History of Medicine

1. History of Medicine

2. Key Issues • Scientific medicine is about 120 years old • Technology based medicine is less than 50 years old • Health care finance shapes medical care and is a huge mess • There is no stable model for medical businesses, leading to constant change and unending legal problems

3. The Profession - Through the 1860s • Going to hospital or doctor increased the chance you would die • Dangerous treatments and no sanitation • Paris physicians prided themselves on dirty uniforms

4. Critical Dates in Medicine

5. 1400s • Birth of Hospitals • Places where nuns took care of the dying • No medical care – against the Church’s teachings • No sanitation – assured you would die

6. Early 16th Century • Paracelsus • Transition From Alchemy

7. Mid 16th Century • Andreas Vesalius • Accurate Anatomy

8. Early 17th Century • William Harvey • Blood Circulation – the body is dynamic, not static

9. 1800 • Edward Jenner • Smallpox and the notion of vaccination

10. 1846 • William Morton - Ether Anesthesia

11. 1849 • Semmelweis • Childbed Fever and sanitation • Controlled Studies

12. 1854 • John Snow • Proved Cholera Is Waterborne • Basis of the public sanitation movement

13. 1860-1880s • Louis Pasteur • Scientific Method • Simple Germ Theory • Vaccination For Rabies • Pasteurization to kill bacteria in milk

14. 1867-1880 • Joseph Lister • Antisepsis – surgeons should wash their hands and everything else, then use disinfectants • Listerine

15. 1880s • Koch • Modern Germ Theory • Organic Chemistry • Birth of the modern drug business

16. 1850s - 1900s • Sanitation Movement - Modern Public Health

17. Schools of Practice - Pre-Science (1800s) • Allopathy • Opposite Actions • Toxic and Nasty • Homeopathy • Same Action as the Disease Symptoms • Tiny Doses • Less Dangerous • Naturopaths, Chiropractors, Osteopaths, and Several Other Schools

18. Legal Consequences • No Testimony Across Schools of Practice • Different from Medical Specialties • Surgery, Internal Medicine, Pediatrics • All Same School of Practice - Allopathy • All Same License • Cross-Specialty Testimony Allowed • Still important with the rise of alternative/quack medicine

19. Most Medical Schools are Diploma Mills • No Bar to Entry to Profession • Small Number of Urban Physicians are Rich • Most Physicians are Poor • Cannot Make Capital Investments • Training • Medical Equipment and Staff • Physicians Push for State Regulation to create a monopoly

20. Transition to Modern Medicine and Surgery

21. Surgery Starts to Work in the 1880s • Surgery Can Be Precise - Anesthesia • Patients Do Not Get Infected - Antisepsis

22. Licensing and Education • Once there are objective differences (people live) between qualified and unqualified docs, people care • You can make more money with better training • You can make more money with better equipment and facilities • Licensing starts to make sense when there is a reason to differentiate between practitioners

23. The Business of Medicine • Mid to Late 1800s • Physicians are Solo Practitioners • Most Make Little Money • Have Limited Respect • Effective Medicine Drives Licensing • Licensing Limits Competition • Physicians Start to Make Money

24. Hospital-Based Medicine • Started With Surgery • Medical Laboratories • Bacteriology • Microanatomy • Radiology • Services and Sanitation Attract Patients • Internal Medicine • Obstetrics Patients

25. Post WW II Technology • Ventilators (Polio) • Electronic Monitors • Intensive Care • Hospitals Shift From Hotel Services to Technology Oriented Nursing

26. Post World War II Medicine • Conquering Microbial Diseases • Vaccines • Antibiotics • Chronic Diseases • Better Drugs • Better Studies • Childhood Leukemia

27. Corporate Practice of Medicine • Physicians Working for Non-physicians • Concerns About Professional Judgment • Cases From 1920 Read Like the Headlines • Banned In Most States • Real Concern Was Laymen Making Money off Physicians

28. Physician Practices • Shaped by Corporate Practice Laws • Sole Proprietorships • Partnerships • Mostly Small • Some Large Groups • First Organized As Partnerships • Then As Professional Corporations

29. Impact of Corporate Bans • Physicians Do Not Work for Non-Governmental Hospitals • Contracts Governed by Medical Staff Bylaws • Sham of “Buying” Practices • Physicians Contract With Most Institutions • Charade of Captive Physician Groups • Managed Care Companies Contact With Group • Group Enforces Managed Care Company’s Rules • Physicians Can Be As Ruthless As Anyone

30. Hospital Staff Privileges • Physicians are Independent Contractors • Hospitals Are Not Vicariously Liable for Independent Contractor Physicians • Hospitals Are Liable for Negligent Credentialing and Negligent Retention • Hospitals Can Be Liable if the Physician is an Ostensible Agent

31. Hospitals Shift From Nuns to Paid Staff

32. Old Days • Charitable Immunity • No Independent Liability for Nurses • No Liability for Physician malpractice

33. Reformation of Hospitals • Paralleled Changes in the Medical Profession • Began in the 1880s • Shift From Religious to Secular • Began in the Midwest and West • Not As Many Established Religious Hospitals • Today, Religious Orders Still Control A Majority of Hospitals

34. After Professionalization • Demise of Charitable Immunity • Liability for Nursing Staff • Negligent Selection and Retention Liability for Medical Staff

35. Joint Commission on Accreditation of Hospitals • 1950s • Now Joint Commission on Accreditation of Health Care Organizations • American College of Surgeons and American Hospital Association • Split The Power In Hospitals • Medical Staff Controls Medical Staff • Administrators Control Everything Else • Enforced By Accreditation

36. Contemporary Hospital Organization • Classic Corporate Organizations • CEO • Board of Trustees Has Final Authority • Part of Conglomerate • Medical Staff Committees • Tied To Corporation by Bylaws • Headed by Medical Director • Constant Conflict of Interest/Antitrust Issues

37. Medical Staff Bylaws • Contract Between Physicians and Hospital • Not Like the Bylaws of a Business • Selection Criteria • Contractual Due Process For Termination • Negotiated Between Medical Staff and Hospital Board

38. Hospital Economics • Old Days • More Patients Meant More Money • More Docs to Admit Patients • Insurance Was So Generous It Cross-subsidized Indigent Care • Now • Insurance and Government Pay is Very Limited - No Cross-Subsidy • Under-Insured or Over-Cared-For Patients Cost Money

39. Managed Care Pressures on Hospitals • DRGs • Capitation • Negotiated Reimbursement • Still Need Butts in Beds • Must Get Them Out Quick and Cheap • Death Can Be Very Cheap • Right to Die – Yes Please Do!!

40. Managed Care Pressures on Docs • When is Denying Care Cheaper? • What is the Timeframe Issue? • Insurers Now Control the Patients • Employee Model • Contractor Model • De-selection • Financial Death • No Due Process