Why Johnny Can't Operate

Time to Heal: American Medical Education from the Turn of the Century to the Managed Care Era

By Kenneth M. Ludmerer

(Oxford University Press, 514 pp., $29.95)

I.

Our present health care system has many deficiencies, most of which are by now widely recognized. One of the most serious, but least appreciated, is its failure to provide adequately for the training of future generations of doctors. No matter what is done about the other problems, good medical care is impossible without well-trained doctors to provide it. Yet the academic medical centers that are responsible for producing new doctors--the 125 accredited medical schools and their 400 or so affiliated major teaching hospitals--are being systematically starved of the resources to do so. The education of doctors is now being increasingly compromised, with possibly disastrous results for the quality of medical care in the future.

That is the disturbing message of Kenneth Ludmerer's important book. It has stirred up the academic medical community, as it should; but it deserves a wide public readership as well. No consideration of the future of health care in the United States can afford to overlook the historical facts laid out by Ludmerer, or the public policy issues that they raise. To set his powerful thesis in its proper context, however, we need first to understand the extraordinary metamorphosis of our health care system in the past three decades.

During those years, especially in the past decade, our health care system has been transformed into a vast commercial market. Once considered primarily a social service and a public responsibility, health care is now commonly viewed as a private industry, best controlled by market forces. Painful experience in the past few years may be forcing a reexamination of that view, but as of now the issue remains to be resolved. For many, the free market recently has begun to look more like the cause than the solution of our current health care problems. Evidence of its deficiencies is accumulating, and public dissatisfaction with the market-based system grows rapidly.

Physicians, the essential providers of medical care, are also becoming disillusioned with market-based medicine. There is much reason for their discontent, because the market threatens not only their economic security but also their professional values and practices. Doctors are more unhappy than I have ever known them to be, in over half a century of experience as a physician, a teacher, and a close observer of the medical profession. Practicing doctors are a heterogeneous population of over 700,000 men and women, so it is risky to generalize about such things. Still, polls show that most physicians think these are very bad times for them. Moreover, they attribute most of their difficulties to the central feature of the new health care market: the managed care insurance companies.

These companies, mostly investor-owned, now control nearly all private health coverage, and a significant part of publicly financed programs as well. In all, more than 170 million Americans receive their care through private managed care plans. Most of them are enrolled in managed care plans by their employers, who usually pay the major part of the premiums. Managed care spread quickly during the 1980s and 1990s, because it promised to control employers' health care costs, which were escalating rapidly under the old system of indemnity insurance. Instead of paying whatever doctors and hospitals charged for each medical service, as in the indemnity system, managed care plans charged employers a set premium in advance for an agreed-upon range of benefits. If the employees used fewer individual services, the managed care companies would profit; if they used more, the companies would lose money.

By limiting contacts between patients and doctors, and by regulating the use of hospitals and specialized services, the plans were able both to control employers' health care costs and to profit handsomely. Managed care plans exercised control over medical services through contracts signed with physicians, and their members had access only to doctors who were under contract with the plan. The contracts not only also defined the terms of payment, but often regulated the procedures under which physicians could practice. Physicians, for their part, had no choice but to accept this arrangement if they wanted an opportunity to treat the increasing number of patients being enrolled in these plans.

In 1993, the newly elected Clinton Administration, having noted the initial success of managed care insurance plans in controlling medical expenditures, proposed a national plan to encourage this form of insurance. Rather than leave matters entirely to the market, the Clinton proposal included an elaborate system of regulated competition among insurance plans, most of which would be managed care. As a member of an advisory committee of health care professionals, asked by the Administration to review the proposed legislation before it was submitted to Congress, I had serious reservations about the bill. I thought it was much too complicated, and I was disappointed that it proposed nothing to encourage not-for-profit, provider-managed insurance and delivery systems. I believed then, as I do now, that commercialization and entrepreneurial incentives are a major impediment to viable health care reform. In any case, the defeat of the Clinton plan was a major political setback for the Administration, and it allowed, by default, an essentially unregulated managed care market to take over the private insurance business.

Note, however, that in controlling expenditures on medical services, the managed care companies were serving the interests of employers more than the interests of the employees covered by the insurance. Employers not only pay for most of the cost of the insurance, they also select the insurance plan or the choice of plans available to their workers. Employers, and not employees, are therefore the customers whom the insurers must court. This peculiar re-arrangement of the usual relationship between insurers and beneficiaries is one cause of the current consumer dissatisfaction with managed care.

And there is another, and perhaps more fundamental, reason. Before managed care, indemnity insurance companies were paid on a "cost-plus" basis, so there was no conflict between the financial interests of the insurers and the medical needs of the beneficiaries. Under managed care, the insurance companies are paid a fixed premium, and so they profit only to the extent that they can limit their payments for medical services. (The companies refer to these expenditures as "medical losses," an odd but revealing term.) A conflict of interest between insurers and beneficiaries is therefore inevitable.

"Patients' rights" legislation has been introduced to protect the public against some of the baleful consequences of this arrangement; but it can do little, I think, to correct the basic misalignment of incentives that accounts for the conflict of interest. Patients do not want any restrictions on the medical services recommended by their doctors, but the managed care companies obviously do. And yet most economists and health care policy experts profess to see nothing wrong with this system. Indeed, they have pronounced it to be the long-needed rationalization of a previously wasteful and unaccountable cottage industry.

Not surprisingly, the private managed care insurance companies, now wealthier and more politically powerful than ever, agree with these experts and are greatly pleased with the transformation. Their trade association, the Health Insurance Association of America (hiaa), is a potent lobbying force in Washington dedicated to protecting the industry's current control of the health care system. hiaa played an important role in killing the Clinton health plan, and it now seems determined to resist any reforms or government regulations that might threaten the business success of its members. The American Association of Health Care Plans is another prominent and influential Washington trade group actively promoting the interests of managed care companies.

Most of the money that does not reach the direct providers of care (mainly doctors and hospitals) pays for the increasing corporate expenses of the insurance companies and provides income for the innumerable new health care-related businesses now living off the health care system. These businesses supply a wide variety of services to the managed care companies, including such things as sales and brokering, public relations and advertising, financing, claims handling, utilization review, management of prescription drug benefits, case and disease management and information technology. Many of these new services are supposed to control unnecessary expenditures on medical care, and to make the system more efficient. Whether they do so is debatable. What is not debatable is that they have greatly increased overhead costs in the health care system.

Despite the predictions of free-market proponents, the managed care market has had little or no lasting effect on the inflationary rise in the total health care budget. It has simply shifted payments away from the direct providers of medical services and directed the money elsewhere. True, total expenditures were briefly held in check during the mid-1990s, but they are once again rising at near double-digit rates. The fraction of total private health expenditures that has been shifted to the corporate overhead of managed care insurers, and to all the other new health care-related businesses, is not precisely known. I would conservatively estimate it to be at least one-third of the total, or roughly $125 billion to $150 billion. Despite the claims of the managed care industry, there is no convincing evidence that this money has improved the quality of our medical care; and there is much reason to suspect the opposite. What is even clearer is that access to medical services is being restricted, and this fact is generating widespread public discontent.

No wonder, then, that the direct providers of care--the doctors and the hospitals--are so unhappy. They believe their ability to take appropriate care of their patients is being compromised by the cost management and the coverage decisions of the insurance companies. Their own overhead expenses have risen as they struggle to survive in a new competitive and commercialized marketplace, and to comply with the red tape and the regulations generated by multiple payers. Reimbursement for their services is being capped or reduced, while increasing rewards go elsewhere in the system.

The declining morale of physicians, and the economic constraints on medical care now imposed by the private insurance market, should worry everyone, not just doctors. More and more employees covered by managed care plans, particularly those with serious illnesses or injuries who need medical care the most, are concerned about their restricted health care choices and their limited access to specialized medical services. Lately, as the costs of premiums have resumed their former rate of inflation, even employers, who had initially demanded that market forces be brought into the health insurance field, are beginning to wonder whether the present system will last--and whether it should.

II.

Much has been written and said about all of this. What most people do not sufficiently appreciate is that the private market has not only made it difficult for physicians to take care of their patients, it has also seriously hurt the academic medical centers and their associated teaching hospitals. The market does not treat teaching hospitals kindly, because they are much more expensive than their non-teaching competitors. Yet they are the wellsprings of modern medicine: the primary sources of clinical research and new clinical knowledge, and the places where the best and most advanced medical treatment is delivered. They care for a disproportionately large share of the sickest and most complicated (and therefore the most expensive) patients, as well as a disproportionate share of the uninsured. And they are the essential providers of medical education, the places where medical students and newly-graduated doctors (interns and residents) learn to become competent practitioners and specialists.

And yet our current health care system, now dominated by industrial practices and a Darwinian free-market philosophy, has little or no interest in helping teaching hospitals bear their heavy social burdens. Kenneth Ludmerer is right to worry that without viable academic medical centers and teaching hospitals, the future quality of medical care will be in grave danger.

In telling the story of medical education in the twentieth century, Ludmerer makes clear that the system of medical education was already in financial trouble for a decade or so before the managed care companies took over the private insurance market. Managed care compounded the problem and converted it into a crisis. The education of medical students is very expensive, and the earmarked funds to cover the costs had never been available in anything like adequate amounts. For most of the century, university-based medical schools had been responsible for the education of medical students; but the institutional budgets of those schools, even the strongest of them, were never large enough to pay the full costs. Schools had to bootleg money for this purpose from two other sources: federal grants intended to support research and research training, and public and private payments to physicians on their faculty for the care of patients. In the same way, major teaching hospitals had always used these same sources--particularly payments for clinical care--to cross-subsidize the costs of educating their interns and residents.

But this strategy was doomed to fail. In the 1970s the policies governing research grants at the National Institute for Health were made more stringent, preventing their use for the support of clinical teaching. And in the 1980s reimbursement of physicians and hospitals by Medicare, Medicaid, and private insurers was cut back, reducing the clinical income that could be used to support education. Adding to the economic squeeze on teaching hospitals was the adoption in the 1980s of a system of hospital reimbursement that essentially paid a fixed amount per patient according to the diagnosis, regardless of the length of stay or the actual costs to the hospital. Obviously such a system of re-imbursement hits teaching hospitals the hardest, because clinical education and the care of the sickest patients require longer average stays and greater hospital expenditures. Payments by Medicare for the partial reimbursement of educational costs in teaching hospitals were also trimmed, most recently by the Balanced Budget Act of 1997.

Despite makeshift funding, medical education had at first flourished in the quarter of a century following World War II. The academic medical centers of the United States had responded to the national call for more and better medical care by rapidly expanding and multiplying. They did more research and treated more patients. They graduated more medical students and produced a growing army of well-trained specialists and primary care physicians. To do all this, they used whatever funds were readily available, ignoring the danger of allowing medical education to become heavily dependent on outside sources that they could not control or even predict. In those halcyon days, when money for medical education was easy and seemingly unlimited, the academic medical establishment was content to live only in the present, with no thought for the future. This was perhaps understandable, but even after the makeshift funding began to decline and the threat to medical education became more clear, the leaders of the academic medical centers were not inclined to address the problem.

I feel qualified to make such an observation because I spent a large part of my career in academic medicine and was active in many of its national organizations. In 1984, I wrote an article in the journal Science entitled "Who Will Pay For Medical Education in Our Teaching Hospitals?" It was based on a speech before the Association of American Physicians, a leading professional society in academic medicine. I warned that makeshift funding would inevitably fail to sustain medical education and would eventually have to be replaced by public support. To justify that support, academic medicine should take more responsibility for addressing problems in the health care system of the United States, and be more accountable to the public for its actions. But at the time, leaders in academic medicine had other concerns. Most of us were too focused on the immediate needs of our own institutions and our own medical specialties to cooperate in seeking more solid support for medical education, let alone to work on solutions for the problems of the American health care system.

III.

The issue became moot after the stunning events of the last decade. Advocates of the free market defeated the Clinton health plan, and market-based managed care quickly gained full control of private health insurance. The effect on the finances of academic medical centers was disastrous; survival became an urgent priority that took precedence over concerns for the quality of educational programs. It became impossible for academic medical centers to cross-subsidize educational programs as they had in the past. The critical problem was not only the lack of money, but also the lack of time for teaching. In today's health care delivery system, time means money; but for clinical education, it is lack of time to teach and to learn that is the most immediate problem. The title of Ludmerer's book underscores this important point. At several places in the volume, he compellingly details the importance of adequate time for teaching, and explains how managed care has made teaching time such a scarce commodity.

The best clinical education occurs at the bedsides of patients in the teaching hospitals. Traditionally, medical students, interns, and residents had time to examine and get to know their hospitalized patients, to participate in their diagnostic or pre-operative evaluations, and to observe the response of patients to treatment--all of this under the supervision of experienced clinicians, who were also faculty members of the medical schools with which the teaching hospitals were affiliated. But now, managed care pays these faculty members only for the clinical care that they provide, and the payments are not generous enough to support extra time for teaching. In addition, the faculty members are expected to see as many patients as possible, as rapidly as possible. Thus, even clinical care may be compromised, and teaching runs a poor second to that.

Moreover, one way managed care controls costs is to keep patients out of the hospital unless they are extremely sick, or require major surgery or specialized diagnostic procedures that cannot be done outside the hospital. When patients do need to be hospitalized, they are moved in and out as quickly as possible (the expression in the medical community is "sicker and quicker"), so that the average stay is much shorter than before. As a result, teaching hospitals, which always had a larger than average share of very sick patients, are becoming little more than centers for intensive care and major surgery.

In today's teaching hospitals, events move too swiftly and patients are too sick to allow time for the proper teaching of students. There is much less time for pedagogic discussion and instruction at the bedside, even if physicians on the faculty were available to teach. The result is that students in teaching hospitals see only brief segments of the medical care process, have less sustained contacts with patients, and receive less personal guidance from experienced faculty. Interns and residents, for their part, are so busy coping with large numbers of sick people that they have little or no time to read, attend teaching conferences, or even talk to their patients. Faculty physicians have less time to teach and their harried, over-worked residents have less time to learn.

To save money, most diagnostic work-ups and preoperative evaluations are now done on an out-patient basis. This shift to ambulatory care also makes clinical education more difficult. Students and inexperienced residents usually are not welcome participants in such care because they slow things down and occupy too much of the attending physicians' time. The same is true of the routine care of patients with chronic illnesses in outpatient clinics. Managed care plans want ambulatory patients to be seen as briefly and managed as efficiently as possible. This leaves no time for teaching.

This growing disjunction between the new, largely out-patient-based health care system and the needs of medical education has stimulated a few medical schools and teaching hospitals to seek support from foundations and other granting agencies for specially designed programs that provide structured education of students and residents in managed ambulatory care settings. The Robert Wood Johnson Foundation has been notably active in this field. Yet such initiatives, however commendable, are little more than demonstration projects, unlikely under the present system to have a major or lasting impact.

Neither such demonstration programs, nor any other limited and local interventions, can solve the basic problem, which is that a market-driven, price-competitive health care system has no incentive to support a common social good, such as medical education. Indeed, all of the incentives in such a system work in the opposite direction. Managed care businesses, struggling to control their "medical losses," view education as simply a large added cost, which they cannot afford and which ought not to be their concern anyway. And whatever limited support the managed care industry might voluntarily give to education is more likely to be focused on training students and residents to meet the needs of the managed care system than on teaching the fundamentals of doctoring.

As Ludmerer so painstakingly documents, we are witnessing the dismantling of a system of clinical education that took the better part of the last century to build. In the last few decades of the century, the academic medical centers of the United States had become a model for the rest of the world in the way they had managed to combine patient care, clinical research, and education into a unified and synergistic enterprise. Under financial pressure from the commercialized health care market, this enterprise is now disintegrating. There is no opportunity to teach or to learn in a health care system driven primarily by cost-containment imperatives, and there is inadequate support for the extra costs of teaching hospitals that take their educational responsibilities seriously and also want to offer state-of-the-art medical care for all who come to their doors. How far the deterioration will go, and what its effects will be on the quality of our health care system and the competence of our new physicians, remains to be seen. Leaders of academic medicine, although still divided and unsure about the future, are now finally united in their deep concern about this issue.

Ludmerer calls the current transformation of medical education its "second revolutionary period." Under the old system in the nineteenth century, medicine had been largely taught as an empirical trade (which it essentially was) in proprietary, free-standing schools. There was no organized system of graduate education in hospitals, and most practical experience was gained through apprenticeship with practicing physicians. The first "revolution" began in the early part of the twentieth century, when the then-prevailing system had gradually been replaced by an intellectually solid, university-based system of medical education. Teaching hospitals, affiliated with medical schools, began to offer carefully supervised programs of residency training under standards established by national accrediting professional organizations. Academic medical centers arose at that time, and new ones continued to appear throughout most of the last century.

The new system was grounded in science and scholarship, and it was committed to advancing medical knowledge and educating physicians. These objectives set American academic medicine apart from the routine delivery of medical services in the community at large. Of course, academic medical centers provided medical care to people who were referred to their teaching hospitals, or who came to their clinics and emergency rooms; but the provision of the best possible care did not compromise their academic objectives. It was an article of faith, supported by much empirical evidence, that the quality of care was enhanced by strong educational and research programs.

In any case, these special functions made the teaching hospitals much more expensive than the others. So long as adequate funds were available (regardless of their source) to cover these extra expenses, medical centers could pursue their special purposes, confident they were fulfilling their part of a "social contract" that served the public interest. But the "second revolution" has changed everything. Pressures for cost containment and the imperatives of the market are causing the reemergence of an inferior educational system, resembling in many ways the system that had existed before the first "revolution" nearly a century ago.

If the United States is to retain its leadership in medical research and education, argues Ludmerer, the tattered "social contract" between academic medicine and the public must be restored. He concludes his book with a call for stronger leadership, and with some brief general suggestions for reform of the academic establishment that might encourage more public support. But these are little more than afterthoughts in an epilogue, lacking the richness of detail and understanding that characterize the body of his work. I do not mean to be too critical: this is essentially a work of history, and we should not expect too much in the way of policy proposals. Ludmerer has done a valuable service in describing and documenting the problem, and in making clear why the current system will have to be reformed. It is for others to propose and to implement the necessary reforms.

IV.

Meanwhile, how have our medical centers been responding? Not very well. According to Ludmerer, "the organized effort and political will among medical educators to behave proactively did not appear to be great. The main emphasis was on expanding the clinical mission, even if that threatened to undermine the core principles upon which the academic health center was based. Critics who contended that medical education followed the flow of money, not principles, had evidence for that belief." I think that his description is accurate; and yet the response of the academic leadership is understandable, even if it is not always admirable. They are struggling to keep their teaching hospitals viable in an economically threatening environment. They are doing what they must do to survive, hoping that help will soon arrive and the climate will improve. They appeal for relaxation in the cutbacks in Medicare, with some modest success, and they ask for contributions to medical education from the private insurers, with no success at all.

This is hardly surprising, because neither government nor private insurers are interested in initiatives that will increase health care expenditures. Moreover, the huge budgets and the lavish new facilities of many medical centers make it hard for the payers to believe that the institutions are as hard-pressed as they claim. Payers also point to the fact that many centers can solicit private philanthropic support for their academic programs, while others can call on state appropriations. What both public insurers and private insurers seem to forget is that neither of these sources can come close to replacing the enormous indirect subsidies the teaching hospitals had received through the indemnity insurance system of the past. Public funding was largely responsible for the continued expansion of academic medical centers in the past half-century, and indirect subsidies have been essential in supporting them. Now, with the recent withdrawal of much of the support, the centers must adapt and improvise to survive.

To survive in a market-dominated health care system, the academic centers have had to do what any business in similar straits would do: cut their costs and increase their revenues. But cutting costs has meant reducing nursing and other professional and technical staff. This has increased the routine busy work and the clinical service burdens of the interns and the residents--not only compromising their learning time, but also raising troubling concerns about the quality of patient care. Even in the best of hospitals, when staffing is short and doctors and nurses are too busy, mistakes are more likely.

Financial pressures on teaching hospitals have also meant the elimination of unprofitable social and community services. To increase their revenues, more hospitals are aggressively marketing and advertising in an effort to attract patients and keep their facilities as full as possible. Hospitals, even those that are part of the same academic teaching program, are not as cooperative with one another as they once were. This increases the duplication of local services and facilities, as each hospital competes for its "market share." Top hospital executives in teaching hospitals behave like beleaguered businesspeople: they are paid large salaries, employ big administrative staffs, and are judged primarily by their financial performance. Their titles, language, culture, and behavior closely resemble those in American industry.

Indeed, they and almost everyone else who works in or with large American hospitals, even the most distinguished teaching institutions, now regard these hospitals as part of an "industry". Most stories in the newspapers about hospitals, even about not-for-profit hospitals, are now to be found in the business section. To blur the distinction between teaching hospitals and businesses even further, several academic medical centers have leased or sold their hospitals to investor-owned hospital chains, in an effort to escape the economic risks of the new health care market, and a few others have dissolved legal ties with their hospitals to allow the latter to compete better in the market.

Business philosophy has come to influence the teaching hospitals in other ways. Seeking new sources of revenue, many academic centers contract with pharmaceutical and biotechnology companies to carry out clinical research. Such arrangements are not necessarily bad, if there are appropriate safeguards to protect the integrity and the independence of the teaching institutions and their medical staffs. Unfortunately, this is not always the case. Medical staff involvement in such contract research takes time away from teaching, and financial connections with the sponsoring companies sometimes create conflicts of interest that affect the objectivity and even the credibility of clinical teachers.

The proliferating connections between teaching hospitals and pharmaceutical firms are threatening the integrity of clinical teaching programs through other kinds of arrangements. Sales representatives of drug firms have always sought to market their employers' products through visits to practicing physicians in their offices. In former times, most teaching hospitals discouraged such visits with the resident staff, believing that their own faculty, and not the pharmaceutical industry, had a responsibility to educate residents and medical students about the uses of prescription drugs in medical practice. Now teaching hospitals seem eager to cooperate with the pharmaceutical industry, because the industry not only supports clinical research but also takes part of the burden of clinical education off the hospitals' budget. Sales representatives are now welcome at most teaching hospitals. They attend and support educational conferences, are present in the operating rooms to advise on the use of their companies' new surgical devices, and they lavish free meals, free trips to medical meetings and all kinds of professional gifts on residents, students, and staff in exchange for the opportunity to hawk their wares.

The Pharmaceutical industry is flourishing, and it has tens of billions of dollars to spend on marketing its products not only to physicians in practice, but also to residents in training at teaching hospitals. Hungry for financial support wherever they can find it, teaching hospitals are turning over increasing parts of their educational responsibilities to the pharmaceutical industry. The long-term effects of this dereliction on the quality and the rigor of the clinical education being received by medical students and residents in the teaching hospitals may be devastating. Physicians are supposed to be trusted and expert advisers to their patients on the effectiveness and the safety of prescription drugs and medical devices. They must be relied upon to judge the relative value of competing products. How can they fill this role if their practical education in the use of drugs and devices increasingly is sponsored by the companies that sell these products?

The growing problem caused by the academic-industrial relationship is resulting in serious ethical dilemmas for academic medicine. In a controversial editorial, Dr. Marcia Angell, the outgoing editor of The New England Journal of Medicine, recently asked: "Is Academic Medicine for Sale?" She provoked much soul-searching in the academic community, and a renewed interest in the issue of the federal government. A subsequent commentary by Secretary of Health and Human Services Donna Shalala in the Journal indicated that the Department of Health and Human Services will be taking a much closer look at the situation. I hope that Shalala's promise will be followed by more stringent regulations. For the situation as it now stands is riddled with conflicts of interest.

It seems likely that the path we are following will be disastrous for the quality of medical education, and for the survival of strong, independent academic medical centers. Still, the problems facing medical education are simply a part of the much broader issues confronting the American health care system. None of the health care proposals now being discussed in the presidential campaign address any of these broader issues. What we need in place of the present commercially-oriented medical market is a not-for-profit community-based health care system that provides everyone with good and affordable care, while supporting medical education and the other infrastructure necessary to advance medical knowledge and improve the quality of health services. To make this change would be a formidable task. Even assuming that we decide to undertake the effort, it would probably take at least a decade to achieve. And yet without major health reform we are not likely even to preserve the present quality of medical care or extend benefits to all our citizens.

The good news is that the major hurdle is not lack of financial resources. We already spend in excess of $1.2 trillion annually on health care, or more than $4,000 per capita. That is almost certainly more than enough to provide decent acute and chronic care for everyone and adequate support for medical education, if the money were spent in a different, more socially responsive, and better organized manner. The problem lies in generating the political will to reform the present system. Opposition will come not only from anti-government and free-market advocates, but also from the powerful vested interests whose newly gained hold on the health care economy would be threatened.

All these obstacles notwithstanding, I believe that a major change is inevitable, owing to simple realities. Medical care is an essential human service. It must be responsive to needs and be governed by ethical values. It cannot be successfully distributed, therefore, by unregulated market forces. Medical education is a vital prerequisite for good medical care. It, too, as Kenneth Ludmerer's masterful history so persuasively demonstrates, cannot thrive in a market-dominated system.