If the Ford Motor Company, which opened in 1903, could successfully standardize and thereby democratize automobiles, then why not enlist the same logic of industrial efficiency to bring uniformity and consistency to the medical realm in the form of standardized institutions, practitioners, and practices? It was such reasoning—vigorously cultivated starting in 1910, when Louis Brandeis famously drew public attention to the term scientific management, and fading with the Great Depression of the 1930s—that Caitjan Gainty explores in this carefully researched, historiographically generative, and thoroughly engaging monograph.
The Product of Medicine, organized thematically, begins by mapping out the deep intercalation between scientific management applied to industrial workers and their labor and the quest for efficiency and standardization in medicine, a crossover exemplified by a figure like industrial engineer Frank Gailbreth, who turned his attention to motion studies of surgery and hospital efficiency. It then explores the Mayo Clinic, which began operation in 1914 as the best-known Progressive Era avatar of standardized, rationalized medical organization and practice. There, the model of efficiency that had its origins in the factory informed the deliberate application of a process-oriented, assembly-line method in medicine. Instead of seeing a solo practitioner, patients moved through the clinic from specialist to specialist in what was termed the cooperative method of diagnosis that resembled labor along the assembly line. Designating a product—at Mayo, that product was an accurate diagnosis—was a crucial first step in the efficiency method, for only then could the processes be studied and rationalized in ways that would improve efficiency. Gainty next turns to the Henry Ford Hospital, where its proudly publicized application of assembly-line practices to the clinic prompted the comparison of patients with Model T cars. By the time it opened in 1921, however, the medical efficiency movement was so deeply entrenched that the new clinic could borrow its model of rationalized process not so much from Fordist factories but from other hospitals, where the cultivation of efficiency and standardization was already in full swing.
Gainty then turns to the two best-studied milestones in the medical efficiency movement. The American College of Surgeons (ACS), formally organized in 1913, launched a program to standardize hospitals and—by creating uniform qualifications for hospital appointments—to standardize surgeons and their practices as well. So too did Abraham Flexner—whose 1910 muckraking Report on medical education made him the best-known figure in the medical movement for standardization—seek to recast medical schools into a single mold, standardizing both institutions and the doctors they produced. Together, Flexner and the ACS took part in catalyzing the transformation in medicine that ensued, contributing to the elevation of the medical profession’s esteem and cultural authority in American society.
At the same time, these moves to standardize medical schools and hospitals also starkly revealed the tensions and contradictions that plagued the medical celebration of efficiency and its social and moral correlates. Gainty convincingly shows how the democratic, egalitarian, and even populist allegiances that rhetorically framed the efficiency movement stood in a tense relationship to its inbuilt antidemocratic and monopolistic tendencies. Professed commitment to egalitarianism and meritocracy fell apart when it came to Black hospitals and medical schools, for example, which fell prey to the antidemocratic, racist currents that were also integral to both the embrace of efficiency and the move for medical standardization.
The voices that come through most clearly in this study are those of the elite physicians and surgeons who led the movement for medical efficiency. In a particularly intriguing chapter, Gainty explores the community health meetings that the American College of Surgeons mounted in the late 1910s to proselytize for the gospel of standardization, seeking to inculcate trust in the standardized doctor who labored in a standardized hospital and provided standardized care. The entertainment and pageantry of these itinerant productions recalled the spectacle of the nineteenth-century medicine show, but with the aim, as one enthusiast put it, to “standardize the public mind” (117). We hear little, however, about how this marketing message was heard or received, or indeed how the wider efficiency movement was perceived by the public or by rank-and-file American doctors. Such attention to how the public appraised the promise of efficiency is one constitutive ingredient in grasping how the promotion of standardized medicine was translated into power and prestige during the Progressive Era.
The Great Depression profoundly disrupted medical and public faith in the power and promise of efficiency and standardization. At this juncture, Gainty shifts her focus to the American Medical Association (AMA). By the early 1930s, not only had efficiency become suspect, but the term assembly line, when applied to medicine, had become an epithet of derision. Instead of efficiency—which the AMA identified with socialism and un-American values—the new emphasis was on the cardinal virtue of a close, personal, individuated doctor-patient relationship. This relationship, the AMA contended, was to be found only in the fee-for-service practice of the individual private practitioner, not the efficient but impersonal group practice assembly line. Antitrust cases brought against the AMA and its monopolistic aspirations in the 1930s and 1940s, when Gainty’s narrative ends, hardened its stance. The contrast that the AMA cultivated between the model of efficient, standardized medical practice that it denounced and the ideal of personalized care would fuel the association’s successful midcentury campaign to defeat pushes for universal national health insurance.
The movement for efficiency and standardization that Gainty so lucidly recounts was one key ingredient in the early twentieth-century sea change in American medicine. There were other important and well-studied currents in this transformation as well, even beyond the historiographic construct of “professionalization” that appears here as something of a straw figure, and Gainty’s reductive assertion that “it was the ‘science’ of efficiency that made medicine modern” is overstated (5). This book is nonetheless an important and welcome contribution to our understanding of a transformative impulse in American culture, and Gainty has given us what is unmistakably the best study we have of the efficiency movement in American medicine.
