Princeton sociologist Paul Starr,^10(PP7980) says, "Acknowledged skills and cultural authority are to the professional classes what land and capital are to the propertied. They are the means of securing income and power. For any group, the accumulation of authority requires the resolution of at least two distinct problems. One is the internal problem of consensus; the other is the external problem of legitimacy."

In terms of consensus, physicians were struggling mightily to come to agreement about their common rules and standards. Internal divisions beset the profession from the mid-19th century until the early part of the 20th century. Concerning legitimacy, in Europe medical degrees granted deference and respect, but in America the meager educational requirements left physicians with a perilously slender margin between themselves and their patients--and sometimes no margin at all. Therefore their powers of persuasion, along with their ability to kindle feelings of confidence and trust, were critical to their success. In America a physician's standing was tied to his own family background, as well as the social rank of his patients. At the top were men who, like William Stewart Halsted, had graduated from elite colleges, attended medical school, and received further instruction in Europe.

Although the AMA was in its infancy in the mid-19th century, it wasn't until 50 years later--the early 1900s--that medical societies began replacing the internal dissension and competitive relationships among doctors with a brotherhood of shared interests (note 2). But in 1900 the AMA still sought to address the issue that had motivated its formation: control of medical education. This was the chosen methodology to consolidate the profession: standardized schooling would ensure both conforming ideas and uniform practice.

Reform of medical education had its beginnings in the ~ 1870s when the Quaker merchant Johns Hopkins died in 1874, j willing half of his $7 million estate to found a university, and the l other half to build a hospital. At the time, this was the most substantial endowment in American history, setting the precedent for linking laboratory research with clinical patient care. The prototype came from Europe, where laboratories in physiology, chemistry, pathology, and histology were transforming hospitals. Johns Hopkins University opened in 1876, the hospital in 1889, and the medical school in 1893. Johns Hopkins School of Medicine had the hitherto unheard of admission requirement of a Bachelor of Arts degree, and the curriculum was lengthened from 3 to 4 years. The crucial half million dollars needed to complete the school was donated by wealthy Baltimore women who made their offer contingent upon the admission of women on the same basis as men.

Johns Hopkins was the paragon of virtue in the eyes of the AMA. This single institution had--and continues to have--enormous leverage on the course of medicine. The policies ensconced there determined which institutions survived to govern the field, how they were structured and administered, and what ideology would triumph (note 3).

Finally standards were being set for medical education as graduate study, with strength in both science and clinical medicine. The next advance was creating residencies in specialized fields. Two towering giants in medicine, William Welch, a pathologist, and William Osler, an internist, were dedicated to building Johns Hopkins as the archetype for training not only physicians, but medical scientists as well. Welch, however, vied for the interests of research, whereas Osler championed the interests of clinical medicine. Osler admonished: "Care more for the individual patient than for the special features of the disease.... Put yourself in his place ... enter into his feelings, scan gently his faults. The kindly word, the cheerful greeting, the sympathetic look--these the patient understands."¹³ Osler further expressed concern that patient care might suffer if it became completely subservient to research, but Welch differed, determined to elevate the role of science in medicine.