I’ve lived through two periods of medicine in this country. The earlier one, before 1964 and third party payers like Medicare and Blue Cross, was quite different than the one most of us are familiar with. My father was a “physician and surgeon” in those days and in his best year never made more then $10,000 dollars. He went to the office 7 days a week (the Sunday visit I suspect was to get some peace and quiet and do paper work), rounded at the hospital every day, made house calls, took out appendixes, delivered babies, treated diabetes, sewed up the lacerations of the cook at White Towers at 3 am, etc. I used to go to the office with him and he would let me go in the dark room with him while he developed the x-ray he just took, or I watched him make a sputum smear, stain it and then look at it through his microscope (which now sits on a chest in my dining room under a bell jar). His patients paid him a buck or two if they had it; if they didn’t we got a present of some kind at Christmas time. For some reason bottles of booze were popular. We had a very well stocked liquor closet for a family who didn’t drink. No one had insurance, to speak of. So he, and many other doctors, worked hard and made an OK, but not a great, living. He died in 1957, shortly after making a house call. I remember him saying the person tried to push some money on him he wouldn’t take. A couple hours after that he was dead. Seven years later, when I was a second year medical student, Medicare came on the scene, bitterly opposed by organized medicine. And the result? Doctors got rich.

The AMA started in 1847 as a small group of doctors intent on improving the economic condition of medicine. In the 19th century there were all sorts of practitioners — Thomsonian Botanicalists, homeopaths, bleeders and purgers )those were the regular practitioners — and lots of ways you could become a doctor. You could go to a medical school, of course. There were lots of them and they made money. Or you could apprentice to a practicing doctor. After two years or so you could hang out your own shingle. Licensing? Nope. The result was ruinous competition. The founders of the AMA hoped to do something about it. They didn’t. For over 50 years hardly anyone belonged to the AMA. It was an irrelevant social club for a few. But in 1900 in re-organized politically and began an era of spectacular growth and success. The AMA didn’t focus on a national organization but a grassroots one. The basic unit was the country medical society. The county society belonged to a state society and the states to the national AMA. Every legislator had a doctor and therefore a personal lobbyist. The first objective was licensing laws and brining medical education to heel. The Flexner Report (1907) about medical school reform was part and parcel of the effort to both bring standards to the profession and stop anybody and his brother from starting a medical school. Country societies brought pressure on hospitals not to let a doctor have hospital privileges unless they were a member, and if you were a member of the country society you were automatically a member of the state and national AMA. Membership grew rapidly. By the end of the progressive era the AMA had an iron grip on medical education and licensing in almost every state. And also effective opponents of any government health insurance as a form of contract medicine.

The AME was bitterly opposed to any form of contract medicine because they had found that companies that offered free or very low cost health care benefits to employees did it at the expense of doctors, paying them very little per capita and providing a new kind of competition to the newly organized AMA rank and file. This opposition to anything but fee-for-service was a consequence of the effort to control low cost competition and became a reflex of AMA policy. For all of my father’s life as a doctor the AMA was a major political power, and it was doctors like my father that were its main beneficiaries (although he was a member, I don’t think he cared much about it. He just paid dues and was a member of the country society like most doctors.). While Medicare and private health insurers made doctors rich beyond their wildest dreams, the AMA understood it would eventually threaten its power. Doctors would become proletarianized. As salaried workers they are very well paid, but they are salaried workers nonetheless, and the AMA has little to offer them except the usual guild-like behavior of fighting for higher reimbursements. As Dem points out, most doctors don’t even belong to it anymore. The AMA represents less than one in five practitioners.

So now we are rapidly moving into a new era of medical practice. No one is quite sure what is on the other side of this transitional period, but whatever it is and however long it takes, it won’t be the same as before, just as the last 50 years were very different than the days when my father practiced (days which no one remembers any more). Like the revolution at the turn of the 20th century and the next one in the 1960s the change came because the old ways were broken, unsustainable.

That’s where we are again. Welcome to the revolution.