History of medicine
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History of Medicine. 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.

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Key issues
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


The profession through the 1860s
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



1400s
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


Early 16th century
Early 16th Century

  • Paracelsus

  • Transition From Alchemy


Mid 16th century
Mid 16th Century

  • Andreas Vesalius

  • Accurate Anatomy


Early 17th century
Early 17th Century

  • William Harvey

  • Blood Circulation – the body is dynamic, not static


1800

  • Edward Jenner

  • Smallpox and the notion of vaccination


1846

  • William Morton - Ether Anesthesia


1849

  • Semmelweis

  • Childbed Fever and sanitation

  • Controlled Studies


1854

  • John Snow

  • Proved Cholera Is Waterborne

  • Basis of the public sanitation movement


1860 1880s
1860-1880s

  • Louis Pasteur

  • Scientific Method

  • Simple Germ Theory

  • Vaccination For Rabies

  • Pasteurization to kill bacteria in milk


1867 1880
1867-1880

  • Joseph Lister

  • Antisepsis – surgeons should wash their hands and everything else, then use disinfectants

  • Listerine


1880s
1880s

  • Koch

    • Modern Germ Theory

  • Organic Chemistry

    • Birth of the modern drug business


1850s 1900s
1850s - 1900s

  • Sanitation Movement - Modern Public Health


Schools of practice pre science 1800s
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


Legal consequences
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


Most medical schools are diploma mills
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



Surgery starts to work in the 1880s
Surgery Starts to Work in the 1880s

  • Surgery Can Be Precise - Anesthesia

  • Patients Do Not Get Infected - Antisepsis


Licensing and education
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


The business of medicine
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


Hospital based medicine
Hospital-Based Medicine

  • Started With Surgery

  • Medical Laboratories

    • Bacteriology

    • Microanatomy

  • Radiology

  • Services and Sanitation Attract Patients

    • Internal Medicine

    • Obstetrics Patients


Post ww ii technology
Post WW II Technology

  • Ventilators (Polio)

  • Electronic Monitors

  • Intensive Care

  • Hospitals Shift From Hotel Services to Technology Oriented Nursing


Post world war ii medicine
Post World War II Medicine

  • Conquering Microbial Diseases

    • Vaccines

    • Antibiotics

  • Chronic Diseases

    • Better Drugs

    • Better Studies

    • Childhood Leukemia


Corporate practice of medicine
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


Physician practices
Physician Practices

  • Shaped by Corporate Practice Laws

  • Sole Proprietorships

  • Partnerships

  • Mostly Small

  • Some Large Groups

    • First Organized As Partnerships

    • Then As Professional Corporations


Impact of corporate bans
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


Hospital staff privileges
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



Old days
Old Days

  • Charitable Immunity

  • No Independent Liability for Nurses

  • No Liability for Physician malpractice


Reformation of hospitals
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


After professionalization
After Professionalization

  • Demise of Charitable Immunity

  • Liability for Nursing Staff

  • Negligent Selection and Retention Liability for Medical Staff


Joint commission on accreditation of hospitals
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


Contemporary hospital organization
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


Medical staff bylaws
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


Hospital economics
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


Managed care pressures on hospitals
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!!


Managed care pressures on docs
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


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