Listed below are topics areas that represent key problems in the history of American medicine- key issues that promote understanding of how and why medicine developed the format that it currently holds. This problem-based approach is the most valuable way to provide information on the history of medicine for physicians because it encourages skill development as well as knowledge acquisition.
These topics illustrate important- indeed key- themes and developments in the history of medicine. Perhaps more important, they set these events into a historical context that also shows patterns of emotional and intellectual responses to health challenges and social change. They show how responses and types of behavior appear, develop, adapt (or fail to adapt) in response to technological advances, population growth and other societal transformations.
They also address the material critically. It is hoped that in addressing critical “why” and “how” type questions, students can better understand not just what happened but also why it happened. Showing how events may fit into a pattern of behavior and change also can help memory- instead of trying to memorize isolated events there is a structure in which to place them so they become part of a whole- we can provide a context that makes events more comprehensible. And perhaps fascinating, alive, and real, providing the basis for discussion.
Learning Objectives:
This problem-based approach to history helps to:
- Develop critical thinking skills
- Enhance Analytical skills
- Promote pattern recognition skills
- Understand psychosocial issues related to the study of health and sickness
- Understand cultural context of biomedicine
- Develop sense of humility based on knowledge of subjective nature of medical science
- Enhance skills in recognizing and addressing basic questions and fears that illness generates in patients
1 Research and in/humanity: or why we need the IRB.
Summary: Research using the scientific method made possible repeatable, structured approaches to answering medical questions and solving medical problems. It made, in effect, possible modern medicine, effective medications, and the range of modern treatments for illness. But such research, like the Tuskegee syphilis experiment, can be driven by bias and be imbedded in time specific concerns and cultures rather than an objective pursuit of greater scientific proof. Thus certain research may ultimately prove more socially and individually damaging than valuable. This situation has been likely to prevail when the research is uncontrolled and performed on subjects who are powerless to speak out (often disenfranchised groups about whom prejudice and misunderstanding exists). News of such experiments and treatments not only drove the formation of modern bioethics but has led to long term distrust of the medical establishment by certain communities. Thus, research and researchers represent not just the present and the future, but also carry with them shadows of the past. They also do so in a tangible way, because issues arising from experiments like Tuskegee made institutional review and oversight a necessity.
Thought questions: How has uncontrolled research shaped the response of communities to medicine? How did it help shape the modern practice of bioethics?
- Sanitation and insurance: rising medical costs and rising government intervention.
Summary: Massive projects such as urban sanitation and water supplies drove greater government intervention. So have the increasing costs of medical treatment, and the instrumentation now required to run a major hospital. American response to increasing costs- both infrastructure and treatment- have reflected specific American ideas about social welfare, the role of government, as well as response to external world events (such as the role of Germany in World War I leading to reactions against health insurance). This mix of American ideas and ideologies generated a range of programs from private to public forms of insurance, municipal water supplies and water treatment plants, and other health initiatives and programs amid the continual and quintessential American tension over the role of government in private lives.
Thought questions: How have the increasing size and costs of producing and maintaining health- from sanitation to hospital care- shaped the role of government in healthcare? How do culture and cultural beliefs also impact the response to this movement?
- Conquering epidemics: smallpox and inoculation of 1721, the 19th century cholera epidemics, polio, and HIV/AIDS.
Summary: Examination of major epidemics shows how attitudes shift and develop over time and vary in response to general fear. But major epidemics, especially outbreaks of “new disease” also show a cyclical pattern of response, building on fear of the unknown and resulting in often predictable behaviors that can be seen when people face events that rapidly transform the structures of everyday life (included in this category can be natural disasters, and dislocation and destruction from war. These behaviors can include bringing out the best or worst in people, from profiting from shortages to nursing the sick. They also can include finding scapegoats for the spread of disease, moral judgments based on how the illness can be spread and resultant stigma. Fears can play out in the political arena, with ideas about the causes of disease and treatments dividing along party lines, as they did during the Philadelphia yellow fever epidemic of 1793. From the introduction of inoculation in New England in 1721 to the transformation of personal responsibility following cholera epidemics in the 19th century, to the rise of polio and its conquest in the 20th century, to the appearance of HIV/AIDs, major epidemics lay bare basic fears, responses and tendencies in the public. These fears, of course, operate in the context of changing social ideas- for instance, episodic cholera epidemics showed the transformation of majority attitudes from moralistic to environmental. With accumulating knowledge about the etiology of disease comes declining fears but stigma may remain.
Thought questions: How do epidemics challenge society’s ideas about personal responsibility for illness? When do people respond with fear, blame and stigmatization? When do communities respond collectively to create sanitation movements, fund research solutions, or ostracize sufferers? How does the nature of the illness, who gets sick, their socioeconomic status or ethnicity, how it is contracted, and knowledge or lack thereof determine responses? What role does scientific research play in calming fears or rapidly changing understanding of new disease biology raise skepticism about the scientific method?
Readings: Charles Rosenberg. The Cholera Years.
- Paradigm shifts: Medical education, scientific medicine and medical authority.
Summary: The rise of scientific medicine in the late 19th century changed the practice of medicine and eventually the shape of medical education and larger healthcare systems. With the incorporation of statistics and science into medicine, it became possible to pursue specific treatments and predictable outcomes- but the production of specialized knowledge also required more standardized laboratory and clinical training and caused medical schools to move toward longer and more intense medical training- a move that eventually resulted in required undergraduate degrees, 4 year medical school terms, clinical internships and residencies. This shift- and increasing medical authority- made possible large scale incorporation of changes recommended by Abraham Flexner (and already being put into place at university medical schools such as Hopkins, Michigan…). The increase in medical authority also made medical licensing laws possible and allowed for greater control over who could enter medicine- resulting in decline in diversity among practicing physicians and limitations on alternative practices.
Thought questions: When does the accumulation of discoveries and new knowledge force major shifts in approaches to medical education? How did the rise of scientific medicine lead to a revolution in the training of doctors? Do all changes in medical education require major shifts, or are some made incrementally and continuously? What are barriers to change?
5 Eugenics and ideas about hereditary differences: “Infection” in the body politic: diagnosing and “treating” the other.
Summary: Major changes in American society, especially those that wrest large numbers of people from a familiar environment, can lead to a sense of social degeneration. With increasing scientific authority, this sense transformed in the early 20th century to a medical model for explaining supposed degeneration, and resulted in the eugenics movement, which explained this “degeneration” in genetic language and which focused on immigrants, the poor, racially different (and racially different based on the early 20th century definition of race) and others whose presence was seen to challenge the authority of the then existing power structure. Modern questions about genetic selection, race, IQ differences, disabilities, and the value of human life all still bring back fears and anger resulting from eugenics practices (including sterilization of the mentally retarded in the US, immigration quotas, marriage laws, and the Nazi Final Solution) and understanding eugenics is vital to understanding how bias and prejudice can come to be cloaked in objective language.
Questions: How did changes in society- urbanization, immigration, industrialization- combine with ideas about health to generate progressive “prescriptions” for healing society? What was the role of medicine in these movements? In what ways were people with what was believed to be “poor” heritage considered an infection in society’s body?
Web resources- Cold Spring Harbor eugenics archive http://www.eugenicsarchive.org/eugenics/ Feel free to browse the image archives and to read through the virtual exhibit section. University of Virginia virtual exhibition on Buck vs Bell http://www.hsl.virginia.edu/historical/eugenics/ . Definitions from the American bioethics advisory commission http://www.all.org/abac/eugenics.htm , while NPR’s Tomorrow’s Children http://www.npr.org/programs/disability/ba_shows.dir/children.dir/children.html explores the rationale for and popularization of eugenics, especially through examining movie The Black Stork/Are You Fit to Marry via conversation with Martin Pernick http://www.npr.org/programs/disability/ba_shows.dir/children.dir/highlights/bsmovsti.html . See also google book resource for In the Name of Eugenics by Daniel Kevles http://books.google.com/books?id=8esnhRxBomMC&pg=PA348&lpg=PA348&dq=eugenics&source=bl&ots=9qdmcRET24&sig=8jzIk3EobeqY0tg149qg5fg0eOA&hl=en&ei=nqtFTMCEDsL38Aayhv3qBA&sa=X&oi=book_result&ct=result&resnum=7&ved=0CDYQ6AEwBjgU#v=onepage&q&f=false
6 Medicalization: The value and drawback to a diagnosis.
Summary: The process of medicalization- the transition made when conditions move to fall within the realm of biomedicine, is a long recognized process. Conditions/differences/behaviors such as homosexuality, masturbation, suicide have all been seen as moral failings (a suicide would be buried in unhallowed ground and possessions taken from the family) then as medical conditions or illnesses or, finally, a behavior or difference that brings or should bring no judgment. A diagnosis can be, literally, a lifesaver when it leads to effective treatment. It also can provide comfort to those who otherwise feared they were in some individual way strange and alone. A name, a recognized condition can provide comfort. Medicalization also can take a normal process of life- birth, aging- and transform it into a medical condition automatically requiring medication and even hospitalization. Or a diagnosis can bring with it a weight of past fear and obsolete understanding of the meaning of illness.
Thought questions: How did intellectual progress from understanding behavior as moral failure to medical diagnosis to (in some cases) behavioral variant rescue individuals from approbation and excommunication? How does recognition and diagnosis of new medical conditions provide comfort for sufferers- or increasingly provide an outlet for pharmaceutical companies? Why does a diagnosis of cancer generate such fear? Is the process of medicalization always a plus- or always a minus?
7 Disease in the community and the rise of public health in the US (and in Florida especially).
Summary: Endemic and epidemic infectious diseases have had a profound effect on human history and even on the human genome, eventually leading to the rise of the public health service and ongoing public health initiatives at the global, national, state, county, and local levels. Public health offices are associated with levels of government and hold a certain amount of legal authority, although public health outreach also includes NGOs and academic researchers. Effective efforts to address infectious disease involved sanitation efforts, quarantine, and other actions that were in place and effective before microbial causes of disease, including vector transmission, were understood. Although infectious disease outbreaks, including yellow fever in Florida spurred the development of Florida’s public health service, this health service also addressed large scale public health crises of the early 20th century, including a prevalence of hookworm, and pellagra. Public health efforts came to address every area of human health and wellness. These efforts can include sanitation, provision of clean water, addressing mental health, potential environmental health issues, vaccination, testing, record keeping, education. One of the great challenges of public health programs, however, is that when public health actions work, they prevent disease. With no disease, society believes public health programs are no longer necessary so these activities may be defunded. So public health can be the victim of its own success.
Thought questions: Why did the responsibilities of public health departments expand as the understanding of potential impact on population health grew? How can public health function without being a victim of its success? How does community response affect the health of those within that community?
8 Access to care and right to health: how understanding of social determinants of health developed to include healthcare.
Summary: Health is not distributed equally in the United States today with many socioeconomic and social factors that distribution. Much of the health distribution today relates to access to healthcare. In the past, especially in the United States, care was not distributed equally, as it is not today. Many things, however, were different starting in the 18th centuries, with a wide open medical marketplace, no existing licensure regulations, and virtually nonexistent scientific backing for medical theories. Allopathic medical training was largely based on brief apprenticeship, while other practitioners, such as midwives, might actually have far more experience or observe more cases during their own training. And, of course rural areas were much less likely to support financially allopathic doctors so they relied primarily on home care and care from “irregular” doctors. Medications could consist largely of medicinal herbs, mercury derivatives available from pharmacies, other metals, and treatments included bleeding, purging, blistering, and other efforts to balance the humors. With the state of healthcare in the 18th c, access to regular, allopathic doctors, while limited for many, did not have the impact on health that it does today. During the 19th century there was a rise in irregular practice and alternative health practices, as well as a growing reliance on home health care fostered by the publication of many home care manuals. Thus access to health care might not have been a deciding factor in health- and that was the case probably until the early 20th century. But even starting from the 17th century in America, biopsychosocial factors influenced health- wealth could determine diet, employment- grueling employment increasing the chance of eventually disability as well as workplace accidents, and other factors such as the possibility of accidents, domestic abuse, vulnerability to infectious disease exposure and other health risks. Even geographical location could determine longevity, especially in the 17th century when illnesses like malaria significantly shortened lifespans of European colonists living in Virginia. This unit explores both the history of health risks as well as the increasing effectiveness of Western, regular, allopathic medicine in treating health conditions.
Thought questions: How does socioeconomic status play out in exposing individuals to health risks? Are there any ways in which higher socioeconomic status might actually have a negative impact on health?
9 Ongoing development of the physician patient relationship.
Summary: One of the most significant- and potentially powerful- healing relationships is that of physician and patient. Perhaps not surprising since the doctor has the rare privilege of being with people during the most significant times of their life, when they are closest to life and death, facing the greatest challenges of their lives, the greatest unknowns. They see doctors when facing questions about why they are in pain, suffering from a major illness, dying. Patients can be at their most vulnerable, dependent, and weak- and also at their most joyous and hopeful. So the relationship is intense, and perhaps it is not surprising that in the past health care providers also were religious leaders in their communities. With this powerful basis, the relationship has changed over time but somehow still remains as a highly- if not the most- effective healing relationship dependent on deep trust and respect. It possibly is the depth of respect and trust that also means patients can be especially critical if their heroes fall from the pedestal. So while doctors may encounter significant criticism from patients, that can be a sign of how high are the expectations, although there have been significant lows, including a period in the 18th century when doctors (especially medical students) became associated with grave robbing and body snatching. Significant and long-lasting changes in the relationship obviously include when medicine split from religion, in Europe in the 17th century and, as a result, healthcare became more secular. Changes over time have focused mostly on the authority of the physician, often tracking with society’s perception of how effective was the medical profession in treating illness. But the perceptions also have gone both ways, with physicians responding to change and challenge by articulating their own view of the profession and the ideal health care professional. Perhaps the greatest changes occurring in the relationship have been wrought by the rise of scientific biomedicine. These changes included the ideal of physicians as objective scientists rather than empathetic providers, or physicians as authority figures or more recently, physicians as partners focusing on patient-centered care.
Thought questions: Can you find historical images of physicians that show how they may have been viewed by the community, and how they viewed themselves? What trends do you see?
Image collections: National Library of Medicine’s Images from the History of Medicine Collection https://www.nlm.nih.gov/hmd/ihm/index.html , Duke University collection https://medspace.mc.duke.edu/collections/4t64gn166?locale=en Johns Hopkins https://browse.welch.jhmi.edu/finding-images/history-of-medicine Wellcome Institute Image Collection. https://wellcomecollection.org/search/images
10 It takes a village: the health care team in an age of specialization.
Summary: Historically, the physician has been a lone figure rather than a group member. And with relatively little differentiation within the profession, the 19th century doctor making house calls with a doctor’s bag, possibly a bag designed to be carried on horseback, is a common image. Although patients might later need nursing care, professionally trained nurses were not available until the late 19th century. And it took changing technology and catastrophic events like world wars- which left many young men with significant but also similar injuries- to cause the development of other health professions like occupational therapy and physical therapy. Once the technology began to spiral and more and more other types of healthcare became possible, many more healthcare professions developed. Now, patient care is facilitated through a team of highly trained providers and the challenges have been to include training not just in caring for the patient but also in working together as a team and recognizing the contributions each team member can provide.
Thought questions: How has technology developed and changed the practice of medicine, creating a practice of health professionals? This unit looks at the development of a health care team, but we also can focus more how technology has changed the interface between doctor and patient- how have telemedicine and EHRs changed the ways teams communicate with patients and with one another?