Part I: ID’s
1. Frank Dent
a. Frank Dent is the plaintiff in the case Dent v. West Virginia, the case that resulted in the advent of medical licensing in the United States during the second half of the 19th century. In the case, Dent declared that it was his constitutional right, as established by the 14th amendment, to pursue his happiness in administering medical care as he saw fit. West Virginia, as a state invested in the well-being of its citizens, argued that Dent caused more harm than good to West Virginians and the case went to the Supreme Court of the United States. SCOTUS determined that although Dent had the right to pursue his dreams, it was the right of the state to protect the interests of the population as a whole, and so in order to pursue his happiness, Dent would need to follow a pre-determined path to his goal. With its decision, SCOTUS effectively instituted the beginning of state-regulated medical licensing in the United States.
2. William Osler
a. William Osler was one of the founders of Johns Hopkins Medical School. He is often remembered in history as the modern “model physician” with his qualities of being wise, prudent, and well- educated. Osler emphasized the importance of multi-faceted medical education, and many of his sayings and words of advice are still referenced in medical training today. At Johns Hopkins, he established a longer medical education length, a residency program following formal education, and increased difficulty in medical school admissions and education standards. Osler is important because he is a direct reason why medicine started to become respected by the American people and be considered as a sovereign profession.
3. Mary Putnam Jacobi
a. Mary Putnam Jacobi was an influential early feminist that directly disputed the validity of certain sexist notions of women’s health. Importantly, she showed with science and empirical studies that ideas perpetuated by the patriarchy were not based in biological facts. She disproved the idea that women were more emotionally unstable than men because of changes in ovulation cycles. Because of her findings, women were no longer considered unfit for the emotionally/physically demanding profession of being a physician.
4. Daniel Hale Williams
a. Daniel Hale Williams was one of the founders of the National Medical Association and one of the biggest players in the early days leading up to the black hospital movement. He advocated for the equal treatment of black people in medical training and treatment and was an important, early civil rights activist working to decrease the disparity he saw in the inclusion and treatment of black people in medical culture.
5. Charles Eliot
a. Charles Eliot was the president of Harvard Medical School that increased the reputation and sovereignty of HMS. Under him, stricter guidelines and higher performance assessments were installed to restrict the admission of students to HMS and ensure that only the highest quality of physicians were produced. He can be seen as the equivalent of Osler at Johns Hopkins in that he revolutionized medical education at Harvard to be what it is today. Because of Eliot, Harvard became the pinnacle of medical education in the United States.
6. Irv Waters
a. Irv Waters is a character in Sinclair Lewis’ novel, Arrowsmith. He provides the antithesis to the characters Dr. Gottlieb and Dean Silva because Waters is solely interested in the commercialism in medicine and the financial gains associated with being a physician. Analogically, Waters represents the financial outcomes behind the reason of some people wanting to become physicians. Lewis portrays Waters in a negative way because Lewis does not agree with commercialism in medicine and instead focuses on portraying Martin Arrowsmith, the book’s protagonist, as a patient and research focused physician.
7. Stephen Smith
a. Stephen Smith was a New York “activist” (unsure of exact term to use) that implored philanthropists to invest in the creation of the New York Metropolitan Board of Health. As mentioned in The Cholera Years, Smith’s goal was to increase sanitation protocol in New York City as a result of the understanding that cholera was the result of poor sanitation in the city. Smith worked with local and state government to pass legislation that would improve quality of health in the city and minimize the outbreaks of Cholera in the future. He can be seen as one of the most influential people in the field of modern Public Health.
8. Nathan Francis Mossell
a. Nathan Francis Mossell was the first black student to graduate from the University of Pennsylvania Medical School. Being that the University of Pennsylvania was one of the first and most revered medical schools at the time, it was a very important and influential occurrence that Mossell received a medical degree from the institution. Receiving a medical degree from a distinguished and influential medical school provided an undisputable example that black people could perform at the same, high level of intelligence as white people.
9. Michael Shadid
a. Michael Shadid was a Lebanese physician practicing in Oklahoma in the early 20th century that was heavily involved in the creation of medical cooperatives in the United States. He was heavily disliked by the AMA, who did not subscribe or endorse the idea of socialized medicine. Cooperative medicine is the collective venture of physicians and patients coming together to create a system that bypasses any “middle-man” so that physicians can directly deal with patients. Patients pay into the system monthly and as a collective to receive treatment at little to no cost.
10. Vannever Bush
a. Vannever Bush is the reason that the National Science Foundation, the main institution that provides funding and grants to medical research, exists. He was in charge of the Office of Scientific Research after WWII and was one of the main engineers behind the Manhattan Project. He urged President Roosevelt to invest more heavily in scientific research in order to ensure that America was at the helm of development and advancement, and as such the NSF was created.
Medicine is equally informed by the biological knowledge of the day as well as the individualized social and practical needs of the patient and physician. As much as superstitious, religious, and cultural ideals influencing medicine can be harmful to patients, the standards of care determined by “scientific”, clinical studies can do more harm than good to patients (as explained by Dr. Moganaki). For physicians to fully address the needs of a patient, doctors like Dr. Groupman are needed that understand the biological and medical underpinnings of disease and consider the humanity and individuality of the patient that is being treated. In other words, a physician needs to treat a patient with both “science” and “art” for a successful treatment. The intersection of these spheres of medicine can be most clearly explained in examples found in Sinclair Lewis’ Arrowsmith, as well as the essay “Bathe”, Gilman’s “Mr. Peeble’s Heart”, and the shift from “natural” to “normal” in medicine. In all of these cases, there is trends of physicians that are conflicted and informed by the overlapping fields of the science and humanities ultimately resulting in the best outcomes for patients.
In Arrowsmith, Lewis uses several characters to exemplify the different qualities of American medicine. Dean Silva represents a very caring, empathetic, and generous doctor that recognizes the humanity of his patients (assumingly modeled after Hopkins’ William Osler). Dr. Gottlieb serves as a mentor to the Martin Arrowsmith, the book’s protagonist, and represents the German influence on American medicine and the notion of the importance of medical research. Then there is the character Sondelius, who is almost a combination of qualities found in Silva and Gottlieb, who represents not only the doctor as a public servant invested in public health, but also a selfless and giving person whose work is directed to the betterment of unfortunate people. What is most impactful about the book is the characterization of such character, their storylines, and the effect that they have on Arrowsmith, who represents the progression of American medicine at turn of the 20th century. All of them are portrayed positively by Lewis speaking to his belief that all of their qualities, whether scientific, artful, or both, are important in contributing to the model of the modern physician.
Gilman’s “Mr. Peeble’s Heart” provides another literary example of a physician balancing the scientific and artful contributions to medicine. The physician in the story assesses the needs of her patient in both a scientific and artful manner by prescribing that her patient takes a trip that he is desperately wanting to take that he had previously been inhibited in taking due to his responsibilities at home. In this specific story, there is no biological sickness associated with the patient, but the physician sees that her patient’s quality of health/life could be improved outside of biological means and acts on that notion. There was no reason to be worried about the biological health of her patient, but the doctor saw beyond this basic need to something greater, and in doing so best treated her patient.
With the essay “Bathe”, specific guidelines are recommended in order for doctors to best treat their patients. In addition to assessing the physical health of a patient, doctors are instructed to listen and communicate with patients in an empathetic and non-authoritative manner. Patients should lead the conversation while doctors direct the patient in avenues that would best suit individual patient’s needs. Yes, doctors should always understand the medical and clinical knowledge associated with diseases, but as important are the emotional and unique circumstances surrounding an individual patient’s situation.
In addition to all of these examples in writing, there is the real-world example of the shift from the “natural” to the “normal” in medicine that was experienced in the 19th century. In the early days of American medicine, heroic medicine, religious ceremonies/practices, and superstitious ideals characterized much of the treatments being afforded to patients by physicians. Medicine was based more on “art” than in science, and the idea of the “natural” balance of a patient prevailed But, with the rise of reputation in medical research and it contributing to the successful treatment of diseases, medicine shifted to accept “normal” qualities of human health such as normal healthy temperature ranges, observable respiratory quality, and overall physical condition of the body. This idea of physical normality provided much of the guidance on medicine through the 20th century, but with more and more studies on the quality of patient care being performed, it was found that not only does there need to be consideration of the physical characteristics of a patient (and those being within normal ranges), but the emotional and psychological well-being of the patient needs to be a center of focus as well. So, in turn, doctors like Dr. Groupman are successful because they focus on administering standards of care to a patient while at the same time providing care in accordance with individualized patient beliefs and emotional conditions.
All of these examples provide a balance of scientific and artful qualities of medicine with physicians providing care that is informed by both normalized and broadly accepted knowledge as well as the individualized, complete condition of a patient. Comprehensive care is characterized by both a physical, science informed evaluation as well as an artful, emotional/social evaluation as well. This is why a physical involves a physician recording vital signs and physical measurements in addition to engaging in a conversation with the patient regarding the patient’s life, stressors, and successes.
The United States is the only industrialized country with a high GDP that doesn’t provide universal healthcare to its citizens. Recognizing this fact and wanting to improve the access to healthcare in the United States, President Obama successfully enacted the Patient Protection and Affordable Care Act in 2010. This success was preceded by many challenges spanning decades of debates, and even today the legislation faces much opposition with constant attempts to “repeal and replace” the PPACA being made by congressional republicans and “President” Trump. To understand why the PPACA passed and what challenges faced its passage past and present, it is important to understand the history associated with America’s view of socialized healthcare involving organizations such as the AMA and programs such as State Children’s Health Insurance Program (CHIP), Medicare and Medicaid.
CHIP, Medicare and Medicaid are all forms of social institutions that were introduced prior to the passage of PPACA aimed at providing medicine to underprivileged and less fortunate members of the population at the expense of more fortunate citizens. Like any social program, these programs are funded by taxpayer money and can be considered, for sake of argument, leftist policies. Not surprisingly, the conservative right with its values of limiting the size and reach of government and minimizing taxes and “penalties” for wealthy Americans has been a constant critic and attacker of CHIP, Medicare and Medicaid. CHIP was introduced by Hillary Clinton in the 1990s as a way to provide basic preventative care to children whose families could not afford the costs of doctor’s visits, medication, and vaccines. The legislation passed and was enacted successfully, but at the beginning of October 2017, the Senate failed to reauthorize CHIP. It is the beginning of December, and states are starting to run out of money to fund CHIP, putting thousands of children at risk. Medicare and Medicaid were social programs started in the 1900s aimed at providing medical care at little to no cost to the elderly and people living at or below the poverty level, respectively. There has always been criticism by the more fiscally conservative legislators, and even now, state expansions to Medicare and Medicaid are being blocked by legislators due to concerns of spending too much money.
Whether it be the PPACA, CHIP, Medicare, or Medicaid, the fear of that is embodied in the republican party concerning each social program’s implementation is rooted in both fears of spending too much money (money that could be used for other programs) as well as misconceptions and select failures of socialized medicine in other countries. Conversations criticizing the possibility of universal healthcare or socialized medicine always involve opponents pointing to the shortcomings of countries like Britain or Germany where universal healthcare is a reality. In Britain, it can take months to be seen by a specialist concerning a non-preventative-health concern, and British doctors complain about not being paid enough by the State. In Germany, similar concerns abound with hospitals going bankrupt as a result of poor funding. In addition, opposition arguments of the past, made by organizations such as the AMA, feared that socialized medicine would negatively impact the quality and integrity of medicine and would ultimately disvalue the authority of the ruling body.
So, why did the PPACA pass? Obama was able to pass PPACA because he worked across party lines, met with insurance companies, and considered the interests of everyone involved. Much research was involved, the program was advertised through social media to educate people on the benefits of implementation of the legislation, and the legislation was rooted in the belief that healthcare is a basic human right that improves the quality of life, so everyone needs to have it. With the passage of PPACA, coverage was expanded to everyone regardless of pre-existing conditions or income levels (through subsidization, a federal health insurance marketplace, and variable rates according to income). In order to make sure everyone has coverage, an individual mandate was put into place requiring every citizen to be covered by some type of health insurance or be at risk of facing a penalty.
Current attempts to “repeal and replace” “Obama Care” have all been unsuccessful, with Senators like John McCain defying his own party to vote “no” on one of the bills introduced. Criticism still abounds surrounding socialized, universal medical care in the United States, and most likely will continue for the foreseeable future because of fears that were mentioned above. That being said, it is an important milestone in American medicine that PPACA is the law of the land because it established, officially, the idea that everyone deserves adequate healthcare and access to health services regardless of social class, race, religion, sex, or any other identifying feature.
Nothing is more American than institutional racism and inequalities faced by people of color due to centuries of oppression at the hands of white people. The article written by Jan Hoffman from the New York Times provides one of many examples of the disparities in health experienced along racial lines. There is no biological reason why black women have almost two times the incidence of cervical cancer than white women in Modern America, but because of the long history of there being barriers to black people having involvement in American medicine (going all the way back to early colonial days) there is still harm being done to people of color in today’s supposedly inclusive society. The reasons for the racial disparity seen in incidences of cervical cancer, as discussed in Hoffman’s article, can be illuminated by considering the effects that phenomena such as the Flexner Report, segregationist policies enacted by the American Medical Association (AMA) after the Civil War, and the Tuskegee experiments (all influenced by racist ideas and notions that can be traced back to slavery in America) have in determining the policy of considering black people in America as second-class citizens deserving quality of care less than that enjoyed by white people in American medicine.
In early America, slavery was a way of life undisputed by the overwhelming majority of white people resulting in the mistreatment and deaths of many enslaved people of color. Black people did not enjoy any personal freedoms that white Americans experienced, were considered property of white slave owners, and were seen as inferior to the white population (even being considered less than human) resulting in inhumane treatment and below-lower-class treatment. On plantations, black people were expected to care for each other and provide medical care for the other enslaved people on the plantation. Eventually, as with cases like that of Dr. Yandell, slave owners saw the need to protect their “investments” and allowed white doctors to treat the needs of enslaved people of color effectively. Unfortunately, this care was still inferior to that given to the white population, and so the institutionalization of black people receiving inferior medical care and treatments was born.
Fast forwarding to postbellum America, the passage of the thirteenth, fourteenth, and fifteenth amendments abolished slavery, but segregationist policies aimed at disadvantaging black people took a stronghold on American culture and medical policy. The AMA was established in the first part of the 19th century and emerged as the sole issuer of physician licenses in the United states during the second half of the century. With licensing though, the AMA was not secretive in asserting its policy of not issuing licenses to black physicians because of the notion that black people were second class citizens and should not be either treating white patients and/or practicing medicine. In addition, the AMA worked to seriously devalue the integrity of black hospitals and medical schools, especially during the first part of the 20th century after the Flexner report.
The Flexner report established qualities and standards of exemplary medical training and education, but because of racist ideals that were being reinforced by segregationist notions, Flexner established that the quality of education being taught to black physicians by African-American oriented medical schools to be inadequate and insufficient. Because of this notion, the AMA dismantled all but two black medical schools (Howard and Maherry) during the early 20th century. Once again, because of the inability of black people to be licensed and trained in medicine, black people were to be treated by white physicians and receive inadequate medical care because of the institutional racism that was intertwined in the medical practices of 20th century hospitals. From this inadequacy of care experienced to the detriment of black people, the black hospital movement began that aimed to establish hospitals centered in the adequate care of black patients under the supervision of black physicians. Organizations emerged such as the National Medical Association that advocated for the adequate care of black people. These organizations fought against the AMA to gain the right and legitimacy to practice black-patient-centered care and the training and licensing of black physicians.
As this fight between organizations such as the National Medical Association and the AMA evolved, racist treatment experienced by black people persisted, most notably during the famous Tuskegee experiments. In short, the Tuskegee experiments resulted (with no logical or convincing reasons rooted in science) in the infection of hundreds of black Americans with syphilis. The most depressing result of these experiments, though, was that many of these people died because of further mistreatment experienced by black people at the hands of a racist medical community.
So, in terms of modern America, it can be resolved with the knowledge of the history of medical treatment of black people in the United States that black people receive inadequate care because of the continued institutional racism of medical practices. It is no surprise that black women unjustly have two times the incidences of cervical cancer than white women. Racism as a social determinant of health, ever present even after the passage of the civil rights act of 1964, declares that black people are second-class citizens and this results in unequal access and administration of health care to black populations. Black women aren’t receiving the preventative screenings and care needed to detect and treat cervical cancer in its early stages, and this is a product of a history of racism in American Medicine.