A History of Medical Residency

Field: Arts and Humanities (Social Sciences)

A History of Medical Residency Joel D. Howell (bio) Kenneth M. Ludmerer. Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. New York: Oxford University Press, 2015. xvii + 431 pp. Notes and index. $34.95. Throughout the eighteenth and nineteenth centuries, the provision of health care in the United States was unlicensed, largely unstructured, and delivered by a wide range of practitioners, from literate laypeople to physicians with varying degrees of training in a wide range of medical systems. Twenty-first century delivery of medical care has become regulated, organized, and dominated by allopathic physicians, who have been trained to practice medicine based on a uniform set of theoretical principles. Health care has also become a major component of every part of U.S. society, consuming about 17 percent of the GDP—and that number will likely continue to rise. Since around the turn of the twentieth century, the organization of medical care has increasingly relied on categorizing physicians as members of specific specialties—surgery, pediatrics, ophthalmology, and so forth. Today, virtually every medical school graduate spends several years preparing to become a specialist in one or more clinical areas. They get that preparation in residency programs, which have done as much as any other innovation to shape the nature of medical practice over the past century. It is the history of those residencies that Kenneth Ludmerer addresses. Given the ubiquity of residency training, as well as the fact that these residencies are often situated at the dominant hospitals that shape regional and national medical practice, it is no hyperbole to claim, as the book's subtitle implicitly does, that this book is not only a history of residency training, but, indeed, of U.S. medicine. This volume builds on Ludmerer's two previous histories of medical training: Learning to Heal: The Development of American Medical Education (1985) and Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (1999). Those two books focused on the history of undergraduate medical education, a topic that has seen a modest amount of attention from other historians. However, surprisingly few scholars have substantively addressed the history of the medical residency. In The Specialization of Medicine with Particular Reference to Ophthalmology (1944), George Rosen drew attention [End Page 126] to the process of specialty formation. Charles Rosenberg's The Care of Strangers: The Rise of America's Hospital System (1992) gave a vivid picture of the early days of the hospital, and Rosemary Stevens' history of specialization, American Medicine and the Public Interest (1971, updated preface 1998) analyzed the creation of the U.S. system of specialties. More recently, George Weisz's Divide and Conquer: A Comparative History of Medical Specialization (2006) was a cross-national analysis of how Germany, Britain, and the United States chose to divide up the specialty landscape. Various local program histories offer an inward look at specific residency programs. But none of these works focused on the history of residency training, and none explored the life of the trainee in anything like the depth of this account. Let Me Heal thus fills a significant void in our understanding of the history of an integral part of the U.S. health-care system. Chronologically organized and clearly written, the book starts with nineteenth-century students' search for clinical experience. U.S. medical schools offered little exposure to meaningful medical practice; postgraduate training opportunities were extremely limited. Americans who wanted additional training went abroad, often to Germany. They came back home not only with additional clinical skills but also with the idea that advanced training could be offered through a residency situated within a clinical department. These early residencies were closely tied to the newly created research university. Initial programs were not intended to prepare all physicians for careers devoted to routine patient care, but to prepare a few physicians to be clinical investigators, scientists serving the larger social good by creating new medical knowledge. Soon after the turn of the twentieth century, post–medical school training spread more widely, usually as "internships," a single year of training during which interns assumed increasing levels of responsibility. Internships came in a couple...