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American physicians have not always enjoyed the high incomes and social standing they do today. The American Medical Association worked with state governments in the late nineteenth and early twentieth centuries to implement licensure requirements and professional self-regulation of training to standardize practice, improve quality, and boost incomes by restricting entry. Federal workforce programs in the mid-twentieth century greatly increased the profession’s size. However, the most important driver of the profession’s standing today isMedicare. Its guaranteed reimbursement dramatically increased earnings, especially in specialties that focus onelderly patients. It also reinforced, albeit inadvertently, an income differential favoring specialty practiceover primary care. Additional public support has come from the National Institutes of Health, which helps to develop technologies on which specialists rely. Government programs did not create the medical profession, however without them, the profession would be smaller, less technologically capable, and far less remunerative.

Chapter five includes a discussion of specific curricular interventions that can work toward getting students to think critically and to reflect deeply and broadly on what it means to be human. It highlights pedagogical approaches that allow students to see that the “real” scientific facts of biological disease cannot be separated from the existential reality of illness and that human beings always already dwell within their lived experiences, even before science and medicine inscribe their particular, abstract truths onto the body. Through exposure to patients’ stories—whether through narratives or face-to-face encounters—reflective writing, dialogue, and quality mentorship, students might come to appreciate the lived experience of illness, to expand their moral imaginations, and to develop a more capacious sense of care that is grounded within a recognition of our shared humanness and potential for suffering. This kind of pedagogy does not result in a “professionalism” that can be measured, quantified, and assessed, but rather a way of being in the world—a posture of openness toward others, an ability to face uncertainty, and the capacity to extend care to all patients even when “nothing else can be done.”

This chapter examines the home as opposed to overseas aspects of medical missions, and explores the role of medical mission dispensaries in British cities in the late Victorian and Edwardian period. Scotland was the forerunner and home of medical missions, providing exemplars and their ideological underpinning. Edinburgh and Glasgow are therefore the focus of this chapter. Medical missions were the most numerous medical domiciliary visitation agency in Scotland’s cities after the poor law in the period before World War One, and were significant in terms of both the level of support received from the medical profession and general public, and in terms of the shear numbers of sick poor treated (measured annually in the tens of thousands). Set down as citadels amongst the poor and immigrant Catholic Irish, medical missions were the quintessential Scottish charity. Domiciliary medical visits were used as a Trojan horse to promote Christianity. They also provided doctors with access to and influence over whole families of the urban poor and an arena within which to train medical students for general practice.

This chapter argues that the authorities of Irish medical schools and hospitals possessed a distinctive attitude towards their women medical students, with women and men being educated together for all subjects, with the exception of anatomy. Women students were nonetheless often identified as a cohort separate from the men, as is particularly evident in the student magazines, where they were figures of fun. In order to reconcile this sense of ‘separateness’, Irish women medical students established their own unique identity through their social activities and living arrangements. The chapter also examines how Irish hospitals displayed a largely positive and welcoming attitude towards women medical students, in contrast to hospitals in London, where women were debarred from admission for the most part.

This chapter describes how two items of business during an otherwise uneventful Yale Corporation meeting on March 21, 1910 shaped the future success of the medical school. “The Secretary read the confidential report prepared by Dr. Abraham Flexner on the condition of Yale Medical School,” and later in the meeting “the President spoke of possible changes in the scope of Professor Smith's work in the medical school, but no formal action was taken.” Flexner's report had been prompted by growing discontent with medical education amid a proliferation of proprietary schools across the country. The Council on Medical Education of the American Medical Association approached Henry Pritchett of the Carnegie Foundation for the Advancement of Teaching about conducting a study of medical education in the United States and Canada.

This chapter proposes that GTA programs are part of a larger trend in which medical education expanded its control over the professional socialization of medical students through an increasing array of knowledges and practices—or call “technologies of affect”—that seek to measure, harness, and manage the affective capacities of medical students. As the affective economies of healthcare shifted, new forms of governance via expert knowledges and technologies were necessary in order to prepare physicians-in-the-making for a changing landscape of clinical practice in which emotion figures centrally. Thus, this chapter also shows that reconfiguration of expertise and affect via research on medical education in this way is both highly evident in the GTA session and explains its durability and relevance.

Chapter 2 describes why delirium tremens became a topic of intense medical interest to American physicians soon after it was first described in 1813. While previously physicians had little interest in treating inebriates, after the delirium tremens diagnosis became widely adopted, drunkards were increasingly put into hospital beds, treated, and studied in a clinical setting. The chapter attributes the widespread adoption of the delirium tremens diagnosis to three main developments. First, the delirium tremens diagnosis derived from developments in American medical education, especially the influence of French physiology and the practice of pathological anatomy. Second, the language and imagery from physicians’ case histories depended on popular romanticism, and especially popular fascination with hallucinations evident in Philadelphia’s popular theater and magic lantern shows. And third, it illustrates how physicians’ case histories linked the disease with concerns about masculine achievement in the context of the profound economic upheaval following the Panic of 1819.

Chapter one begins with a synopsis of the scholarly literature that discusses the epistemology and pedagogy of medicine and the effects they have on physician formation before arguing that this perspective can be deepened and expanded by an understanding of Heidegger’s explication of “calculative thinking.” An understanding of this mode of thinking offers a more comprehensive grounding for the discussion about the inherent problems of medical education and practice. Privileging calculative thinking closes one off to other truths, those truths that are unverifiable, unquantifiable, or intangible. A Heideggerian critique helps to illustrate medicine’s tendency toward a calculative understanding of illness that is defined by a hurried curiosity, as opposed to a meditative thinking that is slower, open to wonder, embraces ambiguity, and considers the ineffable and unquantifiable to be just as “true” or valid as those things that might be scientifically “proven,” a point that will be more fully explored in later chapters. Recognizing the dominance and seductiveness of calculative thinking within medicine is important, as it speaks to the human tendency to turn away from the contingency, vulnerability, and death—a point that is clarified and expanded in chapter 2.

The pelvic exam is a fascinating case for understanding medical socialization today, as it involves a two-pronged navigation of feelings. It is about the emotions of physician and patient, but it is also about the embodied experience of sensation for both. The GTA program today has been shaped as well by the legacy of feminist health activism and the science-driven reform efforts of medical educators. While it is surely an exceptional experience—one or several one-to-three-hour workshops during all of medical school—it is embedded in and demonstrative of larger trends in medical education and, indeed, the medical profession.

Allopathy has become the dominant system of medicine in India today. Since mid-nineteenth century, allopathic medical education institutions have grown exponentially. However, its growth has been problematic. Further, the political influence of modern medicine practitioners has enabled them to gain monopolistic control of state health system, even though they remain marginal to the provision of primary care in the rural areas.

Medical education in India is not sufficiently oriented to the health care needs of the country. The knowledge of medicine has primarily originated in western countries and there are mismatches between medical knowledge and health care problems on the ground in India. While specialties such as cardiology and thoracic surgery have grown, basic treatment of coronary artery disease is not accessible to the majority of people. Medial colleges are also not adequately linked to the health care system, therefore not optimally effective in improving health care delivery and exposing students to all levels of the health system. Addressing these structural problems may involve making medical colleges responsible for health care of geographic areas, development of primary care education, and medical curricula that engage with the local context.

This chapter describes the policy initiatives of the Modi Government such as the appointment of the Hari Guatam and Kaw Committees to review the functioning of the UGC and AICTE respectively and of the work so far on developing a new education policy. It critiques the process adopted for policy development and the salient features of the report of the TSR Committee and MHRD’s discussion draft, the Input Document. It also critiques the far reaching judgment of the Supreme Court mandating a National Eligibility and Education Test (NEET) for admission to undergraduate medical and dental courses of all colleges including minority institutions. It outlines the controversy over teaching German as a third language in Classes VI–VIII of Kendriya Vidyalayas, and the establishment of world class universities. It outlines the measures taken by Modi Government to carry forward the initiatives taken by the UPA Governments to promote skill development.

This chapter examines how patient empowerment seeks to train medical students to cultivate behaviors, attitudes, and values through disciplinary work done on physicians’ and patients’ affects. Because of the pelvic exam’s fraught history of rendering patients as passive objects prior to the intervention of the Women’s Health Movement, this exam serves as an interesting example to tease out threads of patient empowerment and professional authority. Patient empowerment is conceptualized as a technology comprised of discourses, knowledges, and practices that constitute patients as “partners”: fully informed subjects who are responsible for and obligated to participate in the maintenance of their own health.

The evidence suggests that medical care for frail, old people should be interdisciplinary, coordinated, and accessible. Analysis of the current system suggests it should begin with comprehensive assessment of the individual, including physical function, emotional state, degree of social engagement, support system, and medical insurance. Next, the ideal interdisciplinary team should determine the person’s goals of care. Finally, a plan of care should be developed, taking both goals and needs into account. Implementing the plan will require a robust home care program as well as family support. Achievement of such a system will necessitate reforming the complex adaptive system that makes up American health care today. The most promising change agent is the Medicare program itself, which could introduce requirements into medical training programs to assure competence in geriatric medicine and communication skills. With appropriate legislative changes, Medicare could also negotiate with drug companies over price and set reimbursement for medical technology based on cost-effectiveness. Medicare could also develop a new benefit plan for frail elders that offered more intensive home care and other services in exchange for decreased coverage of invasive, expensive, and often non-beneficial hospital-based technology.

This chapter examines how teaching and learning the pelvic in United States medical education have been transformed by feminist practices of care, even as these same practices have been coopted in order to serve the interests of physicians and medical educators. It focuses especially on the disruptive potential of affect and how they are managed by new strategies of governance in medical education. The chapter is also informed by by ways in which, in the 1960s and 1970s, the Women’s Health Movement, medical education research, and transformations in biomedicine altered one another’s trajectories and changed how the pelvic exam is taught to medical students and, thus, the pelvic exam itself.

The conclusion looks at debates about the role of consent in teaching and learning the pelvic exam and what these indicate about affective governance in medical education and the making of physicians. The presence of the GTA program in most medical schools in the United States has meant an enthusiastic embracing of the “patient experience.” And yet, there is still a prioritization of the learning experience of the trainee at the expense of the patient when pelvic exams are performed on patients who are under anaesthesia. The chapter suggests that affective governance in medical education is about producing more efficient workers, and more compliant consumers. In short, it is no longer possible to set aside the important role that emotion and bodily capacities to move and be moved by play in the governance of conduct via expert knowledge.

This chapter examines why privileging calculative or technical thinking is particularly problematic in medical practice. Because medicine and medical education focus on the “real” and the “scientific” (assessing and treating biological disease), the lived experience of illness—including existential issues such as suffering, fear, and inescapable uncertainty—are left largely unaddressed. Thus, some clinicians, especially those who view themselves as scientists or technicians, may believe that they are not called to attend to these issues. It is not enough, however, to say that doctors turn away from answering this call to care simply because they have been trained within a medical culture that fails to acknowledge the lived experiences of patients that fall outside the bounds of calculative thinking and technical rationality. Turning away from the reality of vulnerability and finitude is part of the shared condition of being human. Through an exploration of the philosophical work of Kierkegaard, Heidegger, Merleau-Ponty, and Nietzsche, this chapter shows that medicine’s preoccupation with science, detachment, and certainty is a manifestation of the basic human desire to turn away from the anxiety that emerges in the face of human suffering and the struggle to make meaning in the face of profound illness and death.