall and thats why we have building inspectors, I don't see body inspectors as something that would work though).
I agree that restrictions are too tight though, but the proof is often in the results and if those results are posted, along with an average for the region (different geographical regions tend to have different issues) and type of doctor, we should know how good the doctor is and if they are worth the money. Essentially, its letting capitalism work by ensuring we have the information to make good decisions.
How do you feel about the line I quoted at the beginning of the Wikipedia quote that "There is no evidence that the mass of Americans were dissatisfied with this situation." Clearly there was a way to tell whether a doctor was good or not. I mean you wouldn't just go to a guy that called himself a doctor and expect good treatment without some proof to back up his claim.
I forgot to address the transparency issues, whoops! Totally agree with you on that. It is frustrating that you have to actually ask for an itemized bill to get one for your care and you're lucky if they actually honor the request, no argument from me.I wasn't disagreeing that we need more competition. In fact, I think this is one area where more competition would be good. However, I think the data should be out there for all to see, which is why I recommended posting the success rates somewhere a person can easily find it. Relying on word of mouth is essentially the same as relying on rumor, at least I see them to be equivalent, and rumors tend to have accuracy issues. A person can get a bad reputation real quick based one one problem when in fact they could be doing pretty good overall.
The first thing that comes to mind was that there was less division of labor back than due to a lack of technological and scientific sophistication (wasn't stuff like phrenology still popular at that time?). Since we are not more sophisticated in those areas, people expect more (as they should, or else there is no point in technological progress). Also, there is less division of labor and specialization than and people were able to do a great % of what a doctor could (again due to the primitive conditions). This is no longer the case today.
Yes, and homology was popular back then as allopathic medicine at the time was ghastly. Homology then actually did less harm than allopathic medicine, explaining its popularity. However, with this Flexner Report and states abiding by it, medical schools had to train only allopathic medicine, and only so many.
I still think that you could find the good doctors by independent certification agencies and popular reviews. As for the price issue, that's an issue with insurance which is a problem that was created in order to respond to the problem created by the Flexner Report.
During an emergency you would probably only go to a company that you like (something like Kaiser). You would demand certain certifications that doctors can get from private issuers and the companies that hire them would demand certain qualifications. There are plenty of mechanisms for quality assurance in the free market.
I don't follow. Why would decreasing the amount of doctors back then have made sense?
And do you think that hospitals showing prices for services would increase competition and therefore lower cost?
For doctors, making sure all of them made a very good living. For the state, controlling the excessive cost.
I have no problem with hospitals showing prices, but all of them would charge about the same. All will find a way to jack up to cover those who don't pay. And while a wealthy person not in an emergency may be able to negotiate, the emergent patient really can't. This isin part why normal capitalistic policies don't work well here. how much will you haggle for your daughter's life?
For doctors, making sure all of them made a very good living. For the state, controlling the excessive cost.
I have no problem with hospitals showing prices, but all of them would charge about the same. All will find a way to jack up to cover those who don't pay.
And while a wealthy person not in an emergency may be able to negotiate, the emergent patient really can't. This isin part why normal capitalistic policies don't work well here. how much will you haggle for your daughter's life?
Most people aren't going to ask for certain certifications because they won't understand them unless they specialize in that knowledge. I work in IT and people assume I can do all things IT when I have a specialty, but people do not understand that. The medical field is even more complex, has more acronyms, more terminology, etc. Assuming people can know those certifications is unrealistic because people simply are not smart enough to know everything about everything or even a subset about everything. Heck, I am smarter than average, but theres a ton of stuff I don't know and I am attempting to learn new things constantly. I will never know enough to know how to demand quality from every professional field.
Plus in an emergency, people are going to be confused and disorganized and are prone to make mistakes. Relying on rationality, forsight, or anything like that isn't going to work. And they sure as heck are not going to have time to do research to figure out what they should be asking for. They will ask for a doctor and could get anything if the field is left wide open.
I don't think that restricting the number of healthcare practitioners is necessarily a bad thing. Prehaps it is a bit overdone, but having professional standards and a selection process whereby the best candidates are taken increases the quality of care, and avoids a supplier-induced demand for healthcare services. . For those who point out that there is mal-practice and mistakes by those who did get chosen, I could only imagine it would be worse if it were expanded to everybody who just wanted to get into a program.
I've personally had 1/3 of my physical therapy class drop out because they could not meet the requirements set down by CAPTE to continue in the program. I don't think dropping the program guidelines so we could have more therapists would necessarily have been a good thing for the healthcare industry or the profession of physical therapy.
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