(4 of 7)
In 1904 there were 160 medical schools with 28,142 students and 5,747 graduates annually. Abraham Flexner, an educator, not a physician, was commissioned by the Carnegie Foundation for the Advancement of Teaching to study the situation. He recommended the closing or reorganization of all substandard proprietary schools. By 1930 there were only 76 schools with a total of 21,597 students and 4,565 graduates annually. Little significant expansion of medical schools occurred for the next 20 years, but the "Flexner revolution" helped make the U.S. the world leader in biomedical science and medical education. From 1901 through 1939, the number of Nobel prizes in medicine totaled 42, of which only eight were awarded to Americans. From 1943 to 1975, Americans won 41 of the 74 prizes awarded.
With expanding knowledge and technology, an inevitable subdivision of labor occurred. The general practitioner faced extinction as medical students entered a wide variety of specialties. Specialization advanced to the point where what happened to the patient all too often depended on who saw him first. "Free market" medicine resulted in a gross geographic and functional maldistribution of doctors. There developed a severe oversupply of specialists in some areas (surgery, where work weeks declined as fees rose) and an undersupply in others (pediatric psychiatry and general practice). The g.p. declined from 64% of the total number of doctors in 1949 to 13% in 1973. Meanwhile, the number of graduates of foreign medical schools practicing in the U.S. increased from 20,575, or 8.6% of the total in 1959, to 69,000, or 20% in 1971.
The increasing use of medical technology, while markedly enhancing accuracy of diagnosis and success of treatment, was accompanied by less time spent with patients. Complaints about the dehumanizing of medical care were increasingly heard. Doctors moved their offices close to the hospital and its technology. By the 1950s the house call had virtually vanished as doctor and patient met in the emergency wards and clinics of urban teaching hospitals or in offices next door.
Acute, curative, technology-dependent medicine reached its apogee in the 1960s—and, as expectations rose, so did the costs. The expense of medical care had reached a critical stage with the Depression of 1929-32, when individuals found it increasingly difficult to pay their medical bills. The private sector in the 1930s developed the Blue Cross-Blue Shield insurance system of prepayment for hospitals and physicians. In the public sector, the Social Security mechanism and general tax revenues were used to pay the costs of the indigent sick, the disabled, the elderly and such special groups as veterans, migrant farmers and American Indians. A variety of amendments to the Social Security Act of 1935 culminated in Medicaid (a federal, state and local program for financing medical-care needs of the indigent sick) and Medicare (compulsory health insurance for the elderly). Today 21 million Americans aged 65 and over have such insurance for hospital and extended-care costs.