The Evolution of Modern Medical Practice

1. The Evolution of Modern Medical Practice Strategic Management of Health Care Organizations 26 Jan 2006 Edward P. Richards Professor of Law, LSU Law Center

2. History of Medicine and Medical Science

3. Shamanism • Oldest Medicine • Primitive Tribes • Integrates Religion And Medicine • Persists Even Today In So Called Modern Cultures • Alternative medicine • Psychotherapy?

4. Explicitly Ministers To The Psyche And The Body • Often Sophisticated Rituals And Herbals • Driven By Myths • Trial And Error And Careful Observation • Some Cure, Most Do Not • Leviticus • Public Health Code • Rules Reduce Food Poisoning

5. Useful Pharmacopeia • Ethnobotany • Study Of Plants Used By Ritual Healer • Many Drugs Have Been Discovered • Witches Used Foxglove - Digitalis • Medicinal Chemists • Refine And Modify Botanicals • Who owns the IP?

6. Greco-Roman Rationalism • Galen And Successors • Driven By Rational Theories • Religion Is Left To Priests • Observations Forced To Fit Into The Theory • Plato Was Terrible About This • Mistakes Are Not Corrected • Persisted Until 16th Century

7. Hospitals as Religious Institutions • Started in Europe in the Middle Ages • Some of the Oldest Institutions in Continuous Operation • Run by Nursing Sisters • For the Poor • More Egalitarian in the United States

8. Nursing Only • Church Did Not Sanction Medical Care • Goal Was to Alleviate Suffering • Ease the Transition to Heaven • Most Died From Their Illnesses • Only the Very Sick Entered • Excellent Environment for Infectious Diseases • Changed With Technology in the 1880s

9. Scientific Medicine • Not The Philosopher's Scientific Method • The Imperative To Disprove Theories • The Full Disclosure Of Information • Science Is Constantly Questioning And Rethinking • Scientists are also people • They are susceptible to conflicts of interest • Fame is often more important than money

10. Paracelsus • Philippus Aureolus Theophrastus Bombastus Von Hohenheim • Early 16th Century • Transition From Alchemy • Experiments And Systematic Observations • Antimony

11. Anatomy And Function • Andreas Vesalius • Mid 16th Century • Accurate Anatomy • William Harvey • Early 17th Century • Flow Of The Blood And Operation Of The Heart

12. Edward Jenner • Smallpox • Major Killer • Along with Measles, Wiped Out The Indigenous Peoples • 1798 – Published His Book On Cowpox • First specific treatment based on scientific observations

13. William Morton • Dentist • Ether Anesthesia • 1846 • Rejected by the medical profession and died penniless

14. Ignaz Philipp Semmelweis • Childbed Fever • Fellow Medical Student Died • Controlled Studies • 1849 • Rejected by the medical profession and died penniless

15. John Snow • Cholera In London • Broad Street Pump • Proved Cholera Is Waterborne • 1854

16. Louis Pasteur • Scientific Method • Germ Theory • Vaccination For Rabies • Pasteurization • 1860s-1880s • More powerful than the medical profession • Was friends with the wine growers

17. Joseph Lister • Antisepsis • 1867-1880s • Listerine

18. Koch - 1880s • Koch’s Postulates • Agent Must Be Present In Every Case; • Agent Must Be Isolated From The Host And Grown In Vitro [In A Lab Dish]; • Agent Must Cause Disease When Inoculated Into A Healthy Susceptible Host; And • Agent Must Be Recovered Again From The Experimentally Infected Host. • Limitations

19. Organic Chemistry – 1880s • German/Swiss Dye Industry • Bayer • Hoffman La Roche • Ciba • Became Drug Chemistry

20. Sanitation Movement in Public Health • Shattuck Report - 1850 • Water • Sewage • Food Sanitation - FDA - 1905 • Life Expectancy Goes from 25 – 50+ fast • Slowly Rises to 76.5

21. Tuberculosis Control - 1900 • The Major Killer • Koch And Pasteur • Sanatoria • Pasteurization Of Milk • Disease Control Of Dairy Herds • Effective Drugs Came Later

22. Antibiotics • Sulfa Drugs In The 1930s • Penicillin • Alexander Flemming – 1928 • Purified By Chain And Florey In 1939 • Streptomycin – 1944 • First Antituberculosis Drug • Selman Abraham Waksman – 1944 • (Coined The Term Antibiotic)

23. Medicine and Surgery - 1890s • Medicine Starts to Work • Surgery Can Be Precise • Patients Do Not Get Infected • Professionalism Starts to Matter • What is a Quack if Nothing Works? • Why Train if Training Does Not Matter? • We will see that this is key to legal regulation of medicine

24. Hospital-Based Medicine • Started With Surgery • Medical Laboratories • Bacteriology • Microanatomy • Radiology • Services and Sanitation Attract Patients • Internal Medicine • Obstetrics Patients

25. Reformation of Hospitals • Paralleled Changes in the Medical Profession • Began in the 1880s • Shift From Religious to Secular • Began in the Midwest and West • Not As Many Established Religious Hospitals • Today, Religious Orders Still Control A Majority of Hospitals

26. Post WW II Technology • Ventilators (Polio) • Electronic Monitors • Intensive Care • Shift From Hotel Services to Technology Oriented Nursing • Became capital intensive

27. Post World War II Medicine • Conquering Microbial Diseases • Vaccines • Antibiotics • Shift to Chronic Diseases • Better Drugs • Better Studies • Leukemia • Chronic Diseases are much more lucrative

28. Hospitals Shift From Nuns to Paid Staff • Advantages of Nuns • Work Cheap • Work Long Hours • Well Organized and Disciplined • Keep Physicians In Line • Supply Plummets • Replaced With Paid Staff • Not Many Nuns Even In Religious Hospitals

29. Governmental and Private Regulation of Medicine

30. Pre-Constitutional Period • Limited Occupational Licensing • NY Passed Licensing Law in 1760s • Not Enforced • Extensive Public Health Regulation • Old Notion of Dirt • Nuisance • Managing Fear • People Terrified of Epidemic Disease • Yellow Fever and the Constitution

31. Constitution - Post Civil War • Jacksonian Populism and Distrust of Institutions • Decline of Occupational Licensing • Existing Laws Were Rescinded • Doctors • Lawyers • Continued Growth of Public Health Regulation • Driven by Snow’s Discoveries • Shattuck Report – Boston - 1850

32. Schools of Practice – Mid 1800s • Allopathy • Homeopathy • Naturopaths, Chiropractors, Osteopaths, and Several Other Schools

33. The Profession - 1870s • Most Medical Schools are Diploma Mills • No Bar to Entry to Profession • Small Number of Urban Physicians are Rich • Most Physicians are Poor • Cannot Make Capital Investments • Training • Medical Equipment and Staff • Physicians Push for State Regulation

34. Authority to Regulate Medical Care and Public Health - The Police Power • Historical Right of Societal Self-Defense • Central Colonial Function • Not Police Forces • Public Health and Safety • Left to the States by the Constitution • Can Be Preempted by Federal Legislation • Tobacco Labeling • Medical Device Labeling

35. Constitutional Attacks on State Regulation of Medicine • Equal Protection/Due Process • Discriminating Based on Training • Discriminating Based on Theory of Practice • License as Property Right • Inception of Licensing Laws • Discipline of Licensees • All Trumped by Police Power

36. Constitutional Limits on the Police Power • Civil Rights • Chinese Laundry Cases • Other Shams for Discrimination • Contraception • Sterilization and Abortion • Access to Adequate Pain Relief?

37. The Role of Legal Regulation in Professionalizing Medicine • Protection of Licensees • Quality of Care • Availability of Care • Fair Pricing • Governmental Interests

38. Protection of Licensees • Critique from the Left • Paul Starr - Social Transformation of American Medicine • Critique from the Right • Milton Friedman • “Hostile” v. “Friendly” Licensing • Not Incompatible with Other Goals

39. Improving Quality and Availability of Care • Require Training • Exclude Unorthodox Practitioners • Discipline Incompetent or Impaired Docs • Subsidize Indigent Care with Required Treatment Mandates • EMTALA • Medicare/Medicaid Non-Discrimination Rules

40. Fair Pricing • Sustain Prices to Assure Supply • Prevent Monopoly Pricing • Prevent Gouging Based on Patient’s Limited Bargaining Position • Emergency Conditions • Emotional Vulnerability • Lack of Knowledge • This never worked very well

41. Governmental Interests • Cross-Subsidize Government Programs • Tax the Profession • Political Influence of Professionals • Draw on Professional Expertise • Traditional Public Health • Traditional Mental Health

42. Licensing and Education • Mid to Late 1800s • Physicians are Solo Practitioners • Most Make Little Money • Have Limited Respect • Effective Medicine Drives Licensing • Licensing Limits Competition • Physicians Start to Make Money • Makes sense to invest in training

43. Consolidation of Power • American Medical Association Gains Power • Linked State and Local Societies to the National Society • Linked Medical Staff Membership to Local and State Society Members • Exclusionary Politics • Blacks • Women • Jews

44. Reform of Medical Education • Schools with High Standards Could not Compete • Degree Cost More • Took More Time • Did not Affect Entry to Practice or Success • Race to the Bottom • Schools Were Closing • Curriculum was Weakening

45. Outside Forces • Carnegie Foundation • “Flexner Report” • Most Schools Failed • Not Like US News and World Report Rankings • Incentives to Change • Foundation Money • Student Selection Pressures

46. Effect of Licensing • State Required Training in Approved Programs • Some Programs Were Not Approved • Some Unorthodox Practitioners Had Their Own Schools so They Cooperated • Students Had an Incentive to Attend a Better School

47. How Did Medical Schools Change? • Professionalism of Faculty • Full-Time Salaried Positions • Education Requirements • Emphasis on Research • Driven by Outside Money • Reinforced by the Success of the Research • Development of Modern Residency Training

48. What Happened to Unorthodox Practitioners? • Homeopaths and Osteopaths • Homeopathic Schools Closed • Osteopathic Schools Evolved to be Much the Same as Other Medical Schools • Osteopaths are Now Licensed and Treated the Same as Other Physicians • Chiropractors • Politically Very Powerful • Got Their Own License and Allowed to Keep Practicing

49. Where Are We Now? • All States Require A Medical School Degree • Most Require One Year Post-Graduate Residency Training • No States Have Separate Licenses for Specialties • Private Certification of Medical Specialties • Required by Most Hospital and Health Plans • Extra Training and Examinations

50. Joint Commission on Accreditation of Hospitals • 1950s • Now Joint Commission on Accreditation of Health Care Organizations • American College of Surgeons and American Hospital Association • Split The Power In Hospitals • Medical Staff Controls Medical Staff • Administrators Control Everything Else • Enforced By Accreditation