Given the highly scientific and technical nature of medical practice, it is tempting to assume that the system of residency training developed in response to intellectual forces within medicine. There is much truth to this. After all, the need to learn scientific concepts and principles, to develop skills of critical reasoning, to acquire the capacity to manage uncertainty, to master technical procedures, and to learn how to assume responsibility for patient care all reflected powerful professional demands.
However, residency training in America also developed within a specific cultural context. These cultural forces indelibly shaped the system as well. Their influence was more subtle than those of the internal forces, but it was just as powerful and important.
One important example is that the residency system in the United States developed within a system of charity care. It was this fact that allowed the residency system to provide interns and residents the opportunity to assume responsibility in patient care. The United States, like the rest of the industrialized world before World War II, used indigent patients as “clinical material.” These patients, in keeping with a long-standing Western tradition, received free care in exchange for their participation in clinical education and research. Paying patients, in contrast, were used only in limited ways in medical education-for histories and physical examinations, for example, and only then when they granted permission. Only the indigent patients on the “teaching service” afforded house officers the opportunity to develop management plans, make important therapeutic decisions, and perform surgery and other procedures.
Cultural attitudes toward work and family life of the pre-World War II era also helped shape graduate medical education in America. Learning and practicing medicine were demanding activities, often presenting what seemed like 36 hours of work to do in a 24-hour day. William Osler, the iconic professor of internal medicine at Johns Hopkins, called work “the master-word in medicine.” To succeed, doctors needed to focus nearly totally on medicine, to the exclusion of family, friends, hobbies, and a balanced life.
Cultural attitudes of the period supported physicians in their efforts to learn and practice medicine. The United States as a society had always had a high regard for those who could work themselves up to financial and professional success. It was the country’s strong work ethic and entrepreneurial spirit that attracted many ambitious immigrants hoping to leave poverty behind. Moreover, during the creation and early development of the residency system, a strong union movement had yet to arrive, and there were no restrictions on the length of the work day or work week or even on child labor. Accordingly, Americans were accustomed to hard work. Few eyebrows were raised when medical students and house officers threw everything into their training and gave up their twenties for their future.
Attitudes toward marriage and family life reinforced the strong work ethic. Medicine, like virtually all professional fields at the time, was overwhelmingly a male career. Marriage was viewed as women’s work; the physician’s spouse was expected to support her husband, raise the family, manage the household, and take charge of social affairs. As Osler, who did not marry until he was 42, once stated: “What about the wife and babies, if you have them? Leave them. Heavy as are your responsibilities to those nearest and dearest, they are outweighed by the responsibilities to yourself, to the profession, and to the public . . . Your wife will be glad to bear her share in the sacrifice you make.” Such cultural attitudes validated the importance of professional work and undoubtedly influenced the choices and behaviors of almost every physician.
In short, the development of the residency system was influenced by cultural conditions as well as by professional forces. A two-tiered system of health care with an abundance of charity patients provided the “clinical material” with which house officers could learn to assume responsibility for patient care. The strong work ethic of the era, a culture in which delayed gratification was the norm for those aspiring to professional success, and the view that marriage was “women’s work” made it easier for young physicians to submerge themselves in their training and careers. Few medical educators considered these social circumstances in relation to residency training at the time, so much a part of the natural order did they seem. Even fewer contemplated what the implications for residency training might be should social conditions change.
Image: Queensland State Archives 1580 Womens Hospital Ward Eventide Home Sandgate c 1950. Agriculture And Stock Department, Publicity Branch. Public domain via Wikimedia Commons.