Part IV: Reformers in medical education and practice: Effect of managed care organization in the United States.

BACKGROUND: Part I (Can J Plast Surg 2000;8:25-29) established that standards of professional practice shift constantly. When a standard falls short of professional expectation or when a physician becomes more concerned with financial gain rather than patient care, society needs the action of a reformer. Parts I, II (Can J Plast Surg 2001;9:59-68) and III (Can J Plast Surg 2002;10:103-108) covered 500 BC to 1970 AD and comprised 31 physicians who introduced innovations in medical knowledge or medical philosophy. Part IV deals with a time in which new conditions have been imposed on medical practice. In the United States, medical education and practice felt the repercussions of financial institutions participating in health care management.

STUDY DESIGN: The reformers were scientists who conformed to our definition of 'reformer': a person whose action restored, reshaped or advanced the structure or ideology of medical practice.

RESULTS: This survey demonstrated that the reforms were accomplished by scientists possessing critical judgement and analytical qualities that enabled them to influence the direction of medical education and practice. In the last 20 years, financial institutions imposed different criteria that may require future reformers to reestablish lost objectives.

CONCLUSION: Reforms have been achieved through intuitive leaps, alterations of conventional practice, painstaking research or administrative restructuring. The present health management in the United States requires new solutions.