Lecture Fourteen: Where are We Now?

The first half of American Medical History ends at the Flexner Report, which entirely morphed American Healthcare into a monolithic corporate entity under the complete control of the AMA.  Every aspect of healthcare transformed, from education, to payment, to philosophy, to licensing, to dogma.  The Medical Racial Script, long unspoken and oft ignored, became the law of the land.  What are the repercussions of Flexner today?  We will discuss some of the ramifications of the AMA's cooptation, and the corporate ownership of, healthcare before moving on two the second part of the course.

Transcript

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So let's talk about how this all kind of played out as we moved into the 20th century. And there's so much more to this story to tell because once the AMA grabbed hold of power, it wielded that power quite effectively for many, many years. It took pretty much until the 20th century for the AMA to start to fall apart and be replaced by other organizations which exist today, mostly specialty societies, which, by the way, are among the largest lobbyists in Congress, and also federal societies and patient advocacy groups, such as the Alzheimer Association, the Diabetic Association. And the connection between those groups and organized medicine and the pharmaceutical interests is they're all meshed. Married academic medicine, which is now a bastion of pharmaceutical funding. There is barely, whereas back then Rockefeller and Carnegie kept these schools afloat. The pharmaceutical industry is keeping most American medical schools afloat. There's not a medical school in the country. I actually went to Brown University undergraduate and I spoke with a doctor there about 10 years ago, and he said they were the last to fall to accept pharmaceutical funding for all their research. That's where research comes from. If there's a little bit done in the NIH, but most of it's done in universities through the largest pharmaceutical companies. The pharmaceutical companies actually script the studies, they pay the money for them. If they don't like the outcomes, they don't publish them. And organized medicine today are primarily specialty medical societies, like I said, and we are in the era of specialties. While in the era of Osler and Flexner, uh the ratio was probably about 80-20, 80% generalists, primary care doctors, uh 20% specialists, with which both Osler and Flexner believed was the correct ratio, and which today is the correct ratio in most of the world. In our country, it's flipped, so we have about 80% specialty care and about 20% primary care, because that the actual evolution of this type of system favors specialty care. Because what do we create? The AMA created a system based on the German model and the eugenic framework. Remember what eugenics, taking apart the racial aspect of it, um that there was a philosophy, also, again, the guy who said the human body is as measurable as a bar of steel fit well into this niche German ideology that we just have to test, test, test, treat, treat, treat. So again, the patient has been removed from the equation. The idea of doing a lot of tests and defining a bunch of norms is crucial. And those norms will change over time. The more people are sick with these numerical diseases that we have created through this system of measurement and testing. The more people need to see doctors, primarily specialists, the more they are treated, the more they are treated with drugs, procedures, more tests, more drugs, procedures, you get the picture. American medicine is now a $5 trillion operation, which is uh, you know, about eight times higher than the military budget. So this is all favored specialty care, and that's where we are now. Just to give you a nice sense of that through a disease that most people are familiar with, um, diabetes, back when I trained in the prehistoric ages, um, diabetic with someone with a sugar over 170. And honestly, most of the data, and I had read a lot of the data, um, showed that pretty much if if your sugar stayed under 200, you were okay. And again, we also understood that sugar was not the real issue. Um, we know that diabetes is insulin resistant, so it's a lot more, it's a lot more complicated. But in the flexner system, it's not complicated. There's a measurement. That measurement defines illness. If you are under 170, you're okay. If you're over 170, you're a diabetic. The nuances are erased by this very simple algorithm, again, much like eugenics, um, where people were put in a spectrum of moron or imbecile or mentally deficient, and those were there were cutoffs from the tests that put you in these categories. Now, with diabetes, the 170 became the norm. Ten years later, um, the American Diabetes Association, which is um almost entirely funded by the pharmaceutical industry, lowered it to 140. Um, and then in the early 200s, 2000s, I mean, it lowered it to 126. How it came up with 126, God only knows. And then they invented a new disease called prediabetes, which starts at 99. And it's estimated that about 70% of the popul adult population now has diabetes or prediabetes. Again, by changing the norms of what constitutes illness through this methodology of number, of everything being based on a number, you could change those numbers and make more people sick, more people need drugs, more people need to see specialist doctors. And by the way, in the case of diabetes, there are no studies to um to support these changes. There's not a single study to support these changes. In fact, the biggest diabetes studies, and there are about five of them, um, would support the higher numbers. But these changes were created by expert opinion in the um specialty uh arena, the both American Endocrine Society and the American Diabetes Association. Expert opinion is directly from the German model that the AMA adopted. No longer do we have to have evidence if experts agree on things. And most of the protocols that doctors look at now are expert opinion protocols. Um, and if certain I know people who have been on these expert panels, and when they don't agree with the other experts, they are simply erased from the panel and uh a unanimous decision is reached. It's pretty incredible. But again, this is our healthcare system, and we could see where it came from. The racial part kind of morphed into the German idea of number fixing. So that would that was one aspect of what happened to our healthcare system. We are a numerical-based healthcare system. Most of you listening to this, uh, most of America thinks that's pretty normal. Of course. We go to the doctor, we get a bunch of tests, they tell the people they're sick. But again, this wasn't the norm through most of history. The norm is the patient said they weren't feeling well. The doctor tried to figure out why. The doctor did some things to the patient, mostly through diet and exercise and herbal treatments. And if the patient would tell the doctor when they were better. Now, the doctor tells the patient when they're sick, oh, your cholesterol's high, your sugar's high, you got some blockages here or there, you got stage three renal disease. The doctor tells the patient might be feeling fine. The doctor will then prescribe treatments, it could be procedures, it could be medicines. The patient may feel worse on these treatments, but their numbers will get better, hence, they are cured. It's very different than what was there, and that all came from this major revolution uh that has started in 1900 and that became completely um normalized by the AMA's ascension to power. So that's one aspect of what happened to American medicine. The second aspect is the AMA's power itself, and this should not be discounted. The AMA ruled the roost for almost a hundred years. And by ruling the roost, it not only controlled American doctors, their education, their practice, whether they were licensed, what they were supposed to think and say, but also had such powerful lobbying interests that they were able to control the press, they were able to control Congress. They were the progressive organization who then became anti-progressive. They became a bulwark of protecting doctors, which was really their purpose from the beginning. They were a doctor trade association. So, for instance, you could see debates about health insurance starting in the 1920s, again in the 50s, under Truman, um again under Lyndon Johnson when they actually got through Medicare and Medicaid. Ultimately, the AMA fought it vehemently, and then compromises were made that actually helped the reimbursement of doctors, so the AMA supported it. Then you had the Clinton healthcare system, which it attacked, um, Obamacare, which again it became part of the discussion that doctors would benefit. So it was involved. Every health insurance discussion was impacted by what the AMA would say. And reading through JOM articles during this time, and I have, um, shows you their power. That they controlled the press and Congress. Um, they gave a lot of money, they lobbied intensively, and they were excellent at advertising. Um, anytime uh some group decided that things should be different, that you know we we need patient input, uh, that you know insurance companies were were giving too much uh power to the patient, that that the AMA had an answer to that. So, for instance, if an insurance company felt that a certain procedure was not um what was not shown to be beneficial and then it was not gonna pay for it, the AMA will get on TV with doctors, show some poor sap of a patient dying, and say, look at this, this patient's gonna die because the insurance company is getting between you and your doctor. Very effective advertising. It's still done today, but not by the AMA, but by specialty medical groups. Watch TV and you will see in between all the drug ads, you'll see that. So you pretty much had to be part of the AMA to be a doctor in this country. Um almost immediately, the the AMA membership grew. And even by um 1920, about 60% of doctors who were orthodox and white were AMA members, and that became important. By the 1950s, and there was this great document written by Yale Law School talking about the power of the AMA, their disciplinary power, their ability to control what doctors said and thought, suggested that the number of white male Orthodox doctors belonging to the AMA was somewhere between 80 and 100 percent. This became something you did. Orthodox medicine started as a pre-med where you had to take certain tests, um, which were basically regurgitation tests, not thoughtful critical thinking tests, not tests with nuance, but one right answer, again, with the German model. Get into medical school, you follow a curriculum that was the same at every school in the country with tiny variations, um, based on the same German model that was created uh in 1911 and which today still exists. There's very little um variation in the medical school curricula, and it's the same model that was uh derived from the Flexner report. And then you became you did your internship in residency at an approved hospital, and then you you became a doctor and followed the protocols that the AMA and other groups told you that you must follow. So it's um you know, it's again something that uh seems almost obvious when you look at it today, but looking back at the history, you see where it came from and the power of one organization uh that were that married itself to corporate interest and to academia to create a bohumath that um changed healthcare entirely. And what happened to the African Americans? Um, and we could again, like I said, we could talk about women, Native Americans, uh, Mexicans, Chinese, Japanese, we could talk about Jews. I did a paper on Jewish exclusion uh from this um system, but we'll talk about African Americans so because we have already. So again, the the African Americans uh were put in a corner. They they had to play by the rules and try their best to get funding, to get any kind of uh credentialing, um, status, money, very difficult. I mean, after Flexner and all the way through uh much of the century, African-American doctors and institutions had to beg, plead, borrow, and ultimately devise their own solution to the many barriers enacted by AMA policies and by the AMA's complete disregard for them. Um, not much is written about this. It's really interesting because when you look at the late 1800s, starting with the Civil War, right up until about the Flexon Report, there are so many articles and books written by African-American doctors. They tend to be very optimistic, very hopeful. Things are getting better. Um, during this period, I I scoured the literature. Nothing's written. African-American doctors are silent. You get these articles in the NMA journal that are very bland and basically meant to educate African-American doctors not to discuss anything else going on. And we have very little insight into what was going on other than these few snippets. But we do know that when you are powerless, you cannot control what happens to your own people, and that was certainly the case. I mean, we we had this was the era of forced sterilization. Again, eugenics was quite emphatic about sterilizing people, so that as Supreme Court Justice Oliver Wendell Holmes stated, we don't need any more generations of morons. So anyone who is considered a moron or had some kind of disease could be forcibly sterilized. In this country, we sterilized about a hundred thousand people total. Um, but we also went other places, like in Puerto Rico, the birth control movement, uh, Margaret Sanger leading it, uh, sterilized a third of the women in Puerto Rico over a short period of time without telling them what they were doing. Basically, as research, because they didn't want to do it on white people. Much of the research was done on minorities. And similarly, minorities were um controlled by public health. The immigration was controlled by public health, and also public health determined if a certain group was dangerous, even if the laws did not allow for segregation or expulsion, the public health department could, and this all came from AMA logic. Um tens of thousands of Mexican Americans were expelled uh during the Depression because people didn't want them there. Many of them had been there long before there was an America, and they were expelled not by laws which could not do that, but by public health who claimed that they were dangerous, they were disease spreaders, all the stuff that we had heard through the medical racial script. Many people have heard um about the uh Tuskegee syphilis experiment, which occurred at Suffolky Tuskey Institute. It was actually uh started in 1932 and then went to 1972. And it's important to know that um this experiment, which basically uh allowed a group of African Americans to uh to who had syphilis to basically not get treated, to to watch them suffer and die so they could learn about syphilis over a short period of time. I'm sorry, a long period of time. And this occurred um uh even when treatment was available. So eventually the story broke in 1972 by I think someone in the New York Times or Washington Post who saw what was going on and broke it, and it became really that that the the trigger that changed everything and then opened some eyes, and medical civil rights had already begun, but this really um created uh an idea that yeah, that the African Americans have no power and they can control this. What's important is um Tusky Institute's president, Robert Morton, and its medical director, Dr. Eugene Dibble, very well-respected people are the ones who endorsed this study. And they played major roles, as well as African-American nurses and doctors, in uh in orchestrating the study for all this time. Um and the NMA, National Medical Association, strongly endorsed the study as well. Why? I mean, an NMA article, an NMA editorial wrote that the study um would direct needed federal and corporate funds to the African-American institutions that were conducting the study, enhance the status of these institutions, especially Tusky itself, and fermenting research and focusing, quote, the objective gaze of science on the health conditions of African Americans while improving the reputation of African American health professionals. African-American doctors did not directly challenge the status quo because they understood their subordinate position within the healthcare infrastructure. And they had to defend the status quo and the NMA, even as they pleaded for a small place of the table, sometimes a place of the table that was self-destructive, as in this particular experiment. Without any power influence, but with a strong desire to grow and prosper, African Americans after Flexner had a bend to even self-destructive acts merely to survive. So again, you're gonna get a sense of that in the in the piece you read. And uh in the Duffy piece, you're gonna see what what I think a very uh smart author writes about um the legacy of Flexner, a legacy that has not changed. I read lots of pieces from the uh um later 1900s, 1960s, 70s, uh by by reformers, healthcare reformers, talking about how they were gonna change Flexner, where they were gonna revamp the system. But it's really hard when the system is buttressed by so much money, by such strong institutional uh power, uh, and and by ultimately the government. And uh the govern the system that exists now is very profitable for a large number of people, and it is very doubtful that it's gonna change, and all that is attributable to the AMA's rise during this time um between uh its creation and about 1920. So that's the basic story of the early healthcare system. Uh as you can imagine, the second part of the story is really interesting. How the AMA wielded its power, how people fought back, or what the health of what did the health of our nation um benefit from this? I mean, there's no doubt longevity improved early on, but did that have anything to do with doctors and what doctors did? We could argue that the biggest leap in longevity uh was related to the invention of antibiotics, the idea of understanding hygiene, i.e., you don't drink water someone's pooped in, sterile technique, better surgical techniques, and also better um uh uh maternal care and delivery. Once kids weren't dying, and once women, young women weren't dying, longevity increased. And honestly, after that increase, there hasn't been much more of an increase. In fact, in the last 25 years, the um healthcare system went from a half trillion dollar industry to a five trillion dollar industry, and during that time longevity went down, chronic illness went up. Well, of course, chronic illness went up because we're defining chronic illness more broadly. Everyone's got something now. Um, everyone to see a doctor, get tests, and get medicines. And again, this this is where we have come. Whether that's a good thing or not, whether all this research that is being done by pharmaceutical companies is a good thing or not, uh, is really not even the point of talking about it. It's just the idea of where it came from that's really important. And you can't understand where it is until you see where it was and how it got here, which I hope you guys learned a little about during this course. And I hope the books you read, um, and I hope some of the books, like you know, are more more um about the modern healthcare system. And I just want you to kind of look back and and see how what's here now is related to what we talked about, and some are books from this period of time we talked about to look at a broader spectrum. So I I do think that that um there's so much to learn even beyond this course and a lot of the readings and books I hope you find interesting and keep on learning because it's really important you understand the past if you really want to know where we are now. Thank you so much.