Module 9 Mini Lecture: Doctors, Patients, and Medical Institutions in the Age of Technological Medicine

Physician and Nursing Growth: * In 1950, there were approximately $232,000$ physicians and $375,000$ nurses in the United States. * By 1969, these numbers grew to approximately $325,000$ physicians and $700,000$ nurses. * Between 1955 and 1965, the rate of increase for nurses and technical support personnel was four times greater than the rate of increase for physicians.
Total Employment: By the late 1960s, over $3,700,000$ workers were employed in the healthcare field.
Impact of Technology on Healthcare Costs: * Advancing technologies significantly drove up medical expenses. * Between 1950 and 1970, while the general consumer price index (CPI) rose by $61.5\%$ , overall healthcare costs increased by $124.7\%$ . * Hospital costs experienced the most dramatic spike, rising by $398.1\%$ .

Institutional Shift: Following World War II, healthcare became increasingly centralized in large institutions, with the hospital becoming the definitive center of medical care.
Practice Models: Physicians moved away from an independent, entrepreneurial model. The percentage of physicians employed in private group practices rose substantially between 1946 and 1969.
The Rise of Specialization: * By 1965, only $37\%$ of physicians were general practitioners, and half of those were over the age of 65. * Student interest in general practice plummeted; by 1965, only $15\%$ of medical students planned to become general practitioners.
New Definition of Primary Care: * Board certification for specialists rose in prominence. * In 1969, the American Board of Family Practice was formed to certify primary care specialists. * Being a "general practitioner" was redefined as a specialization where the primary care physician's role was to evaluate and refer patients to appropriate specialists. These physicians generally ceased performing minor surgeries or engaging in specialty realms.

Internal Vacancies: By the 1950s, the United States faced a physician shortage. Yearly, $25\%$ to $50\%$ of intern and resident vacancies at hospitals went unfilled.
Undesirable Positions: The shortage was most acute in small hospitals and mental health hospitals, which many US-trained physicians found unattractive.
Immigration Reform: * To fill these gaps, institutions began recruiting foreign medical graduates in the 1950s. * In 1965, Congress passed a radical revision to US immigration law, signed into law by President Lyndon Johnson. * This reform enabled tens of thousands of physicians from less developed regions, particularly Asia, to emigrate to the United States.

Demographic Disparities in 1950: * While approximately $10\%$ of the US population was African American, only $2.2\%$ of physicians were African American. * In 1956, only 28 out of the 80 medical schools in the US accepted African American applicants.
Systemic Barriers: In the 1950s, many hospitals refused to accept African Americans as interns or residents, denied them hospital privileges, and medical societies often excluded non-white members.
Desegregation Efforts: * In the early 1950s, President Eisenhower ordered the desegregation of all veterans (VA) hospitals. * In the 1960s, various court rulings mandated the integration of hospitals, nursing homes, and mental institutions. * One consequence of integration was the closure of many specific "black hospitals" during the 1960s.

Public Esteem: Medical doctors reached a peak in public esteem during the 1940s and 1950s, largely due to the efficacy of advances like antibiotics.
Decline in the 1960s: * Public trust began to decline as media coverage of medical malpractice and neglect increased. * The growth of medical bureaucracy led many Americans to view doctors as distant, impersonal, and uncaring.
Departure from the "Country Doctor" Ideal: * General practitioners making house calls became nearly extinct. * Rural areas suffered from physician shortages. * Technology-driven medicine required physicians to stay at their practices or hospitals. Consequently, patients began seeking basic medical care in hospital emergency rooms (ERs).

The MCAT and Admissions: * The Medical College Admissions Test (MCAT) was introduced in 1948 to screen applicants. * Competition intensified; by 1956, only half of all applicants secured admission to any medical school. * In 1970, a significant gender disparity existed, with $90\%$ of all admitted students being male.
Institutional Growth: * Six new medical schools opened in the 1950s, and 15 more opened in the 1960s. * The Health Professions Education Assistance Act of 1963 provided federal funding for medical education expansion. * Faculty numbers surged: the average medical school grew from 50 faculty members in 1951 to over 250 by 1970.
Revenue Models: * In 1947, medical schools generated $70,000,000$ in revenue. * By 1970, revenue reached $1,900,000,000$ . * Research grants became the primary source of funding, while tuition became increasingly insignificant as a revenue stream.

Hospitalization Trends: By the 1950s, $75\%$ of Americans had stayed in a hospital at least once, and $50\%$ had stayed two or more times. By 1960, nearly all births in the US took place in hospitals.
Nursing Homes: * Originally expanding in the 1930s due to Social Security (helping the elderly avoid "poor houses"), they grew further in the 1950s. * A functional divide emerged: hospitals focused on acute care, while nursing homes provided chronic medical care for the elderly.

Political Context: The Democratic Party saw overwhelming election victories in 1964, dominating Congress and electing Lyndon Johnson as President.
Creation of 1965: * Medicare: Provided health insurance for all individuals aged 65 and over. * Medicaid: Provided insurance for individuals with incomes below the poverty line. * These programs vastly expanded the availability of nursing home beds by providing reliable funding.
General Insurance Growth: * $12,000,000$ Americans had health insurance in 1940. * $76,000,000$ Americans had health insurance in 1950. * Over $153,000,000$ Americans had health insurance in 1965.

Dramatic Declines in Death Rates: * Polio, Whooping Cough, and Dysentery: Nearly $100\%$ * Syphilis: $95\%$ * Tuberculosis: $88\%$ * Hypertensive heart disease: $78\%$ * Kidney disease: $76\%$ * Maternal death during childbirth: $73\%$ * Appendicitis: $72\%$