The «Golden Age of Medicine»
During and after World War II, scientific and clinical advances enabled doctors to treat a wide range of fatal or debilitating disorders. Patients revered them and they had a free hand to practice medicine as they thought best. «This was truly the golden age of modern medicine,» Aasland notes, «a period where everything seemed possible» (4). But in the 1960s, Beecher’s article and the thalidomide affair documented how medical hubris could wreak havoc on the lives of trusting patients and how professional arrogance led to abuses. In the 1980s, it became clear that individual autonomy had led to large variations in how individual clinicians treated patients with the same kinds of disorders, and to unnecessary hospitalization, surgery, tests and prescriptions (7, 8). Reports of excesses appeared in the late 1960s and early 1970s.
Many practitioners regard this postwar period as the golden age of medicine, because they could practice as they liked. But unrestrained growth in utilization, variation and charges also made this an age of gold for doctors and hospitals. Its benefits to patients were mixed with excessive procedures that induced unnecessary infections, accidents, diseases, and death. Dr. Robert McCleery, for example, organized law students under Ralph Nader to produce a report in 1971 that detailed the low quality of clinical work and injury to patients by ordinary physicians (in contrast to those celebrated in the press at the great medial centers) and the very limited ability of medical societies and state boards to do much about it (9). In 1972, Senator Abraham Ribicoff, who had been Secretary of Health, Education and Welfare, published The American Medical Machine and described its relentless ability to generate bills. «The 1960s and 1970s will be remembered as the years when the sky was the limit in medical costs and nobody seemed to make much headway controlling them,» he wrote (10). In Tulsa, Oklahoma, he found, medical debts accounted for 60 percent of all personal bankruptcies. In same year, Senator Ted Kennedy published his critique, In Critical Condition, based on testimony from citizens at hearings his committee held across the country (11). One listens in to patients bewildered about what their insurance policies covered and shocked at what expenses they did not cover. A wave of similar books followed. As Hernes wryly notes, the doctor, as the patient’s agent may have interests of his own, «possibly some that are in conflict with those of the principal…» (12)
A landmark study of this «golden age» was Profession of Medicine (13) by Eliot Freidson in 1970 and his companion volume with the more thematic title, Professional Dominance: The Social Structure of Medical Care (14). Surprisingly ahistorical, these works nevertheless described in detail the structural dominance of the profession in the United States and the resulting pathologies. Freidson concluded that an organized profession could not discipline itself effectively, in part because professional associations rely on dues and officers are elected, which limits a professional association’s ability to monitor or discipline its members. In other ways as well, they do not stand apart enough to serve as an inspectorate. Rosenthal documented the reasons why and foreshadowed the acute crisis of Britain’s General Medical Council and the intervention by the state to take over professional functions. Professional disciplinary bodies tend to respond slowly to evidence of even egregiously incompetent or abusive doctors, reluctant to discipline, secretive and protective in their non-disclosure to the victims or the public (15, 16). The tradition of professional courtesy, the emphasis on trust and respect, and the insistence on autonomy all assume that quality and practice are above question. Ironically, Freidson himself grounded his concept of professionalism on autonomy as its core, even though it did not sit well with his observations about individual autonomy as a barrier to professional quality. This led me to conclude years ago that accountability is the core attribute of professionalism and autonomy has been a substitute or a delegated form of accountability because systemic assessment of clinical work was not possible until the 1970s (6).
At the heart of the golden age of medicine were medical schools and their teaching hospitals, which in the Untied States grew rapidly to become academic medical centers and then academic health care complexes. Parallel to Freidson’s studies was a closely observed report on the aggressive empire building of academic medical centers in New York City (17). The American Health Empire described how they took over neighborhood hospitals and clinics in low income areas, closed them or reconfigured them, and used poor minority patients as «material» for clinical research or practice-teaching. This history has been described with more grace and circumspection in the later chapters of Kenneth Ludmerer’s Time to Heal (18). Other countries have quite different histories, but the question for them is whether similar dynamics of professional elitism led to fiefdoms of subspecialty medicine being built around medical schools and teaching hospitals and led the profession away from its core societal mission to maximize the well-being of populations, toward the excessive use of hospitals and subspecialty medicine and toward the large variations in quality and cost that results from individual autonomy?
Academic medical empires and what became known as «wallet biopsy» are extreme manifestations of professional dominance, unrestrained in the United States by a missing societal framework of service or concerns for equity. A Scottish doctor recently recounted his elective rotation as a student at a teaching hospital in South Carolina, where even in his untrained state he could tell that the specialists were ordering every test conceivable and performing every procedure possible on patients who could pay. But when he diagnosed a patient in the emergency room as having acute appendicitis and ordered surgery, his supervisor «diagnosed» that the patient had no insurance and ordered a taxi, laughing at the naivete of an overseas student who did not know how medicine is really practiced in the United States.
Outside of academic medical complexes, the pathologies of individual autonomy and organized professional dominance became increasingly apparent in the unfettered world of American medicine. In the 1970s, U.S.physicians incorporated their practices and turned them into businesses. Specialists pooled their earnings (known as «profits» in other lines of work) to build surgi-centers, specialty clinics, diagnostic centers and even for-profit hospitals. Then they referred their patients to them for scans, tests, or ambulatory surgery, thus doubling their profit streams but also their conflicts of interest (19, 20, 21). Outside investors began to take notice. They realized by the early 1970s that health care was a field with high profit margins and almost no rise. For-profit medicine took off. In 1980, Arnold Relman, the revered editor of the New England Journal of Medicine, published an influential essay, «The new medical-industrial complex» (22). What he failed to note, however, was that the medical profession had welcomed corporations into every other aspect of medicine except acute clinical services; so that the shock seems to have been that investors and capitalists moved into the one remaining sector. Physicians usually overlook their active role in creating the medical-industrial complex and the role of entrepreneurial physicians in commercializing hospital and specialty care.
The crisis of professionalism can be dated from the debates provoked by Freidson’s two books or from the international best-seller, Medical Nemesis: the Expropriation of Health (23) by Ivan Illich. He added «iatrogenesis» to the vocabulary of health policy as he documented from leading medical journals an «epidemic» of «doctor-made» sickness and injury from over-testing, excessive prescribing, unnecessary surgery and hospitalization. Illich concluded that «The pain, dysfunction, disability, and anguish resulting from technical medical intervention now rival the morbidity due to traffic and industrial accidents and even war-related activities, and make the impact of medicine one of the most rapidly spreading epidemics of our time» (p35).
This «epidemic» of medically inflicted damage, Illich observed, is not due to malpractice but to routine high-tech interventions. Occasional human error had been replaced with «system breakdown» in complex technological hospitals, he maintained. Medicalization was rampant. Drawing on clinical studies in major medical journals, Illich concluded that «Disabling non-diseases resulting from the medical treatment of non-existent diseases are on the increase,» (p.37 – 8). Thus society was inflicted with social introgensis, or the creation of medicalized life, in which everyone sees him- or herself as having a disorder.
Central to this process was the «pharmaceutical invasion» (70 – 75). Doctors allowed their clinical judgment to be compromised by prescribing the drugs sold by the companies who bought them favors or equipment or luxurious trips to seminars, where they could brush up their professional skills (24). Today, this commercialization of clinical judgment constitutes a deeper and more pervasive threat to professionalism than the «new medical industrial complex» of hospital and health care corporations.
Illich called for self-reliance, including self-diagnosis and self-treatment, and an end to the addictive craving for a therapeutic «fix». Many within the medical profession are not willing to go that far, and yet they need to discuss how even the best of medical interventions in the Golden Age produced millions of patients with long-term disabilities and chronic disorders. Illich provided a coherent account of why the medical profession was in trouble, how high error rates were built into its practices and hospitals and how doctors were becoming appendages to pharmaceutical companies. He described how all this was making patients dependent and weak, rather than more independent and strong, and why self-help and more natural forms of self-care were growing as an international social movement. Twenty years later, the Institute of Medicine caught up with one part of Illich – the systemic nature of medical errors in hospitals – but did not recognize the obvious links to professional autonomy or the commercialization of clinical judgment by an army of highly trained drug reps bearing billions in gifts (25).
Meantime, the Boston Women’s Collective published Our Bodies, Ourselves (26), a handbook of self-care that included detailed instructions and drawings to show women how to examine themselves without putting themselves in a position of dependency and perhaps humiliation by being examined by a doctor. A number of other books began to appear, such as home guides for self-diagnosis written by physicians. The movement for health foods, healthy living, and alternative medicine developed. The development of the internet has greatly increased the range of medical and technical knowledge available to people. As Hernes notes, «professions that before had a near monopoly of knowledge, in the future will be challenged – and provoked – more and more often by those who can access information they cannot themselves produce.» (11)
Significant advances since Illich wrote have increased the capacity of clinical interventions to improve and extend the lives of patients. Today, advances in clinical medicine are credited with about one-quarter to one-third of gains in reduced morbidity, mortality and disability since Illich wrote his diatribe (27, 28, 29, 30). At the same time, his themes have developed so fully into movements of organic, wholistic and alternate forms of health and care that his seminal works are largely forgotten and unread. The professional pathologies he identified, however, continue. The global pharmaceutical companies are medicalizing shyness and less-than-orgasmic sex as psychiatric disorders for which they offer chemical cures. Physicians are being coached by drug reps on how to prescribe chemical adjustments so that everyone feels good, is social gregarious and has great sex, every day of the year. No wonder a Jesuit, concerned about personal character and the soul, became alarmed. Massive addiction to prescription drugs is developing in the United States, such as Oxycontin, Percodan, Vicondin, MS-Contin, Demerol, Ritalin, Dexerdine, Valium, Xanax, Activan and their brand-name equivalents (31). All are approved and written by physicians, who each year in the United States have billions spent on them by representative from each of the large firms to bend their «independent» professional judgment towards the new, high-profit variations within each drug class (32). Would professional doctors not refuse to see these salesmen and take their gifts? This was a major recommendation by David Rothman in a recent analysis of medical professionalism (33).