Opinion
VIEWPOINT
Victor R. Fuchs, PhD Stanford University, Stanford, California. Mark R. Cullen, MD Stanford University, Stanford, California.
Corresponding Author: Victor R. Fuchs, PhD, Stanford University, 366 Galvez St, Stanford, CA 94305-6015 (vfuchs @stanford.edu).
The Transformation of US Physicians (GDP) per capita increased only 2.3% per annum. A gap of this magnitude was not sustainable. In the early 1990s private and public payers of care responded with managed care. This marked the beginning of the most recent transformation, obscured temporarily by substantial objections later in the decade. However, soaring health care costs induced substantial concern throughout the economy, including their effect on the federal budget deficit; the desire to curb expenditure growth became paramount. Recently, the growth in health care expenditures has slowed, both absolutely and relative to GDP. From 1990 to 2013 the rate of increase of health care expenditures per capita, adjusted for inflation, declined to 3.1% per annum.5 This is partly explained by the slower growth of real GDP per capita of 1.6% per annum and partly by changes in medical care markets; the Affordable Care Act may have played a role. The causes of the substantial shifts in medical practice in recent years are reasonably clear, but the consequences for the medical profession less so. Most physicians and many thoughtful nonphysicians wonder whether the change from self-employed practitioners to salaried employees will adversely affect the professionalism of physicians. Preservation of the long-term societal trust of physicians and the special role physicians have in society may be at stake. Physicians might become less professional, but their professional role could increase as their entrepreneurial Preservation of the long-term societal role decreases. Several European health trust of physicians and the special role care systems (eg, Sweden) function at a physicians have in society may be high level, with no evidence that salaried physicians are less professional than at stake. their counterparts in the United States. father’s black bag “contained nothing but morphine and Arguably the professionalism of the patient-physician magic.” Doing well by doing good was not a realistic op- relationship depends on the extent to which, using tion for most physicians until after World War II. Boulding’s categories, it is an “exchange” system or an After that war a new transformation, powered by “integrative” system. In the former, the physician scientific advances, technologic innovations, specializa- provides service to the patient in exchange for a fee—an tion of practice, health insurance, and a booming post- impersonal commercial relationship similar to a stock war economy, created what some have termed a broker executing an investor’s order. An integrative sys“golden age” of medicine. Between 1950 and 1990 tem, according to Boulding, “involves… a whole raft of physicians became both more professional and more social institutions which defines roles in such a way that entrepreneurial. They provided (and sometimes you do things because of what you are and because of owned) expensive diagnostic and therapeutic tech- what I am.”6 In families and religious communities the nologies. A vast expansion of employer-sponsored integrative system is usually important; it also can be imhealth insurance and, after 1965, Medicare and Medic- portant in the patient-physician relationship absent the aid, made care seem, to the patient, largely free. entrepreneurial role. Expensive interventions sparked a demand for health The requisite knowledge for effective practice is insurance to pay for them, and the expansion of insur- also changing. An era in which physicians were trained ance fueled the demand for ever more expensive to “explore every intervention that might help a interventions.4 Health care expenditures per capita, patient regardless of cost” has given way to one in adjusted for inflation, increased at 4.8% per annum which published evidence and cost considerations between 1950 and 1990.5 Real gross domestic product must guide treatment choices. This will demand The current transformation of physicians in the United States—from self-employment to salaried employment, from fee-for-service to “bundled” or capitation payment, from providing acute care to providing chronic care, from inpatient to ambulatory settings, and from solo or small group practice to “team care”— complicates the future of the medical profession. The current transformation was preceded by 2 other major changes for US physicians. An early transformation, usually associated with the 1910 Flexner Report, began around 1900 by the Johns Hopkins School of Medicine and the activities of the American Medical Association.1 Criteria for admission to medical schools were raised, length of training increased, and standards for faculty were tightened. These innovations, plus stricter licensure laws, resulted in a decline in the number of physicians per 1000 population from 173 in 1900 to 125 in 1930. Hamilton summarized the results of the transformation in 1932, reporting that “An ancient and honorable craft had become a profession; the profession has lived on into an epoch in which it has had… to respond to the incentives of business [emphases added].”2 Medical practice became more of a business, but not a particularly lucrative one. Thomas3 wrote that his general practitioner father in Flushing, Long Island, worked long hours for a modest income and noted that his
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(Reprinted) JAMA May 12, 2015 Volume 313, Number 18
Copyright 2015 American Medical Association. All rights reserved.
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1821
Opinion Viewpoint
knowledge and skills (for example, more population health and health economics) different from those conveyed in the typical medical school curriculum. How well future physicians will serve the public will depend in part on how quickly and how thoughtfully academic medical centers adapt to these new challenges. Will the preclinical curriculum continue to be driven primarily by core principles of biology, or will new content achieve parity? Will rounds reflect the full mix of care providers or continue largely as physician-centric? Most importantly, will postgraduate training continue its traditional focus on acute care in an acute care setting? The record of academic centers in adapting to change is not encouraging. The most experienced observers have continuously lamented the failure of medical education to incorporate changes in medical practice. In 1977, Ebert, dean of the Harvard Medical School, deplored “how little change has taken place in the fundamental organization of medical education over the past half century.”7 Nine years later Rogers, former vice president for medical affairs at Johns Hopkins University, agreed: “in design and organization medical education of the 1930s was not significantly different from that of the 1980s.”8 Much the same could be said today. ARTICLE INFORMATION Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
The Practical Cogitator or The Thinker’s Anthology. Boston, MA: Houghton Mifflin;1945: 266. 3. Thomas L. The Youngest Science: Notes of a Medicine-Watcher. New York, NY: Viking Press; 1983:6.
1. Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982:118-121.
4. Weisbrod B. The health care quadrilemma: an essay on technological change, insurance, quality of care, and cost containment. J Econ Lit. 1991;29(2): 523-552.
2. Hamilton WH. The place of the physician in modern society. In: Curtis CP Jr, Greenslet F, eds.
5. Hartman M, Martin AB, Lassman D, Catlin A; National Health Expenditures Accounts Team.
REFERENCES
1822
In other sectors of the economy, competition from new firms forces established organizations to innovate or lose market share; consider, for example, the effect of Japanese car makers on US automobile firms. Medical schools, by contrast, have rarely faced pressure from new entrants, and when new schools are created, they are pressured to conform to existing structures and practices. The current transformation of US physicians arises for reasons largely beyond the control of the profession. Change is inevitable. The leaders of the profession, and especially the leaders in academic medical centers, must make the change as constructive as possible. There are some encouraging developments, such as the emergence of academic medical centers of research and training programs to supplement traditional preclinical and clinical experiences. An upsurge in student interest in the primary care specialties coincides with increased emphasis on ambulatory settings for postgraduate education. Most radical of all, the University of Texas at Austin proposes to create a medical school that will include population sciences as well as biological sciences and will train other health professionals alongside physicians. Perhaps the current transformation will have lasting favorable effects on the profession. National health spending in 2013: growth slows, remains in step with the overall economy. Health Aff (Millwood). 2015;34(1):150-160. 6. Boulding K. Three Faces of Power. Newbury Park, CA: SAGE Publications; 1989. 7. Ebert RH. Medical education at the peak of the era of experimental medicine. Daedalus. 1986;115 (2):55-81. 8. Rogers DE. The challenge of primary care. Daedalus. 1977;106(1):81-103.
JAMA May 12, 2015 Volume 313, Number 18 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
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VIEWPOINT
Victor R. Fuchs, PhD Stanford University, Stanford, California. Mark R. Cullen, MD Stanford University, Stanford, California.
Corresponding Author: Victor R. Fuchs, PhD, Stanford University, 366 Galvez St, Stanford, CA 94305-6015 (vfuchs @stanford.edu).
The Transformation of US Physicians (GDP) per capita increased only 2.3% per annum. A gap of this magnitude was not sustainable. In the early 1990s private and public payers of care responded with managed care. This marked the beginning of the most recent transformation, obscured temporarily by substantial objections later in the decade. However, soaring health care costs induced substantial concern throughout the economy, including their effect on the federal budget deficit; the desire to curb expenditure growth became paramount. Recently, the growth in health care expenditures has slowed, both absolutely and relative to GDP. From 1990 to 2013 the rate of increase of health care expenditures per capita, adjusted for inflation, declined to 3.1% per annum.5 This is partly explained by the slower growth of real GDP per capita of 1.6% per annum and partly by changes in medical care markets; the Affordable Care Act may have played a role. The causes of the substantial shifts in medical practice in recent years are reasonably clear, but the consequences for the medical profession less so. Most physicians and many thoughtful nonphysicians wonder whether the change from self-employed practitioners to salaried employees will adversely affect the professionalism of physicians. Preservation of the long-term societal trust of physicians and the special role physicians have in society may be at stake. Physicians might become less professional, but their professional role could increase as their entrepreneurial Preservation of the long-term societal role decreases. Several European health trust of physicians and the special role care systems (eg, Sweden) function at a physicians have in society may be high level, with no evidence that salaried physicians are less professional than at stake. their counterparts in the United States. father’s black bag “contained nothing but morphine and Arguably the professionalism of the patient-physician magic.” Doing well by doing good was not a realistic op- relationship depends on the extent to which, using tion for most physicians until after World War II. Boulding’s categories, it is an “exchange” system or an After that war a new transformation, powered by “integrative” system. In the former, the physician scientific advances, technologic innovations, specializa- provides service to the patient in exchange for a fee—an tion of practice, health insurance, and a booming post- impersonal commercial relationship similar to a stock war economy, created what some have termed a broker executing an investor’s order. An integrative sys“golden age” of medicine. Between 1950 and 1990 tem, according to Boulding, “involves… a whole raft of physicians became both more professional and more social institutions which defines roles in such a way that entrepreneurial. They provided (and sometimes you do things because of what you are and because of owned) expensive diagnostic and therapeutic tech- what I am.”6 In families and religious communities the nologies. A vast expansion of employer-sponsored integrative system is usually important; it also can be imhealth insurance and, after 1965, Medicare and Medic- portant in the patient-physician relationship absent the aid, made care seem, to the patient, largely free. entrepreneurial role. Expensive interventions sparked a demand for health The requisite knowledge for effective practice is insurance to pay for them, and the expansion of insur- also changing. An era in which physicians were trained ance fueled the demand for ever more expensive to “explore every intervention that might help a interventions.4 Health care expenditures per capita, patient regardless of cost” has given way to one in adjusted for inflation, increased at 4.8% per annum which published evidence and cost considerations between 1950 and 1990.5 Real gross domestic product must guide treatment choices. This will demand The current transformation of physicians in the United States—from self-employment to salaried employment, from fee-for-service to “bundled” or capitation payment, from providing acute care to providing chronic care, from inpatient to ambulatory settings, and from solo or small group practice to “team care”— complicates the future of the medical profession. The current transformation was preceded by 2 other major changes for US physicians. An early transformation, usually associated with the 1910 Flexner Report, began around 1900 by the Johns Hopkins School of Medicine and the activities of the American Medical Association.1 Criteria for admission to medical schools were raised, length of training increased, and standards for faculty were tightened. These innovations, plus stricter licensure laws, resulted in a decline in the number of physicians per 1000 population from 173 in 1900 to 125 in 1930. Hamilton summarized the results of the transformation in 1932, reporting that “An ancient and honorable craft had become a profession; the profession has lived on into an epoch in which it has had… to respond to the incentives of business [emphases added].”2 Medical practice became more of a business, but not a particularly lucrative one. Thomas3 wrote that his general practitioner father in Flushing, Long Island, worked long hours for a modest income and noted that his
jama.com
(Reprinted) JAMA May 12, 2015 Volume 313, Number 18
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ on 05/12/2015
1821
Opinion Viewpoint
knowledge and skills (for example, more population health and health economics) different from those conveyed in the typical medical school curriculum. How well future physicians will serve the public will depend in part on how quickly and how thoughtfully academic medical centers adapt to these new challenges. Will the preclinical curriculum continue to be driven primarily by core principles of biology, or will new content achieve parity? Will rounds reflect the full mix of care providers or continue largely as physician-centric? Most importantly, will postgraduate training continue its traditional focus on acute care in an acute care setting? The record of academic centers in adapting to change is not encouraging. The most experienced observers have continuously lamented the failure of medical education to incorporate changes in medical practice. In 1977, Ebert, dean of the Harvard Medical School, deplored “how little change has taken place in the fundamental organization of medical education over the past half century.”7 Nine years later Rogers, former vice president for medical affairs at Johns Hopkins University, agreed: “in design and organization medical education of the 1930s was not significantly different from that of the 1980s.”8 Much the same could be said today. ARTICLE INFORMATION Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
The Practical Cogitator or The Thinker’s Anthology. Boston, MA: Houghton Mifflin;1945: 266. 3. Thomas L. The Youngest Science: Notes of a Medicine-Watcher. New York, NY: Viking Press; 1983:6.
1. Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982:118-121.
4. Weisbrod B. The health care quadrilemma: an essay on technological change, insurance, quality of care, and cost containment. J Econ Lit. 1991;29(2): 523-552.
2. Hamilton WH. The place of the physician in modern society. In: Curtis CP Jr, Greenslet F, eds.
5. Hartman M, Martin AB, Lassman D, Catlin A; National Health Expenditures Accounts Team.
REFERENCES
1822
In other sectors of the economy, competition from new firms forces established organizations to innovate or lose market share; consider, for example, the effect of Japanese car makers on US automobile firms. Medical schools, by contrast, have rarely faced pressure from new entrants, and when new schools are created, they are pressured to conform to existing structures and practices. The current transformation of US physicians arises for reasons largely beyond the control of the profession. Change is inevitable. The leaders of the profession, and especially the leaders in academic medical centers, must make the change as constructive as possible. There are some encouraging developments, such as the emergence of academic medical centers of research and training programs to supplement traditional preclinical and clinical experiences. An upsurge in student interest in the primary care specialties coincides with increased emphasis on ambulatory settings for postgraduate education. Most radical of all, the University of Texas at Austin proposes to create a medical school that will include population sciences as well as biological sciences and will train other health professionals alongside physicians. Perhaps the current transformation will have lasting favorable effects on the profession. National health spending in 2013: growth slows, remains in step with the overall economy. Health Aff (Millwood). 2015;34(1):150-160. 6. Boulding K. Three Faces of Power. Newbury Park, CA: SAGE Publications; 1989. 7. Ebert RH. Medical education at the peak of the era of experimental medicine. Daedalus. 1986;115 (2):55-81. 8. Rogers DE. The challenge of primary care. Daedalus. 1977;106(1):81-103.
JAMA May 12, 2015 Volume 313, Number 18 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ on 05/12/2015
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