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

Expansion of the Healthcare Workforce (1950–1969)

Between the mid-20th century and the late 1960s, the United States experienced a massive expansion in medical personnel.
In $1950$ , the U.S. healthcare landscape included approximately $232,000$ physicians and $375,000$ nurses.
By $1969$ , these numbers grew significantly to approximately $325,000$ physicians and $700,000$ nurses.
The rate of growth was not uniform across all roles; between $1955$ and $1965$ , the increase in the number of nurses and technical support personnel was $4$ times greater than the increase in the number of physicians.
By the late $1960s$ , the healthcare field had become a major employer in the United States, with over $3.7 \times 10^{6}$ workers (over $3.7$ million).

Rising Health Care Costs and Economic Shifts

The introduction of new medical technologies served as a primary driver in the dramatic increase in healthcare costs during this period.
Inflation trends show a significant disparity between general consumer prices and medical costs between $1950$ and $1970$ : * The general consumer price index (CPI) rose by $61.5\,\%$ . * Total health care costs increased by $124.7\,\%$ .
Detailed breakdowns of cost increases between $1950$ and $1970$ reveal specific pressures on the consumer: * Physician fees increased by $119.7\,\%$ . * Dentist fees increased by $86.7\,\%$ . * Hospital costs saw the most extreme surge, rising by $398.1\,\%$ .

Growing Medical Bureaucracy and Institutionalization

Following World War II, healthcare transitioned from decentralized care towards centralized large institutions.
The hospital solidified its position as the definitive center of medical care.
Physicians began to move away from the traditional "independent entrepreneurial model" of practice.
There was a notable shift toward private group practices; the percentage of physicians employed in such settings rose from $2.6\,\%$ in $1946$ to $12.8\,\%$ in $1969$ .

Specialization and the Shift in Primary Care

The post-World War II era was defined by a strong shift toward medical specialization.
By $1965$ , the status of General Practitioners (GPs) was in decline: * Only $37\,\%$ of physicians were General Practitioners. * Of those remaining GPs, $50\,\%$ were over the age of $65$ . * Among medical students in $1965$ , only $15\,\%$ planned to pursue a career as a General Practitioner.
Board certification in a specialty became a marker of professional prominence during the post-war period.
In $1969$ , the American Board of Family Practice was established. This effectively transformed "General Practice" into a certified specialization known as the Primary Care Specialist.
The role of the Primary Care Physician was redefined as an evaluator who would diagnose patients and then refer them to the appropriate specialists.
Under this new model, General Practitioners (now specialists in family practice) would no longer perform surgery or engage in medical procedures defined as the realm of other specialists.

Physician Shortages and Immigration Reform

By the $1950s$ , a significant labor shortage emerged in the medical field, with $25\,\%$ to $50\,\%$ of intern and resident vacancies at hospitals remaining unfilled annually.
To address these gaps, smaller hospitals and mental health facilities began recruiting foreign medical graduates.
A major legislative shift occurred in $1965$ when Congress radically changed U.S. immigration law.
This reform allowed tens of thousands of physicians from less developed nations in Asia to emigrate researchers to the United States to fill vacancies in the medical system.

Racial Discrimination and the Integration of Medicine

In $1950$ , while African Americans constituted approximately $10\,\%$ of the U.S. population, only $2.2\,\%$ of physicians were African American.
Institutionalized racism was prevalent in medical education; in $1956$ , only $28$ out of $80$ medical schools in the U.S. accepted African American applicants.
In the $1950s$ , African American physicians faced severe professional barriers, as many hospitals refused them internships, residencies, or hospital privileges.
Nonwhites were also systematically excluded from medical societies during this era.
The process of integration began in the early $1950s$ when President Eisenhower ordered the desegregation of Veterans Hospitals.
During the $1960s$ , court rulings mandated the integration of various medical facilities, including hospitals, nursing homes, and mental institutions.
A consequence of this integration was the decline and eventual disappearance of many "black hospitals" in the $1960s$ .

Public Perception and the Modernization of Practice

Public esteem for the medical profession peaked in the $1940s$ and $1950s$ , largely due to the increased efficacy of treatments such as antibiotics.
However, by the $1960s$ , public opinion began to decline. Factors contributing to this included: * Increased media coverage focusing on medical malpractice and neglect. * The rise of medical bureaucracy, which led patients to view physicians as distant, impersonal, and uncaring.
The traditional "country doctor" who made house calls became virtually extinct in the post-war era.
Rural areas suffered from a distinct shortage of physicians.
Physicians ceased making house calls due to time constraints and the increasing reliance on technological equipment housed in practices or hospitals.
As a result, by the $1960s$ , patients frequently sought basic, non-emergency medical care in hospital emergency rooms.

Evolution of Medical Education and Research

Acceptance into medical school became increasingly difficult after the war. The Medical College Admissions Test (MCAT) was introduced in $1948$ as a screening tool.
By $1956$ , only half ( $50\,\%$ ) of all applicants were admitted to any medical school.
Demographically, medical education remained largely exclusionary; as late as $1970$ , $90\,\%$ of all admitted medical students were male.
There was a significant physical expansion of medical education: * $6$ new medical schools opened in the $1950s$ . * $15$ new medical schools opened in the $1960s$ . * The Health Professions Educational Assistance Act was passed by Congress in $1963$ to provide federal funding for this expansion.
Existing schools grew internally; the average number of faculty members per medical school increased from $50$ in $1951$ to over $250$ by $1970$ .
The financial model of medical schools shifted from tuition-based to research-based revenue: * Total income for medical schools rose from approximately $\$70$ million in $1947$ to $\$1.9$ billion in $1970$ . * The majority of this funding was derived from research grants.

The Centrality of the Hospital and Nursing Homes

By the $1950s$ , the hospital was the undisputed center of the U.S. health care system.
Hospital usage statistics by $1950$ : * $75\,\%$ of Americans had stayed in a hospital at least once. * $50\,\%$ of Americans had stayed in a hospital two or more times.
Institutionalized childbirth became the norm; by $1960$ , virtually all births in the U.S. occurred within a hospital setting.
Nursing homes began expanding in the $1930s$ following the introduction of Social Security benefits, which gave the elderly more income.
By the $1950s$ , these facilities focused on elderly patients with chronic medical conditions.
The establishment of Medicare and Medicaid in $1965$ led to a massive expansion in the number of nursing home beds available.

The Great Society: Medicare and Medicaid

Following a landslide victory for the Democratic Party in the $1964$ elections and the reelection of President Lyndon Johnson, major healthcare legislation was enacted.
In $1965$ , the federal government created two landmark programs: * Medicare: Provides health insurance for all individuals aged $65$ and older. * Medicaid: Provides health insurance for individuals with incomes falling below the poverty line.
Health insurance coverage in general saw a massive spike: * $1940$ : $12$ million insured Americans. * $1950$ : Over $76$ million insured Americans. * $1965$ : Over $153$ million insured Americans.

Declining Death Rates (1949–1968)

Advancements in medicine led to dramatic declines in mortality for several conditions between $1949$ and $1968$ : * Polio: nearly $100\,\%$ decline. * Whooping Cough: nearly $100\,\%$ decline. * Dysentery: nearly $100\,\%$ decline. * Syphilis: $95\,\%$ decline. * Tuberculosis: $88\,\%$ decline. * Hypertensive heart disease: $78\,\%$ decline. * Kidney diseases: $76\,\%$ decline. * Maternal death in birthing: $73\,\%$ decline. * Appendicitis: $72\,\%$ decline.