There’s too much more to put on a twitter thread so i’ll stop for now. But if you want to know more HIGHLY recommend ‘social transformation of American medicine’ by Paul Starr. (end thread)

...3) leadership and trainees in a city need to STOP treating med school/residency as a commodity to further their career, and actually stop to take a look around the story of their city. And at some point, settle down, grow roots, meet people, engage, don’t live in silos.

So...solutions? Actively thinking through this myself but should def include 1) making leadership more diverse - people from marginalized communities have different values and we need those right now 2) leaders need to care less about profits/prestige and serve communities…

If you think that we can tackle health disparities, racism in medicine, gender gaps, specialty > primary care, research > community health, one at time you’re wrong. We have to change the system that bred these, all at once.

...When leadership in med schools + hospitals only come from certain groups while trainees are more diverse. When inner cities and rural areas can’t get access to care. When patients face implicit bias. When academics/specialists are held in esteem over community docs

Decades later we are still feeling these effects. I don’t have to list them all but you know. When your med school spends $$$ on basic science research but ignores disparities in their own city. When students feel pressured to go to specialties to make their loans worthwhile

On the one hand standardization made medical training in the US rigorous. But on the other hand, we also made intentional decisions to define narrowly what it means and looks like to be a doctor and to practice medicine

And if you weren’t already wealthy (and often, this meant also white&male) it was impossible to now delay payment for 7-8yrs instead of the 1-2 to get medical training. The # of women, blacks, poor/rural folk getting MDs dropped drastically. Exclusion through impossible barriers

A majority of med schools that existed closed. Some that were under medical sects like christian science or homeopathy but others were small time med schools drawing from marginal communities, whose grads returned to those communities

This was the model Johns Hopkins pioneered and became the benchmark that every other med school was judged against. The catch? Lot of med schools not in the ivory towers or that accepted women, blacks, and poor/rural folk didn’t have massive hospitals or endowments for research.

Then came the Flexner report and the events that followed - every state req licenses to practice, and medical education was formally defined as 3-4 yrs of lectures + patient care, and residency afterwards. Meded became centered on HOSPITALS in CITIES, and research.

Care you got from docs was variable, but it DID allow for certain communities in the margins to have docs that cared about them and was one of their own (women, blacks, rural, or non-NewEng) & the only places they could get training was oft in med schools that only accepted them

Medicine in 1800s was a hodgepodge of self proclaimed docs, academic types, midwives, quacks all w/o a standard licensing procedure or std req for med ed. I.e. no license needed practice and ‘med school’ was taking a few lectures over 1-2yrs

What you might not know: health disparities, lack of POC MDs, gender gap, emphasis on basic science over care of communities, MD brain drain to coasts, are all related and can be traced to the effort to ‘standardize’ medical education in the US in the early 1900s

#medtwitter just got twitter and seeing lots of discussions on what we can do as docs to address systemic racism and health disparities in US. Wanted to throw in some historical perspectives on #meded in US I often find undiscussed but might help us move forward (thread)