Hank Johnson Healthcare Forum

Given the Blue Ribbon set of panelists [CEO of Grady, etc.] I hope partisans don’t show their butt and make a spectacle at this forum. That would be anti-productive.

Here are the thoughts of a 40 year med school professor: Eliot Gardner

Please permit a medical school professor with 40 years of experience in the field to make a few observations:

1) By EVERY objective measure (longevity, infant mortality rates, life years without significant illness, cost to society as a percentage of GDP), our system of heath care is the absolute WORST of all economically developed nations. One doesn’t even need to compare us to other economically developed nations. Hell, Brazil and China have superior neonatal care than we do, and superior childhood immunization rates.

2) Yes, in every nation with a national health care system (whether the ultra free-market Canadian system or the ultra socialized medicine systems of Ireland and the UK, and all gradations in between), practice liability IS greatly diminished by a tort-averse legal system or by actual legal limits on malpractice awards or simply by far fewer malpractice lawsuits even in countries that don’t have tort-averse legal systems.

3) One of the reasons that there are far fewer malpractice lawsuits is that the QUALITY of medical care in those countries is SUPERIOR to ours. Yes, I know that’s hard to swallow for knee-jerk ultra conservatives who believe – as an absolute article of faith – that anything American must perforce be superior. But by all objective criteria and data, it’s true. And why is it true?

Because medical training in all developed countries outside North America is MUCH longer than it is here. The American 4-year-long medical school curriculum developed out of the Flexner Report – a report prepared in 1910 by a special investigatory commission under the aegis of the Carnegie Foundation.

The commission was charged with identifying the best model for medical training. Mind you, this was at a time when there were 1-year medical schools, 2-year medical schools, 3-year medical schools, and a few 4-year medical schools. Hell, in many American states, one didn’t even need to attend medical school to legally practice medicine. All that was required was to “read medicine” for a minimum of 6 months.

“Reading medicine” meant hanging around with a practicing physician for 6 months, reading the books in his medical library (often only 2 books – “Gray’s Anatomy” and “Materia Medica”), being at his side when he examined patients and made diagnoses, and being at his side when he treated patients. It was modeled on the apprenticeship concept. After as few as 6 months, the doctor would send a letter to the State Medical Society stipulating that “John Doe has successfully read medicine in my practice.”

And, hey presto, back would come a diploma awarding the M.D. degree to John Doe, who then became a practicing physician himself. Needless to say, American medical education in those days was a shambles. Most American physicians were flat-out incompetent. Many of the 1-year and 2-year medical schools were Mom-and-Pop operations with inadequate (or no) facilities and teaching that was of a pathetically low level.

Basically, American medical schools were “proprietary” in free-market terms – small trade schools owned by one or more doctors, unaffiliated with a college or university, and run to make a profit. The average length of study (post high school) was only 2 years. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training left a lot to be desired.

The regulation of the medical profession by state government was minimal or nonexistent. American doctors varied enormously in their scientific understanding of human physiology, and the word “quack” flourished. And people were well aware of this reality. Back then, there was a 2-year medical school in Boston with the grand name of “The College of Physicians and Surgeons of Boston”, which was commonly referred to as the “Butcher Shop.”

The Flexner Commission investigated and deliberated for 2 full years before issuing its report. Flexner himself was the child of German immigrants, and had studied and traveled in Europe. He well knew that no one could practice medicine in continental Europe without having undergone extensive specialized university-based medical education. The Flexner Report was scathing. It stated that approximately 90% of American medical schools delivered “substandard” education and turned out “ill-trained and incompetent” graduates. The report pulled no punches.

For example, it described Chicago’s 14 medical schools as “a disgrace to the State whose laws permit their existence… indescribably foul… the plague spot of the nation.” However, some schools received praise for excellent performance, including Harvard, McGill, the University of Toronto, Western Reserve, and most especially Johns Hopkins – which was described as “the model for medical education.” The ONE commonality amongst all the best medical schools was the length of their curricula – 4 years of undergraduate premedical training, 4 years of medical school, 1 year of internship, and 3 years of residency. So that’s what the Flexner Commission recommended.

In effect, it demanded that American medical education conform to prevailing practice in continental Europe. And slowly, over the next 15 years, the 4-year medical school curriculum was made mandatory (by law) as state after state after state adopted the recommendations of the Flexner Report. Of course, knee-jerk free-market radicals unleashed a torrent of hatred and bile against state regulation of medical curricula, even engaging in such anti-Semitic smear tactics as calling the Flexner Report a “Jewish Plot” to destroy the free-market system of educational enterprise in this country.

So, anyway, that’s how the American 4-year medical school curriculum came into being. Approximately 80% of all American medical schools closed their doors and went out of existence because they could not meet the standards set out by the Flexner Report. Now, that was a full century ago. One hell of a LOT of new knowledge has emerged in medicine since 1910. Whole new fields and specializations have emerged. Whole new technologies have emerged. And all of this new stuff is ESSENTIAL to the competent practice of modern medicine.

Yet, here in America, we still hold fast to the 4-year medical curriculum. While all the rest of the world has radically extended the length of medical school – in order to allow students the time to absorb all of the essentials of modern medicine.

In Europe and in other economically developed nations, medical school is a minimum of 6 years long. In some countries, 7 years. In some countries, 8 years. As a result, European medical graduates are FAR more competent than American medical graduates. I saw this with my own eyes while on faculty at Albert Einstein Medical School in NYC for 33 years. I accepted both American and European medical students into my research group at Albert Einstein for research electives in neurology and neuroscience.

Without exception, the European students (often in their 7th year of medical school, out of an 8-year-long curriculum) were FAR better educated and FAR more competent than the American students. Many of the European medical students were BETTER at diagnosis and treatment than the American medical RESIDENTS (already 3 or 4 years past medical school) that I supervised. So, European physicians are by-and-large better physicians than American ones. And this translates very directly into better medical care. Hence, far fewer medical f***-ups. Hence, far fewer malpractice claims. Also, far less “defensive medicine.” Hence, lower costs.

4) Yes, in every nation with a national health care system, medical school is either free or involves minimal fees. So, yes, physicians in those countries enter into their careers with little or no debt burden.

5) Yes, in every nation with a national health care system, billing of physician charges and payment to physicians is electronic. Hence, no need for the extraordinarily high nonmedical personnel payroll expenses that burden American physicians. In Canada, most physicians or group medical practices have only a SINGLE receptionist. ONE.

6) Calling the AMA “the Union” is utter nonsense. Over the decades, the AMA has adopted such rigidly conservative right-wing knee-jerk positions that it has alienated virtually the entire medical profession. At present, fewer than 15% of practicing American physicians belong to the AMA. Most physicians consider the AMA to be a pathetic irrelevancy. And many are more scathing in their views.

7) Medical school reforms are NOT the province of the AMA. The AMA has almost to do with setting medical school standards. That task falls upon the shoulders of the Association of American Medical Colleges (AAMC), and specifically on the Liaison Committee on Medical Education (LCME). Also upon state Commissions of Higher Education. The AAMC has no objection to free medical education in this country free (i.e., paid for by the government). After all, many existing state government-run medical schools (e.g., University of Massachusetts Medical School, Pennsylvania State University School of Medicine, University of Alabama School of Medicine) have tuition and fee schedules that are only a fraction of those at private medical schools. State tax dollars pay the bulk of the costs of educating students at state medical schools. The AAMC has absolutely no objection to this.

Now here’s a really radical suggestion. Why do we need to reinvent the wheel? SCORES of countries in the economically developed world have evolved medical care systems that are patently superior to ours. Why not just choose one and copy it? Or does that make too much f***g sense?

Eliot Gardner