Getting competition under control

Through the end of the nineteenth century it was difficult to make a living as a doctor in part because there were so many of them. Doctoring was largely unregulated, and so anyone could set themselves up as a doctor. Medical schools were mostly for-profit operations whose existence depended on providing doctors-to-be with the credentials they were willing to pay for. Professional organizations did what they could to sanction a few and ostracize the rest, but they were only locally effective, e.g. in New York City. Things were expected to change slowly if at all, due to the hands-off attitudes of state governments.

But perseverance by the AMA paid off. It managed to get licensing requirements established in all fifty states, and to get itself established as the authority by which medical schools were evaluated. Once this was accomplished, the AMA began to drastically increase the educational requirements for doctoring, from a couple of years of part-time study to eight post-high-school years of full-time study as of 1906.

The pressure was too much for commercial medical schools, who couldn’t afford to provide the staff and equipment needed to educate students according to the AMA’s standards; some failed, the rest simply lied about whether they were meeting the standards. Then in 1910 a detailed survey was done of every medical school in the U.S., demonstrating that the remaining commercial schools were lying, which forced them to close their doors.

The result was that doctors were much better trained, but there were also many fewer of them. Those who remained were much better paid; the competition which had kept them poor had been eliminated.

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Time to go?

One of the contrarian email newsletters I read, the Rude Awakening, caught me by surprise with yesterday’s article, called “Exit U.S.” The article began with this:

One and a half million U.S. households are preparing to move out of the U.S. The vast majority of émigrés are in their 20s, 30s, and 40s. And some may not ever return. […]

This news comes from a Zogby International poll of 115,000 Americans conducted over the past two years. Bob Adams, CEO of New Global Initiatives, commissioned the poll when he realized that no reliable database tracks the movement of Americans out of the country. A recent Barron’s article, written by Bob Adams, breaks down the Zogby/New Global Initiatives data as follows:

· 1.6 million (U.S. households) have already made the decision to leave
· 1.8 million are seriously considering and likely to leave
· 7.7 million are somewhat serious about leaving and may do so
· 3.0 million are seriously considering purchase of non-U.S. property
· 10.0 million are somewhat serious about purchase of non-U.S. property

Adding it all up, some 10% of all U.S. households are looking to leave the country, while another 11% are considering living outside the U.S. at least part time.

The article is preceded by a long preamble from the editor discussing indications that foreign investors are fed up with the plunging dollar and beginning to shift their wealth into non-dollar-denominated assets; you can safely skip it, but I learned a few new things reading it.

Indirect costs

Even as American attitudes towards doctors began to shift in the nineteenth century, there was one factor which placed severe limits on a doctor’s ability to establish a practice: the cost of providing his service. Primarily this was because the doctor had to travel from patient to patient in order to do his work, and travel was difficult and expensive even over short distances; a common fee schedule was 50 cents for the visit, plus one dollar for each mile the doctor had to travel. It was also expensive to let the doctor know that he was needed, usually requiring a trip to find him on the part of a family member or neighbor. Rural people were reluctant to go to town to see the doctor, knowing that they would probably lose a day’s work on the farm and not knowing if they would find the doctor once they got there, since he might very well be out on call. As a result, the indirect costs incurred when seeing a doctor far outweighed the direct cost of his service, and folks were either unable or unwilling to pay those costs.

Hard roads were the first innovation that made a doctor’s travel quicker and more efficient. Railroads also helped doctors who focused on consultation; they were able to cover wide areas, and even to barter medical care to railroad workers in exchange for their fare. And when the car came along doctors were able to increase their home visits four- and fivefold.

Meanwhile, the telephone made it possible to establish an appointment system. Initially almost all office visits were done on a drop-in basis, with no guarantee that patients would find the doctor there or that a doctor would have patients on a given day. But as patients were able to call ahead they became amenable to scheduling a time for their visit.

Musical weekend

On Friday most of the family took a day trip to Lexington. We thought eight hours away would be too much for Peter, so Debbie stayed at home with him, but I drove with the other six kids to see our friends Ginny Hawker and Tracy Schwarz peform at the University of Kentucky as part of the Appalachia in the Bluegrass noontime concert series.

We showed up about half an hour early, mostly because UK is in the middle of the city and I wasn’t sure how difficult it would be to park or to find the building where the performance was being held. Not difficult at all, it turns out. Chris had brought along his banjo at Ginny and Tracy’s request; there was also an upright bass there, and they asked us if we’d help them out with a couple of songs at the end. What do you think our answer was?

The program lasted about an hour, very relaxed, with about 120 people crowded into a library room that seated one hundred. The little ones did just fine, about like they do at church. At the end Chris and I went up front to help Ginny with “Long Black Limousine.” Actually, only I was supposed to help with that one, but the fellow who was going to play guitar hadn’t shown up, so Chris provided guitar accompaniment so Tracy could fiddle. We hadn’t really rehearsed it, but when it came to the chorus Ginny gave Chris a glance that said (to him, anyway) that he was welcome to provide a harmony, and he let out with the awesome high harmony that Kari Sickenberger sang on Ginny’s CD; that earned him a look of delight, and a big hug at the end of the song. Chris then switched to banjo and we finished up with “Foggy Mountain Top.” A little bit of visiting afterwards, and then we had to head back home so Chris could get on with the afternoon milking.

Saturday we played at a benefit chili supper at the local lodge; shortly after we moved here our neighbor Leemon Goodin asked us to fill in at the last minute, and since then we’ve played whenever they’ve had such a get-together. This time the schedule was a bit crowded, with a Southern gospel group and a collection of bluegrass players featuring Frank Neat, a legendary banjo builder who lives just a few miles from here. Since Frank is the only local connection I know of to the greater bluegrass world, I wanted him to hear Chris on the fiddle, so I pushed him to join in when the bluegrass folks were playing. Perhaps nothing will come of it, but Chris has now done his part. (He also fiddled for the gospel group, who told me several times they wanted to kidnap him.)

Sunday we played at St. Mildred’s church in Somerset, for their annual community Thanksgiving dinner. Jerome took us along to this last year, but he had to be elsewhere on Sunday and so it was just me and Chris this time. The dinner is held in about the most challenging environment we’ve played in a long time, a former gym with really bad acoustics. Another gospel group also played, and they were good enough to stick around so we could use their sound system, which wasn’t great but much better than none at all. The main reason I like to (occasionally) play in such a situation is that it gives us some much-needed perspective. There are many, many reasons for us to play music aside from the one we like the best, namely having informed listeners give us their complete attention. This time it was most important that Sister Marty, the dinner organizer, be able to count on us to provide some of the music; she was grateful, and that was reason enough. We also got to play some songs we hadn’t done in awhile, we learned some things about doing our best in a stressful environment, we were reminded that not everyone starts out favorably disposed to our kind of music, we were reminded that it’s perfectly OK for people to ignore us, and we brought smiles to a number of faces. All in all it was a good experience. And they fed us a decent meal at the end.

The way things used to be

I’ve just begun reading The Social Transformation of American Medicine, Paul Starr’s Pulitzer prize winning history of the rise and triumph of health professionals in America. According to Starr, doctoring was viewed quite differently not too long ago:

Doctors in America were not always the powerful and authoritative profession that they are today. A century ago they had much less influence, income, and prestige. “In all of our American colleges,” a professional journal commented bitterly in 1869, “medicine has ever been and is now, the most despised of all the professions which liberally-educated men are expected to enter.” Although a few eminent doctors made handsome fortunes, many before 1900 could hardly scrape together a respectable living. […]

Beginning in the 1760s, some educated doctors took the initial steps to reproduce in America the professional institutions that in England gave physicians a distinct and exclusive status. They succeeded in organizing medical schools, and in some fields of work, such as obstetrics, doctors gained ground against rival practitioners. But they failed in their larger efforts to establish themselves as an exclusive and privileged profession. The licensing authority doctors secured had little more than honorific value, and during the Jacksonian period in the 1830s and 1840s, their claims to privileged competence evoked a sharp backlash that crippled their ambitions for the next half century. State legislatures voted to do away with medical licensure entirely. No profession was being allowed, Oliver Wendell Holmes told the graduating class at Harvard in 1844, “to be the best judge of its own men and doctrines.” Lay practitioners, using native herbs and folk remedies, flourished in the countryside and towns, scorning the therapies and arcane learning of regular physicians and claiming the right to practice medicine as an inalienable liberty, comparable to religious freedom.

What exactly was it that changed? I’m hoping this book will tell me.

Still recovering

I’ve just finished restoring the missing weblog posts, the ones I wrote between May 2005 and June 2006. There are more than two hundred of them. Among them is another series of posts on a single topic, namely getting things done.

Getting things done: introduction
Getting things done: the prime stumbling block
Getting things done: avoid busyness
Getting things done: don’t get stuck in the foothills
Getting things done: is this trip necessary?
Getting things done: go find something to do
Getting things done: acquire a taste for low hanging fruit
Getting things done: starting out
Getting things done: examine your motives
Getting things done: seek out good teachers
Getting things done: what to do next
Getting things done: what to do next (2)
Getting things done: avoid procrastination
Getting things done: set achievable goals
Getting things done: do it for real
Getting things done: your turn

Jacques Barzun

In 1992 Mortimer Adler published a book called A Second Look in the Rear View Mirror. It began with words to this effect: “Fifteen years ago, at age seventy-five, I prematurely wrote my autobiography.” He lived another nine years, not quite making it to one hundred.

Now Adler’s good friend Jacques Barzun is himself about to turn one hundred. Here are two good articles about Barzun, one giving a general overview of his life and work, the other a remembrance of studying under him at Columbia.