Medicine’s Professional Project. Important Themes Professional education Professional...

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Medicine’s Medicine’s Professional Professional Project Project

Transcript of Medicine’s Professional Project. Important Themes Professional education Professional...

Medicine’s Medicine’s Professional ProjectProfessional Project

Important ThemesImportant Themes

Professional educationProfessional education

Professional unificationProfessional unification

Professional authorityProfessional authority– State recognitionState recognition– External competitorsExternal competitors

Medieval university rejuvenated Medieval university rejuvenated scientific medicinescientific medicine

Free-standing medical schools prior Free-standing medical schools prior to 1200to 1200– Salerno, Italy (c. 1063)Salerno, Italy (c. 1063)– Montpellier, France (1137)Montpellier, France (1137)

1200 – 1350 CE1200 – 1350 CE– Universities created in Italy, Spain, Universities created in Italy, Spain,

France, & EnglandFrance, & England– Organs of the Catholic churchOrgans of the Catholic church– Focus on teaching of philosophy & Focus on teaching of philosophy &

theologytheology

Elite medical education moved into Elite medical education moved into the universitythe university

MD very prestigious degreeMD very prestigious degree At least 10 years of studyAt least 10 years of study Many physicians also clericsMany physicians also clerics

Focus was to connect medical Focus was to connect medical knowledge with philosophy and knowledge with philosophy and natural philosophynatural philosophy

Few graduatesFew graduates Only Catholics could enrolOnly Catholics could enrol

By end of 17By end of 17thth century, learned century, learned medicine in troublemedicine in trouble

Fall of Galenism & AristotlianismFall of Galenism & Aristotlianism

Several consequences of these Several consequences of these developmentsdevelopments

Belief that Galen had let theory run Belief that Galen had let theory run ahead of the factsahead of the facts

Perception that Hippocrates was Perception that Hippocrates was more empiricalmore empirical

Thomas SyndemhamThomas Syndemham– Known as the English HippocratesKnown as the English Hippocrates

Renewed focus on clinical instructionRenewed focus on clinical instruction

Developed in the NetherlandsDeveloped in the Netherlands Herman Boerhave (1668-1738)Herman Boerhave (1668-1738) Introduced bedside teaching at Introduced bedside teaching at

Leiden UniversityLeiden University Still a very small component of Still a very small component of

medical educationmedical education

Considerable impact on British Considerable impact on British medicinemedicine

Many non-Anglican medical students Many non-Anglican medical students studied in Hollandstudied in Holland

In Leiden, over half of students in In Leiden, over half of students in early 18early 18thth century were British century were British

Scientific curriculum also innovated Scientific curriculum also innovated by Boerhaaveby Boerhaave

Medical curriculum rooted in physics Medical curriculum rooted in physics & chemistry rather than Galen& chemistry rather than Galen

Textbooks authored by Boerhaave Textbooks authored by Boerhaave extended this innovation beyond extended this innovation beyond LeidenLeiden

Medical RegulationMedical Regulation

BritainBritain

Up to 1500 CEUp to 1500 CE State uninterested in regulating State uninterested in regulating

medical marketplacemedical marketplace

15111511 First medical practice act passedFirst medical practice act passed

Could only practice medicine if:Could only practice medicine if:– University graduate, orUniversity graduate, or– Obtained license from local bishopObtained license from local bishop

Limited impactLimited impact Provides some confirmation that Provides some confirmation that

learned physicians had some political learned physicians had some political authorityauthority

Physicians wanted to regulate Physicians wanted to regulate themselvesthemselves

Established a company or guild in Established a company or guild in 15181518

Re-named Royal College of Re-named Royal College of Physicians in 1551(RCP)Physicians in 1551(RCP)

Empowered physicians to license & Empowered physicians to license & control selvescontrol selves

Controlled medical practice within 7 Controlled medical practice within 7 miles of Londonmiles of London

Apothecaries made & sold drugs Apothecaries made & sold drugs prescribed by physiciansprescribed by physicians

Considered a tradeConsidered a trade Belonged to same guild as grocersBelonged to same guild as grocers Formed separate section of guild in Formed separate section of guild in

16011601

Separate Society of Apothecaries in Separate Society of Apothecaries in 16171617

May have been policed by RCPMay have been policed by RCP

Charter held by RCP not a monopolyCharter held by RCP not a monopoly

Legislation was contradictoryLegislation was contradictory Learned physicians were in minorityLearned physicians were in minority 1512 legislation unworkable1512 legislation unworkable

1542 “Quack’s Charter”1542 “Quack’s Charter”

Excepted from penalty “diverse honest Excepted from penalty “diverse honest persons, as well as men and women, persons, as well as men and women, whom God hath endowed with the whom God hath endowed with the knowledge of nature, kind and knowledge of nature, kind and operation of certain roots, herbs and operation of certain roots, herbs and water, and the using and ministering water, and the using and ministering of them to such as be pained with of them to such as be pained with customable disease”customable disease”

Restricted almost no one from Restricted almost no one from practising medicinepractising medicine

Physicians particularly incensed by Physicians particularly incensed by competition from apothecariescompetition from apothecaries

Could not stop them from giving Could not stop them from giving advice or prescribing based on that advice or prescribing based on that adviceadvice

Got legislation which stopped Got legislation which stopped apothecaries from giving free adviceapothecaries from giving free advice

Apothecaries responded by inflating Apothecaries responded by inflating the cost of drugsthe cost of drugs

Could retain business from the poor Could retain business from the poor as long as they were cheaper than as long as they were cheaper than physiciansphysicians

RCP then compelled members to RCP then compelled members to treat the poor freetreat the poor free

Founded dispensariesFounded dispensaries Didn’t workDidn’t work Took legal action against Took legal action against

apothecaries: the Rose Caseapothecaries: the Rose Case

RCP won initial case in lower courtsRCP won initial case in lower courts Lost 1704 appeal to the House of Lost 1704 appeal to the House of

LordsLords Decision eroded power of the CollegeDecision eroded power of the College Apothecaries had right to practice Apothecaries had right to practice

medicinemedicine Eventually became general Eventually became general

practitionerspractitioners

Surgeons also sought to upgrade Surgeons also sought to upgrade their statustheir status

Initially in guild with barbersInitially in guild with barbers 1540: Company of Barber-Surgeons1540: Company of Barber-Surgeons Permitted gradual separation of two Permitted gradual separation of two

groupsgroups 1745, two groups eventually split1745, two groups eventually split

In 19In 19thth century, changes in the century, changes in the medical profession intensifiedmedical profession intensified

1750-1900 a very low point in 1750-1900 a very low point in medicine’s fortunesmedicine’s fortunes

Divided amongst selfDivided amongst self Unable to enlist support of stateUnable to enlist support of state

FranceFrance

Abolition of pre-revolutionary Abolition of pre-revolutionary medical establishment – 1791medical establishment – 1791

Creation of medical free marketCreation of medical free market

Reintroduction of formal recognition Reintroduction of formal recognition because of military needsbecause of military needs– 1794: formal training1794: formal training– licensinglicensing

Would not recognize previous Would not recognize previous divisions within regular medicinedivisions within regular medicine

Same training & qualification for Same training & qualification for everyoneeveryone

Creation of subordinate practitionerCreation of subordinate practitioner– Officer of healthOfficer of health– Abolished 1893Abolished 1893

BritainBritain

Three branches of medicine Three branches of medicine continuedcontinued

SurgeonsSurgeons– Requirement for apprenticeship Requirement for apprenticeship

abolished 1945abolished 1945– Continued to be trained primarily by Continued to be trained primarily by

mentorsmentors– Education limited by experience of Education limited by experience of

mentormentor

ApothecariesApothecaries– Still apprenticeship model; same Still apprenticeship model; same

problemproblem

PhysiciansPhysicians– University educationUniversity education– Little clinical education even after 18Little clinical education even after 18thth

century when recognized as importantcentury when recognized as important– Oxford & Cambridge lacked teaching Oxford & Cambridge lacked teaching

hospitalshospitals

By 1750, all branches recognized By 1750, all branches recognized need for more clinical teachingneed for more clinical teaching

Hospitals provided solution to this Hospitals provided solution to this problemproblem– Wide variety of experiencesWide variety of experiences

Doctors appointed to hospital staffDoctors appointed to hospital staff– Provided services freeProvided services free– Enabled them to take students on the Enabled them to take students on the

wardswards– Could collect better fees from studentsCould collect better fees from students

Teaching hospitals transformed Teaching hospitals transformed medical educationmedical education

Hospitals began to offer lectures Hospitals began to offer lectures

Ultimately developed medical Ultimately developed medical schoolsschools

Distinctions between 3 branches Distinctions between 3 branches began to break downbegan to break down

1886: single qualification for all 31886: single qualification for all 3

State still refused to eliminate State still refused to eliminate unlicensed practiceunlicensed practice

Regular (allopathic) medicine still Regular (allopathic) medicine still prevailedprevailed

Impact of:Impact of:– Poor house infirmariesPoor house infirmaries– HospitalsHospitals

United StatesUnited States

Much more chaoticMuch more chaotic

Rapid population growthRapid population growth

Medicine a state responsibilityMedicine a state responsibility– Each state had slightly different Each state had slightly different

approachapproach

No separate branchesNo separate branches

Result was mix of regulation & free Result was mix of regulation & free marketmarket

13 states had licensing laws by 183013 states had licensing laws by 1830 Little consensus re: who would be Little consensus re: who would be

licensedlicensed

Few American university graduatesFew American university graduates– 11stst medical school in Philadelphia, 1765 medical school in Philadelphia, 1765– Growth of medical schools very slowGrowth of medical schools very slow

Creation of private for-profit Creation of private for-profit (proprietary) medical schools(proprietary) medical schools

Provided deficient medical educationProvided deficient medical education

Degrees from these schools Degrees from these schools considered license to practice in considered license to practice in many statesmany states

Market flooded with graduatesMarket flooded with graduates– 1830s: 7,000 graduates1830s: 7,000 graduates– 1850s: 15,000 graduates1850s: 15,000 graduates

Very few university graduatesVery few university graduates– By 1800, only 250By 1800, only 250

Damaged reputation of regular Damaged reputation of regular medicinemedicine

Not all proprietary schools taught Not all proprietary schools taught regular medicineregular medicine

1919thth century US site of many century US site of many alternative approached to healingalternative approached to healing

Explosion of competition for regular Explosion of competition for regular medicinemedicine

1. 1. HomeopathyHomeopathy

Dates to late 18Dates to late 18thth century Germanycentury Germany

Samuel Samuel Hahnemann (1755-Hahnemann (1755-1843)1843)

HomeopathyHomeopathy– Like cures like”Like cures like”– Treating by similarsTreating by similars

AllopathyAllopathy– use of incompatible or antagonistic use of incompatible or antagonistic

interventions to cureinterventions to cure– Treating by contrariesTreating by contraries

Both approaches have Hippocratic Both approaches have Hippocratic originsorigins

Hahnemann trained as an allopathic Hahnemann trained as an allopathic physicianphysician

Horrified by effects of “heroic Horrified by effects of “heroic medicine”medicine”– BleedingBleeding– PukingPuking– PurgingPurging

Breathing a veinBreathing a vein

Gentle emeticGentle emetic

Taking a physickTaking a physick

General belief that only 1 disease General belief that only 1 disease could exist in body at 1 timecould exist in body at 1 time

Hahnemann reasoned introducing Hahnemann reasoned introducing similar disease would drive out 1similar disease would drive out 1stst diseasedisease

Doctrine of infinitesimalsDoctrine of infinitesimals– Smaller doses created more powerful Smaller doses created more powerful

effectseffects– Responded to anxiety patients had re: Responded to anxiety patients had re:

allopathic therapiesallopathic therapies

Hahnemann settled in ParisHahnemann settled in Paris Homeopathy well established thereHomeopathy well established there

Also gained following in Britain, USAlso gained following in Britain, US

Homeopathic practitioners still existHomeopathic practitioners still exist

Practice not licensed or regulated in Practice not licensed or regulated in all jurisdictionsall jurisdictions

2. 2. Thomsonianism (Botanic Thomsonianism (Botanic Medicine)Medicine)

Samuel Thomson (1769-1843)Samuel Thomson (1769-1843)

No medical training; anti-elitistNo medical training; anti-elitist

Published Published New Guide to HealthNew Guide to Health 1822 1822

Use of medicines from plants not Use of medicines from plants not newnew– QuinineQuinine– AspirinAspirin– DigitalisDigitalis– OpiumOpium

Many of Thomson’s remedies drawn Many of Thomson’s remedies drawn from aboriginal practicesfrom aboriginal practices– LobeliaLobelia– SweatsSweats

Most successful of medical sectsMost successful of medical sects Founded Botanico-Medical College in Founded Botanico-Medical College in

Cincinnati: 1843Cincinnati: 1843

Initial form of Thomsonianism shiftedInitial form of Thomsonianism shifted

Refocus to include book learningRefocus to include book learning

Use of knowledge from regular Use of knowledge from regular medicinemedicine

Rise of eclectic schoolsRise of eclectic schools

3. 3. VegetarianismVegetarianism

Sylvester Graham Sylvester Graham (1795-1851) (1795-1851)

Presbyterian Presbyterian ministerminister

Meat diet over- Meat diet over- stimulatingstimulating

Also advocated avoidance of tea, Also advocated avoidance of tea, coffee, alcoholcoffee, alcohol

Invented graham flour and the Invented graham flour and the graham crackergraham cracker– Made from coarsely ground whole wheatMade from coarsely ground whole wheat

John Henry Kellogg John Henry Kellogg (1852-1943)(1852-1943)

Seventh Day Seventh Day AdventistAdventist

Revived Revived vegetarianismvegetarianism

Became medical director of Western Became medical director of Western Health Reform Institute: 1876Health Reform Institute: 1876

Renamed it Battle Creek SanitariumRenamed it Battle Creek Sanitarium

Great appeal at end of 19Great appeal at end of 19thth & early & early 2020thth century century

Focus on “biological living”Focus on “biological living”

VegetarianismVegetarianism– Included pre-cooked breakfast cerealsIncluded pre-cooked breakfast cereals– granolagranola

Many other medical sects during this Many other medical sects during this eraera– ChiropracticsChiropractics– HydrotherapyHydrotherapy– Christian scienceChristian science– OsteopathyOsteopathy

Some still flourish todaySome still flourish today

Reasons for rise of medical sects in Reasons for rise of medical sects in 1919thth century US century US

Dissatisfaction with allopathic Dissatisfaction with allopathic (regular) medicine(regular) medicine

Appealed to American ideas of Appealed to American ideas of individualism, self-determinationindividualism, self-determination

Appeal to moral reformers and Appeal to moral reformers and religious revival of 19religious revival of 19thth century century

Self-denying lifestyleSelf-denying lifestyle

Sexual restraintSexual restraint– Prohibition on masturbationProhibition on masturbation

Allowing medical sects to flourish & Allowing medical sects to flourish & consumer to make own choices consumer to make own choices seemed more democraticseemed more democratic

Regular medicine in disarrayRegular medicine in disarray State medical practice acts repealedState medical practice acts repealed Created virtual free marketCreated virtual free market

Medicine in CanadaMedicine in Canada

Patterns of British settlement in Patterns of British settlement in North American colonies favoured North American colonies favoured surgeonssurgeons

Brought out with military forcesBrought out with military forces

Also cared for civilian populationsAlso cared for civilian populations Began to provide care normally done Began to provide care normally done

by physicians & apothecariesby physicians & apothecaries

Halifax, first 50 years after Halifax, first 50 years after settlementsettlement– 360 known medical practitioners360 known medical practitioners– 340 were surgeons340 were surgeons

QuebecQuebec– Also could not sustain 3 branches of Also could not sustain 3 branches of

medicinemedicine– Primarily surgeons (80%)Primarily surgeons (80%)

Upper Canada/ Canada West/ OntarioUpper Canada/ Canada West/ Ontario– Similar pattern of medical practitionersSimilar pattern of medical practitioners

Regular medicine unable to establish Regular medicine unable to establish monopoly on practisemonopoly on practise

Medical regulation law enacted 1795Medical regulation law enacted 1795 Outlawed unlicensed medical Outlawed unlicensed medical

practise, including midwiferypractise, including midwifery

UnworkableUnworkable Repealed or amended regularlyRepealed or amended regularly No one prosecutedNo one prosecuted

1818 Medical Practice Act1818 Medical Practice Act Empowered medical board to license Empowered medical board to license

anyone who didn’t possess a British anyone who didn’t possess a British qualification (except British qualification (except British midwives)midwives)

Dilemma: what would be qualificationDilemma: what would be qualification

In US, a degree sufficedIn US, a degree sufficed

In Ontario, decided candidates must In Ontario, decided candidates must pass qualifying exampass qualifying exam

Created disincentive to obtain Created disincentive to obtain medical qualifications in Ontariomedical qualifications in Ontario

Development of Canadian university-Development of Canadian university-based medical schools slowbased medical schools slow

No distinction between 3 branches of No distinction between 3 branches of medicinemedicine

Alternative practitioners popularAlternative practitioners popular

Homeopathy officially legalized 1859Homeopathy officially legalized 1859

Eclectics legalized 1861Eclectics legalized 1861

Regular medicine not self-governing Regular medicine not self-governing until 1865until 1865

Each board set standards for its Each board set standards for its membersmembers

1869: umbrella board: College of 1869: umbrella board: College of Physicians & Surgeons of Ontario Physicians & Surgeons of Ontario createdcreated

Eclectics disappeared by 1875Eclectics disappeared by 1875

Homeopaths still around in 1925Homeopaths still around in 1925

Regular medicine’s response to Regular medicine’s response to external competitorsexternal competitors

Formation of professional societies Formation of professional societies and journalsand journals– AMA (1848): JAMAAMA (1848): JAMA– CMA (1867): CMAJCMA (1867): CMAJ

Also had to deal with issues inside & Also had to deal with issues inside & outside of professionoutside of profession

AMA experienceAMA experience

First meeting called 1846, 2 years First meeting called 1846, 2 years after New York medical practice act after New York medical practice act repealedrepealed

Issues AMA knew it had to work on:Issues AMA knew it had to work on:

Lack of professional legitimacyLack of professional legitimacy Poor medical educationPoor medical education

– Degree equivalent to licenseDegree equivalent to license– Proliferation of proprietary schools of Proliferation of proprietary schools of

medicinemedicine– Reform of medical education had to be Reform of medical education had to be

nationalnational

Ban irregular practiseBan irregular practise

Much of this accomplished through Much of this accomplished through AMA Code of EthicsAMA Code of Ethics

First appeared in 1847First appeared in 1847

Based on British exampleBased on British example

Thomas Percival (1740-1804)Thomas Percival (1740-1804)

Published Published Medical EthicsMedical Ethics, 1803, 1803

Resulted from physician strike in Resulted from physician strike in Manchester infirmary in 1792Manchester infirmary in 1792

Created rules for conduct of Created rules for conduct of physicians in a public institutionphysicians in a public institution

Other codes of ethics set out rules Other codes of ethics set out rules for consultation with other physiciansfor consultation with other physicians– Could not publicly disagree with Could not publicly disagree with

consulterconsulterCreated illusion of professional unityCreated illusion of professional unity

– Could not consult with irregular Could not consult with irregular practitionerspractitioners

For AMA, difficult to sustain this For AMA, difficult to sustain this prohibitionprohibition

Many hospitals allowed variety of Many hospitals allowed variety of medical sects admitting privilegesmedical sects admitting privileges

Dropped this prohibition in 1903Dropped this prohibition in 1903

Can conclude that Codes of Ethics Can conclude that Codes of Ethics are:are:– Statements of behavioural standardsStatements of behavioural standards– Statements of professional power Statements of professional power

politicspolitics