Medicine’s Medicine’s Professional Professional Project Project
Dec 28, 2015
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
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
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
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