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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.

As the previous chapters have suggested, striking changes in medical education had occurred by 1800 in nearly every Western country. In particular, the movement toward practical training in medical teaching had gathered momentum toward the end of the eighteenth century. Not only in Vienna, Paris, Edinburgh, and Leyden but also in scores of universities, hospitals, military schools, dispensaries, lying-in clinics, and private courses spread across Europe and North America, students were finding new opportunities to practice dissection; see patients at the bedside; take case histories; practice surgical, obstetrical, and other procedures; and even diagnose and treat patients under a teacher’s supervision. It is this sea change in attitudes toward practical training that we explore in this chapter. Spurred by Enlightenment concerns for public health and utilitarian concepts of practical training, new clinical experiences were becoming available in many places. Although in some countries, notably France and Germany, the state played a decisive role in fostering the new development, in others, especially Britain and America, students were left largely on their own to gather practical experience, choosing from a variety of lecture-demonstration courses, hospital training, apprenticeship opportunities, experience in outpatient dispensaries, and private classes. National differences in social and political development channeled the strong pressures for utilitarian education into new forms of clinical training. Differing concepts of what constituted a “teaching clinic” came to exist side by side, especially in Europe. In unsettled France, the clinical impulse, which had early centered on surgical practice in urban hospitals and was now promoted by an all-powerful revolutionary government, found its primary outlet in large hospitals. In the German states, on the other hand, politically divided and lacking large hospitals in most university towns, clinics developed largely as small appendages to university programs in medicine. British clinical training, as described in earlier chapters, was centered haphazardly in the London hospitals away from the nation’s universities and was growing also in provincial hospitals and dispensaries. In North America, the search for clinical experience was spread over a great variety of small infirmaries, dispensaries, and private courses, and apprenticeship training remained the dominant mode of getting hands-on practice.

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.

After mid-century, university hospitals became more involved in research and the care of patients with very serious illnesses. This new orientation has created financial, teaching, and patient-care problems. In order to obtain access to more patients and patients with ordinary illnesses, medical schools affiliated with veterans’ and community hospitals. Many of these hospitals have become similar to university hospitals as a result. Medical schools experienced a serious shortage of facilities in their customary teaching hospitals after 1950. Many university hospitals had few beds or set aside many of their beds for the private patients of the faculty. Patients admitted for research purposes had serious or life-threatening diseases instead of the commonplace disorders needed for training medical students. The public hospitals affiliated with medical schools had heavy patient-care obligations that reduced their teaching and research activities. To obtain the use of more beds, medical schools affiliated with more community and public hospitals. The closeness of the affiliation has varied as a function of the ability of the medical school to appoint the hospital staff, the number of patients who could be used in teaching, and the type of students—residents and/or undergraduate medical students—who could be taught there. In 1962, 85 medical schools had 269 close or major affiliations and 180 limited affiliations with hospitals. Fifty-one of the hospitals with major affiliations were university hospitals and 100 others gave medical schools the exclusive right to appoint the hospital staffs. Dependence on university hospitals has continued to decline so that in 1975, only 60 of 107 medical schools owned 1 or more teaching hospitals, with an average of 600 total beds. All of the medical schools averaged 5.5 major affiliated hospitals, which provided an average of 2,800 beds per school. Public medical schools were more likely to own hospitals than private schools (39 of 62 public schools compared to 21 of 45 private schools), but they averaged fewer affiliated hospitals (5.1 compared to 6.0). In 1982, 419 hospitals were members of the Council of Teaching Hospitals (COTH), of which only 64 were university hospitals. Members of COTH included 84 state or municipal hospitals, 71 Veterans Administration and 3 other federal hospitals, and 261 voluntary or other nonpublic hospitals.

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 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 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 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.

The expansion of the functions of medical schools since mid-century has had many unanticipated and adverse consequences for medical education. As a result, medical schools have lost some of their societal support. In the years since 1900, medical schools have made major changes in their structure in order to solve specific educational problems. University hospitals were built to provide clinical training in hospitals that emphasized education and research rather than patient care. Full-time clinical faculty members were employed in order to professionalize a role previously occupied by part-time practitioner-educators. Biomedical research was undertaken to enable faculty members to advance medical knowledge and enhance their skills as educators. Internships and residencies became restricted to hospitals affiliated with medical schools to replace the poorly supervised practical experience provided in community hospitals with a more structured education administered by professional educators. Each of these changes assumed that medical schools could be removed from the hurly-burly of professional life and made to fit the model of the liberal arts college. This assumption failed to recognize the fundamental differences between the two types of institutions. In liberal arts education, the body of knowledge taught to students need not be suitable for practical application in the community. In many fields, like most of the humanities, it has rarely been used outside of institutions of higher education. In others, like the social sciences, the knowledge has been sufficiently tentative that its direct application has been problematic. In still others, like most natural sciences, the knowledge has been so highly specialized that it could not provide a basis for viable careers. As a result, most faculty members in the liberal arts and sciences have spent their careers in teaching and research without the option of nonacademic employment in their disciplines. Medical schools, on the other hand, have continually influenced and been influenced by the practice of medicine in the community. The knowledge taught in medical schools has affected the way that physicians have practiced medicine, but it has also been tested by practitioners and fed back to the faculty for modification and refinement.

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.