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The expansion of clinical service in the two decades following World War II created strains within academic medical centers, largely because of the distractions that patient care inevitably placed on teaching and research. Nevertheless, few academic medical centers lost sight—at least for long—of their unique role as educators of future physicians, and as producers of new medical knowledge and technologies. They worked hard to preserve the learning environment of the teaching hospital, even as that environment came under pressure from changing social, economic, and demographic circumstances. After the war, the strength of American medicine continued to reside in its academic medical centers—the collaborations of medical schools and teaching hospitals that generated knowledge, produced doctors, served as the ultimate arbiters in complicated clinical cases, and defined the standards of excellence in patient care.

After World War I, teaching hospitals championed the same academic ideals as their affiliated medical schools, and the two institutions acted in concert in education, research, and patient care. The relationship between medical schools and teaching hospitals was one of codependency. Medical schools, ever on the alert for clinical facilities, understood that access to the wards of hospitals was essential for teaching and research. Teaching hospitals, in turn, understood that their preeminence in 20th-century medical practice was a consequence of their participation in medical education. Though teaching hospitals of the period served as nearly ideal educational laboratories, this did not occur without costs or consequences. It quickly became apparent that teaching hospitals could not be as efficient as nonteaching hospitals, if at the same time they were providing a rich educational environment. In addition, the fact that indigent but not private patients were routinely used in teaching challenged the common belief that medical education resulted in better patient care.

Domestic tranquility returned quickly to the United States with the end of the Vietnam War. Nevertheless, in the 1970s and 1980s, academic health centers came under new external pressures. Other aspects of the outside environment began to turn sour, as social and demographic trends, new government policies, and changing public attitudes started to work to their disadvantage. Medical schools and teaching hospitals were increasingly perceived as stressed institutions, and a dispirited mood developed among them. Their confidence and sense of autonomy, so prominent before World War II and during the mythic “golden age” of the 1950s and 1960s, dwindled. Always dependent upon external funding, medical schools had never been as truly autonomous as it once seemed. Nevertheless, it now appeared that they were vulnerable to every jolt on an increasingly bumpy road.

Though medical schools and teaching hospitals were separate entities, they operated extremely closely, and their individual successes depended very much on their collaboration. In the late 1920s, the term “medical center” came into use to describe arrangements in which a medical school and teaching hospital occupied adjoining physical sites. The term was first used in conjunction with the opening of the Columbia Presbyterian Medical Center in 1928 and the New York Hospital–Cornell Medical Center in 1932. After World War II these complexes came to be called “academic medical centers.” Though no two were exactly alike, the centers typically consisted of a medical school, a university-owned or controlled hospital, and affiliated specialty hospitals or institutes. Academic medical centers were at the center of efforts to improve the quality of medical care and the health of the people, thus rendering service to the nation at large. In short, academic medical centers, like their parent universities, accepted the duty of utility—that is, of providing service to the society that supported them, and allowed them to pursue their scientific interests.

The explosion of knowledge in all academic disciplines after World War II shattered traditional approaches toward scholarship. Fragmentation of disciplines and academic specialization occurred throughout universities. In medicine, a similar fragmentation of knowledge and practice occurred. The movement toward specialization had been underway for many decades, but as biomedical research progressed, the growth of specialization and subspecialization rapidly accelerated. Though general practice did not disappear after World War II, its attractiveness as a career to physicians in training markedly decreased. Following internship, more and more medical graduates sought residencies to pursue a specialty, and after residency, many sought postdoctoral training in a clinical subspecialty as well. Teaching hospitals quickly met the increased demand for specialty training. Graduate medical education, once only a secondary interest of medical faculties, became one of their primary concerns. At many medical centers, the number of interns, residents, subspecialty residents, and clinical fellows grew to exceed the number of medical students. As the multiversity began to swell with graduate student training programs, the postwar academic medical center became home to a vastly expanded program of graduate medical education.

American hospitals come in a variety of flavors: teaching and non-teaching, for profit and not-for-profit, large and small, government and private, urban and rural. While the patient’s experience varies slightly depending on the type of hospital, all hospitals could be improved to better serve the needs of older patients if they implemented basic geriatric principles.

In the 1970s and 1980s a distinct malaise pervaded many medical schools. As they increased their role in patient care, and as they grew ever larger in size, they struggled to maintain their institutional cohesiveness and clear focus on academic work. In addition, medical schools, long a symbol of public service, began to appear self-serving and unconcerned with the public good. To many, the once-clear distinction between a university teaching hospital and a large community hospital began to blur, as did the formerly clear differences between a university medical school dedicated to serving the public and a scientific corporation seeking to maximize markets and profits.

This chapter offers an account of the London teaching hospitals to show that Keats had privileged access to intellectual capital. London was a hotbed of intellectual ferment, as embodied by professional bodies like the Guy’s Hospital Physical Society and which found expression in the Vitalism Debates. The milieu within which Keats lived and worked is explored, focusing particularly upon characteristic aspects of Romantic medical training that are now obsolete, such as dissection of corpses freshly exhumed by ‘resurrection men’. The only known account of Keats in action as a surgeon is discussed, revealing that Keats was not fully persuaded by the prevailing Brunonian hypothesis of physiology. The chapter draws upon unpublished contemporary manuscripts in dating Keats’ medical notes, thus resolving an important and hitherto uncertain issue.

This chapter studies how the passage of Medicare and Medicaid in 1965 brought new populations of poor and elderly patients to hospitals and clinics nationwide. Medical schools and teaching hospitals became even more involved in addressing the health care needs of their surrounding communities. Since these shifts overlapped with the social activism of the 1960s, many medical students at Cornell became passionately engaged in outreach efforts to underserved patients. Faced with postwar inflation, hospitals focused on private patient admissions in order to increase revenue. Concerns were raised that the shift toward private patients would have a negative effect on teaching and research. In response, Dean John E. Deitrick proposed a system in which all fees obtained by patients would support the clinical faculty as a whole, and all patients would participate in teaching and research efforts.

This chapter examines the underlying cause of the rapid increase in hospital advertising in the United States. A critical component of the explanation is the rise of managed care across the country. In markets that experienced the greatest rise in managed care influence, large teaching hospitals had the most rapid increase in advertising. For all other hospitals, increased managed care reduced ad spending, suggesting that HMOs represent a financial shock to hospitals. The chapter is organized as follows. Section 3.2 discusses the history of hospital advertising and the economics behind advertising for hospitals. Section 3.3 presents various hypotheses as to why hospitals would have changed their advertising behavior at this time. Section 3.4 discusses the data; Section 3.5 presents the empirical results; and the final section concludes.

This chapter looks at Jewish general practitioners and consultants between the world wars. It shows that the massive influx of Jews into the medical profession started during the First World War and continued into the 1920s and 1930s. Although there is a widespread belief among Anglo-Jewish historians that discrimination made entry into the medical profession difficult for Jews, finding a place in an English medical school was in fact—apart from a few isolated incidents—relatively straightforward for Jewish students during the inter-war period. However, problems arose when Jews from an immigrant background tried to obtain house appointments and staff positions in the leading London and provincial hospitals. Even the top students, if they were the children of east European Jewish immigrants, sometimes found it difficult to obtain these positions in the London teaching hospitals or such institutions as the Manchester Royal Infirmary during the 1920s, though it became slightly easier in the following decade.

In this chapter, the author reflects on the importance of diagnosis in medicine. He first describes almshouses that functioned like hospitals in America before citing one thing that makes the intensive care unit (ICU): the drugs that are administered to patients. He then considers the views of doctors and patients regarding disease, suggesting that doctors are interested in disease rather than death. He also talks about the families of the patients, as well as medicine and how it wasn't always taught in the hospital. The author concludes by focusing on William Osler, founder of the teaching hospital and one of the four physicians who began Johns Hopkins Hospital.

In this chapter, the author reflects on the daily and hourly activities of the doctors and nurses in the intensive care unit (ICU) where he works. He describes the ICU as pure medicine and a nursing world and the patient as a network of nine systems: neurologic, cardiovascular, pulmonary, gastrointestinal, genitourinary, renal, integumentary, hematologic, and endocrine. He also considers the principle of the ICU: single-organ-directed interventions to support failing organ systems. He suggests that the teaching hospital is a kind of workshop that makes doctors, where they are put together, assembled, polished, made sure they are in working order, put through tests to make sure they are up to it. Finally, he talks about fourteen patients at the hospital and their various illnesses.

In this chapter, the author talks about what nursing is and what it is not. He begins by citing Florence Nightingale's 1859 book Notes on Nursing, subtitled What It Is and What It Is Not. It was written for women who had personal charge of the health of others, which would be “almost every woman in England.” He goes on to suggest that nursing was not medicine and that a lot of what was medicine has drifted into nursing, from titrating drugs such as dopamine to interpreting arterial blood gases, deciding what's artifact or arrhythmia, and making decisions all day long—functions that used to be limited to doctors. He also mentions Terry Mizrahi's book Getting Rid of Patients: Contradictions in the Socialization of Physicians, which explores the culture of residents and interns in a southern teaching hospital over several years. The author concludes by reflecting on the relationship between the hospital and poor patients.

An academic health center (AHC) consists of a medical school and one or more health professional schools. These schools are joined to one or more affiliated teaching hospitals that are under common ownership or closely aligned with the medical school. This book focuses on the academic health centers (AHCs) that provide medical care to the urban poor. The urban poor belong to a group of people with income below the federal level of poverty and people who are uninsured. The book centers primarily on the relationship between AHCs and the urban poor subsequent to the passage of Medicare and Medicaid.

In this epilogue, the author recalls his conversation with some residents with whom he worked in the intensive care unit (ICU) in the New Mexico teaching hospital and now were leaving because it was the end of their rotation. He says he felt a mixture of wonderment, puzzle, pride, and happiness for one resident, who had been so inept and timid the first weeks but now was the resident in charge, supervising the central line. Another intern went the opposite way—she came in with a hard attitude that faded into her real self that wasn't so bad and even a little endearing. A third intern said, “Great working with you guys.” The interns were happy in their way, going on, while the author and others who are staying are also happy in their way.

This chapter discusses the importance of physician supply issues in the evolution of U.S. health care policy. It first looks at the consequences resulting from the 1963 initiatives to provide financing of medical and other health professional schools. It then discusses the impact of the Medicare and Medicaid statutes on physician supply in terms of numbers, specialization, practice locations and incomes. Medicare provided multiple sources of graduate medical education (GME) funding to the academic health centers(AHCs) and other teaching hospitals to cover the costs of training and employment of residents. The chapter also discusses the factors involved in the expanding and changing character of the physician supply in the United States since the passage of Medicare.